Inpatient treatment planning: Consider 6 preadmission patterns

As described for category 1 patients, perform an extensive physical and laboratory examination, psychological testing, and additional or specialized radiologic testing such as MRI, fMRI, SPECT, or (if possible) PET, as needed. Focus on the possibility of diagnostic reassignment and/or the presence of comorbidities. Seek clinical consultation, especially if academic specialty programs are available in the vicinity. Consultation from medical, neurology, and neuropsychology colleagues can help clarify diagnostic possibilities.

Unlike patients in categories 2, 3, and 4, deteriorating patients often require wholesale changes in medication management because:

• adherence with previous regimens has not produced ongoing remission
  
• illness is worse or progressive and requires a new or more intensive approach.
  

Hospitalization usually needs to be longer for intensive reassessment and to establish a new treatment regimen. Chronic hospitalization may be necessary for patients with severe treatment-refractory illness.

Category 6: malingering

Resnick¹¹ characterized 5 motivations for malingering psychosis and probably mental illness in general (Table 5). Psychiatric malingerers fall into two categories:

• those who have no illness but fake one
  
• those who have mental illness but grossly exaggerate the intensity and gravity of symptoms for secondary gain.
  

Malingerers who have mental illness but exaggerate their symptoms to gain admission are more difficult to discern than those without illness, although Resnick and Knoll¹² identified clinical factors that suggest a person is malingering psychosis (Table 6).

In general, malingering patients should not be hospitalized. If malingering is discovered after admission, discharge those without illness. In those with psychiatric illness, exaggerating symptoms may represent comorbid illness (especially Axis II disorders) or increased dependency because of a psychosocial change, such as loss of housing.

Address the latter with psychosocial support and social work/case management services, as with patients in category 4.

Table 5

5 motivations for psychiatric malingering

To avoid punishment for criminal behavior
To avoid military conscription or combat
To obtain financial gain for disability or lawsuits
To obtain drugs or “do easier time” while incarcerated
To gain hospital admission to avoid arrest or obtain free room and board
Source: Reference 11

Table 6

5 clinical factors that suggest malingering

Absence of active or subtle signs of psychosis
Marked inconsistencies, contradictions
Patient endorses improbable psychiatric symptoms
Mixed symptom profile (such as depressive symptoms plus euphoric mood) Overly dramatic Extremely unusual (endorses a strategic suggestion such as, “Do you believe that cars are a part of an organized religion?”)
Patient is evasive or uncooperative
Excessively guarded or hesitant Frequently repeats questions Frequently replies “I don’t know” to simple questions Hostile, intimidating; seeks to control interview or refuses to participate
Psychological testing (SIRS, M-FAST, MMPI-2) indicates malingering SIRS: Structured Interview of Reported Symptoms M-FAST: Miller Forensic Assessment of Symptoms Test MMPI-2: Minnesota Multiphasic Personality Inventory, Revised
Source: Reference 12

Related resources

• Cuffel BJ, Held M, Goldman W. Predictive models and the effectiveness of strategies for improving outpatient follow-up under managed care. Psychiatr Serv 2002;53(11):1438-43.
  
• Lien L. Are readmission rates influenced by how psychiatric services are organized? Nord J Psychiatry 2002;56(1):23-8.
  
• Maruish ME, ed. The use of psychological testing for treatment planning and outcomes assessment, 3rd ed. Mahwah, NJ: Lawrence Erlbaum Assoc; 2004.