Cases That Test Your Skills

Suicidal and asking for money for food

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How to help patients who malinger

Identifying malingering in patients with obvious secondary gain is important to prevent exposure to potential adverse effects of medication and unnecessary use of medical resources. In addition, obtaining collateral information, records from previous admissions or outpatient treatment, and psychological testing adds to the body of evidence suggesting malingering. We also recommend a comprehensive psychosocial evaluation to identify the presence of secondary gain.

Recommendations for evaluating and managing a malingering patient

Management of malingering (Table 2) includes building a strong therapeutic alliance, exploring reasons for feigning symptoms, open discussion of inciting external factors such as interpersonal conflict or difficulties at work, and/or confrontation.10 In addition, supportive psychotherapy might help strengthen coping mechanisms and problem solving strategies, thereby removing the need for secondary gain.12 Additionally, face-saving mechanisms that allow the patient to discard their feigned symptoms, or enable the person to alter his (her) history, could be to his benefit. Lastly, and importantly, clinicians should focus efforts on ruling out or effectively treating comorbid psychiatric conditions.

From a risk management standpoint, include all available data to support the malingering diagnosis in your progress notes and discharge summaries. A clinician seeking to discharge a patient suspected of malingering who is still endorsing suicidal or homicidal intent will benefit from administrative review, including legal counsel to mitigate risk, and be more confident discharging somebody assessed to be malingering.

We recognize that certain patients could trigger countertransference reactions that impel clinicians to take on a significant caretaking role. Patients skillful at deception could manifest a desire to rescue or save them. In these instances, clinicians should examine why and how these feelings have come about, particularly if there is evidence that the individual could be attempting to use the interaction to achieve secondary gain. Awareness of these feelings could help with the diagnostic formulation. Moreover, a clinician who has such strong feelings might be tempted to abet a patient in achieving the secondary gain, or protect him (her) from the natural consequences of individual’s deception (eg, not discharging a hospitalized patient). This is counter-therapeutic and reinforces maladaptive behaviors and coping processes.13

Bottom Line

Suspect malingering in patients who have attempted suicide and have an obvious secondary gain. Perform a thorough psychosocial assessment, evaluate the patient’s history through collateral sources and medical records, and carefully assess and treat comorbid psychiatric disorders. Helping malingering patients starts with a strong therapeutic alliance; however, be vigilant for countertransference reactions.

Related Resources
• Feldman MD. Playing sick? Untangling the web of Munchausen syndrome, Munchausen by proxy, malingering, and factitious disorder. New York, NY: Brunner-Routledge; 2004.
• Rogers R. Clinical assessment of deception and malingering. 3rd ed. New York, NY: Guilford Press; 2012.
• Brady MC, Scher LM, Newman W. “I just saw Big Bird. He was 100 feet tall!” Malingering in the emergency room. Current Psychiatry. 2013;12(10):33-38,40.

Drug Brand Names
Acetaminophen • Tylenol
N-acetylcysteine • Mucomyst

Risperidone • Risperdal

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