Malingerers are the bane of psychiatric emergency departments, but that
doesn't mean they're not sick, said Jon Berlin, M.D. (foreground), at APA's
Institute on Psychiatric Services in New Orleans. "Why not try to be
productive with them?" Other panelists (from left) included Scott
Zeller, M.D., Rachel Glick, M.D., and Carla Edwards, M.D.
People who lie, threaten, or manipulate others to gain medical attention
have few friends in the health care system. Malingerers are even less welcome
in the psychiatric emergency room, where overstretched resources must be saved
for those who need them most, Jon Berlin, M.D., said at the APA Institute on
Psychiatric Services in New Orleans in October.
Nevertheless, malingerers should not be written off by hospital staff, and
the very annoyance induced by their pleas for medical care may open doors to
the real needs of this population, he said.
"We know more about detecting malingering than about therapeutic
interventions," said Berlin, medical director of crisis services at
Milwaukee County Behavioral Health Division and an assistant clinical
professor of psychiatry at the Medical College of Wisconsin. The real question
is what to do once a malingerer is found out.
He recalled one patient who said, "I want to be in the
hospital." Berlin told him he was in the hospital, to which the
patient replied, "But I want to be deeper in the hospital."
"This is as deep as you're going to get," Berlin said
Others mix psychopathology with symptom exaggeration to try to get the
medical attention they want. Many people threaten suicide to gain admission or
achieve some other end, said Berlin.
A different patient, feeling "overwhelmed," also asked to be
hospitalized. When Berlin denied her request, she asked what would happen if
she said that she was suicidal. Berlin said that approach would destroy the
trust between patient and physician, and he referred her to a respite house to
"These individuals make us feel manipulated and taken advantage
of," he said. "That leads to feelings of dread on our part. We
feel dehumanized by them, and so we dehumanize them back. We start to think of
them only as 'that malingerer.'"
Faced with such patients, emergency physicians need to ferret out
exaggeration, do thorough evaluations, practice good risk management—and
stand firm, he emphasized. Many malingerers begin as outpatients and then end
up making repeat visits to the emergency department. The department should
consider them as established patients, not new intakes, and take progress
notes that can help guide staff efforts the next time they appear.
Malingerers are people who have often burned their bridges with the people
around them, said Berlin. Their only success in life comes from making others
fail. By default, they become cases for psychiatrists. Yet they are rarely
well people. Many have psychiatric or physical comorbidities, he said."
So why not try to be productive with them?"
Helping them can begin with the very feelings of anger or disgust that
malingerers engender in physicians and other staff. That internal barometer
can serve as an indicator of a patient's status for the psychiatrist, as an
EKG does for a cardiologist.
"We have to be aware of these emotions and let them be cues for us
and for others," he said.
He recounted another case in his hospital of a man in his 50s with
diabetes, cardiovascular disease, a cocaine habit, and a mood disorder who was
hostile and demanding while on the observation unit. He was placed in
restraints after he threatened a pregnant chief resident and knocked over a
This was not the patient's first appearance at the hospital. When he was
discharged after observation, Berlin overcame his distaste and walked out of
the hospital with the man to explore further his potential for insight or
Why did he threaten the chief resident? he asked the man. What did he plan
to do with the rest of his life?
"Probably a majority of these patients are not treatable, but
engaging them can reinforce traits in ourselves that can be helpful with other
patients who are more receptive," said Berlin.
However, emergency departments must also set limits on unacceptable
behavior to protect staff, he said. "We shouldn't allow any mistreatment
by either side."
The policy in his health system calls for pressing charges against patients
who cross beyond temper tantrums to the realm of felonies, he said. Sometimes
that is not the solution it may seem at first glance. Berlin has seen cases in
which such patients are taken to jail, threaten suicide there, and are
returned—often the same afternoon—to the psychiatric emergency