Malingerers May Be Annoying, but Don't Write Them Off

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 firmly.

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 stabilize.

“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 table.

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 change.

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 room. ▪