Evidence-Based Reviews

“I just saw Big Bird. He was 100 feet tall!” Malingering in the emergency room

Current Psychiatry. 2013 October;12(10):33-38, 40

References

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4. Resnick PJ, Knoll J. Faking it: how to detect malingered psychosis. Current Psychiatry. 2005;4(11):12-25.

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10. Miller HA. M-FAST interview booklet. Lutz, FL: Psychological Assessment Resources; 2001.

11. Hom J, Denney RL. Detection of response bias in forensic neuropsychology. Binghamton, NY: Haworth Medical Press; 2002.

12. Whitney KA, Hook JN, Steiner AR, et al. Is the Rey 15-Item Memory Test II (Rey II) a valid symptom validity test?: comparison with the TOMM. Appl Neuropsychol. 2008;15(4):287-292.

13. Kelly PJ, Baker GA, van den Broek MD, et al. The detection of malingering in memory performance: the sensitivity and specificity of four measures in a UK population. Br J Clin Psychol. 2005;44(3):333-341.

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This task is repeated 10 times; each time, the provider gives verbal feedback about the accuracy or inaccuracy of that attempt. Studies indicate that a patient who has a severe traumatic brain injury is able to score 85% correct. A score <85%, however, suggests feigning of symptoms (sensitivity, 92.5%; specificity 87.5%).¹³ Hanley and co-workers demonstrated that people who are simulating cognitive impairment had a mean accurate response of 4.1, whereas people who had true amnesia had a mean accurate response of 9.65.¹⁴

Persons who feign psychosis or mood symptoms often inaccurately believe that people with mental illness also have cognitive impairment. Both Rey’s test and the Coin-in-the-Hand Test capitalize on this misconception.

Mini-Mental State Examination. Research also has shown that the Folstein Mini-Mental State Examination (MMSE) can screen for malingered cognitive impairment. Powell compared 40 mental health clinicians who were instructed to feign psychosis and 40 patients with schizophrenia. Using the MMSE, the researchers found that the malingers more often gave approximate answers.¹⁵ Moreover, Myers argued that, when compared with Rey’s Test, the MMSE is superior for assessing malingered cognitive impairment because it has a higher positive predictive value (67%, compared with 43% for Rey’s Test) and a higher negative predictive value (93% and 89%).¹⁶

What can you do for these patients after diagnosis?

Malingering is not considered a psychiatric diagnosis; there are no indicated therapies with which to manage it—only guidelines. When you suspect a patient of malingering, you should avoid accusing him (her) of faking symptoms. Rather, when feasible, gently confront the person and provide the opportunity for him to explain his current behaviors. For example, you might say: “I’ve treated many patients with the symptoms that you’re reporting, but the details you provide are different, and don’t ring completely true. Is there anything else that could explain this?”¹⁷

Regardless of a patient’s challenging behaviors, it is important to remember that people who feign illness—whether partial malingering or pure malingering—often do need help. The assistance they require, however, might be best obtained from a housing agency, a chemical dependency program, or another social service—not from the ER. Identifying malingered behaviors saves time and money and shifts limited resources to people who have a legitimate mental health condition.

Last, despite an empathetic approach, some malingering patients continue to feign symptoms—as Mr. K did.

CASE CONTINUED

Although the psychiatrist on call considered forsaking the police to escort Mr. K out of the ER, he eventually agreed to leave the hospital on his own, stating, “My death is going to be on your hands.”

Eight days later, Mr. K visited the ER at a different hospital, endorsing chronic pain and demanding narcotics.

Bottom Line

As the number of people seeking care in the emergency room (ER) has increased, so has the number of those who feign symptoms for secondary gain. No single factor is indicative of malingering, and no objective tests exist to diagnose it definitively. Furthermore, there are no indicated therapies with which to manage malingering—only guidelines. Keep in mind that people who feign illness, whether partial or pure malingering, often do need help—although not the services of an ER.

Related Resources

Miller Forensic Assessment of Symptoms Test (M-FAST). Psychological Assessment Resources, Inc. www4.parinc.com (enter “M-FAST” in search field).
Duffy S. Malingering psychological symptoms: An empirical review. Illinois State University, Department of Psychology. http://psychology.illinoisstate.edu/cc/Comps/Duffy%20-%20Malingering.pdf. Accessed September 10, 2013.

Drug Brand Names

Quetiapine • Seroquel

Disclosure

The authors report no financial relationships with any company whose products are mentioned in this article or with manufacturers of competing products.

Featured Audio
M. Cait Brady, MD, shares strategies for assessing malingering. Dr. Brady is a Third-Year Resident in General Psychiatry, University of California, Davis Medical Center - Sacramento, Sacramento, California.