Imagine you’re on call in a busy emergency department (ED) overnight. Things are tough. The consults are piling up, no one is returning your calls for collateral information, and you’re dealing with a myriad of emergencies.
In walks Mr. D, age 45, complaining of hearing voices, feeling unsafe, and asking for admission. It’s now 2 am. What would you do?
Of course, like all qualified psychiatrists, you will dig a little deeper, and in doing so you learn that Mr. D has visited this hospital before and has been admitted to the psychiatry unit. Now you go from having a dearth of information to having more records than you can count.
You discover that Mr. D has a history of coming to the ED during precarious hours, with similar complaints, demanding admission.
Mr. D, you learn, is unemployed, single, and homeless. Your meticulous search through his hospital records and previous admission and discharge notes reveal that once he has slept for a night, eaten a hot meal, and received narcotics for his back pain and benzodiazepines for his “symptoms” he demands to leave the hospital. His psychotic symptoms disappear despite his consistent refusal to take antipsychotics throughout his stay.
Now, what would you do?
As earnest medical students and psychiatrists, we enjoy helping patients on their path toward recovery. We want to advocate for our patients and give them the benefit of the doubt. We’re taught in medical school to be non-judgmental and invite patients to share their narrative. But through experience, we start to become aware of malingering.
Suspecting malingering, diagnosed as a condition, often is avoided by psychiatrists.1 This makes sense—it goes against the essence of our training and imposes a pejorative label on someone who has reached out for help.
Often persons with mental illness will suffer for years until they to receive help.2 That’s exactly why, when patients like Mr. D come to the ED and report hearing voices, we’re not likely to shout, “Liar!” and invite them to leave.
However, malingering is a real problem, especially because the number of psychiatric hospital beds have dwindled to record lows, thereby overcrowding EDs. Resources are skimpy, and clinicians want to help those who need it the most and not waste resources on someone who is “faking it” for secondary gain.
To navigate this diagnostic challenge, psychiatrists need the skills to detect malingering and the confidence to deal with it appropriately. This article aims to:
- define psychosis and malingering
- review the prevalence and historical considerations of malingering
- offer practical strategies to deal with malingering.