Lockup Doc

Malingering, which means to feign or exaggerate symptoms for secondary gain, occurs in all medical settings but is especially prevalent in jails and prisons. While it essential for all health care professionals working in corrections to become proficient in detecting malingering, even those working in non-correctional environments will be better clinicians if they learn this skill.

In the December 2009 issue of Current Psychiatry, Lawrence Reccoppa, MD, a correctional psychiatrist from Florida, wrote a brief article entitled, “Mentally ill or malingering? 3 clues cast doubt.”

The “3 D’s,” as he calls them:

1. Demanding Medications

2. Divulging symptoms too eagerly or dramatically

3. Dependent or conditional threats of self-harm, violence, or litigation

As he points out, inmates with real mental illness rarely demand medications. Getting them to adhere to prescribed medication regimens is more typically the problem. Those who insist that only certain sedating or habit-forming medications will work may be malingering.

Mentally ill inmates are not typically eager to point out that they have serious symptoms. Those who are malingering, on the other hand, typically want to make crystal-clear to the clinician that they are having serious symptoms. Personally I have seen inmates who, on the first visit, immediately began telling me about the “little green men” that they were seeing running around in their cells – a red flag for sure!

Patients who have a serious Axis I condition (a non-personality disorder psychiatric diagnosis) do not normally say that they will kill themselves or sue the doctor if they don’t get a particular medication. Those with personality disorders sometimes choose this approach.

The above “3 D’s” is an easy-to-remember clinical pearl. These are some simple “red flags” that indicate possible malingering. A careful history and mental status examination are crucial regardless of whether one suspects malingering.

When clinicians suspect malingering, I believe it is important to remain emotionally neutral and to continue taking a careful history. Although it is tempting to become angry and feel that a patient is wasting the clinician’s time, doing so will not help the situation or stop a patient from malingering.

Patients who believe that examiners are not buying their stories are likely to become more guarded, and eliciting further detailed information from them may be difficult. On the other hand, if malingering patients feel that they are being taken seriously, then evaluating clinicians can proceed systematically through a thorough evaluation. The end result benefits both the patient and clinician (even though the patient may not end up receiving what he wanted).

As I have become more experienced at working with malingerers over the years, I have felt more confident managing risk. Those who do not work with malingerers regularly may very accurately have a sense of when a patient is malingering yet be reluctant not to prescribe a treatment that a patient is requesting simply out of fear of potential litigation. The more one knows about this topic, the better one is able to clearly articulate in the patient record the reasons why the clinical presentation is not consistent with real illness. Ultimately one can then avoid causing the patient harm by avoiding unnecessary tests, procedures and treatments. In a prison environment, a clinician also avoids getting a reputation as easy prey for legal drug dealing.

Another important point that I want to emphasize about malingering is that it is not necessarily an “all-or-none” condition. In other words, a clinician must realize that even those who malinger, while not necessarily mentally ill, are often psychologically distressed. Likewise, patients with well-documented mental illness such as schizophrenia have been known to try to evade criminal responsibility by malingering psychosis.

Even if one is an expert at detecting malingering, it will still be necessary in some unclear instances to give patients the benefit of the doubt by erring on the side of treating symptoms that may be malingered. Fortunately most patients, even in corrections, are not malingerers.