Detecting deception: How to handle a malingering patient
■ Some medical experts say the number of patients who exaggerate illnesses seems to be rising. Doctors can help identify such behavior.
Ronald Schouten, MD, knew immediately that something was strange about the patient who lurched oddly into his exam room and collapsed into a chair. The man, who complained of a head injury, appeared to understand Dr. Schouten's words, but the patient's voice was garbled and his mannerisms were overdramatic.
“His speech deficit didn't make any sense,” said Dr. Schouten, an associate professor of psychiatry at Harvard Medical School and director of the Law & Psychiatry Service at Massachusetts General Hospital. “His hands were shaking violently, and he asked for water. Miraculously, he didn't spill a drop.”
Dr. Schouten learned that the patient, who claimed to have fallen during work, was the subject of a theft investigation. The doctor soon decided the man was a malingerer.
Patients who malinger, or exaggerate illness, can be a problem for health professionals. Malingering is recognized as the intentional production of false or grossly exaggerated symptoms motivated by external gain.
A 2002 study in the Journal of Clinical and Experimental Neuropsychology examined about 10,000 neuropsychological assessments that involved patients who applied for or received compensation benefits or who were involved in injury litigation. Researchers found that 29% of personal injury and 30% of disability claim cases involved probable malingering and symptom exaggeration. Probable malingering was present in 8% of medical cases not related to litigation or compensation claims.
Of the 10,000 cases, 39% of mild head injury cases and 31% of chronic pain complaints resulted in probable malingering impressions.
In his 2007 book, Assessment of Malingered Neuropsychological Deficits, neuropsychologist Glenn J. Larrabee, PhD, said half of people involved in medical-legal claims exaggerate illnesses.
The problem is not limited to workers' compensation and disability cases. Patients pretend to be sick or disabled to avoid work, stay out of legal trouble, obtain medication or receive special accommodations such as extra time on a collegiate exam.
Headlines in the past year illustrate how some patients fake illness for financial gain. For example, 10 New York railroad retirees were arrested in May for disability pension fraud. In 2012, women in Virginia, Arizona and California falsely claimed to have cancer and raised thousands of dollars in donations.
The bad economy is leading more people to pretend to be sick for money, said Donald Schroeder, MD, an Oregon-based orthopedic surgeon and past president of the Oregon Medical Assn. Consider that 55% of 500 fraud examiners said occupational fraud had risen, according to a 2009 survey by the Assn. of Certified Fraud Examiners. Intense financial pressure was listed as the largest contributing factor to the increase.
People “are losing their jobs and are desperate to find a way to support themselves,” said Dr. Schroeder, who conducts exams in personal injury and workers' compensation cases. “They'll file compensation claims, or they'll go to court in personal [injury cases]. The problem is greater than ever.”
Difficulties in spotting malingerers
Physicians face myriad challenges in identifying malingering patients. One is time constraints of medical visits, said David Fleming, MD, chair of the American College of Physicians' Ethics, Professionalism, and Human Rights Committee.
“We're seeing so many patients [who] have chronic conditions, it's difficult to pick up on the fact there may not be an objective reason to treat a particular patient,” he said. “We don't really have the time to investigate. Oftentimes, it's easier” just to treat them.
Lack of a long-term patient-physician relationship adds to the problem. If patients see many different physicians, that limits doctors getting to know and build trust with them, Dr. Fleming said.
Mental conditions that mirror the appearance of malingering can make spotting a fake troublesome, said Christopher Stewart-Patterson, MD, a fellow with the American College of Occupational and Environmental Medicine. Dr. Stewart-Patterson, who practices occupational medicine in Canada, co-wrote an article on malingering in the January/February issue of AMA Guides Newsletter, which is published by the American Medical Association.
Munchausen syndrome, for example, is a disorder in which patients falsify or cause their own symptoms. The condition comes from a desire to be seen as injured or to receive sympathy.
“It's imperative that mental health issues be ruled out as an explanation of the presentation before malingering is seriously considered,” Dr. Stewart-Patterson said.
Faking symptoms of common medical and psychiatric conditions is not difficult, according to Dr. Stewart-Patterson's article in AMA Guides Newsletter. Ninety-seven percent of untrained people can correctly choose symptoms associated with major depressive disorder on subjective checklists, the article said. Sixty-three percent can identify at least five symptoms associated with a brain injury.
Patients easily can go online to learn the symptoms of nearly every disease, said Dr. Schouten. His book, Almost a Psychopath: Do I (or Does Someone I Know) Have a Problem with Manipulation and Lack of Empathy? details how doctors can detect manipulative behavior in patients.
“With the Internet and the availability of all sorts of medical information, you could come up with a list of symptoms,” Dr. Schouten said. “Then, when the physician says, 'Do you have this,' [a patient] has every symptom under the sun.”
A key barrier to pinpointing malingering is a doctor's desire to be supportive of patients, say medical experts.
Family doctors “trust their patients and rely on the histories they take to make a diagnosis,” Dr. Stewart-Patterson said. “[They] often see themselves as an advocate. If a patient is saying, 'I can't do this job,' the tendency is to side with the patient.”
Signs a patient could be faking
But by ignoring potential malingering, doctors are contributing to the problem, said Dominic Carone, PhD, a neuropsychologist who conducts brain injury exams at the State University of New York Upstate Medical University in Syracuse. His book, Mild Traumatic Brain Injury: Symptom Validity Assessment and Malingering, discusses detection of malingering.
Countless dollars in tests, medications and treatments are wasted on dishonest patients, he said.
“Physicians don't want to do harm, but if you don't call malingering out or change the treatment plan, you're harming other patients,” he said. “The system is being clogged up by people who don't need to be going to therapies or diagnostic imaging that” doesn't need to be done.
Keen observation is the first step to confirming suspicions of malingering.
For instance, Carone has seen patients walk in his building who appear to be in normal physical condition but act differently when they notice him watching.
He said doctors should ask themselves: How do patients act when they think no one is looking? Does the patient exam fit with the complaint? How does the medical history match up?
Another red flag is a patient who claims to have every possible symptom of a certain condition, even rare indications, Dr. Schouten said. Physicians should note whether a person's demeanor corresponds with the medical problem, he said. For example, check to see if a person complaining of serious depression laughs and jokes with the doctor and other staff members.
“It's very difficult to maintain a feigning of symptoms over a long period,” Dr. Schouten said. “They're going to slip up.”
Documentation is key. Keeping detailed charts about a patient's presentation and testing results leaves a necessary paper trail and helps other specialists who later examine the patient, medical experts said. Physicians should focus on the facts of a medical visit.
“When doctors interact with the legal system, they are constantly exposed to the legal system's misdirected emphasis on opinions,” said the article in the AMA Guides Newsletter. “The issues of malingering and validity can be addressed purely based on fact, without any interference from opinions.”
Carone suggests telling patients up front that exams may not yield the results they expect.
“The patient needs to know you're going to do an objective assessment, and you might be providing them some information that they don't agree with at the end of the day,” he said. “Setting expectations early is really important, and that helps you pick up on when there's an agenda present.”
Doctors should be cautious when confronting patients suspected of malingering, said C. Donald Williams, MD, a Washington state-based psychiatrist who has written several academic papers on the subject.
When doctors have “a question, they should not make an accusation, but rather act neutrally and professionally,” he said. “We're not prosecuting attorneys. We're professionals.”
Physicians have ethical obligations to report patients in some circumstances, said Dr. Fleming, of the ACP. If patients are using medication for criminal purposes or if fraud is suspected, doctors must tell authorities, he said.
In some cases, physicians must simply say no to patients, Dr. Schroeder said.
“We are taught to do the best for our patients and support them, but there are times when we can't help people,” he said. Sometimes, “I'm the bad guy that has to drop that bomb, who says, 'No further treatment will be beneficial.' Sometimes, the patient needs to hear that.”