Liz Davis, M.A., LPC

Are You Kidding Me?

Posted on 05. Nov, 2009 by Liz in Return to Work, Treatment

Is your PHP patient malingering?

Treatment received in a Partial Hospital setting is centered on a patient’s self-report. Do some patients exaggerate, pretend, or enhance their narratives? Yes.

Patients either step-down or step-up/walk-in to Partial Hospital. Our initial assessment will be based upon self-report in the initial interview and clinical observation. All goes well until we note any of the following:

• inconsistent reported or observed presenting symptoms,
• disappearance of symptoms after admission,
• the appearance of symptoms of other patients in the waiting room (possible contagion),
• pseudologia fantastica – lies, or
• the discovery that someone of importance to the patient engenders the patient’s symptoms.

In order to provide the best quality of care clinicians need to determine what they are really dealing with, regardless of patient understanding or the patient’s attempt to manage the clinician’s understanding. Are the self-reported symptoms ‘real’?  Are the symptoms the patient’s maladaptive attempt to get emotional needs met? Or more problematic,  are the symptoms the patient’s attempt to get financial or legal needs met?

All patients have emotional needs but some patients lack an awareness of, or understanding of their emotional life. Some patients are not able to communicate their emotional needs in an appropriate, adaptive manner in their personal lives and thus seek human warmth and contact in a therapeutic environment. Often, this is when emotional needs transform into medical, often physical complaints.  Are we to consider patients with ’exaggerate’ or ‘feigned’ symptoms as ‘legitimate’ patients?  We also need to further distinguish those with or without ulterior motives.

The DSM-IV identifies the feigning of symptoms without financial or legal motives as features of Factitious Disorder (FD). The DSM-IV identifies the feigning of symptoms with financial or legal motives (called secondary gain) as features of Malingering.

Most research shows that clinical interview alone, without specialized psychological testing, is not an effective method for identifying the exaggeration or faking of psychological symptoms or mental disorders. In addition to the initial interview, a suggested protocol follows:

1. administer the reading subtest from the Wide Range Achievement Test to determine that patient’s reading skills are strong enough to be able to respond to other psychological tests,
2. administer the Miller Forensic Assessment of Symptoms Test (M-FAST) to confirm findings from the clinical interview, and
3. administer the Minnesota Multiphasic Personality Inventory (MMPI-2) to determine if the patient is exaggerating or malingering.

PHP clinicians can assess what needs treatment and focus treatment goals on those needs. Symptoms presented can be confirmed. Symptoms exaggerated or feigned can be identified. We can treat the malingering patient by stressing the health benefits of emotional integrity (the congruence between narratives and inner emotional states) and building a safe environment where the skills required for authentic relating can be role-played and strengthened.

Each suspicious feature that arises during PHP treatment, like:

• the patient’s relentless need to be seen by the psychiatrist daily,
• inconsistent response to treatment,
• observed symptoms are out of proportion with clinical observation,
• worsening of symptoms prior to discharge,
• the seeking of analgesics and/or sedatives, or
• predictable relapses

can be used as opportunities to teach distress tolerance, self-soothing, or more adaptive cognitive processes.

Whether real or feigned, the presenting PHP patient can benefit from treatment. It’s the direction of treatment that we want to ascertain.