A Case of Psychosis-Induced Malingering

A Case of Psychosis-Induced Malingering

To the Editor: Malingering is characterized by the intentional production of false or exaggerated symptoms to achieve external incentives.1 Prevalence estimates range from 7.5% to 33.0%, depending on the population,2 and 13.0% in emergency room settings.3 However, we have found no reports of situations in which a psychotic delusion was driving the desire to malinger for hospitalization. We report the case of a patient with schizophrenia who was paranoid to the extent that he felt it was safer to feign certain symptoms in the emergency department to gain admission so that he could escape his persecutors, who existed solely in his mind.

Case report. A 43-year-old man presented to a large city emergency department with a superficial cut to his left forearm, requesting hospitalization for "hearing voices and depression." Records indicated he carried multiple psychiatric diagnoses, including bipolar disorder, schizophrenia, schizoaffective disorder, polysubstance dependence, and malingering. He had many well-controlled medical comorbidities.

The patient was first seen by a resident and gave varying and conflicting details. He answered the same questions differently, giving different times for when he cut himself and the year in which his sister died. When these inconsistencies were pointed out to him, he said, "I don’ t know then, I can’ t remember." When questioned about the voices, the patient said, "They almost told me to go to the bridge," and could not explain what he meant by "almost." At this point, the patient appeared guarded and distressed, although he did not appear internally preoccupied. His thought process appeared illogical but not disorganized. The patient repeatedly requested hospitalization.

He was then reassessed by both the resident and the attending physician together and asked directly why he wanted to be hospitalized. The patient then burst into tears and said he was not safe at home. He reported that because he was once dropped off in a town car, others in the building think he is a "snitch" working for the police and want to harm him. He looked suspiciously around the interview room, saying, "They can hear me in here as well." After divulging this information, the patient became ambivalent about being admitted to the hospital, saying, "They will call or try to visit here now." Calls were made to his family and residence, and no one could confirm the patient’s account. He ultimately agreed to a voluntary hospitalization—he stayed for 12 days and was resumed on his antipsychotic medications. His paranoia gradually improved, and he socialized more with others. He had no concerns about being discharged back to his home.

We have described a case of a man who was intentionally feigning his symptoms to gain admission to a hospital in order to avoid his persecutory delusions. Paranoia that his persecutors could hear him initially prevented the patient from being honest. This is the first time, to our knowledge, of a patient malingering to escape a feared consequence of psychotic thinking.

This patient presented with many signs that have been associated with malingering, such as evasiveness, inconsistency, hospitalization requests, and fatigue over a lengthy interview.4-6 It is easy to dismiss a patient with this presentation as malingering and quickly discharge. Indeed, data from Yates et al3 showed that 87% of patients in a emergency department who were felt to have a "strong to definite" level of malingering suspicion were discharged. However, it is essential to determine not just what the secondary gain is, but rather why it is important to the patient. When a diagnosis of malingering is suspected, determining the patient’s rationale and motivation is an essential part of the psychiatric history.

References

1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. Fifth Edition. Arlington, VA: American Psychiatric Association; 2013.

2. Ninivaggi FJ. Additional conditions that may be a focus of clinical attention. In: Sadock BJ, Sadock VA, Ruiz P, eds. Kaplan & Sadock’s Comprehensive Textbook of Psychiatry. 9th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2009:2480.

3. Yates BD, Nordquist CR, Schultz-Ross RA. Feigned psychiatric symptoms in the emergency room. Psychiatr Serv. 1996;47(9):998-1000. PubMed doi:10.1176/ps.47.9.998

4. Malone RD, Lange CL. A clinical approach to the malingering patient. J Am Acad Psychoanal Dyn Psychiatry. 2007;35(1):13-21. PubMed doi:10.1521/jaap.2007.35.1.13

5. Cornell DG, Hawk GL. Clinical presentation of malingerers diagnosed by experienced forensic psychologists. Law Hum Behav. 1989;13(4):375-383. doi:10.1007/BF01056409

6. Rogers R. Clinical Assessment of Malingering and Deception. 2nd ed. New York, NY: The Guilford Press; 1997:59.

Robert J. Jaffe, MDa

robert.jaffe@mountsinai.org

Amy L. Johnson, MDb

aDepartment of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, New York

bDepartment of Psychiatry, Weill Medical College of Cornell University, New York, New York

Potential conflicts of interest: None.

Funding/support: None.

Published online: October 27, 2016.

Prim Care Companion CNS Disord 2016;18(5):doi:10.4088/PCC.16l01934

© Copyright 2016 Physicians Postgraduate Press, Inc.