Diagnosing someone as a “malingerer” is about as close to dropping a verbal “bomb” as you can get in the realm of medical diagnosis. Basically, you are calling the patient a liar — there is no kinder way of putting it.
The dangers, of course, are many: you may be missing the real diagnosis; delaying essential treatment; and blackening the name and reputation of an innocent individual. This dreaded issue of malingering comes up not only in psychiatry, but in neurology, pain medicine, forensic settings, and sometimes, in family practice.
As the psychopharmacology consultant to a large, state hospital, I had seen scores of patients with psychotic illnesses — mainly schizophrenia and bipolar disorder, but sometimes, more exotic conditions. The patient sitting before me had some of the hallmarks of schizophrenia, but something didn’t seem quite right.
For one thing, he wasn’t responding to the usual treatments — antipsychotic medication — and he had some features that would rarely be seen in schizophrenia: urinary incontinence, weight loss, and impaired memory. The family history was also negative for schizophrenia or similar conditions. I wondered if some organic problem might have been missed, while also considering the possibility of a psychotic mood disorder.
According to his brother, the patient had been deteriorating over the past month, expressing the belief that “God is punishing me,” keeping to himself, and hardly eating. He denied “hearing voices,” but mumbled to himself and seemed to be, as psychiatrists say, “responding to internal stimuli.”
He had a history of cocaine and alcohol abuse, as well as a string of sexual encounters with multiple partners, without adequate protection from sexually-transmitted disease. This is not the kind of history that endears patients to nurses and doctors, and sometimes raises questions about the patient’s motivation: could it be that the patient was “faking psychosis” in order to get hold of drugs?
He did have a history of abusing Valium, but this is rarely the kind of medication given regularly to psychotic patients — and standard antipsychotic medications, with their considerable side effect burden, are not highly prized by drug addicts. And getting hold of a few days worth of Valium hardly seemed worth an admission to a state psychiatric facility. Nonetheless, some of the medical and nursing staff were suspicious — could the patient be malingering?
With a few minor exceptions, the patient’s physical and neurological exams were normal, as were routine lab studies. Notably, a blood test for HIV — the virus that causes AIDS — was negative (normal), as was a commonly-used screening test for syphilis. A CT scan of the brain, and an EEG — a test of the brain’s electrical activity — were both normal. Alas, for some staff, these normal findings served only to intensify the suspicion that the patient was faking his illness.
The patient’s hospitalization did not go well. Despite trials on several antipsychotic and antidepressant medications, the patient continued to keep to himself, remained incontinent, and seemed confused. Eventually, a lumbar puncture (or “spinal tap”) was performed, at the behest of the patient’s primary psychiatrist. This test is rarely done on psychiatric units these days, except when meningitis is suspected — and this was never high on our list of suspects. But to my surprise and chagrin, the “LP” revealed the likely cause of the patient’s psychiatric problems: neurosyphilis, known in the annals of medicine as “the great imitator.”
Indeed, one of the conditions this disease can imitate is schizophrenia. A simple course of penicillin over the next six weeks led to a marked improvement in the patient’s mental state and a reduction in his urinary incontinence. I had been fooled by the patient’s unremarkable neurological exam, and by the normal results on the “screening” test for syphilis, called an RPR. This blood test can produce a “false negative” in a large number of cases of neurosyphilis — and my patient was a good example.
In a paper on malingered psychosis, Dr. Michael R. Harris observed that “faking mental illness” in order to avoid some unpleasant task is an ancient human pastime. He points to the example of the ancient Greek hero, Odysseus, who pretended to be insane in order to avoid serving in the Trojan War. Yet leveling a charge of malingering against a patient — or allowing suspicions of malingering to fester among the medical staff — may be extremely injurious to good medical and psychiatric care. In a 1996 report on malingering in the Israeli military, two dozen conscripts were repeatedly diagnosed as malingering, when in fact, they had serious psychiatric disorders.
In psychiatry, as in all of medicine, humility in diagnosis is always in order. So is a high degree of suspicion for undiagnosed medical and neurological disorders, in patients with apparent “psychiatric” symptoms.
Harris, M. R. The Malingering of Psychotic Disorders. Jeff J Psychiatry 2000; 15
Witztum E, Grinshpoon A, Margolin J, Kron S: The erroneous diagnosis of malingering in a military setting. Military Medicine 1996;47:998-100