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Spiegel DR. The Emergency Department and Psychiatric Boarding: A Model for the Future. Clin Neuropharmacol 2024; 47:65-66. [PMID: 38743598 DOI: 10.1097/wnf.0000000000000595] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/16/2024]
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Margolis M, Wong TL, Shmuts R, Taylor JB. Consultation-Liaison Case Conference: A Case of Factitious Disorder Imposed on Self. J Acad Consult Liaison Psychiatry 2023; 64:562-570. [PMID: 37499871 DOI: 10.1016/j.jaclp.2023.07.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Revised: 07/11/2023] [Accepted: 07/17/2023] [Indexed: 07/29/2023]
Abstract
We present the case of a young woman with an extensive medical history that most notably includes over 60 emergency-room visits for unfounded respiratory distress that often prompted intubations. Each presentation displays elements of deceitfulness or inappropriate demands that align with factitious disorder imposed on self. Top experts in the Consultation-Liaison field provide guidance for this commonly encountered clinical case based on their experience and review of available literature. Key teaching topics include a review of risk factors for development of deceptive syndromes, distinguishing factitious disorder from malingering and conversion disorder, and the role of a consulting psychiatrist in such cases. Patients with factitious disorder often show signs of pathologic lying, obstinance, and erratic behavior. Such attributes frequently arouse negative countertransference in providers, causing frustration and dread with continuing care, rendering psychiatric involvement. We address the unique challenges in managing factitious disorder and how to effectively collaborate with an interdisciplinary inpatient team with these cases.
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Affiliation(s)
- Michaela Margolis
- Department of Child and Adolescent Psychiatry, Tufts Medical Center, Boston, MA.
| | - Timothy L Wong
- Department of Psychiatry, Rowan School of Osteopathic Medicine, Mt. Laurel, NJ
| | - Rachel Shmuts
- Department of Psychiatry, Rowan School of Osteopathic Medicine, Mt. Laurel, NJ
| | - John B Taylor
- Department of Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston, MA
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Punko D, Luccarelli J, Bains A, MacLean R, Taylor JB, Kontos N, Smith FA, Beach SR. The Diagnosis of Malingering in General Hospitals in the United States: A Retrospective Analysis of the National Inpatient Sample. Gen Hosp Psychiatry 2023; 85:133-138. [PMID: 38455076 PMCID: PMC10917147 DOI: 10.1016/j.genhosppsych.2023.10.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/09/2024]
Abstract
Objective To characterize the socio-demographics and comorbid medical and psychiatric diagnoses of patients in the general hospital diagnosed with malingering. Method We conducted a retrospective observational cohort study using data from the 2019 National Inpatient Sample, an all-payors database of acute care general hospital discharges in the United States, querying for patients aged 18 and older discharged with a diagnosis of "malingerer [conscious simulation]," ICD-10 code Z76.5. Results 45,645 hospitalizations (95% CI: 43,503 to 47,787) during the study year included a discharge diagnosis of malingering. 56.1% were for male patients, and the median age was 43 years (IQR 33 to 54). Black patients represented 26.8% of the patients with a discharge diagnosis of malingering, compared to 14.9% of all patients sampled. Zip codes in the lowest household income quartile comprised 39.9% of malingering diagnoses. The top categories of primary discharge diagnoses of hospitalizations included medical ("Diabetes mellitus without complications"), psychiatric ("Depressive disorders"), and substance use ("Alcohol-related disorders") disorders. "Sepsis, unspecified organism," was the most common primary diagnosis. Conclusion The striking overrepresentation of Black patients in hospitalizations with diagnosis of malingering raises concern about the roles of implicit and systemic biases in assigning this label. The disproportionate number of patients of low socioeconomic status is further suggestive of bias and disparity. Another potential contribution is that the lower health literacy in these populations results in a limited knowledge of traditional ways to meet one's needs and thus greater reliance on malingered behavior as an alternative means. Accurate description of these patients' socio-demographics and comorbid medical and psychiatric diagnoses with reliable data from large samples can lead to improved understanding of how the malingering label is applied and ultimately better patient care.
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Affiliation(s)
- Diana Punko
- Department of Psychiatry, Massachusetts General Hospital, 55 Fruit St, Boston, MA 02114, United States
- Harvard Medical School, 25 Shattuck St, Boston, MA 02115, United States
| | - James Luccarelli
- Department of Psychiatry, Massachusetts General Hospital, 55 Fruit St, Boston, MA 02114, United States
- Harvard Medical School, 25 Shattuck St, Boston, MA 02115, United States
| | - Ashika Bains
- Department of Psychiatry, Massachusetts General Hospital, 55 Fruit St, Boston, MA 02114, United States
- Harvard Medical School, 25 Shattuck St, Boston, MA 02115, United States
| | - Rachel MacLean
- Department of Psychiatry, Massachusetts General Hospital, 55 Fruit St, Boston, MA 02114, United States
| | - John B. Taylor
- Department of Psychiatry, Massachusetts General Hospital, 55 Fruit St, Boston, MA 02114, United States
- Harvard Medical School, 25 Shattuck St, Boston, MA 02115, United States
| | - Nicholas Kontos
- Department of Psychiatry, Massachusetts General Hospital, 55 Fruit St, Boston, MA 02114, United States
- Harvard Medical School, 25 Shattuck St, Boston, MA 02115, United States
| | - Felicia A. Smith
- Department of Psychiatry, Massachusetts General Hospital, 55 Fruit St, Boston, MA 02114, United States
- Harvard Medical School, 25 Shattuck St, Boston, MA 02115, United States
| | - Scott R. Beach
- Department of Psychiatry, Massachusetts General Hospital, 55 Fruit St, Boston, MA 02114, United States
- Harvard Medical School, 25 Shattuck St, Boston, MA 02115, United States
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Obegi JH. Differentiating genuine from feigned suicidality in corrections: A necessary but perilous task. INTERNATIONAL JOURNAL OF LAW AND PSYCHIATRY 2020; 71:101573. [PMID: 32768118 DOI: 10.1016/j.ijlp.2020.101573] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/29/2020] [Revised: 04/11/2020] [Accepted: 05/05/2020] [Indexed: 06/11/2023]
Abstract
Feigning suicidality is common among patients in correctional settings, but there has been little discussion on the differences between genuine and feigned presentations of suicidality. Differentiating suicidality from feigned suicidality is among the riskiest diagnostic challenges. Still, some headway can be made if we compare features of genuine suicidality with those of feigned presentations. To this end, I first describe a typical profile of suicidality. Next, I contrast it with the features that correctional patients who feign suicidality display in California's prison health care system. I also outline the dangers involved in identifying feigned suicidality, and I offer some ways in which to understand feigned suicidality in corrections.
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Affiliation(s)
- Joseph H Obegi
- California Department of Corrections and Rehabilitation, California Medical Facility, 1600 California Dr., Vacaville, CA 95696, USA.
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Nisavic M, Flores EJ, Heng M, Kontos NJ, Quijije N. Case 26-2019: A 27-Year-Old Woman with Opioid Use Disorder and Suicidal Ideation. N Engl J Med 2019; 381:763-771. [PMID: 31433925 DOI: 10.1056/nejmcpc1904043] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Affiliation(s)
- Mladen Nisavic
- From the Departments of Psychiatry (M.N., N.J.K., N.Q.), Radiology (E.J.F.), and Orthopedics (M.H.), Massachusetts General Hospital, and the Departments of Psychiatry (M.N., N.J.K., N.Q.), Radiology (E.J.F.), and Orthopedics (M.H.), Harvard Medical School - both in Boston
| | - Efren J Flores
- From the Departments of Psychiatry (M.N., N.J.K., N.Q.), Radiology (E.J.F.), and Orthopedics (M.H.), Massachusetts General Hospital, and the Departments of Psychiatry (M.N., N.J.K., N.Q.), Radiology (E.J.F.), and Orthopedics (M.H.), Harvard Medical School - both in Boston
| | - Marilyn Heng
- From the Departments of Psychiatry (M.N., N.J.K., N.Q.), Radiology (E.J.F.), and Orthopedics (M.H.), Massachusetts General Hospital, and the Departments of Psychiatry (M.N., N.J.K., N.Q.), Radiology (E.J.F.), and Orthopedics (M.H.), Harvard Medical School - both in Boston
| | - Nicholas J Kontos
- From the Departments of Psychiatry (M.N., N.J.K., N.Q.), Radiology (E.J.F.), and Orthopedics (M.H.), Massachusetts General Hospital, and the Departments of Psychiatry (M.N., N.J.K., N.Q.), Radiology (E.J.F.), and Orthopedics (M.H.), Harvard Medical School - both in Boston
| | - Nadia Quijije
- From the Departments of Psychiatry (M.N., N.J.K., N.Q.), Radiology (E.J.F.), and Orthopedics (M.H.), Massachusetts General Hospital, and the Departments of Psychiatry (M.N., N.J.K., N.Q.), Radiology (E.J.F.), and Orthopedics (M.H.), Harvard Medical School - both in Boston
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Patel A, Daniels G. Hypoglycemia secondary to factitious hyperinsulinism in a foster care adolescent - a case report of munchausen syndrome in a community hospital emergency department setting. BMC Emerg Med 2018; 18:53. [PMID: 30537938 PMCID: PMC6288932 DOI: 10.1186/s12873-018-0208-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2018] [Accepted: 11/26/2018] [Indexed: 11/16/2022] Open
Abstract
Background Factitious disorder causing hypoglycemia is a psychiatric condition in which patients deliberately use blood sugar lowering medications to cause severe symptoms for the purposes of hospitalization or other primary gains. Case presentation We report a case of factitious hypoglycemia in a 19-year-old foster care adolescent female who presented to the Emergency Department with recurrent hypoglycemic episodes, to the degree that the patient required large amounts of dextrose and further management by intensive care unit hospitalization. Further inquiry revealed that the patient intentionally injected herself with large doses of insulin for the purposes of seeking hospital admission. Conclusion Factitious disorder in the setting of recurrent hypoglycemia episodes may warrant a psychiatric referral and appropriate discharge follow-up to avoid multiple hospitalizations. Presentation in a non-diabetic patient from insulin use is a type of illness that is a challenge for emergency department physicians to appropriately diagnose and treat. Classic findings include a low blood sugar level, suppressed C-peptide level, and an inappropriately elevated insulin level. Recognizing these psychiatric presentations is crucial in order to stabilize patients and prevent unnecessary testing.
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Affiliation(s)
- Ashruta Patel
- Philadelphia College of Osteopathic Medicine, Georgia Campus, 625 Old Peachtree Rd NW, Suwanee, GA, 30024, USA.
| | - Gary Daniels
- Northeast Georgia Medical Center Barrow, 316 N Broad St, Winder, GA, 30680, USA
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Kontos N, Taylor JB, Beach SR. The therapeutic discharge II: An approach to documentation in the setting of feigned suicidal ideation. Gen Hosp Psychiatry 2018; 51:30-35. [PMID: 29309988 DOI: 10.1016/j.genhosppsych.2017.12.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2017] [Revised: 12/13/2017] [Accepted: 12/21/2017] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The therapeutic discharge of patients assessed as misrepresenting suicidal ideation, though in the best interests of the patient, physician, and health care system, is an inherently risk-assuming action. The rationale and conduct of the therapeutic discharge has been written on previously. Here, we propose a method of documenting the therapeutic discharge in a way that is useful and teachable. METHOD After describing some other types of note-writing that can be needed in the care of deceptive patients, we describe an approach to each of the major sections of an initial consultation/encounter note as it applies to the therapeutic discharge. RESULTS Each note section is handled slightly differently than ordinarily. The history of present illness follows the sequence, rather than the re-organization of the information obtained. The past medical history requires and reflects a more granular chart review than is usually warranted. The mental status exam is less cross-sectional than usual. The assessment and plan incorporates several components that reflect a reasoning process specific to the therapeutic discharge. CONCLUSION While labor-intensive, the documentation approach advocated for and exemplified here reaffirms aspects of one's identity as a physician, ensures responsible execution of a risk-involving decision, and potentially simplifies subsequent patient encounters.
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Affiliation(s)
- Nicholas Kontos
- Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States..
| | - John B Taylor
- Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - Scott R Beach
- Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
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Teaching Psychiatric Trainees to “Think Dirty”: Uncovering Hidden Motivations and Deception. PSYCHOSOMATICS 2017; 58:474-482. [DOI: 10.1016/j.psym.2017.04.005] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/22/2017] [Revised: 04/11/2017] [Accepted: 04/14/2017] [Indexed: 11/20/2022]
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