Teaching Psychiatric Trainees to “Think Dirty”: Uncovering Hidden Motivations and Deception

The Diagnosis of Malingering in General Hospitals in the United States: A Retrospective Analysis of the National Inpatient Sample

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.

World Psychiatric Association-Asian Journal of Psychiatry Commission on Psychiatric Education in the 21st century

Psychiatric practice faces many challenges in the first quarter of 21st century. Society has transformed, as have training requirements and patient expectations, underlining an urgent need to look at educational programmes. Meanwhile, awareness has grown around psychiatric disorders and there are evolving workforce trends, with more women going to medical school and specialising in psychiatry. Trainee psychiatrists carry different expectations for work-life balance and are increasingly becoming conscious of their own mental health. A tendency to see health as a commodity and the litigious nature of society has elicited additional pressures for healthcare professionals. Cartesian mind-body dualism has created further complexity and this can often be frustrating for patients and care-partners alike. In many cultures across Asia and beyond, patients can present with physical symptoms to express underlying psychological distress with increasing physical investigations. Simultaneously, in various countries, a shift from asylums to community-based interventions and then home treatments have changed psychiatric care in remarkable ways. These changes have added to pressures faced by mental healthcare professionals. However, trainees and other mental healthcare professionals continue to receive similar training as they did a generation ago. The tensions and differences in ideology/orientation between different branches of psychiatry have made responses to patient needs challenging. Recognising that it is difficult to predict the future, this World Psychiatric Association-Asian Journal of Psychiatry Commission makes recommendations that could help institutions and individuals enhance psychiatric education. This Commission draws from existing resources and recent developments to propose a training framework for future psychiatrists.

Instructional Design Strategies for Teaching the Mental Status Examination and Psychiatric Interview: a Scoping Review

OBJECTIVE

The psychiatric mental status examination is a fundamental aspect of the psychiatric clinical interview. However, despite its importance, little emphasis has been given to evidence-based instructional design. Therefore, this review summarizes the literature from an instructional design perspective with the aim of uncovering design strategies that have been used for teaching the psychiatric interview and mental status examination to health professionals.

METHODS

The authors conducted a scoping review. Multiple databases, reference lists, and the gray literature were searched for relevant publications across educational levels and professions. A cognitive task analysis and an instructional design framework was used to summarize and chart the findings.

RESULTS

A total of 61 articles from 17 countries in six disciplines and three educational levels were identified for data extraction and analysis. Most studies were from the USA, presented as educational case reports, and carried out in undergraduate education in the field of psychiatry. Few articles described the instructional rationale for their curriculum. None of the studies compared the effectiveness of different instructional design components. Reported learning activities for each task domain (knowledge, skills, and attitudes) and for each step of an instructional design process were charted. Most articles reported the use of introductory seminars or lectures in combination with digital learning material (videos and virtual patients in more recent publications) and role-play exercises.

CONCLUSIONS

Educators in psychiatry should consider all task domains of the psychiatric interview and mental status examination. Currently, there is a lack of empirical research on expertise acquisition and use of instructional design frameworks in this context.

Suicide and Self-Harm Outcomes Among Psychiatric Emergency Service Patients Diagnosed As Malingering

BACKGROUND

Malingering is a common and challenging clinical presentation in emergency departments (EDs).

OBJECTIVE

This study describes characteristics and outcomes among patients diagnosed as malingering in a psychiatric emergency service.

METHODS

Index psychiatric ED encounters were identified for all adult patients seen during a 27-month period. Mortality data were obtained for patients from the state public health authority, and repeat ED visits for self-harm were obtained from the state hospital association. Patients with a diagnosis of malingering were compared with those without a malingering diagnosis using correlative statistics and multivariable analyses.

RESULTS

Of 4710 encounters analyzed, 236 (5%) had a malingering diagnosis. No patients diagnosed as malingering died of suicide within 365 days of discharge, compared with 16 (0.4%) nonmalingering patients. Self-harm outcomes were available for 2689 encounters; 129 (5%) had a malingering diagnosis. Malingering was significantly associated with a repeat ED visit for self-harm within 365 days in multivariable analyses (adjusted odds ratio 2.52; 95% confidence interval 1.35-4.70); p < 0.01).

CONCLUSIONS

No psychiatric emergency service patients diagnosed as malingering died by suicide after discharge. New clinical approaches must balance malingering patients' apparent low suicide risk with their other substantial comorbidities and risk for self-harm.

From Burnout to Wholehearted Engagement: A Qualitative Exploration of Psychiatry Residents' Experience of Stress

PURPOSE

Physician burnout is endemic across medical education and has numerous deleterious effects. Given the prevalence and negative effects of burnout, there is an urgent need to understand how residents experience and cope with stress and develop explanatory models that inform the development of more effective interventions.

METHOD

Using a qualitative, constructivist approach informed by grounded theory, the authors conducted semistructured interviews from March to April 2019, in which psychiatry residents were asked about their experiences of stress and how they coped. First- through fourth-year trainees at Zucker Hillside Hospital at Northwell Health, Glen Oaks, New York, were invited. Two authors independently and inductively coded deidentified transcripts. A constant comparative approach was used to analyze data and support construction of themes. Theoretic sufficiency was observed after 14 interviews.

RESULTS

The authors constructed an explanatory model for how residents cope with stress and whether they tended toward burnout or wholehearted engagement. The model included 3 themes: self-care, work relationships, and meaning making. Self-care, including time spent with others, provided connection and belonging that bolstered physicians' developing identities. Interpersonal relationships at work profoundly influenced the experience of residents. Positive peer and supervisor relationships enhanced confidence and perseverance. Negative role models and conflict engendered feelings of inadequacy. The ability to shift perspective and build meaning through examining moral values in the face of challenges was crucial for residents who reported success at coping with stress. Residents identified personal psychotherapy as an especially important strategy to facilitate meaning making.

CONCLUSIONS

These findings provide guidance for how residency programs may help residents cope with stress and move away from burnout toward wholehearted engagement. Strategies may include reducing barriers to self-care and to accessing help early in training, creating spaces that promote peer connection and providing training in addressing conflict, and facilitating engagement in meaning-making activities.

How Plausible Is the Implausible? Students’ Plausibility and Prevalence Ratings of the Self-Report Symptom Inventory

Some self-report symptom validity tests, such as the Self-Report Symptom Inventory (SRSI), rely on a detection strategy that uses bizarre, extreme, or very rare symptoms. Thus, items are constructed to invite respondents with an invalid response style to affirm pseudosymptoms that are usually not experienced by genuine patients. However, these pseudosymptoms should not be easily recognizable, because otherwise sophisticated over-reporters could strategically avoid them and go undetected. Therefore, we tested how well future psychology professionals were able to differentiate between genuine complaints and pseudosymptoms in terms of their plausibility and prevalence.

Psychology students (N = 87) received the items of the SRSI online and were given the task to rate each item as to its plausibility and prevalence in the community.

Students evaluated genuine symptoms as significantly more plausible and more prevalent than pseudosymptoms. However, 56% of students rated pseudosymptoms as moderately plausible, whereas 17% rated them as moderately prevalent in the general public.

Overall, it appears that psychology students are successful in distinguishing bizarre, unusual, or rare symptoms from genuine complaints. Yet, the majority of students still attributed relatively high prima facie plausibility to pseudosymptoms. We contend that if such a trusting attitude is true for psychology students, it may also be the case for young psychology practitioners, which, consequently, may diminish the probability of employing self-report validity measures in psychological assessments.

Optimizing Fit: Targeting a Residency Psychiatry Consultation-Liaison Rotation to Various Levels of Training

BACKGROUND

Determining the optimal timing and structure for a core residency rotation in consultation-liaison psychiatry (CLP) remains a key challenge for program directors and rotation leaders. Previous surveys have been conducted regarding these questions, and guidelines from national organizations have been issued, but practices remain varied among institutions.

METHODS

We conducted a narrative review of the literature related to the timing of CLP rotations and generated consensus recommendations based on our experience as program directors, rotation leaders, and residents.

RESULTS

Explicit goals of CLP training in residency include identifying and treating psychiatric manifestation of medical illness and communicating effectively with primary teams. Implicit goals of training may includeconflict management, limit setting, and "thinking dirty."

DISCUSSION

Although CLP rotations earlier in residency often create a better fit within the overarching curriculum and allow for generating early interest in the field, significant amounts of supervision are required, and consultees may look to attendings as the primary consultant. Conversely, while later rotations are sometimes challenging to structure with other outpatient responsibilities, they allow for greater autonomy and may map better onto the informal curriculum. A hybrid model, with training spread across multiple years, is another approach that may mitigate some of the disadvantages of confining consultation-liaison training to a single year. Compelling arguments can be made for placing the core CLP rotation in postgraduate year 2 or 3 or using a hybrid model. Regardless of placement, program directors and rotation leaders should be mindful of tailoring the rotation to the trainees' developmental stage.

Differentiating genuine from feigned suicidality in corrections: A necessary but perilous task

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.

Ethics of Incongruity: moral tension generators in clinical medicine

Affectively uncomfortable concern, anxiety, indecisionand disputation over 'right' action are among the expressions of moral tension associated with ethical dilemmas. Moral tension is generated and experienced by people. While ethical principles, rules and situations must be worked through in any dilemma, each occurs against a backdrop of people who enact them and stand much to gain or lose depending on how they are applied and resolved. This paper attempts to develop a taxonomy of moral tension based on its intrapersonal and interpersonal sources and expressions. The proposed 'ethics of incongruity' (EoI) outlines ways in which values, actions and needs can find themselves mismatched in morally relevant ways between patients and their clinicians, their own psychologies and their societies. Patient-clinician incongruities may manifest as discord, value misalignment and deception. Patient-patient (ie, intrapersonal) incongruities may manifest as incapacity, akrasia and self-deception. Patient-society incongruities may manifest as disenfranchisement, disaffiliation and disregard. Brief explanations of the incongruities in this scheme are provided, as are suggestions on working within them. Using concepts from moral philosophy when applicable, these suggestions may either ease direct resolution of problems arising from the incongruities, or make sense of the moral tension that arises from the human context of the ethical dilemma at hand. This presentation of content and resolution methods for the EOI is no doubt incomplete. Hopefully, refinement of this preliminary proposal will follow, particularly from clinicians, as the ones who, along with their patients, experience medical ethics in directly tension-inducing ways.

"Call Me, Maybe": Supervisor and Resident Comfort With Indirect Supervision in Psychiatry Training

BACKGROUND

Resident supervision is critical for education and ensuring patient safety. After hours, communication with attendings is variable.

OBJECTIVE

The objective was to identify differences among psychiatry residents and attendings regarding the desired level of supervision for issues that arise overnight in the psychiatric emergency department (ED).

METHODS

In a single-site psychiatric ED, an electronic survey containing 30 hypothetical scenarios was administered. For each scenario, residents were asked if they would call attendings and attendings whether they would want to be called.

RESULTS

35/44 psychiatry residents and 15/17 faculty participated, yielding a response rate of 82%. For five scenarios, faculty preferred that residents call for supervision more frequently than residents indicated they would. These included staff or house staff injuries (60% vs. 22.9%, p = 0.011; 93.3% vs. 62.9%, p = 0.039), a patient using heroin in the ED (53.3% vs. 5.7%, p < 0.001), a conflict with the medical ED attending (100% vs. 65.7%, p = 0.010), and a decision about calling in a backup resident (60% vs. 28.6%, p = 0.036).

CONCLUSIONS

In a psychiatric ED, attendings prefer greater involvement in cases relating to psychosocial issues, legal concerns, and conflicts with patients. More work is needed to fully understand these differences and their potential impact on patient care and training.

The therapeutic discharge II: An approach to documentation in the setting of feigned suicidal ideation

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.