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A decade ago, while working as a psychiatry resident in the emergency room of a New York City hospital, I encountered a patient whose medical record revealed that he’d had several hundred prior admissions to psychiatric facilities across the nation. During a 30-minute evaluation, it became clear that the patient was faking an episode of psychosis in order to gain admission to the hospital. When challenged, the patient eventually confessed that he had never suffered from any mental illness. Each month, after exhausting his disability payments, he ate and slept for free on mental health wards, where psychiatrists were afraid to turn away a patient who claimed to be hearing voices and having suicidal thoughts. He was, in other words, a professional malingerer.
Malingering — the act of faking illness for personal gain — is far more widespread than the public might suspect. (It is different from Munchausen syndrome, in which the tendency to feign illness is caused by a genuine psychiatric disorder.) In my decade of experience at several psychiatric emergency rooms around New York City, I’ve rarely worked a 12-hour shift without confronting at least one, and often several, patients seeking hospitalization under false pretenses. A recent study that a colleague and I published in Psychiatric Services found that one in every five patients evaluated at a psychiatric emergency room in lower Manhattan over the course of a month was strongly suspected to be malingering.
The motivations of malingerers vary considerably. Three years ago, I published a rudimentary nosology in the newsletter of The American Academy of Psychiatry and the Law that categorized malingerers into three types. The first type simply seeks “three hots and a cot” — three warm meals and a place to sleep — in hopes of avoiding homeless shelters and food pantries. These men and women, some of whom do suffer from underlying psychiatric illnesses, reflect social service failures on the part of society. A second type of malingerer arrives at emergency rooms in search of prescriptions for opiates or benzodiazepines. While some of these patients may plan to resell their medications, the vast majority do suffer from a severe illness or addiction — though they may exaggerate the extent of their pain and anxiety.
These first two species of malingerers can be thought of as “soft” malingerers. They have genuine and legitimate needs that should not be dismissed merely because they present to hospitals on false pretenses. At the same time, it makes little sense to offer a woman a $750 clinical workup when all she wants is a $5 sandwich, or to house a man on a thousands-per-night psychiatric ward when he could stay at a luxury hotel for far less. Simply having a hospital operate its own safe, clean, and easily accessible homeless shelter adjacent to the psychiatric ER could conserve vast resources.
A third type of malingerer is rarer, yet far more pernicious. These individuals can be thought of as “hard” malingerers, and they seek ends that are nefarious to various degrees: avoiding a court date, convincing a judge to suspend child support payments, hiding from a loan shark or drug dealer, and so forth. I once encountered a patient in an ER who appeared to be seeking an alibi for his extramarital affair. (One diagnostic clue for pernicious malingering is that the patient wishes neither to be admitted to the hospital nor discharged from the emergency room, but expresses a desire to stay for a precisely enumerated period of time.)
Because the Emergency Medical Treatment and Labor Act of 1986 requires every patient who presents to an ER to receive a meaningful evaluation, and because police are generally reluctant to remove from a hospital any patient who threatens harm to himself or others, no matter how implausibly, hard malingerers often achieve their goals. Limited data suggests that, in outpatient settings, malingering for the purpose of obtaining disability benefits could be more widespread than most stakeholders realize. In 2013, neuropsychologists Michael Chafetz and James Underhill estimated based on several smaller studies that between 45.8 percent and 59.7 percent of Social Security Disability claimants were malingerers. To be fair, the sample sizes in the original studies were too small to make such estimates reliable, but because malingering is not a genuine psychiatric disorder, little funding is available to study it, and data outside the forensic setting is hard to come by.
The fact that malingering remains so common is evidence of its efficacy. Few psychiatrists are willing to risk the liability of turning away a patient who professes to be in distress. Given the choice to label a patient as a malingerer or diagnose her with a vague, catch-all illness like “adjustment disorder not otherwise specified,” a reasonable psychiatrist will often choose the latter; it provides more legal cover. Financial incentives also come into play: Many insurers will not reimburse hospitals for time spent evaluating or treating patients who are ultimately labeled as malingerers. And in any case, a skilled malingerer who is ejected from one emergency room will simply travel to another, in search of the weakest link in the chain.
Malingering is not a victimless crime. Every hospital bed squandered on a healthy patient is one fewer that’s available for someone who’s tormented by voices of schizophrenia or who’s in the throes of severe depression. As a result, truly ill patients sometimes have to wait hours in emergency rooms or, when hospitals are at full capacity, travel elsewhere for inpatient care. Because Medicaid picks up the tab for some of the treatment received by malingerers, taxpayers are indirect victims of this fraud.
In recent years, increasing public awareness has led to a recognition that people faking physical illness to gain disability payments are engaged in criminal behavior. If we are serious about reducing health care costs and improving psychiatric care, we must find a way to separate the soft malingerers from the hard malingerers. We need to explore innovative ways to assist the former — and equally innovative ways to thwart the latter. One step might be to create a central registry where mental health providers could report overt, nefarious malingering. Chronic offenders might even face the possibility of prosecution.
Needless to say, physicians should give patients every benefit of the doubt. Yet, the intentions of many malingerers are crystal clear. Years ago, when I asked an incoming patient why he had come to the hospital, he paraphrased for me, nearly verbatim, the admissions criteria from the New York State Mental Hygiene Law. And then, to back up his case, he rummaged in his stack of legal papers and produced a photocopy of the pertinent portion of the statute.
Psychiatrists have been looking the other way for too long. With increasingly fewer resources available for our patients’ needs, we can no longer tolerate impostors who are, in essence, stealing care from the mentally ill.
Jacob M. Appel M.D., J.D., MPH, is an emergency room psychiatrist in New York City.
UPDATE: An earlier version of this essay overstated the statistical evidence offered by researchers Chafetz and Underhill in their 2013 analysis, which was based on several small studies. The story has been modified to make clear that the sample sizes were small, and that definitive conclusions based on them cannot be reliably made.