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.
This should have been better vetted. “In 2013, neuropsychologists Michael Chafetz and James Underhill estimated that between 45.8 percent and 59.7 percent of all Social Security Disability claimants were malingerers.” Seriously? Half of SSD claimants are faking it???
Let’s go into these numbers. First, the linked paper (https://academic.oup.com/acn/article/28/7/633/4884) by Chafetz and Underhill does NOT “estimate” those numbers. The purpose of the Chafetz and Underhill study was “to estimate the cost of malingering in SSD evaluations for adults claiming psychological and mental disability, using the published statistical records from SSA for 2011 (SSA, 2008).” The numbers (45.8-59.7%) are mentioned in the abstract and the introduction. Chafetz and Underhill do NOT come up with those numbers in the paper. So where are they from? Well, the 45.8% number comes from here: https://www.ncbi.nlm.nih.gov/pubmed/17097263, although that paper is restricted in size (136 adults), location (Louisiana), etc.
The other number, 59.7%, probably comes from that paper as well. The Chafetz and Underhill paper states: “In a separate sample, cumulatively 59.7% failed the Medical SVT (MSVT; Green, 2004) at below-chance or chance levels or failed both the MSVT and the SVS.” The Green, 2004 citation is for the kind of test they are referring to, not the number (the citation is: “Green P.. , Manual for the Medical Symptom Validity Test , 2004EdmontonGreen’s Publishing”). The problem is that sample was only 58 adults.
136 and 58 are awfully small numbers to extrapolate to 2,768,928 people (this number comes from the paper that estimates the cost, i.e., the one Appel cited) without corroborating studies to back this up.
I’m also not sure how they got these numbers. I think maybe they came from Table 7 (“Failure rates for adults and children on effort tests (TOMM, MSVT) and the rating scale”). For the first number (45.8%), you have Below chance (%) = 12.4, Chance or below (%) = 33.3, and Failing (%) = 55.8; 12.4 +33.3 = 45.7 (close to 45.8), but 55.8 + 12.4 + 33.3 = 101.5. For the second number (59.7%), you have Below chance (%) = 12.3, Chance or below (%) = 47.4, and Failing (%) = 61.4; 12.3 + 47.4 = 59.7, but 12.3 + 47.4 + 61.4 = 121.1??? Maybe this isn’t where the numbers come from.
My concern here is that these numbers are scary. Can’t you see the “Half of people getting tax-payer money are faking it!” headlines? So they shouldn’t be thrown about without the proper caveats and context, because these are the kinds of numbers that can influence policy.
This is a societal problem, not a problem (if it is a problem) that can be blamed on individuals. Free health care for all upon demand, socialized housing and jobs/universal income would solve the problem of a vanishingly tiny number of unfortunates relying on ER rooms for survival. If you want to get rid of so called “malingerers”, Dr. Appel, take on the dysfunctional health care industry and the All for (non) Profit rip-off hospitals that charge arms and legs for bandages. Or the banks and the military and insurance corporations who feast on the suffering they create. Wrong target, dude.
This article is incomplete unfortunately. It doesn’t take into account those diseases for which diagnosis is difficult, but are real illnesses.
Historically, for example, ulcers were blamed on the patient because of their “inability to handle stress,” when in fact they are caused by a bacteria, H. Pylori. Tuberculosis was thought to be constitutional and because of a bad attitude, when in fact we now know it’s an infection.
Today, patients who suffer from very challenging disorders such as Fibromyalgia, Lyme Disease, Chronic Fatigue, Reflexive Dystrophy are blamed by people like you and told they have a “psychiatric” issue, when if fact it is highly likely that we will discover an agent in these diseases if history is to be any kind of guide.
I’m sure you have had experience with malingerers and it is a real issue (Trump bone spurs forex), but in any differential diagnosis, I might ask you to consider a little less “patient blaming.”
I am a US Navy Submarine Force veteran of the Cold War and Vietnam Conflicts. In the 1970s, before the diagnosis of Post Traumatic Stress Disorder was developed, I was diagnosed with schizo-affective disorder by Veterans Affairs psychiatrists. After eight years of unsuccessful treatment with psychiatric drugs which severely damaged me both physically and emotionally to the point of ischemic strokes and suicidal ideation, I was extremely fortunate to recover completely within a few months. I had learned about Orthomolecular Therapy based on tissue mineral analysis of a hair sample and Creative Psychology through my own research and in 1982 was able to obtain a source of these treatments independent from the VA and at my own expense.
My VA psychiatrist, who later rose to the presidency of the American Psychiatric Association, refused to acknowledge my use of Orthomolecular Therapy, the hair test results, or Creative Psychology and termed my recovery a “spontaneous remission”. Since 1982, I have lived a healthy, productive life, free of not only the need for psychiatric drugs, but all other prescription medicines as well.
In 2007, concerned about the suicide rate of veterans diagnosed with PTSD, I began to attend a PTSD group at a VA CBOC Clinic. After only a few meetings where I shared my story with other veterans, I was taken aside by an unlicensed VA psychologist and VA psychiatrist, a graduate of a one-star medical school in the Philippines. In a twenty minute interview they diagnosed me with paranoid schizophrenia, a rare and extremely disabling condition, and banned from further participation in the PTSD group.
When this new diagnosis affected the renewal of my life insurance policy, I requested the medical records of my recovery in the 1980s. I discovered that all such mental health records in DVA VISN 1, in the 1978 to 1990 time period, had been spoliated. No records remain. I am convinced that thousands of veterans could have made recoveries similar to mine, with thousands of lives saved, had VA psychiatrists run studies on Orthomolecular Therapy and Creative Psychology instead of destroying all evidence of a veteran’s drug-free recovery and attempting to discredit him. I have been examined and tested by well-qualified civilian forensic psychiatrists and a QTC, Inc. C&P medical examiner, who find in me no current evidence of any mental illness.
Feigning or exaggerating illness also is a common way to attempt to avoid compulsory military service.
Such as face news about bone spurs.
How is malingering identified clinically? I see from the abstract of the linked article that you classify based on suspicion. Are these suspicions based on objective clinical measures or are they subjective? I understand it is an opinion article, but it’s pretty vague and appears to be an opinion based on anecdotal experience rather than evidence.
Is there no longer any ethics in publishing anymore? Although there always exist outliers, this paper is nonsense. The process of getting a bed in any kind of mental healthcare facility is so incredibly difficult in the US. Teenagers can be taken to an ER and present with psychosis, delirium, evidence of self harm, state that they are suicidal and be sent to 36 hour voluntary detox after meeting with social wokers who sometimes have borderline IQ levels. Please ensure that studies (even opinion pieces) are evaluated more closely.
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