Malingering And Substance Abuse
Psychiatric patients who malinger do not necessarily have any psychiatric issues to begin with. Often times, they have a history of antisocial behavior such as criminality, spending time in the prison system, homelessness and getting involved with heavy substance use. They may have a history of psychiatric-like features, but even then, they’re often secondary to substance abuse or malingering for the sake of secondary gain.
What is secondary gain? This is when a malingerer wants to obtain something of personal interest, such as spending time in the hospital in order to avoid upcoming court dates. Malingerers are street smart; they know what to say and how to act in the emergency room in order to earn themselves a night or two in the hospital.
The problem with malingerers is that if they tell a psychiatrist in the emergency room that if they do no get admitted, they will cut their throat, jump off the bridge or OD on substances, it puts the psychiatrist in a corner; this corner often leads to the psychiatrist admitting the patient for the sake of the patient’s life.
Even though you may suspect someone to be a malingerer does not mean that the person won’t actually try to kill themselves. For instance, if as a psychiatrist you decide not to admit the malingerer to the hospital and they go and jump in front of a train, there can be potential liability if their family pursues a legal investigation.
That’s because anyone that actually shows up to an emergency room and talks about depression and suicidal ideations is already in a state of mind that is not considered normal. Unfortunately, you have people who abuse the system such as those who are homeless and want a bed to sleep and food to eat when it’s 10 degrees outside.
It’s very difficult as a psychiatrist to accept or deny malingerers into a hospital. Accepting them is difficult because you suspect that they are playing you for a fool, but you also don’t want to take a chance with legal liabilities and them actually harming themselves. Denying them is also difficult because you are now taking a chance that they won’t actually kill themselves.
Believe it or not, even after a malingerer obtains a hospital admission, they may decide to cut their hospitalization short due to getting annoyed over something such as “cold food.” So even though they have a place to sleep, food, psychiatric medications and round the clock care and comfort, they may ask for a discharge the very next day for reasons not even worth further mentioning.
Unfortunately, malingerers are part of the healthcare system and they have to be dealt with. But even for them I feel bad because at the end of the day we are all human beings!
Are you Ready? (This is Defeating Stigma Mindfully)