Friday, September 19, 2008

When patients try to fool doctors - four interesting types of fakers

Most people have heard of Munchausen's syndrome, a fascinating condition in which patients try to fake a condition in order to draw attention or sympathy.

There are a few syndromes that doctors need to keep in mind, some of which are quite fascinating, in which the patient tries to fool the doctor for various reasons. Here are some of those conditions, how the patients fool the docs, and how the docs avoid being fooled.

1. Drug-seekers

What are they

In a sentence, the bane of any ER physician's existence. They're either addicted to pain meds, or obtain and fill prescriptions then sell them on the street to addicted people for a huge profit.

How they fool doctors -

Drug seekers can be very slick. I have seen a patient had another doctor vouch for them, one who wore their full police uniform, an adorable 80-year-old church organist, and even nurses and doctors ... all of whom were found to be getting prescriptions for pain medications and selling them illegally.

How doctors recognize them -

Besides being highly suspicious of any patient who asks for narcotics, some regions have databases that doctors can use to determine if a patient has filled a suspicious number of pain prescriptions. However, some drug seekers raise a lot of suspicion on their own. They'll claim to be allergic to every non-addictive type of pain medication, which is statistically unlikely. Others are just bad actors. They’ll shriek and cry at the lightest touch when a doctor pokes their back to find out which part hurts… then later, the doctor will give them a friendly pat on the back, and find that the supposedly painful spot no longer seems to hurt.

2. Malingerers and Insurance Hopefuls

What are they -

A "malingerer" is defined as a person who fakes an illness with the intention of avoiding duty or work. I'll lump these in with patients who fraudulently fake or exaggerate illnesses to try and get insurance payouts.

How they fool doctors -

Malingerers will seem to have a lot of pain, and some actually are suffering from very real pain. They use this, however, to prey on a doctor’s empathetic side. They can also be quite convincing actors when they demonstrate just how incapacitated they are.

How doctors recognize them –

By knowing the physical exams and anatomy very well, doctors can get suspicious if the results of a few different tests of the same joint or muscle aren’t consistent. Some malingerers, though, can be fooled quite easily. Even I have had my suspicions raised with a patient who struggled to raise her arm a few inches when I asked her to demonstrate her range of motion. When I then asked her to show me how high she could raise it before her accident, she effortlessly shot her arm up high above her head!

3. Psychogenic nonepileptic seizures

What are they –

This is a term for people who appear to be having seizures, but it turns out that they are actually not suffering from epilepsy – for various reasons, they’re faking the seizures.

How they fool doctors –

Anybody in a doctor’s office or emergency room who is having what appears to be having a violent seizure, will obviously get the benefit of the doubt. In fact, in some cases, it is many years of investigating and giving high doses of seizure medications before a doctor realizes that the patient has been having nonepileptic seizures the whole time.

How doctors recognize them –

Research has shown that nonepileptic seizures occur more commonly in a doctor’s office or waiting room, or when there is a witness around. Some medical textbooks suggest giving such patients a sugar pill or an injection of water while telling them that this medicine has been known to cause seizures, and seeing if the patient starts shaking. While this can seem deceitful, the lie isn’t usually necessary: some patients still have these fake seizures even if they are told that they are being given something that can induce both real and fake seizures. Other things doctors look for are things such as where the patients bite their tongues, which is often in a different location for real and fake seizures, and the length and frequency of the seizures.

4. False comas

What are they –

Hopefully I don’t need to explain what a fake coma is. I will mention though, that people fake comas for a variety of reasons. Some people with psychological conditions feel safe in a hospital, and fake a coma so they are surrounded by doctors and nurses. Others have been found to fake being knocked unconscious on a ski hill, because they can’t afford a bus ticket home and would instead prefer taxpayers pay for a helicopter to fly them to the nearest city.

How they fool doctors –

By laying very, very still.

How doctors recognize them –

While there are some non-invasive tests that can be done to determine if a coma is indeed real, sometimes doctors aren’t even trying to “catch” a fake coma when they do their neurological exam and find that some results don’t add up. Also, patients who appear to be in a coma but resist the doctor opening their eyes, or flinching when the doctor’s stethoscope swings close to their face, obviously raise suspicion. Obviously to determine legitimacy it’s important the doctor knows what is normal, because strangely enough, patients with legitimate comas have been seen to do odd things such as cross and uncross their legs.


~~~~~


It goes without saying that doctors need to be careful when they suspect such occurrences. If a doctor confronts a suspected drug-seeker, malingerer, false coma patient, or psychogenic seizure patient, this can result in a very upset and sometimes even abusive patient. Two sentences that I know of that have resulted in a doctor getting punched in the face by a patient: “For the last time, I am not going to give you strong pain medication,” and “This isn’t a real seizure!” Even worse, if a doctor is wrong, they will be withholding care from people who are suffering very real medical conditions.

That’s not to say, however, that these “fakers” don’t need help. While the financial gains for drug-sellers or insurance scammers are usually based on greed alone, people who are addicted to drugs, or feign comas and seizures, can have very real and complex psychogenic conditions (to give you an idea of how complex these conditions can be, some patients may not even be aware they are faking). While they can make a doctor’s work more challenging, at the end of the day all of these people do need real treatment – not with narcotics or anti-seizure medications, but with psychological counselling to determine the underlying reasons that are compelling them to fake these conditions.


10 comments:

Alex said...

One way to detect fake unconsciousness/coma: with the patient lying on their back, hold the patient's hand about 10-15cm above their face, then let go. If the hand misses their face, they're faking. It's almost impossible to let yourself hit you in the face.

healthskills said...

Hi there
I'd argue with you a bit about malingering. It's not a medical condition at all - it's simply fraud to fake a medical condition (and it's not necessarily pain) to obtain money.
Health professionals are lousy lie detectors.
And there is no way to determine whether someone's pain is 'real' or not.
So I don't think it's reasonable at all to suggest that you can test for the 'authenticity' of pain by doing the tests you describe. In fact, there is no way to test for pain - we simply need to accept that the person is describing what they experience. Leave fraud detection to the people who do this for a living: the private investigators, and let us get on with helping people with pain without trying to work out if they're real or not.
You'll do more good than harm by recommending these things for chronic pain:
- getting on and doing things
- returning to normal activity
- and minimising the use of medications
and if they're really having a hard time - send them to an interdisciplinary pain management centre.
cheers
Bronnie

Anonymous said...

Bronnie

I disagree with you completely. Despite being overrun with fakers, and bullshit artists, hospitals still err on the side of the patient. However, when the case is so obvious, so blatant, and frankly so insulting as to fool even a child, we need to act to stop abuse.

To simply prescribe a narc doesn't resolve the situation. The person is still diverting it, still addicted to it, still not treating the underlying disease, or whatever. Pain is a symptom.

Don't tell me you just hand over the keys when some gandy walks in and says, "I'm in pain. I got allergies to Aspirin, Tylenol, Toradol, Ibuprofen, Nubain, Naproxyn, Motrin, Codeine, Demerol, Morphine, and Fentanyl. Only that one D- drug help. I don't remember the name. But that D something or other drug is all I can take."

Bullshit flags waving wildly in the wind.

There's nothing wrong with having a high index of suspicion. Simply handing out narcotics is poor medicine. It's not in the patient's best interest of facilitate their addiction. Treating the addiction is.

Particular in state-funded systems be it NHS or Medicare/Medicaid in the US.

neuro-transmitter said...

Very insightful opening commentary, and interesting posts in response.

I particularly note the recognition that the "faker" is commonly ill - although the illness is not the one claimed as the focus.

One interesting subgroup of "fakers" is patients with what I all "obsolescence syndrome": fundamentally, people who have become socially obsolete and who become fakers as a way to exhonerate themselves from their obsolescence. An example is the uneducated, obese, 50 y/o plumber with modest degenerative processes who has a minor back strain but then devolves into a chronic pain syndrome as a route to career change.

Sadly, while fakers seek to exploit they are commonly themselves exploited. Pain clinics (particularly those that pander to the accident claim game) are sometimes exceedingly hesitant to find any answer other than some biological construct. Other pain doctors also default to the "pain is whatever the patient says it is" in order to avoid confronting the difficult issues and to avoid the loss of business which stems from real answers. Accident claim lawyers may stand willing to attack anyone who fails to "appreciate" the "severe and permanent injury of my client". All of these purport themselves to be patient advocates. But, the real story is that the patient becomes a tool to the advocate's own economic agendas.

Often, outsiders fail to realize how much "stomach lining" the truly good doctor gives up to the pursuit of truth in these difficult patients. As reflected in the original discussion, the doctor may be maligned or even attacked for simply trying to pursue the truth.

The patient's real advocate is the provider who seeks the truth, because in the end the patient's illness does not care about anyone's preferred view of it. The illness will behave according to its truth. And, in the case of hidden addiction or psychiatric problems we know the outcome of failing to treat the real illness.

Regards,
John

Anonymous said...

Feel the blog is really insightful.

I suffer from "fakers" disorder or NEAD. It's great being told your an attention seeker because a paedophile had a good time with you many years ago.

The "fakers" stances silences victims of child abuse by shaming them into believing they are responsible for the injuries they have sustained. And, actually supports the behaviour of paedophiles. Victims are to ashamed to come forward and more children risk the same future.

Good luck in keeping your children safe. It's your conscience.

Anonymous said...

...forgot to mention. Just for the record.

Between 50% and 75% of psychiatric patients including those struggling with dependency issues have a history of childhood poverty, neglect,psychological, physical and sexual abuse.

Many of these drug addicts are self medicating for very legitimate reasons. It's rather unpleasant to be passed around a few paedophiles as a child, or starve for several days, watch your parents shoot up or let your alcoholic dad beat you with an iron bar.

I would just like you to reflect on your own conditioning and marvel at how you managed to become a med student. If you sit on the other side of the fence it's easy to fool yourself that anyone can do it if they work hard in school or are brighter enough.

Vitum Medicinus said...

Anonymous - I'm going to stand up for myself here and take objection to be likened to one who "supports pedophiles," and I am sure my readers will agree that there is no need for me to expand upon that further.

What I will express is my genuine hope that you can find a way to treat the source of the very real pain I won't deny you are experiencing from your past emotional and physical trauma. "Self-medicating" with substances (alcohol? narcotics?) will in the end cause you more harm than good. There is help available.

I do appreciate you taking the time to comment and am always interested in seeing a good discussion take place here.

Anonymous said...

I have never touched a street drug in my life, nor would I.

I was a school teacher until developing NEAD.

I spent many summers teaching children in specialist camps on the dangers of street drugs.

I witnessed children exposed to these environments firsthand. That is why I am so knowledgeable.

I did not mean to offend you and I did not mean to imply that you had direct involvement in covert activity.

I was merely pointing out that ignorance can be very damaging.
I would hope that you could reread my comment objectively.

I like a good discussion also. Thank you for your feedback.

Anonymous said...

Just thought I would add that reality and legitimacy are personal, social and cultural perceptions.

Bio medicine places great emphasis on the "test" to define legitimacy. Testing is a reflection of current scientific understanding - no more and no less.

There is very little scientific understanding of dissociation. It is new ground, the tests and tools have not been developed yet.

But, when science catches up these so called psychogenic or "fakers" conditions will eventually be viewed as legitimate.That's how the system works.

Biomedicine has immense cultural influence in the western world. But, as I have explained previously these influencing views of reality and legitimacy are only perceptions.

Anonymous said...

As a (non-pain) patient, with relatives who work in the medical field, I feel there are better approaches.
First, I think doctors should be better informed as regards to pain management. Of course, non-drug techniques (e.g. "TENS" units, etc. are often very costly and not covered by insurance). Yet, many types of pain, even subjectively reported pain, are, in fact, real and have real causes; yet, narcotics are not necessarily the best (or only) drug approach to treatment, especially for the long-term (even pain with objectively diagnosable signs).
I feel that g.p.'s (family doctors, ob-gyns, internists), should be more informed and trained on the different types of medications available for pain, and make referrals to pain management specialists when appropriate (e.g. neurologists, physiatrists--not psychiatrists-LOL!, rheumatologists, surgeons, oral surgeons/dentists, orthopedists, nephrologists, oncologists, urologists, etc.), and agree to follow-up and consult when appropriate.
Also, some patients may "appear" to be drug seeking (by asking for narcotics--even specific drugs) but may be under the impression that narcotics are the only option for their type of pain (complicating matters).
Small supplies of narcotics should be given initially, strict follow-up with medical records requests and/or pharmacy records verification releases (In addition to; and/or if medical records are not available; pain med contract agreements; thorough documentation of treatment; trained office staff to document phone calls; no early refills; thorough examinations and interviews, etc.