"Sufferers of schizophrenia are no more dangerous than anyone else."
"If I'd had cancer, people would have rallied around, but because I had schizophrenia, few wanted to know."
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.
Shortly after I decided to go into medicine, I knew the day would come when I would have to deal with a branch of medicine that both fascinates and intimidates me: psychiatry.
I'm not sure what it is about dealing with psychiatric patients that makes me so nervous. Perhaps it's how much I value my own cognitive abilities. Maybe it's the stories I've heard of patients in acute psychotic episodes, throwing furniture and yelling obscenities. Or it could be that every psychiatric ward I've ever been to or seen in movies sends chills down my spine.
But now that I've started my Clinical Skills unit on interviewing psychiatric patients, my naivety has resulted in a few surprises. I was blown away when I interviewed someone who has a severe form of a psychiatric condition, yet could still carry on a coherent conversation. I was also quite stunned after the patient told me about their ability to carry on conversations with squirrels in the park and according to their chart had to be tied down in four-point restraints on admission to the hospital, yet answered a number of Mental Status Exam questions testing insight, judgment and thought process as any normal person would.
Of course, the psychiatrist training us told us that there are a few exceptions to this.
For example, some patients will speak in what is termed Word Salad (ie. "I was running down the sidewalk, over the alleys in the supermarket. Sometimes the store is full of nuns, and sometimes the airplanes fly lower. But when I was younger, they threw me over the furnace and the time was singing."), and another patient he remembers didn't speak a single word in the interview, later revealing that he did so because he thought the psychiatrist could read his thoughts.
The patient I interviewed was a bit shy at the start but completely warmed up to me after a little bit. I was a bit nervous when the patient listed off their favourite weapons, stood up to demonstrate self-defence fighting techniques with intense enthusiasm, and then looked at me with hollow, peircing eyes and shouted "I'M GOING TO F------ KILL YOU!" (fortunately while recounting a conversation with somebody else, but it was still pretty intimidating!).
After getting a bit of history from the patient, I looked through the interviewing handbook we'd been given, and asked a couple questions from the "Anxiety" and "Depression" categories, but didn't get very far. Then I picked a question from the "Psychotic" category: "Do you have any abilities that other people don't?" and the patient lit up like a Christmas tree.
"Oh, definitely. I can clean out my brain."
"Really?" I replied, trying hard to stay professional and not crack a smile.
"Oh, yeah, I do it all the time."
"Could you tell me how you go about doing that?" I inquired.
"Sure, all you have to do is fill up the inside of your skull with water. Let it fill up slowly - not high enough that you'd drown, but close to the top." The patient held up hands to demonstrate the appropriate depth. "Then, all you do is shake it around a bit" - again I was given a demonstration of proper procedure - "and after that let it drain out, all through your nose and drool it through your mouth, all the way out until it reaches your navel."
After the interivew, I mentioned to the preceptor that I was stunned that given a demonstration like that, the patient could still answer a number of simple Mental Status Exam questions testing insight, judgement and comprehension correctly. "That's normal for someone with this disorder," said the psychiatrist. "Some of my patients with schizophrenia are incredibly high-functioning - they carry on normal lives with successful jobs - accounting, engineering for example." I wonder how many are doctors.
So that was my first psychiatric patient. I'll get to watch other students in my small group interview a number of other patients over this unit, and hopefully see a variety of pschiatric conditions. For me, however, after a few weeks' exposure to psychiatry, I've concluded that to me, psychiatry is a speciality just like pathology. While I'd never want to become a pathologist given the stigma, I have to admit that the more I learn about it, the more fascinated I am by it.
I went to a Resident's Research night the other night at a fancy business club downtown. I was attracted by the possibility of the free cocktails, the free gourmet dinner, the experience of seeing this fancy club for free, and not one bit by the free research speech in between.
We arrived, suitably conforming to the club's dress code, and were pointed to a conference hall in the public area of the club. I never did get to see the private member's area with the billiards tables and the swimming pool and the brandy and stacks of the Wall Street Journal. Strike 1.
After that, the first thing we noticed is that there was a price list beside the bar. By "Cocktails 6:30 - 7:00" on the invitation, they meant "Cash Bar 6:30 - 7:00." BIG difference. Strike 2.
At the end of the speech, though, which was mostly out of my league (but it kept my attention because the resident spoke so fast) they served a fabulous and delicious three-course dinner with all the wine we could drink. Outstanding. Reset the count; 0 balls, 0 strikes.
And the best part: right before they served it, they told us that a pharmaceutical company was paying for the dinner. I had been wondering how long it would be before I was getting food from the drug companies; my time had come. I have pretty much arrived. (And I don't feel coerced one bit: to be honest, other than mentioning the name once, they did a bad job of making an impression. I can't even remember the name of the drug company. That makes it OK, then, doesn't it?)
It was well worth going just for the (free) dinner, but the best part happened after dinner. Two young psychiatrists came and sat down at the table where I was sitting with about five other first-years from my class. They told us a lot about psychiatry, answered our naïve questions ("Do you have a couch?" - answer: only about 3 shrinks in the entire metropolitan area use couches), and joked around with us, and gave us some great advice.
Before I get to the advice, let me make this clear: I know absolutely nothing about psychiatry, and in fact, in all seriousness, I am a little bit frightened by the thought of being around psychotic patients. Okay, I know that statement is laden with ignorance and so forth. Go ahead and make your judgments... Strike 1, against me... but hear me out:
Despite my ignorance, I am really interested in actually overcoming my ignorance and getting to know what the profession is like (reset the count against me, 0 balls, 0 strikes). I got the doc's contact info and I'm looking forward to shadowing them in the near future to get a handle on what they really do.
All that being said, however, the most valuable part of the entire evening was the advice that the psychiatrists gave us. I'll leave you with that; it should be helpful to anyone trying to figure out what specialty they should enter.
"No matter what fascinates you now, it is going to become routine after you do it day in and day out. So, when you're in a rotation or shadowing, take a close look at the residents in that field, and see if their level of happiness, their lifestyle, the things outside of what they do for work, jive with what you're hoping for in your career. If they don't, then look for another specialty."
