Malingering in the Psychiatric Emergency Department: Prevalence, Predictors, and Outcomes

This study was evaluated by the Program for the Protection of Human Subjects at Mount Sinai Icahn School of Medicine and exempted from institutional review board review. The study took place at Mount Sinai Beth Israel, an academic medical center in New York City, in the comprehensive program in emergency psychiatry (CPEP). The CPEP is a locked psychiatric evaluation unit separate from the medical emergency department, staffed 24/7 by an attending psychiatrist, with psychiatric resident, social work, and ancillary staff support. Patients arriving in the CPEP were triaged as medically stable. The study sample did not include patients in the medical emergency department who had psychiatric consultation unless those patients were transferred to the CPEP.

There were 14 attending psychiatrists working shifts in the CPEP during the study period. These physicians were asked to complete one questionnaire for every patient evaluated in the CPEP throughout the month of August 2017, with instructions regarding patient handoff to ensure that only one form was completed for each patient.

We operationalized the definition of malingering to exclude defensiveness (the minimization of symptoms in effort to appear well) and nonmalingering provocative behavior and to specify both intentionality (to exclude somatoform and dissociative symptoms) and secondary gain (to exclude factitious disorder). Questionnaires asked the physician to “circle the extent that you suspect the patient is malingering (intentionally producing false symptoms or exaggerating symptoms, with secondary gain).” Possible responses were as follows: not suspected, slightly, moderately, strongly, or definitely. We used the scale described in the 1994 study by Yates and colleagues for comparison (7), which reflected malingering suspicion as a matter of degree (4).

Questionnaires were completed after comprehensive assessments, which involve subjective, objective, and collateral information. Assessments were made by attending psychiatrists, who have the most experience evaluating psychopathology and medical illness and using clinical judgment to discern primary and secondary gain (16). Although psychological testing for malingering could be helpful (22), it was not used because it may be impractical in the emergency setting (23) and likely to interrupt care and diminish the response rate.

Physicians noted patient gender, age, symptoms thought to be malingered, associated external gains, and initial disposition. The three disposition options were as follows: admit to inpatient psychiatry, hold for further assessment (which could include admission to an extended observation bed in the CPEP), or discharge without holding. During the study period, there was an approximately 4.5-day period when extended observation beds were unavailable, and physicians were asked to indicate their disposition as if this option were available. Questions about ethnicity and other demographic information were not asked in questionnaires to reduce the number of questions in the survey, and review of medical records was not part of the study.

During the study period, there were 429 patient encounters in the CPEP, and 414 questionnaires were returned. Nine of the 414 questionnaires were excluded because no malingering rating was indicated. The remaining 405 questionnaires were included in the analyses—a 94% response rate. One questionnaire noted that a patient evaluated in the CPEP was then admitted to a medical floor with psychiatric one-on-one observation. This case was coded as a psychiatric admission because this was the intention of the physician had the patient not developed an acute medical issue.

Data were analyzed with IBM SPSS, version 25. Initial analyses used chi-square tests, Fisher’s exact tests, analyses of variance, t tests, Mann-Whitney U tests, or Kruskal-Wallis tests, with two-tailed values of significance. Significant findings (p≤.05) were entered into logistic regression models to determine significant independent predictors of the variables studied.

To our knowledge, this is the largest investigation of malingering in the psychiatric emergency department to date. Our findings describe the high frequency of suspected malingering, especially of suicidal ideation and for the gain of hospital admission, and highlight the clinical relevance of malingering suspicion for patient disposition.

Patients with the highest degree of suspicion of malingering were discharged rather than held for observation, which demonstrates the certainty of the physicians’ assessments and the lack of significant genuine symptoms necessitating further care in the hospital or unclear symptoms requiring further workup. Among patients who were strongly or definitely suspected of malingering, 71% were discharged (14% of all 405 encounters).

The findings suggest that malingering may be more prevalent in the emergency setting than previously reported. In the 1994 study by Yates and colleagues (7), 13% of 227 psychiatric emergency patients were strongly or definitely suspected of malingering by residents, although there was suspicion for 42% of patients overall. These differences may result from population and study variations, but they may also result from our use of attending physicians to determine malingering, who may assess with more sensitivity than trainees.

The finding that a high suspicion of malingering was predicted by the number of symptoms thought to be malingered may suggest that the most strongly suspected malingerers in this sample were more obvious in “overacting” the part, a malingering technique that has been described elsewhere (2, 24). Patients for whom the suspicion of malingering was only mild or moderate may be malingering less, may conversely be more skilled and evade high suspicion, or may represent a group of patients for whom malingering is less certain. Given these issues, disposition analyses included patients with any suspicion of malingering rather than any particular subgroup.

Suicidal ideation may be the most frequently malingered symptom because of its subjectivity and lethality, as well as the patient’s anticipation of the clinician’s reluctance to discount such a self-report. Although most patients suspected of malingering were discharged from the emergency department (and we hypothesize that many who were held were later discharged), malingering of suicidal ideation appears relatively effective: among patients for whom there was any suspicion of malingering, those suspected of malingering of suicidal ideation had 22-times greater odds of being admitted than discharged, compared with those not suspected of malingering of suicidal ideation, when the analysis adjusted for degree of suspicion and significant secondary motivations.

The most common secondary gains were to be admitted to the hospital and to stay in the emergency room. Neither particular secondary gains nor the number of secondary gains were associated with the degree of suspicion of malingering, although seeking admission and seeking social work or housing services were each associated with being admitted to the hospital. Social needs may be common among patients who malinger in this setting, and hospitalization may facilitate service coordination. Encouraging the use of community resources has been shown to reduce emergency room visits (25), and further research may determine which resources would be most helpful to reduce the number of patient encounters involving feigned psychiatric symptoms.

It has been shown that in low-income households, resources are exhausted at the end of the month, which may result in acute medical needs (26). Although the study period was limited, our findings suggest that the incidence of malingered psychiatric complaints may not be related to timing in the month.

Geographic variability in factors affecting social needs, such as substance use disorders (27) and homelessness (28), as well as the accessibility of services to meet such needs, may provide a context for our findings. It is not known whether malingering is more prevalent in winter months. This hospital’s urban location within walking distance to other hospitals may facilitate peregrinating psychiatric patients, among whom malingering is common (29).

This study was designed to investigate malingering in the context of routine clinical care in the emergency setting, with emphasis on promoting the survey response rate, minimizing disruption of patient care, and preserving confidentiality of physicians and patients. The high response rate suggests minimized reporting bias, and the large physician participant group increases generalizability. The design, however, did not facilitate gathering additional demographic, racial-ethnic, diagnostic, or longitudinal information about each patient and did not permit comparison of data across physicians or shifts. Although malingering was assessed by attending psychiatrists after a comprehensive assessment, there may be variability in both the ways individual clinicians determined malingering and in their final determinations. It is important to note that results of clinical assessments can differ from results of those obtained via psychological testing and patient report (6, 8). This study did not identify patients who presented repeatedly, which is relevant because experience with known procedures plays a role in developing a malingering strategy (30) and because high utilizers of psychiatric emergency services have been described to have distinctive characteristics (31). Information regarding presenting symptoms was not collected for any patient, and it is not known whether particular symptoms were more likely to be suspected as malingered or whether co-occurring psychiatric symptoms were present in addition to malingered symptoms. Prior research suggests that particular diagnoses may be associated with malingering (32). More comprehensive future studies will further advance understanding of the nature and purposes of malingering.

Malingering is not a rare clinical phenomenon (33), and our findings show that suspicion of malingering is common in the psychiatric emergency setting. The prevalence and perceptions of this behavior have implications for both patients and physicians regarding the treatment relationship. If a patient was suspected of malingering, discharge was likely, although factors such as seeking social work or housing services, seeking hospital admission, or feigning suicidal ideation each increased the odds of hospitalization. Malingering for community services may indicate unmet social needs, and future work may identify areas for intervention.

The authors acknowledge Lisa J. Cohen, Ph.D., and Zimri Yaseen, M.D., for statistical consultation and comments on the manuscript and Anna Lisa Derrien, M.D., for editorial contributions. The project was designed and conducted at Mount Sinai Beth Israel, where Dr. Rumschik was affiliated through June 2018.