Strange: The same patient who thanked me with a fist-bump (“BOOM!”) was also complaining he couldn’t move his legs. Eighteen-year-old Ralph, we’ll call him, had just undergone a 45-minute general anesthetic for a dental procedure. His parents stood beside him, the father fidgeting and the mother distracted. His sister was there, too, stroking his hair attentively in a way that made me uneasy.
Let’s be honest. I thought he was lying from the get-go. But after performing an anesthesiologist’s version of a neuro exam, I didn’t know what to think. I even mashed my hardest into the half-moon of his big toenail with a reflex hammer with no response on his part. Have you ever seen someone trying not to make an expression? That’s how Ralph looked.
I wanted to appear calm and collected, but Ralph was doing a better job of it. His gauze-stuffed cheeks made me think of Marlon Brando. “Ith thith normal, Doc?” No, but I wasn’t going to say as much. I’ve seen my share of complications, and this wasn’t one of them.
What to do? I didn’t want to be the guy who makes headlines by watching an otherwise healthy young man suffer irreparable spinal cord ischemia. I was familiar with normalcy bias—the idea that things are OK this time because things have always been OK. If, God forbid, Ralph had experienced a neurologic insult, the window of doing something about it was closing fast.
But I didn’t want to cry wolf, either, ordering stat neurosurgery consults, racing Ralph to the scanner and bumping other patients out of the way. What’s more, I’m supposed to be a good steward of medical resources, both money and manpower. How much would an acute post-op paralysis workup cost? Or maybe I was making this about me; was I too concerned about risking my credibility among colleagues?
The Plan: Do Nothing
I scrolled through his medical history. At 12 years of age, Ralph had been hospitalized for an infection, became septic and ended up on life support for two weeks before ultimately making a complete recovery. No residual effect, and no other medical history. Now he had become a strong student-athlete by report. He had no risk factors predisposing him to a perioperative complication, and the anesthetic had been picture-perfect.
I pulled the parents aside to let them know my plan: Do nothing. They received that surprisingly well. But the father said his son would never fake anything like this, which I found odd because I hadn’t asked. The mother shared her son’s casualness (“la belle indifference,” mental health professionals call it). I told his parents I would be back in a few minutes to reassess, and then I left to find an older colleague.
I caught Dr. Higgins up to speed as we walked to the recovery room. Ralph was still sitting on his stretcher but now his legs were raised to his chest, bent at the knees. Ralph said his mother had done that for him. Why? Because he’d asked her to. Then she apparently had gone, and the father and sister didn’t offer another explanation.
More talking, more examining. Ralph had been in the PACU for nearly two hours by that point. Meanwhile, the board nurse was paging me about room assignments. I had four other patients asleep on the table, one of whom required jet ventilation, and I had two nerve blocks waiting on me in holding. I didn’t know if Ralph was malingering, but he was definitely mal-loitering. He was taking up a slot in a crowded recovery room, and I wanted answers. I must have looked frazzled when Dr. Higgins wandered back into the PACU. He looked at Ralph and said, “OK, son, it’s time to go home.” Ralph stood up, dressed and walked out of the hospital, just like that.
Phew! I was relieved. Then I found the whole thing humorous. Finally, I was furious. I replayed the events over and over. What should I have done differently? Should I have called his bluff sooner? One colleague said I should have tested his response to a twitch monitor. Fair enough, but electrocution doesn’t sound like the most delicate option. There are case reports of patients feigning unconsciousness after general anesthesia, some of whom didn’t respond to painful stimuli. The solution? Stealthily squirting ice water in the ear.1 Even if this idea had occurred to me, I can’t imagine the family applauding my creativity. I stewed about it for a few days, and then I called an expert.
Dr. James Walker is a neuropsychologist with an interest in “forms of deception.” I phoned him after reading his article, “Fibs and Faking: Malingering in Children,”2and told him about Ralph. He said Ralph may have been seeking a secondary gain such as attention or avoidance of responsibility by deliberately faking his symptoms. That’s textbook malingering, as defined by the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. Perhaps Ralph had learned the sick role during his childhood illness, and was taking advantage of this setting to gain more sympathy from his family.
Malingering: A Long History
Ralph wasn’t the first person to try something like this. “Malingering” first appeared in print in the 1890 Webster dictionary,3 but the behavior no doubt predates recorded history. In fact, King David has been called a malingerer for feigning insanity to avoid being murdered.4 Malingering is classically seen in soldiers attempting to avoid military duty, but now it predominantly appears in the courtroom. Disability cases are rampant with malingering.
Malingering has direct implications in the perioperative setting, too. Dr. Walker said some patients familiarize themselves with the classic symptoms of a certain illness in order to undergo needless surgery. Anesthesiologists deal with malingering all too frequently (“Doc, I’m allergic to Percocet 10s but not 20s”), but like all physicians, we’re not that great at spotting it. Traditionally, the incidence of malingering was thought to be quite low,5 but other research suggests it may be much higher. Just thinking about it makes physicians paranoid. A paper published in 1991 reported that one surgeon believed 75% of his patients were malingering.6
Entire textbooks have been written about the detection of malingering.7Waddell’s signs are perhaps the most well-known method for malingering busting,8 but medical literature is full of other techniques, including modifications of the Minnesota Multiphasic Personality Inventory (MMPI). For example, the MMPI-2 Md Scale specifically targets depression malingering.9 Then there’s the Confusion-revised and Infrequency scales of the Psychological Inventory of Criminal Thinking Styles (PICTS), which has been used for screening mental health complaints in inmates.10 Still other variations specifically target feigned post-traumatic stress disorder.11 And don’t forget the Structured Inventory of Malingered Symptomatology (SIMS), a 75-item true-or-false questionnaire based on “well-established detection-strategies: rare symptoms (RS) and symptom combinations (SC).”12
Here’s the take-home message: Malingerers overdo it; they over-exaggerate. That was the problem with Ralph’s story. If he had complained of a headache, hallucinations or even a memory disturbance, I would have been less suspicious.
Now that I was convinced Ralph was malingering, Dr. Walker said Ralph might actually have a factitious disorder: He might have been deliberately faking paralysis for no real external motivation. Or he could have a conversion disorder, meaning that he was still fabricating his symptoms, but unconsciously doing so. (The most famous conversion disorder is psychosomatic blindness, in which the patient has no organic cause for visual deficits.) So here’s the question: Did Ralph make up his ailments deliberately?
“Deliberately”—that word hung in my mind. Ralph had wasted my time, and I wanted someone to blame. If he had deliberately misled me, then somehow I was comfortable resenting him for it. But if he hadn’t conjured up the symptoms on purpose, was he absolved of responsibility?
The answer is maybe. Dr. Larry Churchill is a professor in the Center for Biomedical Ethics and Society at Vanderbilt Medical Center, in Nashville, Tenn., who has dealt with similar cases on the wards. After listening to my story, Dr. Churchill compared patients with conversion disorders to addicts: “In some sense, an addict cannot control his behavior, but he is still responsible for taking measures to find help.” Looking back over my own drinking days, I knew the uncomfortable truth in Dr. Churchill’s argument. I couldn’t be angry at Ralph anymore. I actually felt sad for him. I empathized with his powerlessness, and I needed to know what to do if a similar situation ever arose again.
To my surprise, Dr. Churchill told me I had handled the situation “beautifully.” By taking Ralph’s complaint seriously, by asking for a colleague’s help and by not acting impulsively, I had taken good care of my patient. Dr. Churchill said it would have been fair to ask Ralph if he was telling the truth (“though it probably wouldn’t have done any good”). Should I have entered a “malingering” note in the chart to alert future care providers? I don’t think risk management would have approved. What about an intervention? A psych consult? These were luxuries of time I couldn’t afford. But I could spare compassion, and I tried to. I hope Ralph would agree.
In summary, be vigilant—or not, as the danger of a heightened awareness of malingering is finding false positives. Management in these scenarios cannot be done by protocol, and we must use good judgment on a case-by-case basis. Some patients really do suffer from hyperalgesia, or complex regional pain syndrome or fibromyalgia. The more conscientious physician (and certainly the more popular one) will err on the side of being suckered.
That’s certainly how I felt as I watched Ralph stroll out the PACU doors. But I understand now that he was not in sound mental health. It doesn’t sound doctorly to say Ralph was lying, but in fact, those were his words. Smack in the middle of the charade, Ralph asked me spontaneously, “How do you know when someone is lying about this?” Usually, Ralph, when I’m asked that question.
- Albrecht RF. Factitious disorder as a cause of failure to awaken after general anesthesia.Anesthesiology. 1995;83:201-204.
- Walker J. Fibs and faking: malingering in children.Child Adolesc Psychiatr Clin N Am. 2011;20:547-556.
- Palmer IP. Malingering, shirking and self-inflicted injuries in the military. In:Malingering and Illness Deception. Halligan P, Bass C, Oakley D, eds. London, England: Oxford University Press; 2003.
- Frederick Malingering/Cooperation/Effort. In:Ziskin’s Coping with Psychiatric and Psychological Testimony. London, England: Oxford University Press; 1970.
- Miller H. Accident neurosis.Br Med J. 1961;1:919-925, 992-998.
- Leavitt F. Predicting disability in time using low back pain formal measurement: the Low Back Pain Simulation Scale.J Psychosom Res. 1991;35:599-607.
- RogersClinical Assessment of Management and Deception. New York, NY: The Guilford Press; 2008.
- Waddell G, Bircher M, Finlayson D, et al. Symptoms and signs: physical disease or illness behaviour?Br Med J.1984;289:739-741.
- Steffan JS. An MMPI-2 scale to detect malingered depression (Md scale).J Personality Assessment. 2003;10:382-392.
- Walters G. Screening for malingering/exaggeration of psychiatric symptomatology in prison inmates using the PICTS Confusion and Infrequency scales.J Foren Sci. 2011;56:444-449.
- Hall RC. Detection of malingered PTSD: an overview of clinical, psychometric, and physiological assessment: where do we stand?J Foren Sci. 2007;52:717-725.
- Rogers The SIMS screen for feigned mental disorders: the development of detection-based scales.Behav Sci Law. 2014;32:455-466.
Dr. Harvey is an anesthesiologist at Vanderbilt University Medical Center, in Nashville, Tenn.
The author acknowledges with thanks the assistance of Michael Higgins, MD, MPH, professor, Department of Anesthesiology; and Katherine Dobie, MD, assistant professor, Department of Anesthesiology, and chief, Ambulatory Division, Vanderbilt University Medical Center.