The Diagnosis of Malingering in General Hospitals in the United States: A Retrospective Analysis of the National Inpatient Sample

Friday, November 11, 2022

2:15 PM – 3:45 PM

Location: Room 203

Presenting Author(s)

Diana Punko, MD, MS (she/her/hers)

Attending Psychiatrist
Massachusetts General Hospital
Boston, Massachusetts

PDF

Co-Author(s)

James Luccarelli, MD, DPhil

Instructor in Psychiatry
Massachusetts General Hospital
BOSTON, Massachusetts
AB

Ashika Bains, MD

Consultation-Liaison Psychiatrist
Massachusetts General Hospital
Boston, Massachusetts
RM

Rachel MacLean, MD

Resident
Massachusetts General Hospital
Boston, Massachusetts
John Taylor, MD, MBA, FACLP (he/him/his)

VP, Population Health and Executive Medical Director; Attending Psychiatrist; Assistant Professor of Psychiatry
Author Health; MGH; Harvard Medical School
Boston, Massachusetts
Nicholas Kontos, MD, FACLP

Director of Fellowship in Consultation-Liaison Psychiatry
Massachusetts General Hospital
Lexington, Massachusetts
Felicia A. Smith, MD

Associate Chief of Psychiatry, MGH
MGH
Newbury, Massachusetts
Scott R. Beach, MD, FACLP

Psychiatrist
Massachusetts General Hospital
Boston, Massachusetts

Abstract: Background/Significance: Deceptive patients—those with factitious disorder or malingering behaviors—pose a particular challenge when admitted to a general hospital. Given what must be ruled out (i.e., psychopathology aside from factitious disorder), ruled in (i.e., a deception syndrome), and intervened upon (i.e., discerning and addressing the patient's motives), decisions about “what to do with” these patients often fall to the consulting psychiatrist. There is very little literature that characterizes patients who engage in deceptive behavior, and this lack of information contributes to malingering being challenging to detect and intimidating to declare.

Methods: The National Inpatient Sample (NIS), an all-payors database of acute care general hospital discharges in the United States, was queried for the year 2019 for adult patients discharged with a diagnosis of “malingerer [conscious simulation],” ICD-10 code Z76.5. We examined this group for socio-demographic variables in addition to associated medical and psychiatric diagnoses to better characterize how this label is being applied. As the study was performed on publicly available de-identified data, the Mass General Brigham Institutional Review Board determined this to be Not Human Subjects Research.

Results: In total, 45,800 hospitalizations (95% CI: 43,836 to 47,774) during the study year included a discharge diagnosis of malingering. Of these, 56.1% were for male patients, and the bottom quartile of household income was the most represented at 39.9%. In the full presentation, we will comment on race characteristics as the complex details are beyond the scope of this brief abstract. The principal discharge diagnoses for hospitalizations including a diagnosis of malingering were “Sepsis, unspecified organism,” “Hb-SS disease with crisis, unspecified,” “Major depressive disorder,” and “Alcohol dependence with withdrawal, unspecified.” The median cost of hospitalization was $25,549, and the median length of stay was 3 days.

Discussion: Malingering is a rare discharge diagnosis among patients in general hospitals, and these results likely are an underestimate given the hesitancy of clinicians to make this diagnosis. The data revealed a surprisingly even sex distribution. Interestingly, many malingering diagnoses rely on subjective symptoms as opposed to objective clinical signs that can be definitively ruled in/out. A major limitation of this study is that we only have information about the diagnosis of malingering and are not able to comment on the true incidence as it is frequently under-documented as a formal discharge diagnosis for several reasons including the stigma associated with the label and a myth that hospitalization costs will not be covered if it is listed as the billing diagnosis.

Conclusion/Implications: Further research is needed to better characterize the incidence of malingering and its impact on healthcare. Future directions include evaluation of outcomes, including repeated presentations, hospitalizations, suicide attempts, and medical complications, as well as whether the diagnosis of deception syndrome persists.