Malingering

Does anyone know of a screening tool nurses can use to assess malingering vs valid presentation of mental illness? I work in a correctional facility and it is beneficial for convicted felons to fake mental illness for many reasons. Also, If you know someone is malingering, what is your response to them to get them to give it up?

There is a psychological test referred to as the MMPI that is designed to extract certain psychiatric "traits", while also assessing for malingering by asking similar questions in multiple formats and with subtle differences...the test is very long and most often the patient will take a few days to complete it at as tolerated. However, any test like this is only a piece of the whole puzzle...if someone is malingering, there are deeper issues going on that will take years to undo, as they took years to develop...if negative attention is the only attention the individual has ever been successful at getting...he/she will not readily give that up easily...

the mmpi has to be scored and interpreted by qualified, licensed psychologists, so it's not really a "screening" tool that a nurse could use. i'm a psych cns and i've never worked in corrections, but i'm not aware of any "screening tool" for malingering and, as a staff rn, i would not be willing to take responsibility for making those kind of decisions ('way outside scope of practice). if it were me, i would just refer all those people to the mental health clinicians and let them make the call -- that's their job, not yours.

it seems like this would be much easier said than done, as there is usually a long wait to see psych, at least where i have worked. and even psych can't really read their minds. they can only form an impression, just like nurses or anyone else can. just my . i know it's their job and they are trained for it, i guess i just am cynical. i do agree that every inmate probably needs to see psych to figure out how to make the remainder of their lives better than whatever brought them to jail.

for op: you are not really having to be concerned with the behavior so much as with protecting your license, as someone stated. i know a lot of guards and nurses seem to think everyone is malingering unless they are bleeding, not breathing, febrile, seizing, or otherwise overtly ill. some staff, including nurses, are very suspicious of every medical complaint and this makes me very angry and frustrated. not everyone is faking it.

you are not a lab, you do not have x ray eyes. yet, you are probably called upon to make decisions that not even an er doc makes without labs, consults, imaging, and old records. it is not your job to decide if someone is faking illness. you should only do a good objective assessment - vs, bowel sounds, breath sounds, pulses, edema, perrl or not, mae or not, whatever is appropriate to the inmate's c/o. after that, treat by protocol is you have these at your disposal or refer to the appropriate place - md, dds, psych, er, wherever you deem appropriate after your righteous assessment.

never compromise your license, never compromise your safety. i know it requires a lot of courage to not go along with the guards or your peers if they are urging you to say someone is malingering. do not argue with them and make a bad name for yourself. just express fear of losing your license if you were to wrongly brush aside a complaint and the patient suffers harm.

the ones urging you to brush someone aside are not going down with you when you face lawyers, judges, and the board. they will not be paying your bills when you lose your job. you are a nurse, not a punishment tool of the guards. just don't ever say all of this to them. just quietly, without condemning them, do your job. does that make sense? i hope you don't run into this too often.

i know how hard it is to feel like you're an oddball, standing alone against a bunch of people wanting you to side with them. the truth will come out soon enough if all the labs, exams, etc. come back negative and then the inmate will be at their mercy and they can be about their business with him, without you being compromised.

one tool you can use is to let them "ride the pine" for a good long while if you do suspect they are not being truthful. for anyone who doesn't know, that means they should sit on the bench in the hall and wait. and wait and wait and wait. it's not necessarily definitive but i have seen staff use this technique to invite those who are not inclined to wait change their minds about seeing the nurse that day. maybe they have to get to work or will miss their meal, exercise, canteen, the movie, clothing exchange, visitors, whatever if they wait too long. sort of like triage, the waiting room, and leaving ama. just check on the person often enough and thoroughly enough to be certain he is ok. don't be cruel.

once in a while, you might even ask someone directly if they are really having "10" level pain in their rlq or are they needing to achieve some other goal. it probably won't get you anywhere but the inmate knows you're not a complete pushover. try humor, too, gently. just treat them like the human beings they are, made in god's image, no matter what demonic stuff they are accused or convicted of having done.

the trick is to never argue with them. you don't want to make an accusation unnecessarily. where would it get you if you did? don't make enemies inside. you might need the inmates' help if something bad goes down. treat them kindly, as you would want to be treated and you will earn their respect, i think. don't be mushy or improper in any way, keep that professional distance.

WOW, THANKS FOR ALL THE INPUT. I FOUND THE MMPI ON THE INTERNET. I'M AWARE THAT TAKES A PSYCHIATRIST. THAT'S NOT QUITE WHAT I WAS LOOKING FOR. I JUST THOUGHT IT WOULD BE MORE SIMPLE THAN IT IS. I WAS HOPEING THERE WAS A SIMPLE SCREENING TOOL SPECIFICALLY FOR NURSES JUST LIKE THERE ARE OTHER SCREENING TOOLS SUCH AS AIMS TEC. I WOULD NEVER GO OUT OF MY SCOPE OF PRACTICE.:heartbeat

I imagine the reason there is no screening tool is because whether or not someone is malingering is a very high-level, sophisticated clinical decision, not a "yes-no" question like whether someone is having abnormal movements.

Again, whether or not referring someone to psych is "easier said than done" (and I don't doubt that it is -- but that's the larger system's problem, not the individual nurse's), it seems to me that is the only correct response of a staff RN. Making a determination that someone is malingering as opposed to having a legitimate psychiatric problem is diagnosing, which is clearly outside the generalist RN's scope of practice.

I'm not saying that to be critical of you at all -- just pointing out that you're well within your rights to refuse to be put in the position of making those decisions! If you are being "leaned on" at work to screen people with psych sxs and make decisions about who may be faking, they are pressuring you to operate outside the scope of your practice and they are clearly in the wrong. If that is what's happening, you may want to take this up with your (nursing) superiors.

THANK YOU FOR YOUR CONCERN AND HELPFUL INFORMATION. NO ONE IS PRESSURING ME TO SCREEN, I WAS JUST CURIOUS, IT IS NOT MY AREA. I JUST WENT TO AN INTERESTING SEMINAR ON THE SUBJECT AND DID NOT THINK TO ASK THIS QUESTION WHILE I WAS THERE. THE PSYCHIATRIST AND THE PSYCH NP TALKED ALOT ABOUT MALINGERING.

Does anyone know of a screening tool nurses can use to assess malingering vs valid presentation of mental illness? I work in a correctional facility and it is beneficial for convicted felons to fake mental illness for many reasons. Also, If you know someone is malingering, what is your response to them to get them to give it up?

Also keep in mind that there are mental illnesses that can appear to patients/clients malingering but are in fact mental illness. For example, many of the Somaform Disorders (hypochondriasis, conversion disorder, somatization disorder, pain disorder, etc) fall into this categorey that Im speaking of.

Somatoform disorders differ from malingering (faking a disorder to achieve a goal) and factitious disorders (mental disorder in which symptoms of physical or mental illnesses are deliberately induced; also know as munchausen syndrome) in that people with somatoform disorders actually believe that a physical condition actually exists although no physiological basis for the complaints exists...but the patient/client believes the symptoms are real. Many people diagnosed with somatoform disorders also are likely to have comorbid disorders such as mood disorders, personality disorders, and substance abuse (which Im sure you see quite frequently in a correctional facility). Not sure if this helps at all but just thought it might be something to be aware of.

Just realized your question was posted a while ago, oh well ha. Im a new member so just getting use to the site.

Interesting thread. I recently had a re-admit and the guy actually had the diagnosis from years ago. Now he has metastatic CA, and comes to us as he goes ED to ED seeking pain meds (opiates of course, no one goes to an ED for a tylenol or 2 eh?). He has avoided his oncologist; scared I guess. Just goes to show ya, you never know! Anyway, here's a link to an article from (see below)

http://www.psychiatrictimes.com/display/article/10168/54091

Psychiatric Times on malingering, high percentage in the correctional facilities. Of course we don't give dx, but the more knowledge you have the better eh?