Need advice - is this malingering?

[FullGlass, BSN, MSN, NP]

I am a PMHNP and need advice on if this pt is malingering and their request to get SSI.  Have been seeing a pt, let's call them X, who just graduated from high school.  They are on the autism spectrum, mild to moderate.  They also suffer from ADHD, anxiety, depression, PTSD.  The patient is high-functioning - has friends, has had romantic partners, got decent grades, and is going to start college in the fall.  They live with a parent; no indication of poverty.

This pt had been stable and doing well for a few years, but recently had PTSD triggered again after break up with romantic partner, which brought up many bad memories.  Given the patient's current mental state, they will not start college until Spring 2026 or Fall 2026.  Pt has never worked.

My honest assessment is that pt is likely not able to work at present and probably not for another year.  However, other than this recent retriggering, they have been high-functioning and there is no reason they could not work at least part-time after current sx resolve to previous level.

Because they have never worked, they are not eligible for the state temporary disability.  SSI is through Social Security and is needs-based; does not require work history (SSDI is for people who have worked), but does require the person to be disabled.  

My employer has a policy of not certifying for permanent disability, we only do temporary.  However, we can provide basic information like this is our patient, how long we have treated them and so on.  The patient would need to see a provider that does the permanent disability exams to get certified as permanently disabled. 

I just feel like how can this person know if they are too disabled to work when they have never even tried?  If they are capable of a fairly normal life, and even college, how can they be that disabled?  Normally, I am a soft touch, and this is the first time in several years of practice that I have not wanted to certify a patient as disabled.  Also, I have never had a high-functioning teen ask to be certified for SSI, when they are still living at home and family is not impoverished.

I have asked my boss for advice on how to handle this, but also am wondering how other NPs would handle this type of situation.  I don't know what to say to patient or how to express my misgivings.  

 

 

[JKL33]

I would follow employer's policy of limiting to temporary disability in this case. From what you have reported about the situation that's the extent of what you can fairly/honestly gauge anyway, and is your stated professional opinion above. 
 

I don't chastise you for wondering about malingering—I think it's pretty natural to wonder about the whys.  Why does this person believe they are permanently disabled? But with regard to what you will do about the specific question at hand it is irrelevant. You already have your answer/professional opinion about the specific question at hand. 
 

You do not have to elaborate in the way you are worried about when speaking with your patient. Going back to basics takes any need for that off your plate. Your professional opinion is above. Your statement should  be very simple, along the lines that in your practice you are professionally able and allowed to write opinions in support of temporary disability if appropriate. Your professional opinion is that your patient does meet those criteria, and so you are happy to provide that documentation in support of them. If they want to discuss permanent disability let them know the basics and how they can pursue that avenue. 
 

I am neither soft touch nor judgmental/harsh about this topic. 
 

 

[sleepwalker, MSN, NP]

This individual sounds capable of understanding consequences. I would recommend a discussion with him and his parents (if authorized) regarding the future ramifications of being labeled "permanently disabled". This is not something to be taken lightly and not a decision you just can just change your mind on later and suddenly decide that you don't want to be disabled any more. 

[FullGlass, BSN, MSN, NP]

sleepwalker said:

This individual sounds capable of understanding consequences. I would recommend a discussion with him and his parents (if authorized) regarding the future ramifications of being labeled "permanently disabled". This is not something to be taken lightly and not a decision you just can just change your mind on later and suddenly decide that you don't want to be disabled any more. 

Thank you for your response.  Legally, this pt is an independent adult.

My professional opinion is that this pt is NOT permanently disabled.  It would be best for them to work PT or volunteer PT.  Sitting at home ruminating about trauma and being disabled is setting them up for a lifetime of failure.  Getting out of the house and working would improve their sense of competence and self-worth.  Or volunteering and helping others can be very therapeutic. 

The practice owner confirmed we will not certify for SSI or SSDI.  We can write a letter stating they are our pt, how long, and what they are being treated for.

I think I just hate to say no to pts and was wondering how to handle this type of situation if it is something we can certify (temporary disability).

Also, I learned that there are doctors who are contracted by Social Security to perform perm disability exams.  The SS website has a list.  Also, disability lawyers typically refer their clients to their preferred doctor.  I think this pt does not have a very good lawyer.