Faking Psychiatric Conditions for Fun and Profit

The nurse was on to McMurphy's ruse...because she was actually paying attention

A story from the New York Times on  August 27, 2014 caught my eye:

“Ex-Police Officer Pleads Guilty to Playing Role in a Disability Fraud Scheme  By JAMES C. McKINLEY Jr.

A former New York City police officer accused of playing a major role in a scheme to defraud the Social Security Administration pleaded guilty on Wednesday and agreed to testify against his co-defendants. Prosecutors said that the former officer, Joseph Esposito, was one of four people who concocted a scheme that bilked the federal government out of more than $27 million. 

The group allegedly helped scores of police officers, firefighters and other city workers obtain disability benefits by feigning mental illnesses, in some cases by falsely claiming they had been psychologically scarred by the terrorist attacks on the city on Sept. 11, 2001…

Court papers… described Mr. Esposito’s role as pivotal. He recruited many of the people who applied for the benefits and introduced them to three others accused of helping to run the operation …referred most of the applicants to two psychiatrists for treatment and to establish a year’s worth of medical records. On several telephone calls recorded by the authorities, Mr. Esposito was captured coaching applicants on how to mimic the symptoms of depression and post-traumatic stress when being examined by doctors…

With diagnoses and treatment records from the doctors in hand, Mr. Hale and Mr. Lavallee would complete and submit applications to Social Security, using stock phrases like “I don’t have any interest in anything” and “I am up and down all night long.”

Psychiatric symptoms cannot be measured objectively under the best of circumstances.  Doctors must rely on patients' self reports or on how they appear in the examining room. And people can be excellent actors in situations like this without ever having taken an acting lesson in their life.  Faking a psychiatric syndrome is in most cases extremely easy to do.

So it does not necessarily follow that a psychiatrist is not doing his job correctly if he or she is deceived into thinking a patient meets DSM criteria for one disorder or another.  This is especially true when a patient is only seen in the doctor’s office, where an appointment may last a relatively short time. It is obviously more advantageous if a psychiatrist has a way of observing patients when the patients do not realize they are being observed.  In a hospital setting, for example, patients may let down their guard during a quiet afternoon spent socializing with other patients, and not realize that a nurse is watching them out of the corner of her eye.

However, the job of the schemer/faker has gotten considerably easier, whether they are trying to fake a disability claim, looking for an amphetamine prescription, or even trying to enroll in a study for which subjects get paid. This is because diagnostic interviews have gotten shorter and shorter, and doctors have begun to rely on the use of shortcuts such as symptom checklists – two things that I have been ranting about frequently on this blog. 

Under these circumstances, dishonest patients do not have to worry much about being caught in an apparent contradiction, nor do they need concern themselves with describing their symptoms in detail in a way which might seem to the examiner atypical for the condition they are faking. The doctors ask no follow-up questions, the answers to which might then raise suspicions that they are possibly being duped.

The use of the all important follow-up questions is particularly vital in sorting out the clinical significance of a psychiatric symptom that may seem to be present. A good psychiatrist functions much like a good investigative news reporter.  He or she can look for signs that the patient does not know exactly what the doctor needs to know, is exaggerating symptoms, or is possibly making some unspoken assumptions. The doctor can then ask for further clarification, which is an excellent technique for unmasking possible fabrications or half-truths.

Another recent trend that makes it easier for a patient with a hidden agenda to fake a psychiatric disorder is the tendency of some doctors to type away on an electronic medical record while the patient reports his or her symptoms - instead of making eye contact with the patients and observing them carefully while they talk. Cues to fakery that involve facial expressions and body language will of course be missed.  Not to mention that the doctor's attention is being split between two tasks instead of just one, making all clues to dishonestly less likely to be noticed.

Of course, even a doctor who does a real and complete diagnostic interview the way it is supposed to be done can still be faked out. But doctors who do not do one are far more likely to be duped. Apparently, many of them do not really care if they are – as long as they get paid.