Patients who fabricate or exaggerate psychiatric symptoms for primary or secondary gain may elicit negative responses from health care professionals. As clinicians, we may believe that such patients are wasting our time and taking resources away from other patients who are genuinely struggling with mental illness and are more deserving of assistance. However, patients who are fabricating or exaggerating their symptoms have legitimate clinical needs that we should strive to understand. If we view them as having reasons for their actions without becoming complicit in their deception, we may find it easier to work with them.
Managing patients who are fabricating or exaggerating
Caring for patients who attempt to mislead us is a challenging proposition. The relevant research is scarce, and there are few recommended interventions for managing patients who fabricate or exaggerate symptoms.1 Direct confrontation and accusation are often unproductive and should be used sparingly. Indirect approaches tend to be more effective.
It is important to manage our countertransference at the outset while establishing and maintaining rapport. Although we may become frustrated, we should avoid using sarcasm or overt skepticism; instead, we should validate these patients’ emotions because their emotional turmoil could be driving their fabrication or exaggeration. We should attempt to explore their specific motivations by focusing our questions on detecting the underlying stressors or conditions.2
To assess our patients’ motives, consider asking the following:
- What kind of problems have these symptoms caused you in your day-to-day life?
- What would make life better for you?
- What are you hoping I can do for you today?
We should ask open-ended questions as well as interview patients over a long period of time and on multiple occasions to observe the consistency of their reported symptoms. In addition, we should take good notes and document our observations to compare what our patients tell us during their appointments.
Addressing inconsistencies
While exploring our patients’ motives, when it is appropriate, we can gently confront discrepancies in their report by asking:
- I am confused about your symptoms. Help me understand what is happening. Can you tell me more? (Then ask specific follow-up questions based on their answer.)
- What do you mean when you say you are experiencing this symptom?
- I am not sure if I understand what you said correctly. These symptoms do not typically occur in the way that you described. Could you tell me more?
- The symptoms you described are unusual to me. Is there something else going on that I am not aware of?
- Do you think these symptoms have been coming up because you are under stress?
- Is it possible that you want to (avoid work, avoid jail, be prescribed a specific medication, etc.) and that this is the only way you could think of to get what you need?
- Is it possible that you are describing what you are experiencing so that you can convince others that you are having problems?
Despite our best efforts, some patients may not drop their guard and will continue to fabricate or exaggerate their symptoms. However, establishing and maintaining rapport, exploring our patients’ potential motives to mislead, and gently confronting discrepancies in their report may maximize the chances of successfully engaging them and developing appropriate treatment plans.