Many people have been emotionally or financially hurt at sometime in their lives: people sometimes do not reciprocate feelings, fail to appreciate another’s worth, fall out of love, betray, leave, retrench or disappoint another. These are all part of the pain of being human, and do not necessarily reflect people with difficult personalities. But some people have personality types with toxic behavior patterns that frequently damage others or cause intense pain, and as they journey through life leave in their wakes more than one hurt, financially devastated or troubled person. They include everyday sociopaths, bullies, and people with passive aggressive personalities. People with these personalities usually find it difficult to change their behaviour towards others because they simply don’t want to; they get what they want, but at the expense of other people, according counselling psychologist, university lecturer and co-author with Hazel Edwads of Difficult Personalities (Choice), Dr Helen McGrath.

According to Dr McGrath, many people with toxic personalities can be difficult to recognise; they can present as charming, caring individuals whose only concern is for others, when in fact they have a total lack of conscience about their behaviour or actions or how it impacts on those around them.

The passive aggressive personality

Robyn* describes her 10-year relationship with Steve* as “living with Dr Jeckyl and Mr Hyde.” At times Steve was aggressive and nasty towards Robyn, telling her she was exclusively responsible for any family problems. “If the children were sick, it was my fault; if the car broke down, it was my fault,” recalls Robyn, who has now been divorced from Steve for two years. Steve resented Robyn’s success in her job, and would sulk whenever she worked on a big project. “Steve would launch into a litany of my faults as a wife and mother, and blame me for abandoning the family to go to work. It was a no win situation – we needed the money, but if I didn’t work, he would berate me for being lazy.”

Robyn undertook most domestic and parenting responsibilities as Steve procrastinated on almost every job – from paying bills to collecting the children from child care. “When I tried to speak to Steve about these issues, he would become silent or stalk out of the house. It became easier to do things myself.” On the other hand, Steve could be charming. “We’d spend romantic weekends in the country, where John would be affectionate and loving. He’d convince me that our life could be perfect – if only I stopped `over-reacting’ about his behaviour. “In front of others Steve was a doting husband and father constantly nagged by his wife. He would snigger at comments I made, making me look stupid in front of others, and later tell me I was imagining things. At times I thought I was going mad.”

At work Steve rarely did his share of the workload or follow cooperative plans, much to the frustration of his co-workers. He made excuses as to why work wasn’t completed on time, and regularly blamed others for his tardiness. He made jokes about his boss to workmates, and loathed colleagues who moved onto better positions.

Dr McGrath: “People with a passive aggressive behaviour pattern like Steve often lack assertiveness skills and instead find satisfaction in controlling another person’s life. “Passive aggressive’s can be eaten up by jealousy and resentment, and have so little belief in their own ability they feel incapable of trying to compete with another person. So instead they attempt to bring that person down. “They are essentially cowards who are not prepared to outright attack someone like Robyn, but will undermine them at every opportunity. They can’t handle retaliation, and will often give the silent treatment to anyone who questions their behaviour. “At work they can harbour a deep anger towards colleagues they perceive threaten them in some way. In their need to control others they can frustrate, undermine or sabotage their workmates: some spread rumours, deliberately procrastinate, or stubbornly refuse to negotiate. “Often people like Steve invent plausible excuses for their behaviour, and workmates can end up feeling paranoid and stupid if they complain. As game players, they can waste an enormous amount of productive time and emotional energy at work.”

- In a romantic relationship, ask a partner showing passive aggressive behaviour to attend counselling with you. In the workplace, seek advice from a supportive colleague or superior. Through counselling, a passive aggressive person may eventually acknowledge that they could lose a relationship or job unless they change their behaviour.

- Refuse to be caught up in the game. Use rational self-talk such as “I won’t get upset over another instance of non-cooperation or sabotage. Either I will let it go or I will be assertive. But I won’t just fume.

- Where possible, don’t work with them. Consider a transfer. Don’t put yourself in a position where you have to collaborate with them or where they can undermine you.

- In either a romantic of job situation, try and keep your cool. If you become upset or aggressive you’re just playing into their hands. They will be enormously satisfied if they can produce out-of-control behaviour in you.

The sociopathic personality

The sociopath at work: By the time Roger* was in his late 40’s he was married with two teenage children, a successful lawyer, and partner in his law firm. He was financially secure, lived in an up-market suburb, and was a well-respected member of the community. But Roger lived a double life; he was using client’s trust funds for his own use, involved in unethical money-making scams, and having sex with a young employee and several clients. Roger travelled regularly, and was often out of contact with his office and family for several days. He’d always have an excuse such as fatigue or unreliable plane timetables, and would be furious if anyone questioned his disappearances, insisting they were paranoid. The truth was a girlfriend usually accompanied Roger business trips, and they would spend several days at expensive hotels.

Roger was repeatedly unfaithful to his wife, who usually believed his sincere claims that he would never look at another woman. But if his wife became suspicious, the charm would disappear and Roger would insist she was going mad. Roger’s mistresses were convinced they were the only woman he loved, and that he would soon leave his wife to make a new life with them. Mostly indifferent towards his children, Roger criticised them for their behaviour or dress, or make them feel guilty by complaining about the cost of their school fees.

Dr Mc Grath: “People like Roger like to portray themselves as charming and caring, but it’s all an act. The lives of sociopaths like Roger are an interchangeable mask: they can be cold and ruthless, with no qualms about ethical rules or boundaries in their quest to get what they want. “Sociopaths act on their impulses without regard for the devastating consequences their actions bring to others. But they can appear to be perfectly normal – even the most severe sociopaths may have areas of their lives where they behave in a kind and generous way. This contradiction often confuses and causes enormous distress to their victims. “People like Roger can be described as `successful’ sociopaths, while `unsuccessful sociopaths’ have very few skills or attitudes that allow them to become successful in society on their own merit or hard work.

“`Unsuccessful sociopaths’ can be either irresponsible lawbreakers or sadistic and violent. They are usually social losers who may destroy property, harass others, use aliases, disappear owing money, or suddenly leave a partner or children without support. “But while `successful’ sociopaths like Roger are not `social losers,’ and usually don’t have a pattern of assault or obvious crimes, they love the thrill of deceit and rewards that come through dishonesty, and can be excellent liars. “Unfortunately for their victims, very few who come into contact with sociopaths have the whole picture, so the pattern of their behaviour often isn’t obvious for a long time.”

Dealing with a sociopath

- Check if you suspect. If you begin to identify a possible pattern of sociopathic behaviour, check out as many facts as you can. It may take a while for the pattern to emerge, as sociopaths are masters of deceit.
- Consider leaving. While most people do not stay with a lover, co-worker, friend or boss with sociopathic behaviour, human beings are full of hope and it may take some time – and a lot of misery – to reach this conclusion.
- A sociopath in the workplace may cost a company money, legal action or loss of staff due to their actions. Small businesses who may take people “on trust” can be caught by skilful sociopaths and face financial ruin. Be diligent about checking previous qualifications and employment.
- Don’t cover for a colleague, boss or partner whom you believe is behaving in unprincipled ways.
- Develop a healthy mistrust if a potential partner seems charming and almost too good to be true. They may be genuine, but check their stories.

Bullies

The bully at work: Melinda*, a well-dressed woman in her 40’s, worked as a manager for a large company. She was on excellent terms with her superiors and friendly towards the majority of her co-workers. But when Tina*, a bright, attractive woman in her late 20’s, began working in the office, the darker side of Melinda’s nature appeared. Within days of Tina’s employment, Melinda began to monitor Tina’s every move, and kept detailed records of her coming and going’s from the office – even timing her toilet breaks. Melinda was highly critical of Tina’s work, and would set her up to fail by not giving her the information she needed to complete a task. At meetings and in the lunch room, Melinda would snort in derision, roll her eyes, or smirk at colleagues when Tina put forward her ideas. As the months went by, Melinda spread untrue rumours about Tina’s sexual orientation, and made unflattering remarks about everything from her hairstyle to the clothes she wore. Urged by concerned friends, Tina eventually approached senior management about Melinda’s bullying, only to be told that Melinda was a valued, long-time employee, and that the problem was obviously a clash of personalities. Humiliated and depressed, Tina left her job.

The bully at home: Because Melinda’s household ran better if she got her own way, her husband and children learnt to accept that she ran the show. Although Melinda spread unkind rumours about an attractive, successful sister-in-law, she was charming while she did it, giving relatives the impression she was an innocent bystander to family matters. A controlling mother who dominated her husband, Melinda was kind to her children’s partners – as long as they accepted her dominance. She wrecked havoc in her children’s relationships if her position was challenged.

Dr McGrath: “Bullies like Melinda cold-bloodedly attempt to undo another person as part of their plan to retain popularity and power. “Bullies are usually have an arrogant, inflated view of themselves, so can be threatened by anyone who is likeable, well qualified or attractive. They are prepared to intimidate, humiliate or emotionally destroy another person in order to get what they want. “Some bullies don’t look like they need to intimidate another person – like Melinda, they can be well presented and charming. But the more toxic bullies are, the more difficult they are to pick. – they’re very good at covering their trails. “Other bullies target people who are less articulate, of a different religion, lack social skills, are overweight, or show signs of anxiety. “If a target takes their problem to senior management, they can be fobbed off as over-reacting – people like Melinda work hard at endearing themselves with their superiors. “Surveys show that bullying is becoming a major cause of workplace stress, and is widely recognised as an important health issue. A company where bullying is rife is characterised by high staff turnover, excessive sick leave or stress-related compensation leave.”

Dealing with a bully:
- Have the courage to report bullying to management or authorities.
- Tell someone. Keeping quiet about bullying can be harmful to your mental health.
- Change your usual response to the bullying. For example, with a smile say “Thank you for telling me,” and walk away.
- In any contact with the bully, sound and act confidently, not in a frightened manner.
- In a group, ignore what they say and talk to the person nearby.
- Helplessness fuels bullies. So ask them to stop. Say “I want you to know that I find your behaviour unpleasant and childish. I don’t know why you need to do it and I don’t care, but if it continues I will report it.”

The rigid personality

Rigid controllers never budge on their decisions, are self-righteous, rarely prepared to see another person’s point of view, and have an undue preoccupation with detail. People with this behaviour pattern can be difficult to work and live with because they make cooperation difficult and leave others feeling devalued and powerless because of their inflexibility. They often have an inability to express warmth and tender emotions. People with a rigid personality need to work hard to see other people’s perspectives, according to Dr McGrath. They can be helped with counselling, but only if they realise they have a problem.

The anxious personality

People with an anxious personality stress out at the drop of a hat. They tend to magnify anything remotely threatening, be perfectionists and stress others and themselves by their unrealistic standards, be rigidly controlled by routine; procrastinate about decisions in case they make a mistake; and be over-controlling as they try to make sure nothing goes wrong. Those with an anxious personality can be helped with medication, naturopathic remedies, relaxation strategies and counselling, according to Dr McGrath.

The demanding personality

People with demanding personalities are terrified they will be abandoned. They see potential abandonment everywhere, and can become manipulative and demanding to others to ensure they are not left alone and that their needs are met. Their controlling, needy behaviour often ends up driving away the very people they wanted to keep. People with this personality pattern should seek help through counselling to help them change their interpretations of separation as rejection, says Dr McGrath. They can learn to rid themselves of irrational feelings of abandonment and develop greater self-esteem.

Sandy Guy

http://www.mannet.com.au

In the late 1800s Jeremy Bentham invented a new jail design, which he called the Pan Optiplex, or Pan OpticonD—which means all seeing in Latin. The prison was arranged in a semicircle with cells that faced a guard tower, positioned in such a way that the guards could see the inmates, but the inmates couldn’t tell if they were being watched. The principle was psychological; if the inmates believed they were being watched, they’d behave themselves. Any human being will behave differently if they think they’re being watched, which is why behavioral scientists who want to watch people (or other animals) go out of their way to hide behind two-way mirrors and concealed cameras. Conversely, it’s why the cheapest “security” measure is a realistic looking dummy camera mounted somewhere conspicuous.

In the war we’ve just wrapped up in Iraq we saw the deliberate use of conspicuous observation on the battlefield. Some have speculated that reporters had been embedded with specific units in order to conduct a magic trick on a large scale. The magic, in this case, is indirection—and stage magicians use this by hiring sexy women in revealing costumes to act as their assistants. You look at the girl and the flash-powder explosions and your eyes aren’t looking at the magician palming a card. Penn & Teller perform a trick on stage where an almighty big bang goes off at the back of the auditorium, shocking the entire audience into turning around to look behind them, while something obvious and sneaky happens on the stage. So by embedding reporters in some units, attention is drawn away from others who can conduct business that the Pentagon doesn’t wish to explain.

There’s nothing to suggest this isn’t true, but the Pentagon could have killed three birds with one stone. In addition to the above, embedding reporters applies the pan opticon effect on the soldiers of that unit and makes them behave better than they would’ve. Back home we get 24/7 footage of professional, honorable soldiers, giving the whole US operation a cleaner image than it deserved.

This effort probably wasn’t put on entirely for home consumption, though, because having a positively enhanced image of war and liberation is a powerful diplomatic weapon, too. War has always been about directly achieving political goals, and a useful byproduct of victory has always been the ability to swing a credible threat at the negotiating table afterwards. But now a new variant of war may have been invented: war as a factory for desirable byproducts.

This would be a type of war that’d join the armory of methods we already know: terrorism, guerilla warfare, conventional warfare, deterrence-based warfare (the Cold War and the realm of nuclear weapons), shadow warfare (spies and covert ops), and trade war. This new type of war would be fought with separate units, where the soldiers carry guns as usual but trained to be more like method actors than regular soldiers.

In pan-opticon warfare, the creation of a diplomatically useful image is more important than the battlefield objective. This makes it possible to “lose” but still win, if for example, it creates the impression of your enemy as a man who fights dirty in order to win, and creates an impression of your soldiers as men who fight honorably even when it’s futile. That doesn’t mean you have to lose the battlefield objective, it just means such an event isn’t always a disadvantage (or even unintentional).

The image that’s been manufactured by the war can then serve a political use. If it succeeds in casting your side as honorable and heroic liberators and your enemy as a villain then it can make it politically possible for hesitant allies to stand by your side in public, make it harder for your enemy’s supporters to do the same for him, thwart enemy attempts to demonize you, and even take the wind out of the sails of your internal critics. In Iraq a higher objective than deposing Saddam Hussein was to humiliate the Arab world into change, and with the combination of indirectional reporting, and the behavior of troops aware of cameras, made not only the fall of Baghdad appear relatively painless, but made the Americans look magnanimous.

All this from putting a camera in with the men; cameras seem to make soldiers suck in their tummies more, wear braver and prouder expressions, and above all, stops them from misbehaving on live TV.

And if pointing a camera at our own troops has an effect on the way they behave, it may be worth a shot to see how it affects the enemy as well. Not at the level of generals and presidents, but at the level of grunts who may see a camera and decide, at that moment, not to fight because they feel an unseen audience of billions judging them that instant. Surrenders were already seen as likely in Iraq, but perhaps we might see a specific trend after someone tabulates the figures for units assigned a reporter, and those units without. If we do, then the camera will have gone from a passive gatherer of intelligence to an active element of battlefield psychological operations.

The Pan Optiplex of Jeremy Bentham’s imagination didn’t go away, in fact all modern jails include the element of constant perceived surveillance for the psychological effect it has, more than to catch anyone in the act of misbehaving. And what works there can work everywhere, and it can scale up to any level, because the pan-opticon effect works as long as you think you’re being watched, so it can work even if you aren’t, in fact, under active surveillance. A camera doesn’t actually have to be there so long as you believe there is. So let’s say the ghost of Candid Camera is ressurected in a rash of Reality TV shows that focus on filming people who aren’t aware of it, like “Scare Tactics” on the Sci-Fi channel, and they slowly begin to convince all of us that, at any moment, we may be on camera…

http://www.disenchanted.com/dis/humanity/scare_tactics.html

Malingering is intentional production of false or exaggerated symptoms motivated by external incentives, such as obtaining compensation or drugs, avoiding work or military duty, or evading criminal prosecution. Malingering is not considered a mental illness. In the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV), malingering receives a V code as one of the other conditions that may be a focus of clinical attention.

Pathophysiology: Malingering is deliberate behavior for a known external purpose. It is not considered a form of mental illness or psychopathology, although it can occur in the context of other mental illnesses.

Mortality/Morbidity: The total cost of health insurance fraud in the United States (including untruthful claims by patients and medical personnel) was more than $59 billion in 1995, resulting in a cost of $1050 in added premiums for the average American family.

Strongly suspect malingering in the presence of any combination of the following:

1. Medicolegal presentation (eg, an attorney refers patient, a patient is seeking compensation for injury)
2. Marked discrepancy between the claimed distress and the objective findings
3. Lack of cooperation during evaluation and in complying with prescribed treatment
4. Presence of an antisocial personality disorder

* Malingering often is associated with an antisocial personality disorder and a histrionic personality style.

* Prolonged direct observation can reveal evidence of malingering because it is difficult for the person who is malingering to maintain consistency with the false or exaggerated claims for extended periods.

* The person who is malingering usually lacks knowledge of the nuances of the feigned disorder. For example, someone complaining of carpal tunnel syndrome may be referred to occupational therapy, where the person who is malingering would be unable to predict the effect of true carpal tunnel syndrome on tasks in the wood shop.

* Prolonged interview and examination of a person suspected of a malingering disorder may induce fatigue and diminish the ability of the person who is malingering to maintain the deception. Rapid firing of questions increases the likelihood of contradictory or inconsistent responses. Asking leading questions may induce the person to endorse symptoms of a different illness. Questions about improbable symptoms may yield positive responses. However, because some of these techniques may induce similar responses in some patients with genuine psychiatric disorders, exercise caution in reaching a conclusion of malingering.

* Persons malingering psychotic disorders often exaggerate hallucinations and delusions but cannot mimic formal thought disorders. They usually cannot feign blunted affect, concrete thinking, or impaired interpersonal relatedness. They frequently assume that dense amnesia and disorientation are features of psychosis. It should be noted that these descriptions also may apply to some patients with genuine psychiatric disorders. For example, individuals with a delusional disorder can have unshakable beliefs and bizarre ideas without formal thought disorder or affective blunting.

* The most common goals of people who malinger in the ED are obtaining drugs and shelter. In the clinic or office, the most common goal is financial compensation.

Physical: Typically, deficits on physical examination do not follow known anatomical distributions. A patient’s attitude toward the examining physician often is vague or evasive.

Differentials:

Conversion Disorders
Factitious Disorder
Hypochondriasis
Somatoform Disorders

Other Problems to be Considered:

Antisocial personality disorder
Dissociative disorder
True medical or psychiatric illness related to presenting complaints

Tests:

* The Minnesota Multiphasic Personality Inventory (MMPI) can detect inconsistent or atypical response patterns associated with malingering (see Image 1). The F scale and the F-K index are the most valuable indicators.

Medical Care:

* Do not accuse the patient directly of faking an illness. Hostility, breakdown of the doctor-patient relationship, lawsuit against the doctor, and, rarely, violence may result.

* The more advisable approach is to confront the person indirectly by remarking that the objective findings do not meet the physician’s objective criteria for diagnosis. Allow the person who is malingering the opportunity to save face.

* Alternatively, the physician may inform people who are malingering that they are required to undergo invasive testing and uncomfortable treatments (provided, of course, that such warning is true).

* The likelihood of success with such approaches is inversely related to the rewards for the malingering behavior.

Consultations:

People who malinger almost never accept psychiatric referral, and the success of such consultations is minimal. Avoid consultations to other medical specialists because such referrals only perpetuate malingering. However, in cases of serious uncertainty about the presence of genuine psychiatric illness, suggest psychiatric consultation.

Psychiatric consultation may be suggested as an augmentation to dealing with an acknowledged symptom. For example, the primary physician might propose, “Your pain has to be causing your system a great deal of stress, and we know that only makes the pain worse. Consultation from a psychiatrist might help us with your pain by reducing the stress.” Without being confrontational, the physician must remain honest.

Prognosis:

* Malingering behavior typically persists as long as the desired benefit outweighs the inconvenience or distress of seeking medical confirmation of the feigned illness.

Medical/Legal Pitfalls:

* Because malingering for the purpose of compensation constitutes criminal behavior, document the diagnosis meticulously. When in doubt, assuming that the patient is not malingering is a better course of action.

http://www.emedicine.com/med/topic3355.htm

History:

Malingering has been recorded as early as Roman times by the physician Galen, who reported two cases. One patient simulated colic to avoid a public meeting, whilst the other feigned an injured knee to avoid accompanying his master on a long journey.

Widespread throughout Soviet Russia to escape sanctions or coercion, physicians were limited by the state in the number of medical dispensations they could issue. With thousands forced into manual labour, doctors were presented with four types of patient; 1. those who needed medical care; 2. those that thought they needed medical care (hypochondriacs); 3. malingerers; and 4. those that made direct pleas to the physician for a medical dispensation from work. This dependence upon doctors by poor labourers altered the doctor-patient relationship to one of mutual mistrust and deception.

Symptoms:

There is a rich and diverse array of methods for feigning illness. Physical methods reported include trying to deceive measuring devices such as thermometers, inducing swelling, delaying wound healing, over-exercise, drug overdose, self-harm, or directly reporting diagnostic signs of disease, learnt from a medical textbook. Patients may report a factitious history, such as describing epileptic seizures or a heart attack, sometimes supplementing this with the use of agents which mimic disease, such as taking neuroleptic drugs to mimic tremor. Detection is made more difficult in those who do have a diagnosed, organic disease already. In these cases, malingering is sometimes described as a “functional overlay” on an existing disease.

Predisposing factors:

Malingering appears to be more common in societies with regimented, enforced labour (industrial malingering), universal military service (military malingering), or the ability to sue for damages arising from accidents (medicolegal malingering). Malingering is more common in women than men and is more prevalent amongst those employed in health-related fields. Psychodynamic theory suggests patients may have been neglected or abused as children and are attempting to resolve issues with their parents.

The DSM-IV-TR states that malingering is suspected if any combination of the following are observed

1. Medicolegal context of presentation
2. Marked discrepancy between the person’s claimed stress of disability and the objective findings
3. Lack of cooperation during the diagnostic evaluation and in complying with prescribed treatment regimen
4. The presence of Antisocial Personality Disorder

Detection:

Some feature at presentation which are unusual in genuine cases include:

1. Dramatic or atypical presentation
2. Vague and inconsistent details, although possibly plausible on the surface
3. Long medical record with multiple admissions at various hospitals in different cities
4. Knowledge of textbook descriptions of illness
5. Admission circumstances that do not conform to an identifiable medical or mental disorder
6. An unusual grasp of medical terminology
7. Employment in a medically related field
8. Pseudologia fantastica (ie, patients’ uncontrollable lying characterized by the fantastic description of false events in their lives)
9. Presentation in the emergency department during times when obtaining old medical records is hampered or when experienced staff are less likely to be present (eg, holidays, late Friday afternoons)
10. A patient who has few visitors despite giving a history of holding an important or prestigious job or a history that casts the patient in a heroic role
11. Acceptance, with equanimity, of the discomfort and risk of diagnostic procedures
12. Acceptance, with equanimity, of the discomfort and risk of surgery
13. Substance abuse, especially of prescribed analgesics and sedatives
14. Symptoms or behaviors only present when the patient is being observed
15. Controlling, hostile, angry, disruptive, or attention-seeking behavior during hospitalization
16. Fluctuating clinical course, including rapid development of complications or a new pathology if the initial workup findings prove negative
17. Giving approximate answers to questions (eg, a horse has 3 legs; 7 X 6 = 41), usually occurring in FD with predominantly psychological signs and symptoms (see Ganser Syndrome)

When malingering takes on a legal context it is more common either for private investigators to find evidence of malingering (say, videotaping a “paralysed” person walking around their home), or reports from friends, colleagues, or family members.

If a psychiatrist or neuropsychologist suspects malingering in a case of possible brain damage (i.e. caused by head trauma or stroke), they may look for a discrepancy between the patient’s reported functions of daily living and their performance on neuropsychological tests. In theory, any neuropsychological test could be used in this way, depending on the context. No one test, administered by itself, can proffer a diagnosis of malingering, so a neuropsychological examination typically consists of a battery of tests. Three tests commonly used to determine malingering are:

* Computerized Assessment of Response Bias (CARB)
* Minnesota Multiphasic Personality Inventory (MMPI)
* The Test of Memory Malingering (TOMM)

Treatment:

Treatment is psychological, and varies according to the underlying cause of the individiual’s unique symptoms. Treatment options may include psychotherapy, family therapy, cognitive behavioural therapy, or pharmacotherapy. It is important that other members of the medical team such as nurses, ward assistants, and physical therapists are informed about the patients’ history. On being confronted with a diagnosis of malingering, many patients discharge themselves immediately, only to present at another medical facility to try again.

Although malingering patients do waste a lot of resources, they are still entitled to the same safeguards as other patients. For instance, it is not considered ethical (or legal) to “blacklist” patients by warning other healthcare facilities about them without the patient’s permission, searching through their personal effects to find evidence of malingering, or covertly videotaping them without their consent.

Impact on Society:

Malingering is damaging in three ways. Firstly, by reducing the productivity of industry or the military through absenteeism, secondly by depleting private and governmental social security, disability, worker’s compensation, and insurance benefits, and thirdly by draining the medical system of resources. Malingerers take up the time and energy of medical personnel, as well as requiring detailed and expensive testing to rule out obscure conditions. Therefore malingering deprives genuinely unwell individuals of the care they deserve.

Related Conditions:

Factitious disorder
Ganser syndrome
Munchausen syndrome

http://en.wikipedia.org/wiki/Malingering

SB 993 (Aanestad and Calderon), legislation which would authorize prescriptive authority for appropriately-trained psychologists, was held for further study and review in the Senate Committee on Business, Professions, and Economic Development on April 23, 2007. Senator Mark Ridley-Thomas, the Committee’s Chair, suggested that the Committee hold a hearing in Fall 2007 to discuss the issue of access to mental health services and the role of psychologists in solving the mental health crisis in California.

SB 993 is sponsored by the California Psychological Association (CPA), the American Federation of State, County, and Municipal Employees (AFSCME) Local 2620/Bargaining Unit 19, the National Alliance of Professional Psychology Providers (NAPPP), and the Service Employees International Union (SEIU). SB 993 is joint-authored by Senator Sam Aanestad (R-Grass Valley) and Senator Ron Calderon (D-Montebello), and co-authored by Senators Alan Lowenthal, Ph.D., Gloria Romero, Ph.D. and Jack Scott.

CPA and all co-sponsors of the bill strongly argued that the debate surrounding health care reform in California, the lack of access to affordable psychiatric services in the community, and the deterioration of services in California’s state hospitals and prison system made passage of this bill critical and timely. The legislation clearly outlined the proposed required training that would qualify appropriately trained psychologists for a license authorizing them to prescribe medications relevant to the mental disorders that fall within their scope of practice. Representatives from the California Medical Association, the California Psychiatric Association, and NAMI California testified that psychologists lack the medical training to safely prescribe medication, and that the bill would NOT increase access to consumers in need. Some Senators on the Committee suggested that the bill should more fully address access issues and M.D. collaboration in the future. These are some of the concepts we will be considering as we move forward in the legislative process.

Senator Leland Yee, a psychologist and State Senator representing San Francisco and San Mateo counties, requested that all parties (psychologists and psychiatrists) make an effort to meet and discuss a possible compromise on the bill. He stated his opinion that psychologists are behavioral scientists and not physical scientists, and expressed his belief that the bill would fail to increase access since he predicted that prescribing psychologists would charge as much as psychiatrists for their services and that they would not practice in underserved areas.

We were honored to have DOD Prescribing Psychologist Dr. John Sexton, New Mexico Prescribing Child Psychologist Dr. Mario Marquez, and CPA President-Elect Dr. Miguel Gallardo testify in favor of the bill. Dr. Paul Guest, a psychologist at Patton Sate Hospital also provided testimony for the bill. We also received the support of the California Primary Care Association, which represents 600 clinics throughout the State, and the California Narcotic Officers Association.

A BIG Thank You to each and every person who took the time to send an e-mail, fax a letter, or make a phone call in support of SB 993. Senate offices reported that there were HUNDREDS of letters of support from psychologists clogging EVERY fax machine–we should be proud of ourselves for the outstanding grassroots support generated for this important legislation.

CPA knows that prescriptive authority is a tough fight, but we have laid a good foundation this year! Your help now is critical in order to maintain this momentum and continue our efforts to achieve this important step for the patients we serve! The debate does not end here…we are at the beginning of a long, sustained campaign to make prescriptive authority a reality in California. For more information, please contact Amanda Levy at alevy@cpapsych.org or (916) 286-7979, ext. 106.

Additional information:

Y According to the National Institute of Mental Health, 1 in 4 people suffer from a diagnosable mental illness and 1 in 17 people suffer from a severe mental illness in any given year.

Y The lack of access to Psychiatrists in the community has made this issue more critical than ever-there are 11 counties in California without a single psychiatrist, and an additional 17 counties that have five or less psychiatrists.

Y The severe, long-term shortages of psychiatrists have caused the cost of psychiatrists’ services to skyrocket with no change in sight.

Y The state and local public sectors are in an uncontrolled price battle to find psychiatrists who don’t exist. In the community, patients, Medi-Cal and health plans are unable to find psychiatrists at an affordable cost who are available.

Y The lack of access to psychiatrists have resulted in over 80% of psychotropic medication being prescribed by general practitioners (non-psychiatrists) with limited training in mental health and limited time with their patients.

CRISIS IN STATE FACILITIES:

1. California Prisons, with over 32,000 mentally ill inmates reported a 67% vacancy rate for psychiatrists in September 2006. The prison system is under control of a Federal Court Receiver, who has begun offering up to $300K per psychiatrist. Psychiatrists continue to leave county mental health and the California Department of Mental Health to go to the prisons, creating another crisis in the public sector.
2. The California Department of Mental Health with 6,500 mentally ill patients reported a 40% vacancy rate for psychiatrists in February 2007. Atascadero State Hospital has only 9 psychiatrists on staff for over 1300 patients. The vacancies are growing with no end in sight.
3. An answer to the growing vacancies and compromised patient care: Allow appropriately-trained psychologists to prescribe medication. It’s been done elsewhere and has been proven to be safe.

SAFETY:

1. Prescribing psychologists in other states and the military have an unblemished record of prescribing safely. Opponents of this bill have no evidence to support any claim about problems with safety.
2. The psychologists within the Department of Defense have seen over 160.000 patients with NO DEATHS or ADVERSE OUTCOMES.
3. Louisiana and New Mexico psychologists written over 40.000 prescriptions without incident.
4. Psychologists employ a behavioral approach and their prescribing patterns have demonstrated that they prescribe LESS MEDICATIONS to FEWER PATIENTS with the SUCCESSFUL OUTCOMES.

CPA, which has a long history and keen interest in advancing prescriptive authority for psychologists, will keep all interested parties informed of developments in this legislative battle that will most certainly require significant commitment and resources. Your help now is critical in order to achieve this important step for the patients we serve!

For more information, please contact Amanda Levy at alevy@cpapsych.org or (916) 286-7979, ext. 106.

Contact Us!
3835 North Freeway Blvd, Suite 240
Sacramento, California 95834
Ph: (916) 286-7979 Fax: (916) 286-7971
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Psychiatric disability determination is a complicated task for the psychiatrist. With filings for disability benefits increasing, the task is becoming unavoidable. The increasing social cost of disability requires that psychiatrists learn how to respond appropriately to petitions for psychiatric disability benefits. However, there is a significant dearth of education on psychiatric disability assessment. The various disability programs are reviewed; criteria of disability determination and difficulties involved in making an assessment are examined. Characteristics of disability petitioners are reviewed, and practical suggestions are provided for psychiatrists on how to approach a psychiatric disability evaluation. Finally, recommendations for the inclusion of psychiatric disability assessment training in residency programs are outlined.

Psychiatric disability compensation, as well as all types of disability compensation, represent a basic act of societal justice, that is, to help out those who are too sick to work. Disability payments allow people with serious mental or medical illness to live in society; to meet their financial obligations; and to have the basic necessities of life, such as food, housing, and medical care. However, the increasing societal cost of caring for disabled individuals (a consequence of benefits paid and lost productivity) has sparked much controversy in recent years, as evidenced, in part, by the growing debate over welfare and Medicare reform in political arenas. Therefore, we sought to review psychiatric disability determination and compensation programs, and their impact on the psychiatrist.

Psychiatric disability costs society over $12 billion per year (1). About 10%–30% of Social Security recipients (more than 1 million people) receive psychiatric disability benefits, an increase of more than 50% in the past decade (2). About one-fifth of disability applicants claim a mental illness (3; Social Security Administration, personal communication, 1997). In 1996 there were 1,338,000 applications filed for Social Security disability benefits; of those, 645,800 (48%) were awarded benefits, of which 131,219 were for mental disorders (Social Security Administration, personal communication, 1997).

With the increasing number of disability petitions, an increasing number of psychiatrists can expect to be called upon to render a professional opinion about patient disability. Few psychiatrists, however, feel competent in this area, and many try to avoid this complex task (4). Psychiatrists need to learn how to respond appropriately to petitions for psychiatric disability benefits. Unfortunately, most psychiatric residency training programs do not include disability assessment in their didactic curricula (5), and supervising psychiatrists may be reluctant to address the subject during supervision of residents. This shortcoming may stem from a general unfamiliarity with the mechanics of a disability assessment and the countertransference issues that frequently arise when a patient presents with a disability petition. Consequently, the discomfort with disability assessment may be perpetuated to the next generation of psychiatrists, as the psychiatric resident may feel anxious, frustrated, and inadequately supported when called upon to perform a disability evaluation. This inadequacy may cause the resident to feel resentful or hostile, and present a threat to the doctor–patient alliance.

We will 1) review the psychiatric disability programs and limitations in the disability determination criteria, 2) examine the characteristics of disability petitioners; 3) provide guidelines on the approach to a psychiatric disability evaluation, and 4) outline suggestions for the inclusion of disability assessment in the curricula of psychiatric residency programs.

TYPICAL REASONS FOR A PSYCHIATRIC DISABILITY ASSESSMENT

There are several reasons for which a psychiatrist may be called upon to perform a psychiatric disability evaluation. These may include a request for medical leave of absence, a worker’s compensation case, short- or long-term disability insurance claims or Social Security benefits, and requests for compliance with the Americans With Disabilities Act or with the Family/Medical Leave Act (6). This article will focus primarily on psychiatric disability determination in the context of an application for Social Security benefits, as this is the scenario most commonly encountered (3), particularly in the academic setting.

The different programs with which a psychiatrist should be familiar include the following.

1. Emergency Aid
These programs (formerly called Welfare or General Relief) are locally managed with variable eligibility standards and payment rates depending on the geographic location. Eligibility for these programs was originally determined by economic need, but a psychiatric or medical disability expected to last 60 or more days is now required to qualify. Benefits typically include a monthly stipend, and full coverage for outpatient treatment and medications (Department of Transitional Assistance, Boston, MA, personal communication, 1997).

2. Worker’s Compensation
This is a program for workers injured on the job. Settlements are usually made in a lump sum allotted for medical care. No monthly stipends are involved. Medications are not included in the coverage. Benefits are subject to utilization review. In general, worker’s compensation is difficult to obtain for psychiatric disorders (Office of Workers’ Compensation, Boston, MA, personal communication, 1997).

3. Department of Veterans’ Affairs
This compensation program, often referred to in the vernacular as “Service-Connected Disability (SCD),” is for veterans of the U.S. armed forces who have been disabled by injuries or disorders incurred in the course of military service (7). Benefits are based on degree of disability secondary to injury sustained while in service. For example, a veteran with 100% SCD would receive a greater monthly stipend than one with 50% SCD. Recipients also have full medical and psychiatric benefits, including medications.

4. Private Insurance Plans
These plans are primarily for medical or psychiatric care expenses. Monthly stipends and coverage may vary with different policies and companies.

5. Social Security Administration (SSA) Programs
The SSA was formed in 1935 for retired workers, dependents, and their survivors. The Social Security Disability Insurance Program (SSDI) was established in 1954, and today is the largest disability insurance program in the United States (3). About one-sixth of all Americans collect Social Security benefits (8).

SSDI is for disabled individuals who have worked a certain number of years and have paid into the SSA disability fund through the Federal Insurance Contributions Act (FICA) (9). Benefits range from 20%–60% of earnings, depending on number of years of work and average yearly earnings, although there is a limit on the maximum stipend that an individual may receive (10).

The Supplemental Security Income (SSI) program is for the aged, blind, or disabled with limited income and property (usually less than $2,000 in property), or for individuals who have not worked long enough to pay into the SSA, and so are ineligible for SSDI (9, 11). Benefits include a standard monthly nationwide stipend, which many states will supplement with added money (11).

Recipients of Social Security benefits usually have their medical care covered by the following programs.

Medicare:
Medicare covers SSDI beneficiaries who are over 65, blind, or disabled (9, 12). The basic plan includes Part A, which covers hospital insurance. Individuals become eligible after 2 years on SSDI. Medicare recipients may also opt to pay an additional small monthly fee for Part B, which covers outpatient medical insurance, but does not cover medications. Psychiatric benefits include 190 lifetime days in a psychiatric facility, although individuals who have exhausted their lifetime allotment will be covered for a stay in a general hospital’s psychiatric ward.

Medicaid:
Medicaid is a federal state-shared health insurance program for SSI beneficiaries and other economically needy individuals (9). This program provides essentially unlimited care, including medications, but eligibility for specific treatments is subject to approval on a case-by-case basis.

It should be observed that an individual who is both disabled and poor may qualify for SSDI on the basis of disability, SSI on the basis of insufficient income and disability, Medicare (after 2 years on SSDI), and Medicaid (based on SSI or medically needy status) (9).

THE MECHANICS OF A DISABILITY PETITION

Although different compensation programs may have different systems for determination of eligibility, the principles of disability determination are essentially the same for all programs, that is, to answer the question of whether a patient can work. As a representative example, we will focus on the Social Security disability evaluation system, because it is the one most commonly encountered by psychiatrists.

A patient wishing to be considered for a Social Security disability evaluation for a mental disorder must file a claim with Disability Determination Service (DDS), which is made up of a disability evaluation analyst (a non-M.D. trained in disability evaluation) and a physician (though not necessarily a psychiatrist). The DDS will request a report from the petitioner’s outpatient psychiatrist and use it to determine functional limitations and residual functional capacity. If the petitioner is turned down, an appeal may be requested within 60 days. In such a case, another DDS team will review the patient’s claim, and may require a face-to-face meeting with the petitioner. The outpatient psychiatrist may be contacted again for further information (9).

If the review is unfavorable, the patient may request a hearing with an administrative law judge. If the judge rules against the patient, a review by the SSA appeals court in Baltimore, Maryland, may be requested. If the SSA court also renders an unfavorable verdict, the patient may obtain legal counsel and file suit in a federal district court (9).

An individual who is granted nonpermanent disability will be subject to a continuing disability review at least every 3 years (9).

CRITERIA OF DISABILITY AND DIFFICULTIES IN ASSESSMENT

The specific SSA guidelines for disability determination are issued every 5–10 years and involve specific diagnostic categories (9). These categories include organic mental disorders, psychotic disorders, affective disorders, mental retardation, anxiety disorders, somatoform disorders, personality disorders, and substance abuse (the last of which was recently eliminated). In addition to diagnoses, the assessment must include professional and social function, and should take into account the effect of medications and residence (13). The guidelines have varied over the years, and the reclassification or elimination of categories often results in litigation if many individuals lose their eligibility for benefits (14). For example, eligibility on the basis of substance abuse was recently eliminated, perhaps because of the belief that disability income may facilitate drug abuse, though this remains a controversial question (15–21).

To be considered disabled, an individual must be unable to engage in “any substantial gainful activity (i.e., which earns more than $500/month) by reason of any medically determinable physical or mental impairment or impairments that can be expected to result in death or can be expected to last for a continuous period of not less than 12 months” (9). The word “any” implies that the activity could be in a line of work other than the customary one (3).

Despite this straightforward description, determination of psychiatric disability is not simple (13), largely because determination involves a prediction of the future. Outpatient clinic assessments may not reflect the true extent of disability (22, 23). Disability may fluctuate with time, as seen in patients with bipolar disorder who may be very productive during a manic or hypomanic phase, but very unproductive during a depressed phase. Emphasis may be placed on subjective (nonmeasurable) rather than objective (measurable) impairments (24). Histories presented may not be corroborated, and patients may exaggerate or falsify their symptoms. Sadly, a few cases can cloud the fact that people do become disabled from psychiatric illness. Some practitioners harbor a professional bias against patients with certain diagnoses, such as dissociative disorders, fibromyalgia, and chronic fatigue syndrome (25, 26). Directing a patient to return to work prematurely may harm the patient or his/her co-workers, which can result in a malpractice suit (6). On the other hand, being labeled as disabled may permanently remove a patient from the workforce, often to his/her detriment.

Interpersonal factors can also render disability assessment difficult. Adverse interactions between clinicians and petitioners may complicate matters (e.g., if the patient presents in a hostile or entitled manner) (26). The treatment alliance may be disrupted when the physician disagrees with the patient’s claim, or needs to question the patient’s honesty (4). Conversely, the physician’s role as patient advocate may decrease objectivity, as the psychiatrist may feel pressured to give the patient what he/she wants. This dilemma is especially common in long-term treatment relationships, in which the patient may expect that “of course my doctor will do this for me” (4, 6).

If the patient has a legitimate disability, such as a chronic psychotic disorder, the psychiatrist may feel sympathy. Frustration may arise if the patient is not disabled but chooses to be considered so because of unresolved passivity or dependency issues. Substance abusers may also cause frustration if they are viewed as creating their own problems. Finally, a psychiatrist may become angry or hostile if the patient exhibits antisocial traits and appears to be malingering for financial gain.

As a consequence of a psychiatrist’s personal values, opinion may be affected (4). For example, a practitioner with strong beliefs about personal responsibility may be opposed, on principle, to disability seeking, and may view the patient as being rewarded for idleness (4). Conversely, a practitioner with more liberal beliefs may be inclined to sympathize with a disability-seeking patient. Psychiatrists need to be aware of their personal and political values and not allow them to cloud their clinical judgment.

Some practitioners may refuse to perform an assessment. However, the patient may then remind them that they are legally mandated to provide a report. Some may postpone the task, but in those instances, the agency will usually call the practitioner and obtain the information over the telephone. Some clinicians may provide a vague assessment; one study showed that about 50% of disability assessment reports are unsatisfactory (27). Finally, a psychiatrist may confront the patient by telling the person that the psychiatrist does not believe him/her to be disabled.

CHARACTERIZING DISABILITY PETITIONERS

Most applications for psychiatric disability benefits are rejected (Social Security Administration, personal communication, 1997), suggesting that many individuals claim a disability when they are not truly disabled. Disability petitioners are more likely than nonpetitioners to receive Axis II diagnoses (28), and their ability to express hostility seems to correlate positively with their obtaining benefits (29). Therefore, it is of interest to examine whether there is a characteristic component to disability seeking.

Studies of the demographics of disability petitioners (4, 14, 29, 30) found several characteristics in common: limited education and job skills, repeated job failure, unmarried status, history of unstable family relationships and abuse, poverty or economic insecurity, and migrant status.

Specific personality traits common to disability petitioners have also been examined. Perl and Kahn found disability petitioners to be dependent, passive, unmotivated, guilty, anxious, and prone to depression (29). Heiman and Shanfield found them to be rigid, obsessive, lacking introspection, and vulnerable to frightening episodes (4). Forrester suggested that disability seekers have an external locus of control, manifested by a tendency to blame their problems on others, and to view the disability determination process as arbitrary (31). Many disability petitioners also view themselves as being in an adversarial relationship with sociopolitical forces (4). The compensation war becomes, for them, a metaphor for class struggle, pitting the working class (represented by the disabled worker) against the capitalistic owner class (represented by the government, employers, or the insurance companies).

Disability seeking involves, for many, a primary gain (avoiding a difficult job situation), a secondary gain (being taken care of), and a tertiary gain (financial reward). The disabled individual may feel ashamed of his/her condition, but at the same time feels afraid to return to work (4). Disability seeking may also involve an unconscious neurotic element (the illness) and a preconscious exaggeration of symptoms (the weakness). Heiman and Shanfield thus paraphrase Descartes’ “I think therefore I am” with “I think (I am disabled) therefore I am (disabled)” (4). These individuals appear to use their illness to rationalize their decline in productivity, and eventually become entrenched in “honorable” disability (29).

The following three vignettes represent different types of disability determination cases.

Case No. 1
A 24-year-old man, with bipolar disorder, antisocial personality traits, and a history of multiple arrests for car theft, was released on probation into court-mandated pharmacological treatment. He was treated with valproic acid, with excellent results. During the early course of the treatment, the patient applied unsuccessfully for Social Security disability benefits. The patient remained on “General Relief” for a few months and eventually returned to full-time work.

Case No. 2
A 49-year-old woman, with a history of dysthymia, claimed psychiatric disability for depression, despite mountain-biking three times a week. She obtained legal counsel early in the process, and was awarded Social Security disability benefits after a long court battle. Eventually, the patient began insight-oriented therapy to explore issues of motivation and dependency.

Case No. 3
A 40-year-old woman with severe posttraumatic stress disorder (PTSD) initially began a course of psychotherapy and medications, with fair improvement. Early in the treatment, she applied for Social Security disability successfully. Shortly thereafter, she terminated therapy but agreed to continue taking medications. Since then, her condition and motivation for improvement worsened significantly. Her compliance with treatment decreased, and the patient eventually became housebound.

In Case No. 1, the individual was not disabled but attempted to be labeled as such to obtain financial gain. In being rejected for disability benefits, he was able to find the motivation to return to full-time employment. This case also illustrates the impact that the cyclic nature of mental illness may have on the disability assessment. The patient presented in a hypomanic, but stable, condition during his evaluation; perhaps if he had presented during a full-blown manic or depressive episode, he might have qualified for disability compensation. In Case No. 2, the individual was not disabled but managed, through the resourcefulness of her attorney, to be judged disabled in a court of law. This patient seemed to be motivated by a desire to be taken care of and to assume no responsibility. Referral to psychotherapy was made in the hopes of helping her to regain the motivation to eventually return to gainful employment. In Case No. 3, the individual was legitimately disabled by her PTSD symptoms. However, the award of disability benefits may have contributed to her loss of motivation for improvement in her condition.

The cases presented here, and in the work reviewed, suggest that awarding disability benefits may result in adverse outcomes, which emphasize the importance of making an appropriate determination. Disability seeking may also represent a characteristic trait, particularly in those who are less disabled. While the selected cases seem to reflect a pattern of antisocial and dependent traits, we have observed, in our clinical experience, a broad range of character traits—for example, narcissistic and passive-aggressive, among others—that may impact on disability petitions. Further research may help clarify whether disability seeking is an independent entity, or a form of a mixed personality disorder.

GUIDELINES FOR OFFICE ASSESSMENT OF PSYCHIATRIC DISABILITY

The psychiatrist who is called upon to make an assessment of disability has several medicolegal obligations. First, there is an obligation to the patient, which is to certify disability only when appropriate, and to return the patient to work only when it is safe to do so. Second, there is an obligation to the employers and co-workers, which is to return the patient to work only when it is safe to do so (6).

The dual obligation of the psychiatrist may present an ethical dilemma, which arises when the treating psychiatrist is called upon to perform the assessment and report on his/her own patient. This scenario is very common, particularly in the Social Security system, which routinely solicits an opinion from the petitioner’s psychiatrist. Strasberger et al. (32) reviewed the role conflict involved when psychotherapists must also serve as expert witnesses in cases involving their own patients. While the article focuses primarily on psychotherapy dyads, their observations are relevant to psychiatrists in general. The authors argue that when a psychiatrist acts as the patient’s legal advocate, it often compromises the therapeutic relationship, regardless of the therapist’s position (i.e., “for” or “against” the patient’s wishes) in the case, and may cause harm to the patient (via therapeutic undoing) as well as to the therapist (who is placed at risk of legal liability). Consequently, the roles of therapist and expert witness are viewed as irreconciliable, and the authors argue in favor of keeping the two roles separate as much as possible. Our own observations of the difficulties in assessment illustrate how this ethical dilemma may be played out in the disability setting, and are essentially in agreement with Strasberger and colleagues. Nonetheless, because of the inevitability of this dual role, psychiatrists need to be comfortable with their dilemma, and not allow it to impede their task. A good understanding of the mechanics and criteria of a disability evaluation can help the psychiatrist to maintain a professional balance in such a situation.

The initial steps in an office assessment are to discuss the limits of confidentiality with the patient, and to obtain a signed release of information. The psychiatrist should obtain a standard history and, if indicated, perform a physical and neurologic exam. The mental status exam should focus particularly on concentration, attention, interaction, insight, judgment, and emotional state and lability (6).

It may be helpful if the psychiatrist understands the patient’s job description and is able to assess specific work-related abilities (e.g., comprehension; ability to follow instructions; and gauge ability to perform repetitive, complex, and varied tasks at an adequate work pace). However, if the patient has been unemployed for a long time (as is often the case), there may be no specific job description to speak of. In such a case, the psychiatrist may be better off using the wealth of clinical information available, so that the agency can assess for itself what the patient might be able to do in a job setting. Other items to assess include the worker’s ability to relate to and influence others, and to take responsibility. The side effects of medications and their impact on the worker should also be considered in the assessment (6). Other useful aids in assessment may include psychological, neuropsychological, and occupational therapy evaluations (6). There is controversy as to whether the treating psychiatrist should try to obtain collateral information from past psychiatric records, employers, and family, as this step enters the realm of a forensic investigation and may further complicate the treatment alliance (32). A psychiatrist who chooses to pursue such an investigation must take the time to discuss it thoroughly with the patient, and make sure to obtain written consent from the patient.

Once the assessment is complete, the psychiatrist must prepare the report. This task may take different formats (usually a letter or a form), but it has general guidelines (3, 6): 1) objectivity equals credibility, 2) diagnosis is not equal to disability, 3) symptoms and signs must be differentiated, 4) specific examples of function should be given, 5) only information relevant to the question asked should be given, 6) the prognosis with treatment should be emphasized, and 7) an opinion on disability need not be given. If the psychiatrist cannot be objective or obtain enough information, he/she may state this in the assessment form/letter, and offer a referral to an independent evaluator.

Dealing with patients who seek disability benefits requires tact to protect the alliance. When discussing the subject with the patient, it may be best to appear nonjudgmental and cautiously pessimistic. The psychiatrist may emphasize the difficulties involved in obtaining disability benefits, and remind the patient that the decision rests with the disability determination service or the courts, rather than with his/her psychiatrist. Some practitioners may fill out the assessment form in the presence of the patient. This approach saves time (and minimizes countertransference reactions, as the psychiatrist does not spend extra time on paperwork), and may embarrass the patient into truthfulness. If a claim is rejected, it is acceptable for the psychiatrist to commiserate with the patient, as a means of protecting the alliance. Arguments with the patient over disability should be avoided, however, and clinicians should consider termination if a patient tries to bully or threaten them.

If the patient obtains legal counsel in the disability petition, the psychiatrist may be asked to discuss matters with the attorney. To avoid misunderstandings, the psychiatrist should not use the patient as an intermediary, but rather should provide information requested directly to the attorney. This step may involve sending the attorney a copy of the patient’s record, filling out a form, or writing a letter. Some psychiatrists may choose not to bill the attorney for the consultation, so that their objectivity is less likely to be questioned. Finally, psychiatrists must beware of attorneys who try to pressure them into saying things that are inaccurate.

DISCUSSION:

Programs for the protection of the disabled are a necessary part of a civilized society (7). Published research data suggest that, by and large, the disability determination systems function in a fair and just manner. For example, a study by Massel et al. (23) suggested that, through elaborate testing batteries, most Social Security disability awardees are indeed unable to work. Likewise, a study by Rosenheck and colleagues (33) suggests that most people who are turned down for disability benefits are no more likely to return to work than those who receive benefits (presumably because they are too sick to do so). Also, the lack of disability benefits was shown to correlate with a greater incidence of homelessness in the mentally ill (34).

Nonetheless, the disability compensation system may be prone to abuse (35), and in some instances may do more harm than good, as the label of disability can encourage dependency and result in poorer treatment outcomes. The psychiatrist who knows how to do a competent disability evaluation plays a vital role in maintaining the integrity of the disability determination system, as well as the protection of the patient’s well-being, which requires familiarity with the criteria of disability to ensure that benefits go only to deserving individuals, and only for the necessary amount of time.

There is, unfortunately, a significant dearth of education on disability assessment in psychiatric training. This is particularly serious, because psychiatric residents generally find themselves caring for sicker, lower-functioning patients, usually in the setting of a university hospital clinic or in a community center affiliate of their residency program. It is these very patients who are most likely to apply for disability benefits, given the severity of their illness and their lower socioeconomic background.

Therefore, it is critical that psychiatric trainees be better prepared for the task of disability assessment. Since there is a lack of empirical research and protocols regarding education in disability determination, we wish to propose a number of ways in which residency training programs might begin to address this topic. Residency programs should consider incorporating at least one or two sessions on disability determination into the didactic curriculum for psychiatry residents, beginning early in the postgraduate second year. Such a program could include a lecture covering the different disability programs and general principles involved in making an assessment (as have been outlined in this article). In addition, a session reviewing actual disability petition cases could be used to guide the residents through the process of a disability assessment. Residents who receive a disability petition from a patient should be required to meet with a supervisor who has some expertise in the area, prior to assessing the patient and writing their report. In particular, the supervisor should review with the resident the ethical conflicts involved in disability determination. If logistically feasible, supervisors might consider observing the resident during the disability assessment, so as to give feedback afterward.

Residents who receive such guidance will likely feel much more comfortable when called upon to perform a disability assessment. Above all, they will develop competence in an important and socially significant application of the clinical assessment skills that residency teaches.

It must be observed that our proposed approach to education about psychiatric disability determination lacks empirical data to substantiate its effectiveness. It does, nonetheless, represent an attempt to organize our thoughts about, and our approach to, disability determination, in a reasonable manner. Therefore, this article is not intended to be simply an instruction guide on disability but is meant to serve as a means for setting a framework for the development of further thought and education on this important topic. We hope that the suggestions provided in this article will make the task of dealing with the disability petitioner more comprehensible, and less intimidating, to both the beginning and the experienced psychiatrist.
David Mischoulon, M.D., Ph.D.

ACKNOWLEDGMENTS:

The author thanks Dr. Theodore Stern, of the Massachusetts General Hospital’s Psychiatric Consultation-Liaison Service, for his critical reading of this manuscript, and his many helpful suggestions and encouragement.

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