CASE STUDIES IN HYPERTENSION JOEL HANDLER, MD, SECTION EDITOR
Malingering: An Unusual Cause of Resistant Hypertension
Article first published online: 26 APR 2012
© 2012 Wiley Periodicals, Inc.
The Journal of Clinical Hypertension
Volume 14, Issue 7, pages 475–478, July 2012
How to Cite
Handler, J. (2012), Malingering: An Unusual Cause of Resistant Hypertension. The Journal of Clinical Hypertension, 14: 475–478. doi: 10.1111/j.1751-7176.2012.00633.x
- Issue published online: 2 JUL 2012
- Article first published online: 26 APR 2012
A 45-year-old man with a history of chest pain, headache, narcotic dependency, and uncontrolled hypertension presented to the emergency department at Lakeview Hospital, in Anaheim, California, with a 3-day history of worsening chest pain and headache. He completed a 3-day hospitalization with negative objective findings a month previously when he presented with headache and chest pain. Following that discharge he felt well and reported home blood pressures in the 140s/80s mm Hg. Three days prior to admission, throbbing left-sided chest pain radiating to the left shoulder returned, accompanied by worsening right occipital headaches. Home blood pressures were above 200/100 mm Hg despite self-titration of labetolol to 800 mg 3 times a day per instructions of his former primary care physician in northern California. Additionally, vision in the baseline “85% blind” right eye had worsened. He complained of dry heaves along with chronic left-sided weakness and numbness from a past stroke. Initial emergency department blood pressure was 229/143 mm Hg. The patient stated adherence to an antihypertensive regimen of lisinopril 40 mg, spironolactone 25 mg, labetolol 800 mg twice a day, minoxidil 10 mg twice a day, furosemide 40 mg twice a day, amlodipine 10 mg, and terazosin 20 mg at bedtime.
The patient had a history of refractory hypertension since age 18 and had repeated negative workups for secondary hypertension at multiple hospitals in northern California. Retrieval of some of those records described a small right basal ganglion intracranial hemorrhage in 2009, but confirmatory imaging studies were unavailable and brain computed tomography scan findings in southern California were normal. According to his northern California primary care physician, the patient had been seen by multiple cardiologists, endocrinologists, and neurologists. Headaches, attributed to uncontrolled hypertension and tension, were managed with topiramate 50 mg twice a day, chronic long-acting morphine, and dilaudid. Medical history was positive for gastric bypass surgery leading to a 120-pound weight reduction and a negative endobronchial biopsy for hemoptysis. The patient had separated from his wife in northern California and moved to southern California to live with his sister. His first two hospital days were marked by refractory headaches and hypertension with blood pressures consistently above 180/110 mm Hg on his outpatient regimen. Creatinine was 1.2 mg/dL (normal 0.6–1.2 mg/dL), spot urine microalbumin was undetectable, echocardiogram showed mild left ventricular hypertrophy, and a urine toxicology screen was positive only for prescribed opiates. A fundoscopic examination by an ophthalmologist was normal. In addition to long-acting morphine 30 mg twice a day, the patient was asking for dilaudid 4 mg every 4 hours for headache.
A hospitalist asked a nurse to make sure the patient “was really taking his blood pressure pills.” When the nurse brought a flashlight into the room, the patient asked what it was for and the nurse explained that she wanted him to open his mouth to make sure the pills were swallowed. The patient had pocketed the pills in his cheek and turned his head aside to swallow them. Once medication ingestion was regularly confirmed, blood pressures were consistently approximately 120/70 mm Hg on lisinopril 20 mg and labetalol 200 mg twice a day. Headaches resolved.
Diagnosis of Malingering and Difficulty of Detection
The Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition, Text Revision) (DSM-IV-TR) describes the essential feature of malingering as “the intentional production of false or grossly exaggerated physical or psychological symptoms, motivated by external incentives.”1 The external incentives for malingering include obtaining drugs, obtaining financial compensation, evading criminal prosecution, and avoiding work or military duty.
Although narcotic-seeking behavior was clearly seen in this patient, normal physician resistance to making opiates available was reduced because there appeared to be a reasonable explanation for his pain: severe headache due to resistant hypertension. What made this patient unusual was the fact that hypertension proved refractory even in the hospital.
The DSM-IV-TR associates “presence of antisocial personality disorder” with malingering and some of those features were apparent to physicians caring for this patient. There were dozens of hospitalizations throughout the state of California, but evidence for this fact required significant detective work because the patient was not offering history further back than a couple of hospitalizations, sparse hospital records did not include information related to prior hospitalizations, and discharge summaries indicated that the patient had refractory hypertension rather than drug-seeking behavior. Sometimes there were records of neurology consultations stating that severe hypertension was causing the headaches, with contrary opinions from nephrologists stating that severe headaches were causing the hypertension. Multiple hospitals were involved and hospitalizations were short (never more than a few days).
Differentiation of Malingering From Factitious Disorder
Factitious disorders, of which the most notorious example is Munchausen’s syndrome, is characterized by the “intentional production of physical or psychological signs or symptoms,” but in contrast to malingering, the motivation is “a psychological need to assume the sick role.”1 The subtype of factitious disorder “with predominantly physical signs and symptoms” includes feigned or self-produced pain, impaired wound healing, hypoglycemia, anemia, seizures, diarrhea, and fever.2DSM-IV-TR diagnostic criteria for factitious disorder are (1) intentional production or feigning of physical or psychological signs or symptoms, (2) motivation for the behavior is to assume the sick role, and (3) absence of external incentives for the behavior.3
Malingering and Factitious Disorder Overlap Syndromes
Because the differentiation of malingering and factitious disorder relies on the reason for the behavior as interpreted by the physician, there is a spectrum of uncertainty, overlapping conditions, and bias leading to mistaken diagnosis. Usually the direction of physician bias leads to a diagnosis of malingering when there is any indication of secondary reward and self-harm is less severe.4 Deliberate self-harm, in the absence of suicidal thought, is a threshold for consideration of factitious disorder rather than malingering.4,5 In this light, however, for the present case, the diagnosis of pure malingering was not clear cut.
The patient was knowledgeable about the stroke risk of uncontrolled hypertension and there was a prior hospitalization for a right basal ganglion intracranial hemorrhage attributed to uncontrolled hypertension. Motivation for surreptitiously falsifying ingestion of antihypertensive medication was primarily the external incentive of obtaining opiates, consistent with malingering. Apparent lack of concern regarding the risk of another perhaps devastating stroke may have been a measure of the severity of his opiate addiction, or it may have been a marker of motivation to assume the sick role, consistent with factitious disorder. In this case, there is inability to completely distinguish factitious disorder, which is considered a psychological disease, from malingering, which is considered a conscious calculation.
On the other end of the overlap between malingering and factitious disorders are instances where Munchausen syndrome has entered the legal system for secondary gain.6–8 Cases have been reported of (1) self-induced cutaneous infections following orthopedic surgery leading to medico-legal action, and (2) allegations of eye drop tampering against the product manufacturer.6 In the latter case, a woman had been using binoculars to dilate her pupils before staring into the sun causing a series of corneal and retinal burns leading to blindness. In each of these cases, the severity of factitious harm outweighed potential secondary gain so that factitious disorder was felt to be the primary condition.
Explaining Malingering Behavior: Psychometric Test Detection
Presently accepted models to explain the motivation of a malingerer are the criminologic model and the adaptational model.9 An example of the criminologic model includes obtaining illicit drugs to sell on the street. Examples of the adaptational model occur in adversarial settings where the malingerer is feigning a psychological disorder or disease in a criminal trial to escape a severe sentence. Types of malingering have been described as (1) pure: fabricating an illness that never existed; (2) partial: where true symptoms are mild but exaggerated; and (3) false imputation: where symptoms from an unrelated condition are ascribed to the condition where reward can be obtained, such as back pain occurring from a prior fall ascribed to a motor vehicle accident.9 In the present case discussion, headache was likely to have been purely fabricated.
Malingering is often a difficult clinical diagnosis. A mistaken diagnosis is harmful when true disease is missed, and excessive diagnostic testing is costly and potentially injurious when malingering is not considered. Various neuropsychological testing measures have been developed as stand-alone tests or as embedded measures in more general testing formats. However, with experience, malingerers have developed awareness of single detection strategies, leading to the creation of complex multipronged detection strategies with imperfect utility.10,11 Some attorneys may undermine psychometric detection of malingering by coaching their clients.12
Although malingering is generally felt to be entirely a conscious behavior, once learned, there is evidence of a subconscious repository for symptom amplification. Undergraduates instructed to exaggerate symptoms on a malingering test continued to report more psychological symptoms than controls when later asked to respond honestly to the same test.13 The conscious calculation of benefit vs harm in shaping malingering behavior implies that the potential for harm could reduce malingering. In an experimental study, three groups of first-year psychology students were administered standard personality testing under different conditions. One group was offered $100 to simulate psychological impairment, another group was offered the same inducement with the additional caveat that getting caught would lead to loss of course credit, and there was a third control group. The group offered both the financial incentive and the warning demonstrated reduced malingering compared with the pure inducement group, but still had higher malingering scores than the control group.12
A higher-than-expected rate of malingering may be related to its acceptability. A nationwide survey found that 20% of Americans felt that purposeful misrepresentation of claims in the compensation system was acceptable.11 At least 20% of patients with legal complaints and chronic pain referred to a single neuropsychological clinic were found to have evidence of malingering on two diagnostic systems, Malingered Pain-Related Disability and Malingered Neurocognitive Dysfunction.11 Confounding factors, not discernible from malingering on these tests, noted by the authors, included psychological overlay and somatization disorders.11
Distinguishing Illnesses of Deception From Similar Psychiatric Disorders
The differential diagnosis, which includes the two illnesses of “deception,” malingering and factitous disorder,14 also includes nondeceptive somatization disorder and hypochondriasis. The DSM-IV-TR description of somatization disorder requires multiple physical complaints prior to age 30 occurring over several years that cannot be explained medically or appear exaggerated out of proportion to what can be explained medically.15 Criteria are 4 different pain site symptoms, 2 gastrointestinal symptoms, 1 sexual or reproductive symptom other than pain, and one pseudoneurological symptom.16 Hypochondriasis is a preoccupation with fear of disease based on misinterpretation of bodily symptoms, which is persistent despite medical evaluation and reassurance, but does not reach delusional intensity.16 The present case does not fulfill criteria for these disorders.
How Often Does Opioid Administration for Nonmalignant Pain Lead to Addiction?
Malingering to perpetuate delivery of narcotic agents in this case probably arose as a consequence of opioid addiction. The question arises of how often chronic nonmalignant pain patients exposed to chronic opioid analgesic therapy develop addiction. Fortunately, that fraction appears to be very low. In a structured evidence-based review to answer this question, 79 references were subjected to 12 quality criteria, and 67 reports scored a quality rating >65%.17 The summary finding of the high-quality reports was that 0.59% of chronic nonmalignant pain patients exposed to chronic opioids developed abuse.17
Lists of what has been characterized as drug-seeking behaviors include demands for immediate action, unusual knowledge of controlled substances including requests for a specific agent, nonadherence with nonopioid alternatives, lack of interest in diagnosis, exaggeration of medical problems, mood disturbances, multiple visits for the same complaint, lost prescriptions, and adoption of an unmeasurable complaint such as headache.18–20 The current case was more believable because he described his headache in a nonemotional fashion. This patient raised red flags because of recurrent headache hospitalizations and dependence on morphine and especially dilaudid. His drug-seeking problem would have been recognized and managed as the primary concern if he did not have refractory severe, uncontrolled hypertension.
Disguising Antihypertensive Medication Ingestion in the Hospital as a Cause of Refractory Uncontrolled Hypertension
This patient with abundant experience in the hospital and strong malingering drive developed a technique to mask pill ingestion even in the hospital with standard nurse observation by pocketing his antihypertensive medication in his cheek. Presumably he would expel this medication when left alone. Requests for dilaudid became so frequent and sustained hypertension was so poorly explained that closer patient observation was requested, leading to discovery of this behavior. Within a few months of the experience with this malingering individual, a schizophrenic patient with uncontrolled hypertension in the hospital was noted to similarly disguise noningestion of antihypertensive medication despite observation of pills going into the mouth followed by a water swallow.
Treatment of Malingering: Case Outcomes
The recommended treatment for malingering, once discovered, is variable. Confrontation is one approach, but some specialists emphasize the importance of allowing the malingerer to save face.9 The ability to change behavior depends on the overall psychological health of the patient, along with the size of the secondary reward. Associated psychological aspects such as depression may be treatable and reduce the self-perceived need to malinger, but antisocial personality traits often associated with malingering are not treatable. The health professional needs to avoid care withdrawal, also understanding that family may or may not already be cognizant, and therefore either supportive or disapproving of the patient’s malingering behavior. A nonconfrontational approach allows the patient to continue the complaint without admitting that the symptoms are falsified.9
Following the second hospitalization when “cheeking” of antihypertensive medication was discovered, the malingering patient was never seen in our health care system again. The schizophrenic patient exhibiting similar behavior of falsified ingestion suffered a severe stroke, after which his hypertension was well controlled on three medications administered via a gastrostomy tube.
- 1American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. Fourth Edition, Text Revision (DSM-IV-TR™). Washington, DC: American Psychiatric Association, 2000; 739–741. V65.2 Malingering.
- 2Ibid. DSM-IV-TR™ Factitious disorders, 513–517.
- 3DSM-IV-TR™ Guidebook. eds, , , . Chapter 15: Factitious disorder and malingering. Arlington, VA: American Psychiatric Publishing, Inc. 2004; 285–288.
- 4The A, B, C’s of factitious disorder: a response to Turner. Medscape J Med. 2009;11:27., , .
- 8Illness or illusion? distinguishing malingering and factitious disorder. Primary Psychiatry. 1995;2:39–41..
- 15Ibid. DSM-IV-TR™ 300.81 Somatoform Disorders. 485–511.
- 16Ibid. DSM-IV-TR™ Guidebook. Chapter 14: Somatoform Disorders. 267–283.
- 17What percentage of chronic nonmalignant pain patients exposed to chronic opioid analgesic therapy develop abuse/addiction and/or aberrant drug-related behaviors? A structured evidence-based review Pain Medicine. 2008;9:444–459., , .
- 19Recognizing patients with drug seeking behavior. Mich Med. 2004;103:14–15..