IT WAS with surprise, chagrin, and mild admiration that I recently learned a patient I had seen for an evaluation had not told one word of truth. Heel to toe, starboard to port, every life detail he offered was complete fabrication. Call it a paradox: he was genuinely false.
Psychiatrists are supposed to have an expertise in human nature. But maybe it's wrong to think anyone can penetrate a soul that does not wish to be seen. In this case, someone had come to the clinic for something other than our expertise. Abusable prescriptions are the traditional uncreative reason - but that wasn't what he wanted. He made no request for Xanax, and had no stuttering recollection that only one medication had ever controlled his anxiety, and he wasn't certain but he thought it might begin with a Z. Also, drug-seeking behavior isn't so hard to detect; there's something piteous and defiant about it at the same time - you feel you are just the next landing place in a desperately roaming life.
He probably lied to us because he wanted services the clinic offers to those who qualify: help with housing, vocational training, medical insurance, funding. The trauma and depression he described was heart-rending; the tears looked salty. It never occurred to us not to believe his stories. Weeks afterward, the intake coordinator told me she had learned additional facts from another source that made those stories impossible.
Impenetrability is a tricky thing. If he had been feigning psychosis, we might have had a better chance of unmasking him. There are clues: continuous inaudible hallucinations, black and white visions, indiscriminate agreement with every symptom, inconsistencies between his self-report and our observations.
I once met a man in the intensive care unit who claimed to be unable to think straight for his delusions, though he had no trouble injecting himself in an orderly way with pain medications when nurses left the room and watched him on the monitor.
These clues can be found on Google, under malingering. It gives no trade secrets away to disclose them. Different fields also have different "tells"; in neurology, if you drop the limp hand of an unconscious patient straight onto his face, it lands with a direct slap. Drop it onto the face of someone feigning unconsciousness, and miraculously, it lists to the right or left of center. Someone faking a seizure is rarely incontinent, his blood chemistry is not off-balance, and his electroencephalogram is unnaturally serene.
But in psychiatry, it is still easy to be fooled. One study found that psychiatrists are unable to recognize fakery during interviews almost half the time - odds no better than chance. One of the problems is subjectivity of symptom report. Another one (strange to think of this as problematic) is that we meet people with belief. We don't want to consider deception in the differential diagnosis. A former teacher once told me it is necessary to begin every relationship by finding something to admire. The admiration may not last, but it must be present at first, not only for the sake of our patients, but for the sake of our selves. Otherwise the job is strictly forensic.
We like to start with sympathy. Being duped by a stranger, though, gave me pause for thought. Sympathy is a soft, fur-lined emotion. It doesn't sniff the air suspiciously. These are times in psychiatry, and in history, when being duped has devastating potential. Sniffing the air is very sensible.
Yet, I wasn't sorry. I am not ready to give up the pleasure of viewing a stranger as honorable on first meeting, or of taking their pain at face value. It's still preferable to give credit where it is not due rather than to suspect globally. Sniffing is a lonesome and unsatisfying activity.
The fabricated person who came to our clinic meant to misuse our services. Based on the story he told (and we believed) we qualified him immediately and unquestioningly for the services. What happened next was more interesting than the deception. After we qualified him, he simply disappeared. I know why he came. But after all the trouble he took to talk us into himself, I don't know why he left.
Elissa Ely is a psychiatrist.
