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Antisocial and Borderline Personality Disorders in the Emergency Department: Conceptualizing and Managing “Malingered” or “Exaggerated” Symptoms

  • Victor HongEmail author
  • Loreen Pirnie
  • Ahmad Shobassy
Personality and Impulse Control Disorders (R Lee, Section Editor)
  • 7 Downloads
Part of the following topical collections:
  1. Topical Collection on Personality and Impulse Control Disorders

Abstract

Purpose of Review

Patients with antisocial personality disorder (ASPD) and borderline personality disorder (BPD) are often suspected of malingering or exaggerating symptoms, though there is no clear evidence that they do so more than other patients. We review the manifestations, etiology, and management of seemingly feigned symptoms in these disorders, particularly related to their presentation in the emergency department (ED).

Recent Findings

It is dangerous to assume that all patients with ASPD and BPD are intentionally feigning symptoms in the ED. However, when ASPD patients are known to be malingering, the focus should be shifted to addressing the motivation behind malingering and the patient’s true goals, ideally done with a curious rather than confrontational approach. BPD patients also may appear to be malingering or exaggerating symptoms, but their presentation often is more accurately attributed to the lack of ability to mentalize and effectively communicate their needs, as well as emotional hypochondriasis.

Summary

Education of ED staff, demonstrating genuine concern, and attempting to find a common goal with patients will aid in keeping an objective view of the patient’s distress, minimizing escalation, and optimizing patient outcomes.

Keywords

Antisocial personality disorder Borderline personality disorder Malingering Emergency department Factitious disorder 

Notes

Compliance with Ethical Standards

Conflict of Interest

The authors declare that they have no conflicts of interest.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by any of the authors.

References

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  1. 1.
    Boggild AK, Heisel MJ, Links PS. Social, demographic, and clinical factors related to disruptive behaviour in hospital. Can J Psychiatr. 2004;49(2):114–8.CrossRefGoogle Scholar
  2. 2.
    Goldstein RB, Dawson DA, Chou SP, Ruan WJ, Saha TD, Pickering RP, et al. Antisocial behavioral syndromes and past-year physical health among adults in the United States: results from the National Epidemiologic Survey on Alcohol and Related Conditions. J Clin Psychiatry. 2008;69(3):368–80.Google Scholar
  3. 3.
    Goodwin RD, Hamilton SP. Lifetime comorbidity of antisocial personality disorder and anxiety disorders among adults in the community. Psychiatry Res. 2003;117(2):159–66.CrossRefGoogle Scholar
  4. 4.
    Compton WM, Conway KP, Stinson FS, Colliver JD, Grant BF. Prevalence, correlates, and comorbidity of DSM-IV antisocial personality syndromes and alcohol and specific drug use disorders in the United States: results from the National Epidemiologic Survey on Alcohol and Related Conditions. J Clin Psychiatry. 2005;66(6):677–85.CrossRefGoogle Scholar
  5. 5.
    Pascual JC, Corcoles D, Castano J, Gines JM, Gurrea A, Martin-Santos R, et al. Hospitalization and pharmacotherapy for borderline personality disorder in a psychiatric emergency service. Psychiatr Serv. 2007;58(9):1199–204.CrossRefGoogle Scholar
  6. 6.
    •• Hong V. Borderline personality disorder in the emergency department: good psychiatric management. Harv Rev Psychiatry. 2016;24(5):357–66.  https://doi.org/10.1097/HRP.0000000000000112. This article offers guidelines for how to optimally manage individuals with borderline personality disorder in the emergency setting, utilizing the Good Psychiatric Management framework.
  7. 7.
    Penfold S, Groll D, Mauer-Vakil D, Pikard J, Yang M, Mazhar MN. A retrospective analysis of personality disorder presentations in a Canadian university-affiliated hospital’s emergency department. BJPsych Open. 2016;2(6):394–9.CrossRefGoogle Scholar
  8. 8.
    American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 5th ed. Arlington: American Psychiatric Publishing; 2013.CrossRefGoogle Scholar
  9. 9.
    • Rumschik SM, Appel JM. Malingering in the psychiatric emergency department: prevalence, predictors, and outcomes. Psychiatr Serv. 2019;70(2):115–22.  https://doi.org/10.1176/appi.ps.201800140. This study analyzed a survey completed by attending psychiatrists in a psychiatric emergency room regarding patient visits ( N = 405) to learn about the prevalence of malingering in this setting and its primary characteristics. It found that about one-third of the patients were suspected of malingering and suspecting of malingering influenced disposition. CrossRefGoogle Scholar
  10. 10.
    Rogers R. Development of a new classificatory model of malingering. Bull Am Acad Psychiatry Law. 1990;18(3):323–33.Google Scholar
  11. 11.
    Black DW, Gunter T, Loveless P, Allen J, Sieleni B. Antisocial personality disorder in incarcerated offenders: psychiatric comorbidity and quality of life. Ann Clin Psychiatry. 2010;22(2):113–20.Google Scholar
  12. 12.
    McDermott BE, Sokolov G. Malingering in a correctional setting: the use of the structured interview of reported symptoms in a jail sample. Behav Sci Law. 2009;27(5):753–65.  https://doi.org/10.1002/bsl.892.CrossRefGoogle Scholar
  13. 13.
    Brady MC, Scher LM, Newman W. “I just saw Big Bird. He was 100 feet tall!” Malingering in the emergency room. Curr Psychiatr Ther. 2013;12(10):33–40.Google Scholar
  14. 14.
    •• Simpson SA, Sharp CS. Malingering disorders. 2017. This article is a comprehensive analysis of the issue of malingering and how to detect and manage it. Google Scholar
  15. 15.
    Simon JR, Dwyer J, Goldfrank LR. The difficult patient. Emerg Med Clin North Am. 1999;17(2):353–70 x.CrossRefGoogle Scholar
  16. 16.
    Gabbard GO. An overview of countertransference with borderline patients. J Psychother Pract Res. 1993;2(1):7–18.Google Scholar
  17. 17.
    Zanarini MC, Frankenburg FR. Emotional hypochondriasis, hyperbole, and the borderline patient. J Psychother Pract Res. 1994;3(1):25–36.Google Scholar
  18. 18.
    Deans C, Meocevic E. Attitudes of registered psychiatric nurses towards patients diagnosed with borderline personality disorder. Contemp Nurse. 2006;21(1):43–9.CrossRefGoogle Scholar
  19. 19.
    • Derks Y, Westerhof GJ, Bohlmeijer ET. A meta-analysis on the association between emotional awareness and borderline personality pathology. J Personal Disord. 2017;31(3):362–84.  https://doi.org/10.1521/pedi_2016_30_257. This meta-analysis is aimed at exploring the evidence that the BPD characteristic of emotional dysregulation is due to low levels of emotional awareness. A moderately positive correlation was found after analyzing 39 studies that met their criteria. CrossRefGoogle Scholar
  20. 20.
    Merckelbach H, Prins C, Boskovic I, Niesten I, À Campo J. Alexithymia as a potential source of symptom over-reporting: an exploratory study in forensic patients and non-forensic participants. Scand J Psychol. 2018;59(2):192–7.  https://doi.org/10.1111/sjop.12427.CrossRefGoogle Scholar
  21. 21.
    Bolton JM, Robinson J. Population-attributable fractions of Axis I and Axis II mental disorders for suicide attempts: findings from a representative sample of the adult, noninstitutionalized US population. Am J Public Health. 2010;100(12):2473–80.  https://doi.org/10.2105/AJPH.2010.192252.CrossRefGoogle Scholar
  22. 22.
    Fonagy P, Bateman A. The development of borderline personality disorder--a mentalizing model. J Personal Disord. 2008;22(1):4–21.  https://doi.org/10.1521/pedi.2008.22.1.4.CrossRefGoogle Scholar
  23. 23.
    Gunderson JG. Borderline personality disorder: a clinical guide. American Psychiatric Pub; 2009.Google Scholar
  24. 24.
    Fonagy P, Bateman AW. Mechanisms of change in mentalization-based treatment of BPD. J Clin Psychol. 2006;62(4):411–30.CrossRefGoogle Scholar
  25. 25.
    Beautrais AL, Joyce PR, Mulder RT, Fergusson DM, Deavoll BJ, Nightingale SK. Prevalence and comorbidity of mental disorders in persons making serious suicide attempts: a case-control study. Am J Psychiatry. 1996;153(8):1009–14.CrossRefGoogle Scholar
  26. 26.
    Oldham JM. Borderline personality disorder and suicidality. Am J Psychiatry. 2006;163(1):20–6.CrossRefGoogle Scholar
  27. 27.
    Zanarini MC, Frankenburg FR, Hennen J, Reich DB, Silk KR. Prediction of the 10-year course of borderline personality disorder. Am J Psychiatry. 2006;163(5):827–32.Google Scholar

Copyright information

© Springer Nature Switzerland AG 2019

Authors and Affiliations

  1. 1.Department of PsychiatryUniversity of MichiganAnn ArborUSA

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