Tales from the Couch

Seeing the patient from psychiatry’s perspective

Show Me The Money

When You See Dollar Signs In A Patient's Eyes

 

I was asked to evaluate psychiatrically, Mr. Smith, a Workers Compensation claimant. While working in construction, he struck his head, sustaining a brief loss of consciousness. At a nearby hospital, he was examined, x-rayed, had an MRI and follow up examinations. No abnormalities were noted. A year later, he hadn’t returned to work.

When I was asked me to examine him, he presented as a befuddled 28 year old man whose father drove him to my office. During the examination, he stared off into space. He was unresponsive to my questions, and when he answered, did so with non sequitors. When asked the date, he replied remotely, “I don’t know….nineteen something…” (It was 2012). His presentation was that of a compromised individual with little cognitive awareness of the world. It was as if the blow to his head had left him completely dysfunctional. It was impossible to obtain any meaningful information from him and the examination was an exercise in futility.

I grew suspicious, since his presentation was not consistent with Post-concussion Syndrome. I suspected this was an “act” deriving from Mr. Smith’s fantasy of how a “brain damaged” person would present. Mild, closed head injuries could cause headaches; blurred vision; irritability and mild cognitive impairment (all usually resolving over weeks or months). Mr. Smith’s presentation was inconsistent with that diagnosis. Rather, his clinical picture seemed—to my experienced eye—catastrophically exaggerated.

I interviewed his father, separately. “He’s changed completely. He stares off into space,” he said. I tried to obtain a description of his son’s activities and was told, “He does nothing. Just sits in his room and comes out to eat.” I also obtained his son’s developmental, educational, work and social history. There was no prior history of head trauma or any psychiatric or psychologic difficulty.

I said nothing about my suspicions, but prepared a report detailing the history and findings. The differential diagnoses included severe Traumatic Brain Injury (which I felt was unlikely); Post-concussion Syndrome (severe and extended, also unlikely) and Malingering (feigning or exaggerating illness, most likely). I recommended neuropsychological testing to further delineate the claimant’s presentation and the possibility of Malingering.

In a separate memo to the employer, I stated the claimant’s presentation was atypical and seemed feigned. I suggested he be placed under surveillance.

I heard nothing about Mr. Smith until months later when I received a call from the employeer's attorney who had referred the case to me. “Do you remember Mr. Smith…the man who hit his head?”

“Yes. What happened with him?”

“We put him under surveillance and have video of him doing carpentry on three different construction sites. He was angling for a huge settlement.”  

As I’d learned over the years, when evaluating any patient in the context of litigation, you must always be aware that money can, in some instances, play an enormous role in a patient’s presentation. “Disproportionate disability” or “Malingering” (outright fakery) can be in play.

My job includes teasing apart legitimate injury from distorted disability. I must have an “ear” tuned, listening for cognitive dissonance. While most claims are legitimate, some  claimants are simply trying to milk the system for money.

Mark Rubinstein

Author of Mad Dog House and Love Gone Mad and The Foot Soldier

 

 

 

 

 

 

Mark Rubinstein, M.D., is a former professor of psychiatry at Cornell. His most recent book is the novel Mad Dog House.

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