Recognizing Manipulative
Behaviors by Patients
--by Tom Trimble, RN CEN

ENW! feels that a catalog of manipulations can be instructive, but cautions that many patients have real basis for behaviors that help them to control their environment or to maintain direction of desired medical interactions.  To do so, particularly with socially less acceptable disorders or with chronic disorders that may be difficult to demonstrate and which arouse little sympathy may be adaptive rather than maladaptive.  Always be prepared to give the benefit of the doubt to the patient and seek to see things from the patient's point of view.  Clinical observation and vigilance is not characterized by cynicism.

The purpose of this article is solely to orient new staff to recognize the subtleties of patient interactions, which they may not yet have encountered, that may be intended to manipulate the caregiver's emotions and attitudes to help the patient achieve his goals, rather than through direct negotiation. While some examples concern patients with pain problems, it is very important to treat equally and fairly all patients who complain of pain. It is not usually possible in a single ED visit to verify malingering or fictitious complaints. Good pain management requires ongoing follow-through which cannot usually be provided in the emergency setting. Patients who have frequent similar visits should have follow-up with a Pain Management specialist and their primary health care provider and a common treatment plan developed and individualized for that patient. ENW! does not in any way denigrate any patient or suggest unfair treatment.

1. [The Most Famous] "There's only one pain medicine that works for me; begins with a "D", Duh . .Dem . . .Demerol!"

2. ["You're So Great!"]  "---I remember you! You took care of me before . . . You're the BEST nurse . . .---Not like that other one that was so MEAN and made me wait hours for some pain medicine!"

3. [Any Drug Allergies?]  "I'm allergic to ALL pain medicines EXCEPT Dilaudid."

4. ["I really have disease"]  "I'm here from out of town (thousands of miles away). And, I've just gotten an attack of {chest pain, kidney stones, my rare disease], I'm having terrible pain. I just happen to have a copy of my {chart, X-rays, doctor's letter} with me . . . No, I don't have a copy of the cath report . . . ---I forget where that was done!"

5. [Allergies to Alternative Agents]  "My allergies are Codeine, Toradol™, Darvon™, Aspirin and NSAIDs, ALL psych meds; ---Percodan™'s OK!  {Five days after the release to market of Toradol™ occured the first probably spurious claim to me of "allergy" to the new drug.}

6. [Uniquely Tolerant]  "I have a 'high tolerance to pain medicines' ---That's NOT enough; I'm going to need at least 150 mgms of Demerol™ and 75mgms of Vistaril™! {Last reported episode of pain six months ago}

7. ["Your Golden Opportunity"] "Why, yes, I am the Executive Producer for The Rolling Stones, a really big Hollywood Movie Director, International Financier, Grand Vizier for Ali Pasha, etc., and I know all those other famous people,  and can get you a fabulous travelling job as personal Nurse to so-and-so.  Here's my card.  I want you to come see me after the end of the month when I get back to Monaco and I'll take you all around in my personal 150' yacht . . . Oh, yes, you can bring a couple of friends, too.  I'm just so grateful to you for helping me out."

8. ["The Stone Soup Method:"]  "Oh, good, that's beginning to feel a little better, Thank You! . . . Say, do you think you could get me a couple of extra pillows, ---and, ---and, some warm blankets?  This bed is so hard.  I know that it's not your fault.  That's great.  Thank You.   Gee, I really haven't eaten . . . Do you think that you could find a little something to eat.  That would be great.  Maybe, some turkey and some nice soup . . . Yes, thank you so much.  And, could you just turn off the light as you go?   Do you have a TV here or anything?  Say, by the way, . . .

9. [Contentious] "Say, WHO does that doctor think he is? ---Saying that he can't give me any pain medicine unless he can diagnose a treatable disease!  He's a Quack!  He's no REAL doctor . . . ---I've been to all the best doctors there are!   You can't get away with this!  I want a phone to call my lawyer RIGHT NOW!   I'm gonna sue Your Ass!  You're never gonna work again!  I want your NAMES!   ---And I  want your Supervisor, RIGHT NOW!

10.   ["The 'Rush' Act":]  "You don't have to give it that slow!  ---Just push it right in!"

11.   ["Sarah Bernhard:"]  When surreptitiously observed, patient appears comfortable or resting, yet when patient knows himself to be watched there is a histrionic display of writhing and moaning and grimacing; effort is put forth only when secondary benefits may be gained.

12.   ["The Dying Swan":]  The patient who has somehow gotten in the car that has brought him {usually with "excruciating" back pain} now professes to be entirely incapable of self-movement to extricate himself to the awaiting gurney.   Often compounded with a "flop act" when trying to undress the patient for monitoring and examination which appears without evidence for recognizable neuromuscular disease.   Seemingly without gumption to resist or overcome the influence of any actual disease.

13. ["Pseudo-Collapse":]  For a dramatic entrance, or to forestall unwanted discharge, the malingerer goes to a public area (with witnesses) and ostentatiously crumples to the floor and begs for help.  No injury has occurred in the "Hollywood Fall".

14. [The False Swoon  & "The Drop Test':]   The malingered loss of consciousness has inconsistent or self-beneficial findings to the exam, such as the "victim's" hand and arm, seemingly flaccid, when elevated and dropped over the face defies gravity and cannot fall upon the victim in injurious fashion. but falls gracefully aside.  Resistance to eye-opening, lack of Lash reflexes, and breath-holding during administration of Aromatic Spirits of Ammonia, are not normal responses.

15. [Another Tip-Off Phrase:]  "None of the Doctors has ever been able to give me a diagnosis or to fix it.  I've been to Doctor after Doctor; it's always the same.  I want you to tell me what's wrong."

"What's Your B.S. Quotient?: Recognizing Manipulative Behaviors by Patients"
[http://ENW.org/BSQ.htm]
is a WebArticle presented by
Emergency Nursing World ! [http://ENW.org]
©Tom Trimble, RN [Tom@ENW.org]

MP3 files provided by: Joe Lex, MD
 

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