A 34-year-old man comes to the emergency department for evaluation of abdominal pain. He reports severe pain unrelated to meals that is sharp, stabbing, and 10 out of 10 in severity. The patient has been hospitalized twice in the past year for similar symptoms and states that a diagnosis was never found. He declines when asked to sign a release of information to obtain his prior medical records. Vital signs are within normal limits. On physical examination, heart and lung sounds are normal. Abdomen is soft and nondistended with normoactive bowel sounds. The patient grimaces and moans in pain throughout the evaluation. Laboratory evaluation and abdominal CT scan show no abnormalities. After hearing the results, the patient asks for a note to excuse him from work so that he can recover at home for a few days. Which of the following additional features is most likely to be present in this patient?

Question

A 34-year-old man comes to the emergency department for evaluation of abdominal pain.  He reports severe pain unrelated to meals that is sharp, stabbing, and 10 out of 10 in severity.  The patient has been hospitalized twice in the past year for similar symptoms and states that a diagnosis was never found.  He declines when asked to sign a release of information to obtain his prior medical records.  Vital signs are within normal limits.  On physical examination, heart and lung sounds are normal.  Abdomen is soft and nondistended with normoactive bowel sounds.  The patient grimaces and moans in pain throughout the evaluation.  Laboratory evaluation and abdominal CT scan show no abnormalities.  After hearing the results, the patient asks for a note to excuse him from work so that he can recover at home for a few days.  Which of the following additional features is most likely to be present in this patient?

Quizplus · Accepted Answer

11ec160b_3626_3e39_9249_4f4f6e5dd185_MD0001_00 This patient's subjective report of severe pain and distress without objective findings (normal physical examination, repeated hospitalizations without diagnosis), refusal to provide release for prior medical records, and evidence of external gain (time off from work) are suggestive of malingering. Malingering is a behavior characterized by intentional falsification or exaggeration of symptoms to obtain an obvious external reward (eg, medications, financial gain, avoidance of work responsibilities or criminal prosecution). These patients often have a dramatic presentation based on subjective complaints rather than objective findings and may refuse to provide a release of information. Malingering should be differentiated from factitious disorder, in which the patient intentionally falsifies symptoms with the goal of assuming the patient role, rather than obtaining an external reward. Patients with factitious disorder often welcome invasive diagnostic testing and surgical procedures. In contrast, patients who are malingering will often refuse to undergo invasive medical procedures. (Choice A) Chronic feelings of helplessness are associated with depression and some personality disorders. Although patients with these disorders may also be preoccupied with somatic symptoms, they do not intentionally exaggerate or falsify their symptoms for an external gain like this patient. (Choice B) Excessive anxiety related to unexplained physical symptoms is characteristic of somatic symptom disorder. These patients do not intentionally falsify their symptoms; their presentation is genuine. In contrast, this patient is not excessively anxious and appears to be exaggerating his symptoms for an external gain. (Choice C) Preoccupation with having a serious illness is a key feature of illness anxiety disorder. These patients fear having a serious diagnosis despite few or no symptoms. This patient has exaggerated symptoms and is focused on avoiding work responsibilities rather than fear that a serious medical condition has been missed. (Choice D) Although malingering can be associated with conditional threats of self-harm, suicide, or violence (eg, a patient threatens to kill himself if demands are not met), recurrent suicidal behaviors (eg, gestures and attempts) are associated with borderline personality disorder and are often motivated by fears of abandonment. Educational objective: Malingering is a behavior characterized by intentional falsification or exaggeration of symptoms to obtain an obvious external reward. The presentation is typically based on a subjective report of symptoms, and these patients commonly refuse to undergo invasive medical procedures.

A 34-Year-Old Man Comes to the Emergency Department for Evaluation