True pain and suffering: There is no place for manipulation

“Well then, if you won’t prescribe the Xanax for me, I guess I’ll just have to get it off the street.”

“If you send me home, I promise you’ll be reading about me in the obituaries tomorrow.”

“I’m in terrible pain. You have to treat me. You have to give me narcotics. If you don’t, I’ll call the state medical board and report you.”

I hate to be manipulated.

Hate. It.

There is a certain subset of patients, many of whom have primary personality disorder problems or abuse substances, who come to the ED with nothing more in mind that getting exactly what they want. They will say anything, do anything, act any way, pull any stunt to get their way.

These are the folks who will hit themselves to cause bruises to make it look like they are being abused. The man who will prick his finger and squeeze drops of blood into his urine sample to create hematuria, bolster his story about having kidney stones, and get that morphine that he craves. The woman who will inject small amounts of feces into her  young child to cause the temperature spike that will get the child admitted to the hospital for a fever workup. (Not to do anything for the child, but to satisfy the mother’s own need for attention via the hospital admission. You may have heard of this one: Munchausen syndrome by proxy.)

These folks often know that they have you over a barrel, and they enjoy getting and maintaining the upper hand. Coming to the hospital ED is not a traumatic experience for them. It’s a challenge, an adventure, and a game to be played and won. They want to see you squirm, make you sweat and make it difficult for you just because they can.

Oddly enough, you might think that once one of these folks is discovered, it would be easy to dispatch them and move on to the next case. Not so. It actually takes more time  with this kind of presentation that with other, more straightforward cases.

Why? The person may actually have an illness that needs to be diagnosed and treated, and this is just the way they respond to the stress. They might actually go out and accidentally kill themselves, not really meaning to, after your call their bluff and release them. They may be going into a serious narcotic withdrawal, or delirium tremens (DTs) and you miss it because you were so focused on their demands for painkillers that you neglected the fact that they also drink a case of beer a day.

If you come into the ED and tell me a story, a reasonable story of pain and suffering and need for psychological treatment and comfort, I will do all in my power to help you. I will give you the proverbial shirt off my back. I will willingly spend emotional, physical and financial capital to find out what’s wrong with you and help you.

If you come in and try to scam me, lie to me, manipulate me and make me bend to your will just for kicks or your own secondary gain, I will go cold as ice. Now the caveat here is that I will work up your complaint and figure out what is going on and why. I will figure out that this is a personality thing, a need for attention, an unconscious need to be sick, or some such. I’ll figure that out, as that is what I’m trained to do.

I’ll treat you professionally and the same way I would treat anyone else. But keep in mind that you have changed the game for us. You have set this up as us against them, protagonist against antagonist, cop versus robber.

The doctor-patient relationship should be one that consists of mutual respect, achieving a common goal, honesty and teamwork.

Where there is true pain and suffering, physical or emotional, there is no place for manipulation.

Greg Smith is a psychiatrist who blogs at gregsmithmd.

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  • buzzkillerjsmith

    Borderlines and anti-socials are brutal cases, energy vampires. Good thing I have psychiatrists and psychologists to send them to keep them out of my clinic for a little while. Maybe you should do the same. Oh, wait a minute….

    Sorry, I couldn’t resist. If it makes you feel any better, I do keep most of the somatoforms. You all could have it even worse. Just sayin’.

    • Greg Smith MD

      Thanks for any help! These situations are difficult in any setting, yours and mine.
      G

      • Esther Klein Buddenhagen

        You don’t have to get involved in long-term treatment, but there are ways to handle the kinds of things you handle and to stay reasonably cool at the same time.

        • Greg Smith MD

          That’s the name of the game in the ED especially. Stay cool, do a good evaluation and recommend appropriate treatment for all patients, regardless of pathology.

    • a mom

      empathy- empathy- energy vampires might be accurate, but i’m not sure it’s the most effective way to think of individuals with these horribly real, painful disorders. dbt is a great treatment for borderline personality traits…. if you don’t know about this treatment you absolutely should.

      • Greg Smith MD

        You’re right. There are specific treatments even for personality disorders that are very debilitating and require years of intervention. The main problem in a state like SC is the (non) availability of the treatment and those trained to implement it.
        G

  • meyati

    Then I go into the ED after my hounds and I were attacked by really large dogs, fell off a ladder, tripped on a sidewalk crack while jogging with my hounds and talking on a cell phone-My arm was shoved into my rotator cuff and I couldn’t move my arm at all, etc. I’m allergic to acetaminophen and NSAIDs. I refused all painkillers that had these ingredients and went home to suffer. I just finished radiation for cancer- My beloved dog of 6 years was sleeping and bit me, when I was taking a rawhide bone from him. I told the ED that I was going to throw up from the pain. I didn’t understand why a person that refuses oxycontin is called a dope addict. Why couldn’t they give me just one codiene? Doctors used to give it to me for broken bones, a hysterectomy, sinus surgery, but now they are idiots.

    They finally gave me a codeine sulfate. I think the difference was that my son went in the exam room with me. He told them that I rodeod and broke horses. Not very often, but I did end up in the ER and they gave me codeine. What type of dope addict refuses painkillers? Now I know that if I go to the ER-I need to take a large male in with me to be a witness. Anyway my pain and off color eased up, so they gave me a script for that. I had part of my nose and lip cut out last Halloween. I went home without a script for anything. I used sherbert and self-hypnotism to control the pain. Why do these jerks want to prescribe something that simulates an inner ear infection, with the loss of balance, nausea, some hearing loss, tinnitus? Why do they want to make a patient sicker? `

  • ninguem

    That’s not manipulation, that’s blackmail.

    Patients who make those sorts of threats to me are shown the door.

    They can make those sorts of medical board threats as well, I’ve been on the receiving end of them, but the Board, though not the doctor’s friend, does not look kindly on these “inadequate narcotic” complaints. Short of open fractures, terminal cancer, I suppose.

    The board has contacted me to let me know they disposed of the “inadequate narcotics” complaint as unfounded.

    • Greg Smith MD

      Good! Nuisance complaints must be dealt with in that way.

  • Esther Klein Buddenhagen

    Indeed people with personality disorders are very difficult to deal with and very, very frustrating and difficult to treat without special training. In the olden days, Marsha Linehan (sp?) and her group in Seatle offered this training and even in the community clinic in which I worked, it was enormously helpful, especially for people with BPD. My community mental heath center in southern Illinois managed to come up with the bucks to send some of us to Chicago for two weeks and also to provide follow up in southern Illinois. If you could come up with the money, this would be worth your time.

    I can’t find myself terribly empathic when it comes to people with what still may be referred to as antisocial personality disorders, but that MIGHT be my limitation. I think it is really, really, really important not to be so nasty about people with personality disorders. Difficult, yes, but also human.

    • Greg Smith MD

      Esther,

      Definitely agree with the last point.
      I consider all my patients the same way as much as humanly possible. Those with true personality disorders are often less likely to get complete workups and thorough evaluations because of the prickly nature of the interactions.

      Greg

      • rbthe4th2

        THANK YOU for your honesty and candor. My question would be, what does the patient do when they’re treated this way? You have the power to destroy us and do use it. I’ve seen it first hand, and the worst was a deacon’s wife, a grandmother, who was honest. The doc didn’t want to fix his mistake.
        What do we do to get it right for us? btw I’m NOT asking for a lawsuit. There are times when its appropriate, but many times, its just an education and attitude adjustment issue.

      • anon3

        why would it be hard to consult with someone with a personality disorder, when unlike all other patients, you have an exact description of how they tick, and therefore know what to say, and what to definitely NOT say? Also what is “true” personality disorder, as opposed to.. well whatever other kind you get?

  • misdreavus

    Gosh. Tried to say something, but couldn’t get it posted. Here I go again.
    :/ That does sound awful. And I think I do get how docs feel. I have autism and docs always think I am trying to manipulate them. One doc said he thought I had borderline personality disorder because my symptoms are really vague. But the reality is that I have horrible issues with time and place. I get mixed up quick. Things that happened a month ago I can think happened last week. And if the interview shifts, I can start getting very confused. A psychologist says this is actually part of autism (trouble shifting attention during the conversation). But more than one doc has suspected personality disorder because of how I interview during exam.
    I did try to work around the situation by keeping a journal of symptoms so I can be specific about time, place, etc. My new PCP was pissed. He demanded to know why I couldn’t just look him in the eye and answer questions. Why did I keep referring to the paper of symptoms. I pointed to my head and said that I’m a little handicapped. He said I could keep looking at the paper after that.
    Just be careful, cuz not all patients are trying to manipulate you Doctor Smith. Some of us really are a bit handicapped. Docs are always turning “cold as ice” with me when I have trouble answering their questions. I just get easily confused and have trouble when they change topics too quickly.

    • Greg Smith MD

      misdreavus

      Point definitely taken.
      Thanks for your comment.

      Greg

      • AnnaLee Helm

        Another WOW… I am glad you responded to misdreavus, what a truly humbling moment this must have been for you to answer with “Greg” and NOT Dr. Smith… careful there Doc, your humanness is showing! Psych patients come in all kinds of packages and are inherently trusting you to try to understand WHY we are presenting to you, and not there to be a PITA (Pain in the Ass) like some patients who even have this notated on their permanent medical chart!

  • fporch

    As a longtime hospital administrator I remember a mean old lady named Phoebe.
    She showed up in our ER nearly every day with a complaint that would
    require a workup of some sort. She was unusual in that she was not
    narcotic pain seeking, she just likes having people jump to her often
    rude demands. The first time I met her making rounds in the ED, she looked so sad I place my hand on he shoulder and asked if someone was taking care of her. She shrugged my hand off and hissed “Don’t touch me!” After leaving the ER, Phoebe would use a secluded wall phone
    to call various local government and social organizations and abuse
    people over the phone (until I shut her “office” down by having the
    phone removed). Afterwards, she would go out in front in a hospital wheelchair to aggressively panhandle cigarettes and money until I finally threatened
    her with jail to get her to stop harassing patients and visitors. Phoebe’s
    favorite ploy was to collapse downtown and have some good citizen load
    her in his car for an “emergency” trip to the ER (the Ambulance Squad
    had long ago cut her off for any home response). One week she did not show up and we learned she had died in her sleep. When I read her obituary I was very surprised to learn Phoebe was in her
    40′s, not 60′s as I assumed. The photo showed an attractive young women
    with eyes full of hope. I still wonder how her life turned out so
    badly. I was again surprised to learn that several of the ED nurses were very fond of Phoebe, despite her casuistic personality.

  • rbthe4th2

    Yes, this is what docs do when they marginalize our complaints (for months). Then when I hit rock bottom, you have to do an emergency 5 day admission to the hospital because the signs were so bad they couldn’t be ignored. Oh yes, after the doc tests me AFTER the emergency admission and sees how bad things really are … tell me again about the game playing.
    I see it all the time. What happens is that we give you complaints for a few months, I tell you here is the problem, its never acted on, tested or anything, and I get called crazy … and oh we can’t imagine why things were this bad. They were never documented in the record.
    Trust works both ways docs. You need to listen to us and explain to us why something is right. However, I’m a very educated patient. I don’t tell you my background. If I did, you would treat me special. I want to be treated like any one else, because that is how I know who is here for my health and who is here to play games.

  • Patricia

    It’s good to hear a doctor’s point of view on these cases. Because it’s better to know that you are having a human reaction to difficult situations. However as others have already said, many of these people are suffering and I guess think that because they must manipulate to get what they need, they have to do that. And that is where your true compassion must go towards…that need in them.

    I get that it’s hard though. People with personality disorders are difficult to deal with (the training idea is a great one!). But doctors are the gate-keepers to getting relief from pain (whatever the pain is). And that is not always in the form of a narcotic. I have had experiences lately that have made me really form a distrust for doctors. The worst was when I cried and pleaded with my son’s pediatrician to address his severe weight loss. I got the impression he thought I was an over-involved mother. It’s lucky (and too bad) that I had to diagnose my own son with diabetes. If I had waited for the doc, he would have been in the ICU or worse.

    So maybe training is the answer, and protocol. Not just an individual doctor’s opinions, thoughts, moods, reactions; that is a dangerous way to go about this.

  • NYC Patient

    Early in my career, I worked with some great orthopaedic surgeons who could spot such patients a mile away. Now, being a patient with 13 herniated discs, stenosis, and the like, I know all too well about pain. While it is NOT indicative of my pain, I refuse to take pain medication. Many, many, many have been offered over the past 2 years. There are times I just want to say screw it and take something, but I then remind myself of the addicts.. both those in the US and abroad and the stereotype stigma such patients receive – somehow that gives me the wherewithal to not give in.

    There undoubtedly needs to be better tracking and monitoring. It will not catch everyone milking the system for the drugs, but it would definitely make a change for the better.

    Dispensing guidelines also need to change. Every surgery I’ve had (2 bunionectomies, 1 sinus, 1 lumbar discectomy, 1 OPEN hepatectomy) has given me more than double the pain killer needed.

    For the first bunionectomy, I became very sick with the vicodine. For the second, I took nothing. Literally, nothing. Thought I was going to die the first night, but after that the recovery was much better – no pain, no swelling, no need for crutches and I was back to work without missing a step 3 days later.

    The sinus surgery came with codeine. Took it once the day of surgery but that was it.

    Lumbar discectomy came with flexiril and 100 percocet. Yes, 100. The bottle was huge. Spent 2 1/2 days in hospital and took it 2-3 times for 4 days post-op then at night for a few days. Still have over 70 left……..

    Open hepatecomy came with 60 dilaudid. Had no idea what it was but when they gave me that itty-bitty pill after removing the PCA 4 days later, I think I had my first high ever (never done drugs, don’t drink at all, etc.). And I didn’t get the horrendous headache that came with the percocet or nausea. Discharged with my meds 6 days later looked up the wonder dilaudid after reading the info sheet form the hospital pharmacy. It was quickly apparent that that was not something I wanted to take a lot off…so I took it twice a day for a few days, then once a night for a few nights and that was it. Over 40 left……….

    Not everyone has the same pain tolerance but there is no reason on this earth to justify the quantity dispensed. 100 percocet….really??? Aside from the standard “legally” looking inserts, no information is given regarding how to take to avoid forming a dependency.

    If it wasn’t for addicts in my family (alcohol, Rx, and drugs) and for seeing the ugly head of addiction in 3rd world countries, I doubt I would be so concerned about what I take. The average person can not be expected to be so which is why there has to be more awareness, reader friendly materials, etc.

    Something has to change. It is very demoralizing for medical providers to be taken advantage of in this way and for the system to enable it – in the end NO ONE benefits! Well, maybe the drug companies but they really …. insert a variety of phrases here…

  • AnnaLee Helm

    Wow… this is why I am not jumping for joy with the knowledge that my Psych. Records will be accessible by who knows how many people if I am in the ER because of a NON-PSYCH or otherwise explainable reason, and honestly think that I will not be treated differently than a patient without a psychiatric diagnosis… Yes, this may include being brought there by a “significant other” who tells the ER doctor that you are dangerous and need to be committed using a false report while you cool your jets, oblivious to this happening. This happened to me. My BF had been up drinking the night before and wanting to fight with me so he could do this then, but I wouldn’t engage his nonsense. When he threatened to have me committed I knew I would have to be dangerous to others, homicidal, suicidal, something gravely ill, and I was clearly NOT. The next day, he would not stop harrassing me to go check myself into a H, so I DROVE US BOTH to the H in my county (I was born there, had both my kids there, and knew and went to church with around 10 people there) knowing the ER doc would see I was fine and would get him off my back. They called me back and before being seen by anyone, my BF told the docs that I told my neighbor that I was going to kill him with a golf club! Of course, I had no way of knowing what he told anyone, and thought I was the patient and I would get my turn once he came to examine me. Instead, the doc called the cops and they called the ICU in another county to have me committed for being dangerous to my BF! It took me forever to ever find out what the charges were that he made, but I was never told. I had to hire a lawyer myself to get my records about that entire day, including police reports, (which the county cops didn’t even MAKE) and try to forget that I was tackled to the floor, thrown in 4 point restraints and held there while they waited on my Psych Doc to fill out the paperwork. Of course, he was a mile away from the H they were taking me to, and I was supposed to be this BIG EMERGENCY and it was 1 o’clock on a sunny Tuesday afternoon and he didn’t even see me that day. Instead, I got an ambulance ride to the Big City Psych Ward, stripped, shouted at, tied back down and shot up with Haldol without anyone ever telling me what was happening to me… I was held for 6 days… this was 10 years ago, and I can tell you I RELIVE THAT DAY EVERY DAY TO THIS DAY! If the ER doc had just spoken to me, the PATIENT FIRST, then all of this could have been avoided, Instead, the ER Doc was complicit with my BF and my family, (Unknown to me at the time) who told them all kinds of outright lies to get me put away. I lost everything I owned when I released, my property had been put in plastic bags and set outside by the curb, and this BF ended up marrying the woman he had been sleeping with behind my back, and moved HER into my house. I have never been the same, and I never will be,.. I ALWAYS get the “look” from any new caregivers because anyone can see the records that claim I threatened to kill this BF to OUR NEIGHBOR, who told him, who told the ER Doc, who NEVER ASKED ME! I am sick just knowing there are records out there that claim this like it really happened! Of course, once I saw them for myself, the administration would not redact this from my records when I requested that they do in light of what had happened. I could see the Risk Management lady, who just said they would take care of it… THEY NEVER DID. I have never been arrested or had anything criminal on my records, but now I have THIS on my records, permanently it would appear. I would say that this was COLD. I would hope that you would take 5 minutes and talk to ME, the patient in question, and you would have seen I had reason to be annoyed with the BF who reeked of alcohol and was obviously drunk when you spoke to him, and I would have gone home and packed up HIS stuff and he could have hit the road. It was MY house! The ER doc didn’t even TALK to me, let alone examine me for cause. How humiliating it was and continues to be. I hate it.

  • katerinahurd

    I am not a psychiatrist, but I do understand and sense angry writing when I read it. You were not manipulated. You just fell into a trap of a better actor. Would you agree that we live in the century of the pill. Would you agree that diagnoses such as chronic pain syndrome, fatigue syndrome are created by physicians rather than being objective? What is your take on the rising administration of epidurals during delivery and c- sections even when not medically necessary? What would you have said if I were to refuse all pain medication. Would I be a masochist?

  • anon3

    You sound like a huge dick.

  • Dorothygreen

    After hearing that prescription drugs now out rank cocaine and Heroin in the Us as well as being easier to get on the black market (even Craig’s list), I guess i don’t understand why you have any folks manipulating you at all. Ever heard of the prescription drug mill in Dade County, FL? Physician run. There was not even any tracking in the state. Maybe now, don’t know.

    So, to me your post sounds rather arrogant and hardly understanding how huge the problem of prescription drug addiction is in the US and how many physicians enable this to happen.

  • anon3

    Here is a question… why do you care if someone knocks themselves out or gets high on pain meds? Are your power and control issues really that bad? Did you ever consider that someone might genuinely be in that much pain etc that they do consider killing themselves if they do not get relief, relief that only you can give them? (For the record, I do not have a problem with pain or take any painkillers). It is too bad that you consider that a deadly result of not responding to patient, somehow makes them manipulative. You cannot fathom that your bad decision or mistake to not believe them over the extent of their pain, could result in their death, or them getting dodgy meds from drug dealers and ending up sicker. You cannot accept that a patient being anything other than overly polite and thinking you are god and know best when you deny them something, is a liar and horrible person for trying to get you to change your mind in the only way they know how. They are manipulating you in the sense that they are trying to get you to change your mind, but they are not manipulating you in the sense that what they are saying is not true or not worth saying. The real question is why you would drive your patients to such utter desperation that they end up either unintentionally, or intentionally, insulting you and making overt attempts to control you, because you will not do the right thing and are denying the patient what they need.

    It is truly disturbing that someone in charge of people’s lives, is functioning in such a totally illogical and in fact emotional, and majorly disordered way (I am talking sociopathy, personality disorder / narcissism etc). I am also sure that if a genuine liar druggie reported you to the board, there would be nothing to worry about, as if it was as clear as you say, they would be ignored and laughed at. If it is NOT clear and you may risk getting into trouble, then you should have reconsidered your decision to refuse them meds.
    Where there is true pain and suffering, people are desperate and when people will desperate, not only will they try anything, they will specifically act out of character and in ways they are not proud of, including threats. I am surprised that after so much training and apparent experience, you do not realise this? Unless it is because you do know but are choosing to ignore it.

  • Janice Lynch Schuster

    As someone new to the world of chronic pain, I find your comments offensive. I sustained lingual nerve damage on March 11, and I have been trying ever since to find treatment for the terrible pain in which I now live. I have tried a number of traditional and alternative therapies, with modest success. I had a severe allergic reaction to one promising medication, and a milder allergic reaction to another. I am now on large doses of prednisone to combat the rash and swelling, but appear to be having a reaction to the prednisone itself. As the pain spirals out of control, I find it increasingly difficult to enjoy my life, or to play my roles as a mother, wife, sister, daughter, friend, and worker. As I write, it is 6:52 am. I have been up since 2 am. I believe the pain doctor’s office will open at 8, but it can take hours to get through to a provider. Last night, I spoke to the on-call physician who urged me, despite the level of pain I was experiencing, NOT to go to the emergency room. As a chronic pain patient (Percocet, 5/325, twice a day, and Klonipin, sublingual, 0.25 mg twice a day), the physician believed that the ED staff would respond to me as if I were a pill-seeking addict. They would be flind or immune to my pain, and would offer no comfort. I would be classified with drug-seeking behavior–and not the reality of my situation, which is that I am utterly debilitated by pain. When it is at its worst, I cannot eat, sleep, or talk.

    As the mother of four children, I have some prior experience with pain. But at least that had an end in sight.

    You may hate to be manipulated, Dr. Smith, but I hate to suffer like this.

    • Greg Smith MD

      Don’t believe your situation is at all what I was writing about.
      Hope you can find some reasonable pain control that works well long-term for you.
      Greg

      • Janice Lynch Schuster

        It is similar. My pain mgmt doctor told me not to go to the ED last night because they would label me as a pill-seeking addict. I did see the pain expert today and am trying a few new meds. So far as I can tell, it is just a crapshoot.

    • Minerva

      Same thing happened to me. After sustaining severe nerve damage after a serious accident where a drunk driver caused my car to flip on the highway, I have been in chronic pain. I am on narcotics and see a pain physician every month and never violate the trust built. I take my meds as prescribed, never run out early, submit to random testing, don’t get meds from any other doctors, etc.

      One night I got extreme nausea, vomiting, and abdominal pain. I avoided the ER and called my personal physician. She was on vacation and the on call doctor said to go to the ER. While there, he took one look at the meds I was on and said my problems were all because of the pain medication and injected me with something. The next thing I knew it was the next day. He had given me narcan without any warning, or concern for my actual symptoms. After having a severe reaction he injected 2 mg ativan (which I only know because I requested the records). He then put down that I was “extremely sedated” (anyone would be after being given that much ativan IV) and should be taken off pain medication. Again he never ran tests or did anything other then glance at my medications.

      All I wanted was something to stop the vomiting and nausea. I wasn’t there for anything else and yet I was treated and labeled as an addict for nothing other then the medications I was on. That doctor was asked to leave the practice within a month and both my regular doctor and pain doctor were shocked at what happened.

      I hate being manipulated and treated like dirt because of someone’s bias.

  • Diane Spencer

    You know what, this is exactly why people that need it, are abused along with the medical field. My disease is so rare hardly any of the medical field has heard of it, and even with a diagnosis just because they never heard of it I get abused. I was so angry for so long, but now I see how much doctors and nurse work so hard to help people and you are as abused as I am. They make a choice, I did not, I would not wish what I have on another soul, and this is the very reason the whole system is a nightmare. There are rehabs all over this country but nothing for my disease and the success rate is so low, when we would love to have a place to go to be treated with compassion and dignity, so now I see your side and thank you, I just hate it we all have to suffer over people’s poor choices.