Everything I'm about to say in this post never took place. I'm making it all up. I'm putting up this hypothetical story because it could happen someday, or maybe it already has happened but I just don't know it. Anyway, I'd like your thoughts.
Here's the story:
I'm sitting in my prison clinic and I hear inmates sitting out in the hall talking. One of the inmates happens to be my patient but he doesn't know I can hear him. He is bragging that the first time he met me he "told Dr. Clink all kinds of stuff" and got put on meds. He added that when he gets out of prison he will be "set" because he'll have "a check for life". He doesn't mind taking meds because the pills he gets are "good stuff that helps me rest" and that what he doesn't take he trades away.
Curious, I pull his chart and look up his intake history which I completed two months before. When I saw Inmate X then I noted that his hygiene seemed a bit poor but he was calm and polite. He was slow to answer questions and at times seemed distracted as though listening to internal stimuli. He was evasive about questions regarding his past psychiatric history and refused to elaborate upon prior symptoms or treatment beyond acknowledging one hospitalization in his late teens (he's now in his mid-20's). He didn't remember the name of the hospital and couldn't or wouldn't tell me why he was there. He was not suicidal. His speech was sparse, and although not overtly thought-disordered his questions at times were a bit 'off the mark' and tangential. He acknowledged feeling "paranoid" around other inmates but no clear delusions were elicted. The rest of his mental status examination was unremarkable.
Concerned about possible psychosis I start him on risperdal. At followup visits he reports medication compliance but gives no additional information other than that found in the intake history. No new or additional apparent symptoms are seen at followup.
So here are my questions, which I'm particularly interested in having our psychiatrist readers address: Does this patient truly have a psychotic disorder or have I misdiagnosed him? What would you do to differentiate psychosis from malingering? To differentiate malingering from "faking good" (or bragging) in an inmate with a real psychotic disorder? What do you do when the social worker comes to you to fill out entitlement papers on this inmate who has announced his intention to defraud social security?
Thanks in advance for your thoughts. I await your ideas.