In this episode, I speak with Dr. Nicholas Kontos, Program Director of the Consultation–Liaison Psychiatry Fellowship at Massachusetts General Hospital, about one of the field’s most challenging topics: malingering and factitious disorder. We discuss how to move beyond the impulse to “catch deception” and instead adopt a framework of clinical curiosity, empathy, and ethical clarity. Dr. Kontos introduces the concept of “thinking dirty”, the disciplined consideration of complex motives such as safety, shelter, or secondary gain, while preserving therapeutic respect. The conversation covers practical strategies for differential diagnosis, documentation, and the therapeutic discharge, reframing it as a compassionate boundary rather than a punishment.
Takeaways:
Clinicians must be willing to consider non-altruistic motives (sex, money, drugs, safety, attention) without moral judgment. This mindset sharpens diagnostic reasoning while maintaining therapeutic respect.
The classical distinction between factitious disorder and malingering is often clinically unstable. Both exist on a behavioral spectrum shaped by unmet needs, structural deprivation, and adaptive strategies
Properly framed, discharge is not punitive but restorative, a boundary that ends maladaptive cycles while affirming the patient’s moral agency
The note itself is a clinical act. A comprehensive chart review, clear description of inconsistencies, and transparent reasoning both protect the patient and clarify physician thought
Effective care balances compassion with stewardship of finite resources. Clinicians serve both patient and system by refusing to reinforce maladaptive behavior while still honoring human dignity
Teaching Psychiatric Trainees to “Think Dirty”: Addressing Hidden Motivations in the Consultation Setting (Beach, 2017)
The Therapeutic Discharge I: An Approach to the Management of Deceptive Suicidality (Kontos, 2017)
The Therapeutic Discharge II: An Approach to Documentation in the Setting of Feigned Suicidal Ideation (Kontos, 2018)
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Produced by: Human Content
Chapters:
00:00 Introduction to Psychiatry Bootcamp
00:24 The Importance of Discussing Malingering
02:15 Introducing Dr. Nicholas Contos
02:30 Understanding Deceptive Patients
07:56 Primary vs. Secondary Gain
14:48 Therapeutic Discharge
29:14 Clinical Interview Strategies
39:45 Humorous Patient Interactions
40:08 Techniques for Identifying Inconsistencies
41:26 Standardized Instruments and Their Limitations
42:59 Effective Documentation Strategies
47:55 Challenges in Diagnosing Malingering
54:56 The Role of Empathy and Ethical Considerations
01:01:34 Understanding Factitious Disorder and Malingering
01:09:43 Final Thoughts and Reflections
