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

• 1. Teaching Psychiatric Trainees to “Think Dirty”: Addressing Hidden Motivations in the Consultation Setting (Beach, 2017)
  2. The Therapeutic Discharge I: An Approach to the Management of Deceptive Suicidality (Kontos, 2017)
  3. The Therapeutic Discharge II: An Approach to Documentation in the Setting of Feigned Suicidal Ideation (Kontos, 2018)

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