Background Malingering involves intentional falsification of symptoms for external gain, affecting 8% of medical cases and costing $150 billion annually. Detection is challenging due to its episodic nature. The DSM-IV- TR classifies malingering as a condition of clinical attention without precise criteria. Socio-economic factors contribute to its prevalence among prisoners, employees avoiding work, and homeless individuals seeking benefits.

Case Presentation A 32-year-old homeless male was admitted from the ED under suicide precautions. He traveled from another state seeking a new start but lacked support. Previously hospitalized for hypoglycemia while on escitalopram and cyproheptadine for PTSD, he was admitted to our hospital's general medical floor. He was referred to our team for inpatient psychiatric consultation due to possible suicidal ideation. The patient reported a "medium" mood with lapses in medication adherence due to a TBI from an MVC three months ago. He denied current suicidal ideation, hallucinations, or mania, attributing suicidal thoughts to missed SSRI doses. His PTSD originated from the MVC that rendered him paraplegic and caused the death of the driver and the traumatic loss of his parents in the Iraq War in 2010. He experiences nightmares and flashbacks but denies hypervigilance. His history includes a suicide attempt in 2010 leading to hearing loss and several psychiatric admissions for suicidal ideation. He recounted an interrupted suicide attempt where a bullet struck metal and lodged in his leg, later removed surgically. Concerns arose due to dramatic and questionable details, further complicated by the attending physician recognizing him under a different identity. Physical therapy for paraplegia showed inconsistencies in sensory perception, with intact sensation in all extremities but claimed loss in the lower extremities.

Discussion Factitious disorder and malingering were assessed through evaluations by the primary team, Neurology, and physical therapy. For example, factitious or malingered insulin use involves assessing insulin levels to differentiate between exogenous and endogenous sources. Managing these disorders involves confronting the patient with gathered information. In this case, when confronted with his prior name, he confirmed previous use. Regarding the falsification or malingering of paraplegia, the teams informed him that placement in a nursing home or subacute rehabilitation was not possible because his clinical exam did not indicate acute or subacute rehab needs Having a primary care physician can help mitigate malingering, though this is difficult for homeless patients. Hospital protocols should ensure thorough history evaluations and vigilance to manage malingering cases.