Non-confrontational management approach
› Core therapeutic strategy
› Maintain neutral, supportive interview style
› Avoid communicating suspicion verbally or nonverbally
› Confrontation typically escalates behavior and damages therapeutic alliance
› Address underlying unmet needs
› Social work consultation for housing, food, safety
› Substance use disorder treatment referral
› Document thoroughly without punitive language
› Objective findings, test results, observed inconsistencies
› Avoid speculation about intent in clinical notes
Management of comorbid psychiatric illness
› Antidepressant therapy for genuine comorbid depression
› Selective serotonin reuptake inhibitors (SSRIs) first line
› Sertraline 50 mg PO daily, titrate by 50 mg every 2-4 weeks
› Maximum 200 mg daily
› Escitalopram 10 mg PO daily, titrate to 20 mg after 1 week if tolerated
› SNRIs for depression with comorbid pain
› Duloxetine 30 mg PO daily, titrate to 60 mg after 1 week
› Maximum 120 mg daily for comorbid pain indication
› Response monitoring at 4-8 weeks
› PHQ-9 as objective tracking tool
› Medication switch or augmentation if inadequate response
› Antipsychotic therapy for genuine comorbid psychotic illness
› Risperidone 1-2 mg PO daily for psychotic disorder
› Titrate by 1-2 mg every 1-2 weeks
› Target 4-8 mg daily for most patients
› Olanzapine 5-10 mg PO daily
› Metabolic monitoring: weight, glucose, lipids
› Sedation risk particularly in elderly
› Avoid antipsychotics empirically for feigned psychosis
› No benefit and exposes patient to side effect risk
Substance use disorder treatment
› Opioid use disorder management
› Opioid agonist therapy initiation if appropriate
› Buprenorphine-naloxone 4-8 mg sublingual induction in moderate withdrawal
› Titrate to comfort within 24 hours
› Bridge to outpatient opioid agonist program
› Avoid opioid prescribing when suspicion is high and no objective findings
› Document clinical reasoning explicitly
› Review PDMP before any controlled substance prescription
› Benzodiazepine and alcohol use disorder
› Alcohol withdrawal management when indicated
› CIWA-Ar scale for severity stratification
› Lorazepam 1-2 mg IV or PO for CIWA-Ar greater than 8
› Symptom-triggered protocol preferred
› Avoid benzodiazepine prescribing for anxiety without objective indication
› SSRIs as first-line anxiolytic for outpatient management
› Hydroxyzine 25-50 mg PO PRN as non-addictive anxiolytic option
Functional neurological disorder treatment
› FND-specific approach when diagnosis established
› Psychoeducation as primary intervention
› Explain genuine neurological mechanism of FND
› Distinguish from faking to reduce stigma
› Physiotherapy for functional motor symptoms
› Gait retraining
› Distraction-based movement techniques
› Cognitive behavioral therapy (CBT)
› First-line psychological intervention for FND
› Targeting maladaptive illness beliefs and avoidance
› Avoid prolonged unnecessary investigations
› Repeat testing reinforces illness behavior
› Psychoeducation framing reduces harm
› Controlled substance avoidance strategy
› Opioid prescribing when suspicion is high and no objective pathology
› Decline with clear, non-punitive explanation
› Document objective exam findings and clinical reasoning
› Offer non-opioid analgesia for pain complaints
› Acetaminophen 650-1000 mg PO every 6-8 hours
› Ibuprofen 400-600 mg PO every 6-8 hours with meals, if not contraindicated
› Topical diclofenac for localized musculoskeletal pain
› Naloxone prescribing for suspected opioid use disorder
› Harm reduction regardless of malingering suspicion
› Naloxone 4 mg intranasal device
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