Taiwanese Journal of Psychiatry

LETTER TO THE EDITOR
Year
: 2021  |  Volume : 35  |  Issue : 2  |  Page : 99--100

Malingering by proxy presenting with symptoms of posttraumatic stress disorder: A case report of child abuse


Hsing- Jung Li1, Frank Huang-Chih Chou2, Wen- Huei Lin3, Kuan- Hsu Chen1, Ching- Hong Tsai1,  
1 Department of Child and Adolescent Psychiatry, Kai-Syuan Psychiatric Hospital, Kaohsiung City, Taiwan
2 Department of Office of Superintendent, Kai-Syuan Psychiatric Hospital, Kaohsiung City, Taiwan
3 Department of Social Worker, Kai-Syuan Psychiatric Hospital, Kaohsiung City, Taiwan

Correspondence Address:
M.D Hsing- Jung Li
No. 130, Kai-Syuan Second Road, Kaohsiung City 802
Taiwan




How to cite this article:
Li HJ, Chou FH, Lin WH, Chen KH, Tsai CH. Malingering by proxy presenting with symptoms of posttraumatic stress disorder: A case report of child abuse.Taiwan J Psychiatry 2021;35:99-100


How to cite this URL:
Li HJ, Chou FH, Lin WH, Chen KH, Tsai CH. Malingering by proxy presenting with symptoms of posttraumatic stress disorder: A case report of child abuse. Taiwan J Psychiatry [serial online] 2021 [cited 2021 Dec 6 ];35:99-100
Available from: http://www.e-tjp.org/text.asp?2021/35/2/99/318956


Full Text



According to the diagnostic criteria of the Fifth Edition of the Diagnostic and Statistical Manual for Mental Disorder [1], posttraumatic stress disorder (PTSD) can occur after a traumatic experience, such as threatened death, serious injury, or sexual violence, causing severe symptoms that interfere with a person's psychological, physical, interpersonal, occupational, and social functioning.

Malingering-by-proxy (MAL-BP) is a form of abuse with motives such as pursuing money, getting more medicine, avoiding military service or imprisonment, getting a vacation, or other benefits and desires. It is commonly seen in general hospitals, where patients often complain about pain, cognitive deficits, and toxin exposure to feign symptoms [2]. Malingering PTSD is involved in criminal, civil, and disability evaluation [3]. Parents are often the perpetrators, directing or pressuring one's child to exaggerate or feign symptoms to obtain financial compensation or assuming a victim or hero rôle [4]. MAL-BP can coexist with Munchausen by proxy and both are forms of maltreatment. The difference is that the latter assumes a sick rôle psychologically. The diagnoses differ every time depending on the motivations (external or internal) [5]. Therefore, false PTSD can adversely affect treatment, planning, and management [3]. To accurately identify genuine cases of PTSD is important and, as part of the differential diagnosis, to rule out instances of false PTSD.

 Case Report



A 10-year-old girl patient with a history of domestic violence perpetrated by her alcoholic father was presented with her mother at a child psychiatric outpatient clinic. The presenting problems were inattention, depression, nightmares, anxiety, and insomnia, fluctuating over the previous years. The patient reported trauma-related reenactments, distressing dreams, persistent avoidance of reminders, negative beliefs and emotional state, poor concentration, and restless sleep. Academic and medical records' review indicated no presence of the above symptoms before the onset.

Patient's past visits to different general hospitals in different counties did not confirm the diagnosis. Neuropsychological assessment revealed no evidence of psychiatric disorder, and the child was uncooperative and feigning deficits. The above-mentioned related symptoms were told by mother at outpatient clinic but not observed during hospitalization. The mother-daughter relationship was ambivalent. Children sometimes regress and sometimes mature paradoxically during hospitalization.

Parents had been divorced for many years. Father was still in jail and had not returned home. Mother dominated everything in the family including financial situations. The mother later revealed that they had applied for disability benefits and compensation from a commercial insurance. We did a thorough history, physical examination, and neurological examination, and relevant social history. We then referred them to the social affairs bureau across counties for intervention according to the team comprehensive workup. She was discharged without any psychiatric diagnosis. Requests for benefits are denied.

The patient finally returned to school. She was relatively stable in school after discharge. Mother and daughter were difficult to separate, they still lived together. Although they lived in other countries, they were not returning to our clinic. Follow-up still needed continuous visits through the staff at social affair bureau.

 Comment



If the PTSD-like symptoms appear to be feigned, clinicians need to consider the motivation behind it, which involves legal, personal, financial, and social levels [6]. Assessment of family members and interaction with caregivers, especially mothers, is important [7],[8]. Therefore, early involvement of team-based approaches and the integration of medical information are particularly essential. Long-term follow-up is necessary and should be approached from a biopsychosocial perspective. We hope that this letter-to-the editor can help clinicians to ensure the valid genuine PTSD, while false PTSD can be approached proactively and wisely (The institutional review board of Kai-Syuan Psychiatric Hospital approved this case report for publication [protocol case number = KSPH-2018-04, and date of approval = March 19, 2018) without the stipulation of obtaining any informed consent.)

 Financial Support and Sponsorship



None.

 Conflicts of Interest



There are no conflicts of interest in writing this letter-to-the editor.

References

1American Psychiatric Association: The Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5). Washington, DC, USA: American Psychiatric Association, 2013.
2McDermott BE, Feldman MD: Malingering in the medical setting. Psychiatr Clin North Am 2007; 30: 645-62.
3Matto M, McNiel DE, Binder RL: A systematic approach to the detection of false PTSD. J Am Acad Psychiatry Law 2019; 47: 325-34.
4Chafetz M, Melissa Dufrene M: Malingering-by-proxy: need for child protection and guidance for reporting. Child Abuse Negl 2014; 38: 1755-65.
5Meadow R: Munchausen syndrome by proxy: the hinterland of child abuse. Lancet 1977; 2: 343-5.
6Knoll J, Resnick PJ: The detection of malingered post-traumatic stress disorder. Psychiatr Clin North Am 2006; 29: 629-47.
7Amlani A, Grewal GS, Feldman MD: Malingering by proxy: a literature review and current perspectives. J Forens Sci 2016; 61 Suppl 1: S171-6.
8Lin WC, Chan YY: Munchausen syndrome and Munchausen syndrome by proxy: a case report. Taiwan J Psychiatry 2021; 35: 42-3.