CASE Suicidal and hungry
Mr. L, age 59, attempts suicide by taking approximately 20 acetaminophen tablets of unknown dosage. He immediately comes to the emergency department where blood work reveals a 4-hour acetaminophen level of 94.8 μg/mL (therapeutic range, 10 to 30 μg/mL; toxic range, >150 μg/mL); administration of N-acetylcysteine is unnecessary. Mr. L is admitted to general medical services for monitoring and is transferred to our unit for psychiatric evaluation and management.
During our initial interview, Mr. L, who has a developmental disability, is grossly oriented and generally cooperative, reporting depressed mood with an irritable affect. He is preoccupied with having limited funds and repeatedly states he is worried that he can’t buy food, but says that the hospital could help by providing for him. Mr. L states that his depressed mood is directly related to his financial situation and, that if he had more money, he would not be suicidal. He cites worsening visual impairment that requires surgery as an additional stressor.
On several occasions, Mr. L states that the only way to help him is to give him $600 so that he can buy food and pay for medical treatment. Mr. L says he does not feel supported by his family, despite having a sister who lives nearby.
What would you include in the differential diagnosis for Mr. L?
a) major depressive disorder (MDD)
b) depression secondary to a medical condition
c) neurocognitive disorder
d) adjustment disorder with depressive features
e) factitious disorder
The authors’ observations
Our differential diagnosis included MDD, adjustment disorder, neurocognitive disorder, and factitious disorder. He did not meet criteria for MDD because he did not have excessive guilt, loss of interest, change in sleep or appetite, psychomotor dysregulation, or change in energy level. Although suicidal behavior could indicate MDD, the fact that he immediately walked to the hospital after taking an excessive amount of acetaminophen suggests that he did not want to die. Further, he attributed his suicidal thoughts to environmental stressors. Similarly, we ruled out adjustment disorder because he had no reported or observed changes in mood or anxiety. Although financial difficulties might have overwhelmed his limited coping abilities, he took too much acetaminophen to ensure that he was hospitalized. His motivation for seeking hospitalization ruled out factitious disorder. Mr. L has a developmental disability, but information obtained from collateral sources ruled out an acute change to cognitive functioning.
HISTORY Repeated admissions
Mr. L has a history of a psychiatric hospitalization 3 weeks prior to this admission. He presented to an emergency department stating that his blood glucose was low. Mr. L was noted to be confused and anxious and said he was convinced he was going to die. At that time, his thought content was hyper-religious and he claimed he could hear the devil. Mr. L was hospitalized and started on low-dosage risperidone. At discharge, he declined referral for outpatient mental health treatment because he denied having a mental illness. However, he was amenable to follow up at a wellness clinic.
Mr. L has worked at a local supermarket for 19 years and has lived independently throughout his adult life. After he returned to the community, he was repeatedly absent from work, which further exacerbated his financial strain. He attended a follow-up outpatient appointment but reported, “They didn’t help me,” although it was unclear what he meant.
Between admissions to our hospital, Mr. L had 2 visits to an emergency department, the first time saying he felt depressed and the second reporting he attempted suicide by taking 5 acetaminophen tablets. On both occasions he requested placement in a residential facility but was discharged home after an initial assessment. Emergency room records indicated that Mr. L stated, “If you cannot give me money for food, then there is no use and I would rather die.”
What is the most likely DSM-5 diagnosis for Mr. L?
c) brief psychotic disorder
d) dependent personality disorder
The authors’ observations
Malingering in DSM-5 is defined as the “intentional production of false or grossly exaggerated physical or psychological symptoms, motivated by external incentives.”1 These external incentives include financial compensation, avoiding military duties, evading criminal charges, and avoiding work, and are collectively considered as secondary gain. Although not considered a diagnosis in the strictest sense, clinicians must differentiate malingering from other psychiatric disorders. In the literature, case reports describe patients who feigned an array of symptoms including those of posttraumatic stress disorder, paraphilias, cognitive dysfunction, depression, anxiety, and psychosis.2-5