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Malingered Dementia Associated With Battered Women's Syndrome

Received November 21, 1996; revised February 28, 1997; accepted April 3, 1997. From the Wake Area Health Education Center, Wake Medical Center, a teaching affiliate of the University of North Carolina at Chapel Hill. Address reprint requests to Dr. Gittelman, Wake Medical Education Institute, 3024 New Bern Ave., Suite 301, Raleigh, NC 27610. e-mail: daddkg{at}med.unc.edu

Key Words: Dementia • Malingering • Domestic Violence

Domestic violence is a problem affecting a significant number of households in the United States and around the world.¹ Domestic violence encompasses a broad range of violent behaviors perpetrated by family members and other intimate partners against each other. Battering may be considered a form of domestic violence that occurs in a repetitive, cyclical fashion, with one partner as the chronic batterer and the other partner as the chronic victim of battering.² The majority of batterers are men and the majority of the victims of battering are women (among heterosexual couples).³ Another specific characteristic of battering is control. Whereas domestic violence consists of sporadic assaults arising from arguments and hot tempers, battering includes violence and other behaviors intended to keep the victim within the control of the batterer. Physical and sexual assaults, as well as emotional degradation, financial destitution, and isolation from family and friends, have been described as means used by batterers to control their victims.⁴ The case reported is one of malingered dementia induced by a battering husband upon his wife so that he could have her at home within his control.

Case Report

Mrs. C, a 58-year-old, married, white woman, was admitted to the intensive care unit of a large county teaching hospital with an apparent doxepin and diazepam overdose (serum doxepin plus nordoxepin > 300 ng/ml), requiring intubation and vasopressors. Upon recovery of consciousness, neither the patient nor the family had an explanation for the overdose. Neither the patient nor her family had been prescribed doxepin, and the patient denied recall of the incident, let alone suicidal intent. She did appear to have a depressed affect and mood. Cognition was noted as "grossly intact," but Mini-Mental State Exam was not performed. Laboratory values revealed hypothyroidism (thyroxine: 1.2 µg/dl, thyroid-stimulating hormone: 45.3 µIU/L), for which she was prescribed levothyroxine (0.075 mg po qd). Electrocardiogram revealed prolonged QT interval that returned to normal prior to discharge (presumed effect of tricyclic antidepressant toxicity). Chemistries, complete blood count, urinalysis, coagulation studies, and computed tomography scan of the head were normal. Her discharge diagnosis 5 days after admission was organic mood disorder attributable to hypothyroidism, and she returned to the care of her local physician.

Four months later, Mrs. C was readmitted to the intensive care unit with altered mental status, thought caused by a cerebrovascular accident or transient ischemic attack. No abnormal laboratory (including urine and serum toxicologies) or radiologic evaluations (including brain magnetic resonance imaging) could be found. Her 24-hour Holter monitor did reveal multiple, premature ventricular contractions with rare episodes of bigeminy and trigeminy. However, the consulting cardiologist did not think these results accounted for her presenting symptoms. Thyroid studies had returned to normal since initiating levothyroxine. Subsequent mental status examinations demonstrated persistently depressed mood and impaired memory, orientation, attention, fund of knowledge, insight, and judgment. There was a family history of depression, suicide, and early-onset dementia. A trial of nortriptyline (75 mg po qhs) was initiated for treatment of major depression and possible dementia of depression. She did not return to work, and she began to receive disability compensation for emotional and cognitive problems.

During subsequent outpatient treatment, the husband reported improved mood and cognition, although this was not apparent to her psychiatrist. Neuropsychological testing demonstrated "severe cognitive deficits consistent with Alzheimer's dementia." Over the next 5 years, she was followed on a monthly basis, and her condition remained stable. Her husband accompanied her to all of her clinic visits and did all the talking while the patient sat passively, appearing distracted, answering all queries with "I don't know." Once during this 5-year period, one of her children suggested that Mrs. C was being mistreated by her husband. However, Mrs. C did not admit to mistreatment by her husband, even when questioned without his presence. Soon after this report, Mrs. C's husband died of a massive stroke. Mrs. C made one more clinic visit but was then lost to follow-up until a year later, when she was admitted to a nearby university teaching hospital because of a nortriptyline overdose. Mrs. C described the overdose as accidental, not a suicide attempt. She was briefly hospitalized on the psychiatric unit, prescribed fluvoxamine (100 mg po qhs) but was released at her insistence, and referred back to her previous psychiatrist for outpatient treatment.

On reevaluation by the original psychiatrist, Mrs. C exhibited symptoms of major depression but few of the cognitive problems she had previously displayed. She then recounted chronic and repeated mental and physical abuse by her husband during their 30 years marriage. This pattern of abuse culminated in his coercing her to feign cognitive problems, thereby obtaining long-term disability compensation and her presence at home under his scrutiny. Mrs. C had felt so intimidated by her husband while he was alive, and for a time after he died, that she could not alter the behavior forced upon her, nor could she report the fabrication of this "disabling" neuropsychiatric illness. On the other hand, she reported her symptoms of depression were genuine and in need of effective treatment.

Subsequently, Mrs. C has returned to living independently, with assistance from her attentive children. In her psychotherapy sessions, she has expressed relief for the opportunity to discuss the abuse she received from her husband. Her depressive symptoms have responded to reinitiating nortriptyline (fluvoxamine seemed to be ineffective). She has shown interest but has so far been unwilling to participate in a support group provided by a battered women's service.

Discussion

This case report illustrates the diagnosis of malingering, as described in DSM-lV, "the intentional production of false...physical or psychological symptoms, motivated by external incentives such as ...avoiding work, obtaining financial compensation...etc. Under some circumstances, malingering may represent adaptive behavior, for example, feigning illness while a captive of the enemy during wartime."⁵ Malingering is generally a volitional act. However, in this case Mrs. C's malingering was coerced by her husband. She had no past history of malingering and by all accounts had been a steady worker at the same job for over 20 years. Her feigned cognitive problems were adaptive as she faced worsened verbal and physical abuse had she not complied with her husband's demands. Interestingly, victims of battering have been compared psychologically with prisoners of war and terrorism.⁶ Mrs. C's diagnosis was not conversion disorder, as she did not appear to have a subconscious conflict producing her symptoms and her dementia symptoms were intentionally produced. Nor were her symptoms indicative of a factitious disorder, as her goal was safety and survival, not to assume the role of a patient.

The near-complete resolution of Mrs. C's cognitive problems during the year following her husband's death, lack of laboratory abnormalities other than hypothyroidism, and her own testimony would seem to rule out other etiologies for her apparent dementia. Mrs. C could have had symptoms of dementia caused by hypothyroidism on her initial presentation, which were then exploited and coercively perpetuated by her husband. Alzheimer's disease was considered given her initial presentation of impaired memory and a family history of dementia. However, her dementia was of acute onset, and never progressed over the 5 years, suggesting Alzheimer's disease was not the etiology of her dementia. Although the course of Mrs. C's dementia might have appeared to be that of multi-infarct dementia, computed tomography and magnetic resonance imaging of her brain revealed no abnormalities. Supplementation with levothyroxine corrected her hypothyroidism but had no effect on her cognitive problems. Other laboratory abnormalities that might have caused dementia were not detected. "Pseudodementia" was suggested by her "I don't know" answers and depressive disorder. However, with pharmacotherapy of her depression, the dementia did not resolve.

Although the clinical presentation of a case of battering as dementia may be unusual, battering is often a precipitating factor in suicide attempts by women.⁷ Battering and other forms of domestic violence are common in the medical setting. Surveys of emergency room,⁸ family practices,⁹ and obstetrics and gynecology outpatients¹⁰ have shown a prevalence rate of past and present experience with domestic violence that ranges from 20% to 40%. Psychiatric inpatients have been shown to have a higher prevalence of experience of domestic violence.^11,12 Posttraumatic stress disorder, depressive disorders, and substance abuse disorders, as well as suicide attempts, have been found to be associated with victims of domestic violence.^13,14 Research has demonstrated higher somatization and health care utilization among patients who have experienced physical and sexual abuse in childhood and adulthood.^15,16

The battering of Mrs. C, and her malingering, were not discovered until after the death of her husband, when she felt safe enough to reveal the truth. More history from Mrs. C's children may have led to an earlier diagnosis, although they were intimidated by him as well. Health care workers have been shown to have a poor rate of detecting, documenting, and referring victims of domestic violence.¹⁷ Nondetection of domestic violence is often attributable to a low index of suspicion by health care workers, lack of education, and vague presenting complaints (depending on the medical setting, headaches, fatigue, or chronic pain may be as common as trauma from physical abuse¹). The reasons for health care workers' nondocumentation and nonreferral of domestic violence include lack of time, pessimism about effecting a change, not wishing to open "Pandora's Box," viewing domestic violence as irrelevant to the medical model, and personal experience with domestic violence.^18,19 However, one study showed most patients welcome routine inquiry by physicians about domestic violence and believe that physicians can help victims of domestic violence.²⁰ Recommendations for physician intervention in cases of domestic violence are found in Table 1.

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Table 1

Prevalence studies of domestic violence in medical settings have not differentiated sporadic acts of violence from battering, nor have they focused on medical–surgical inpatients or the effects of intervention. Research should focus on the role of the consultation-liaison (C-L) psychiatrist in the evaluation, treatment, and referral of patients who have experienced domestic violence. The C-L psychiatrist is in a unique position to help victims of domestic violence deal with the psychiatric sequelae of their predicament and should be familiar with this common clinical problem.

REFERENCES

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