Article Summary Reports Title PageClient Background: Describe all of the key background points about the person/patient based on the information provided. What information would you like to know mo

Article Summary Reports  

1. Title Page

2. Client Background:  Describe all of the key background points about the person/patient based on the information provided. What information would you like to know more about? 

3. Abnormal Behavior:  Describe how and why this behavior is considered abnormal (i.e., the 6 criteria from chapter 1) 

4. DSM Classification:  Describe the official diagnosis. Match the case symptoms with the diagnosis. What research in chapter7 and 8 is consistent with this diagnosis?   

5. Describe the Treatment Plans.  What are some other possible interventions based on your chapter?

6. Conclusion: What did you learn from this real case about abnormal psychology?

Citations.  If you use resources other than course materials, please cite that reference appropriately using APA style (author, date). The paper must be at least 2-3 pages in length (not including cover and reference page) and must be doubled-spaced, 12-point font and submitted on a Microsoft Word document

Review:  Opioid Use Disorder (DSM-5 Criteria - APA, 2013)

Problematic pattern of opioid use leading to clinically significant impairment or distress, with at least two of the following within a 12-month period: 

1. Opioids taken in larger amounts over a longer period than was intended (high usage rate) 

2. Persistent desire to cut down or unsuccessful attempts to cut down or control opioid use (can't control it) 

3. A great deal of time spent on activities trying to get the opioid, use it, or recover from it (high time allocation) 

4. Craving, or strong desire to use opioid (psychological dependence). 

5. Recurrent use of opioid disrupting major responsibilities or obligations (Obligations Disrupted)

6.  Continued use despite problems caused by opioid use (substance abuse) 

7.  Important social, work, or recreational activities stopped due to opioid use (stopped normal functioning) 

8.  Repeated use of opioid in physically hazardous situations (dangerous settings)

9.  Repeated use despite knowledge of having persistent problems due to opioid use (self-aware/knowledgeable of problem)

10. Tolerance established (high tolerance) 

11.  Withdrawal symptoms and signs noted (withdrawal) 

 Here is the real case. 

Case 26-2019: A 27-Year-Old Woman with Opioid Use Disorder and Suicidal Ideation

Nisavic Mladen (Links to an external site.); Flores, Efren J (Links to an external site.); Heng, Marilyn (Links to an external site.); Kontos, Nicholas J (Links to an external site.); Quijije Nadia (Links to an external site.). The New England Journal of Medicine (Links to an external site.); Boston Vol. 381, Iss. 8,  (Links to an external site.) (Aug 22, 2019): 763-771. DOI:10.1056/NEJMcpc1904043

Presentation of Case

Dr. Andrew Cruz (Psychiatry): A 27-year-old woman was evaluated at this hospital because of a suicide attempt.

Approximately 3 months before admission, the patient became homeless and was staying intermittently with friends. Two months before admission, she began to ingest clonazepam daily, and 3 weeks before admission, she began to use intranasal heroin daily. She had depression and anxiety, and 2 days before admission, she expressed that she felt “tired of living this life” and wanted “to end it all.”

On the evening of presentation, the patient reportedly smashed her cell phone on the ground and ate the glass shards as a suicide attempt. Nausea and diffuse abdominal discomfort developed, and she reportedly had an episode vomiting, with the vomit containing 2 teaspoons (10 ml) of blood. Three hours after the ingestion, she presented to the emergency department of this hospital with throat, chest, and abdominal pain. She reported that she had “regret” about the ingestion and wanted “help” with her substance use and suicidality.

The patient reported past sexual trauma but did not provide details; she did not report any previous suicide attempts, homicidal ideation, or hallucinations. A limited review of systems was notable for anorexia, diaphoresis, diarrhea, impaired sleep, fatigue, mood lability, nightmares, and flashbacks. Her psychiatric history included polysubstance use disorder (with the use of intravenous heroin, fentanyl, benzodiazepines, and cocaine), cutting behavior during adolescence, and anxiety and depression. She had never undergone psychiatric treatment or hospitalization. Her medical history included hepatitis C virus infection, obesity, genital herpes simplex virus infection, and a low-grade squamous intraepithelial lesion of the cervix; in addition, a motor vehicle collision had led to open reduction and internal fixation involving the left arm. She took no medications and had no known adverse reactions to medications. She worked in a local store and had a small child. She had smoked one and a half packs of cigarettes daily for the past 10 years and was a current smoker. She drank 1 pint of vodka daily and reported no history of withdrawals or blackouts. Multiple relatives, including both of her parents, had a history of substance use disorder.

On examination, the temperature was 36.8°C, the pulse 70 beats per minute, and the oxygen saturation 96% while the patient was breathing ambient air. She appeared disheveled, tearful, and anxious. Abdominal examination revealed mild tenderness on the right side on palpation. On examination by a psychiatrist, she had limited eye contact and mumbling speech, along with poor concentration, depressed mood with a congruent affect, and poor insight and judgment. The complete blood count and levels of electrolytes, urea nitrogen, creatinine, lactate, bilirubin, alkaline phosphatase, and albumin were normal; the aspartate aminotransferase level was 162 U per liter (reference range, 9 to 32), and the alanine aminotransferase level was 52 U per liter (reference range, 7 to 33). Ethanol was not detected in the blood, and human chorionic gonadotropin was not detected in the urine. A urine toxicology screen was positive for opioids and cocaine metabolites. The findings on an electrocardiogram were normal and unchanged from a tracing obtained 10 years earlier.

Dr. Efren J. Flores: The results of radiography of the neck, chest, and abdomen were normal, without a visible radiopaque foreign body. Computed tomography (CT) of the abdomen and pelvis, performed after the administration of intravenous contrast material (Figure 1), revealed gallbladder wall thickening and trace perihepatic fluid. These findings can be seen in patients with acute hepatitis. There was no evidence of pneumoperitoneum or of a radiopaque foreign body.

Dr. Cruz: Intravenous normal saline, morphine sulfate, and piperacillin–tazobactam were administered. The patient was evaluated by the surgery and psychiatry services. Because of concern about the patient’s risk of self-harm, an order that authorized temporary involuntary hospitalization was implemented.

The next evening, the patient reported that while she was trying to get out of a stretcher, she “heard a pop” in her right elbow, which was accompanied by immediate pain without any numbness or tingling. On examination by an orthopedic surgeon, the olecranon process appeared to protrude posteriorly and medially without ecchymosis. The patient was not able to move the arm at the elbow, although range of motion was intact at the shoulder and wrist.

Dr. Flores: A lateral image of the right elbow (Figure 2A) showed posterior dislocation of the elbow with impaction of the olecranon process of the ulna into the distal humerus outside the olecranon fossa. An anteroposterior image of the right elbow (Figure 2B) confirmed dislocation of the elbow with malalignment of the ulnotrochlear and radiocapitellar joints.

Dr. Cruz: After the administration of acetaminophen, ibuprofen, oxycodone, and intravenous morphine, the elbow was manually reduced and a splint was applied. Additional radiographic images were obtained.

Dr. Flores: Lateral and anteroposterior images of the right elbow obtained after closed reduction and splinting (Figure 2C and 2D) showed normal alignment of the ulnotrochlear and radiocapitellar joints.

Dr. Cruz: During the next 18 hours, the patient remained under observation, with a plan for transfer to an inpatient psychiatric hospital for ongoing care. One hour before transfer, the patient went to the bathroom without her observer and then reported that she could not move her right arm.

Dr. Flores: A lateral image of the right elbow showed that the splint was in place and showed posterior dislocation of the elbow with impaction of the olecranon process of the ulna into the distal humerus outside the olecranon fossa. An anteroposterior image of the right elbow confirmed dislocation of the elbow with predominant involvement of the radiocapitellar joint. There was irregularity of the radial head and lateral humeral epicondyle that was consistent with a nondisplaced fracture.

Dr. Cruz: Intravenous morphine was administered. The elbow was again reduced, and a circumferential fiberglass cast was placed.

Dr. Flores: A lateral image of the right elbow obtained after the second closed reduction and casting showed normal alignment and the presence of a cast.

Dr. Cruz: The next afternoon, after the plan for transfer to a psychiatric hospital was shared with the patient, she was found in the bathroom without her observer, where she was banging her left arm against the wall. She reported pain, and oral oxycodone and intramuscular hydromorphone were administered.

Dr. Flores: A lateral image of the left elbow obtained hours after the second reduction and casting of the right elbow (Figure 2E) showed posterior dislocation of the left elbow and a fragment from a displaced fracture of the trochlea. There were two screws in the lateral humeral epicondyle from previous open reduction and internal fixation.

Dr. Cruz: Intraarticular nerve block was performed. The left elbow was reduced, and a long-arm circumferential fiberglass cast was placed.

Additional management decisions were made.

Differential Diagnosis

Dr. Mladen Nisavic: This 27-year-old woman with active polysubstance use disorder (with the use of alcohol, benzodiazepines, cocaine, and opioids) presented to the hospital after a reported suicide attempt by means of foreign-body ingestion. During the initial safety evaluation and surgical stabilization, a history of polysubstance use, anxiety, depressed mood, and trauma was elicited; she reported no previous suicide attempts.

The patient’s initial vital signs were normal, and she had no physical findings consistent with active alcohol withdrawal. The report of diarrhea, diaphoresis, and abdominal discomfort would arouse concern about early opioid withdrawal, given the recent use of opioids and reported history of opioid use disorder. Drug screening was notable for the presence of opioids and cocaine. Alcohol and benzodiazepines were not detected, nor was the heroin-specific metabolite 6-monoacetylmorphine.

Initial plain radiography of the chest and abdomen and abdominal CT did not reveal any ingested foreign bodies. It is important to note that small pieces of metal, glass, and plastic (which are presumed components of most cell phones) may not be reliably detected on imaging studies. However, in this case, the complete absence of imaging findings raises the question of whether the patient is being truthful about attempting suicide.1 It is also important to note that, despite the ultimate absence of trauma and of evidence of foreign-body ingestion, the patient reported clinically significant pain and intravenous opioids were administered.

My concern regarding this patient’s overall engagement and truthfulness with the team is further confirmed on review of her subsequent stay in the surgery unit. Over the course of 3 days, the patient had two episodes of seemingly spontaneous dislocation of the right elbow before she was observed actively attempting to dislocate her left elbow. Despite the presence of an observer, details regarding the way in which the first two injuries occurred are scarce; in both cases, the patient reported afterward that the dislocation was spontaneous and claimed to have no insight into the event. Despite prompt orthopedic treatment, she reported clinically significant pain with each dislocation and intravenous opioids were administered. Furthermore, the second and third dislocations had a notable temporal correlation with the planned transfer to an inpatient psychiatric facility, with the injuries occurring mere hours before the transfer was meant to occur.

In summary, a young woman with polysubstance use disorder self-presented after a self-reported suicidal gesture, and ultimately, no objective evidence of foreign-body ingestion was discovered. During routine surgical observation for clearance before planned transfer to an inpatient psychiatric facility, the patient appears to have engaged in repeated acts of self-harm, and until she was discovered engaging in such an act, she described each new injury as unintentional. With each incident, she reported clinically significant pain and intravenous opioids were administered.

Which diagnosis or diagnoses may explain this patient’s recurrent pattern of self-harm and limited engagement with the team? It is important to construct a broad differential diagnosis even if the diagnosis initially appears certain. Maintaining a broad differential diagnosis can help us to adequately confirm the major problem and to potentially identify less active or obvious contributors to the clinical situation. During psychiatric assessment, it is critical to consider each major component of the psychiatric review of symptoms and the way in which each component may apply to the case and help us to understand the patient’s behavior and actions. Such an approach offers a thorough and methodical path toward establishing the pertinent diagnosis and identifying any additional problems.

In gaining an understanding of this patient’s presentation, some of the major components of the history — such as depressed mood, anxiety, and post-traumatic stress disorder — are notable. Despite her initial endorsement of mood, anxiety, and safety concerns, she quickly stopped reporting these symptoms during her stay in the surgery unit. In addition, there are few findings that would allow us to ascribe the patient’s behavior to an episode associated with untreated major depressive disorder. An underlying thought disorder or acute mania may be considered, primarily given the bizarre nature of her recurrent injuries. However, neither of these diagnoses appears to be consistent with the remainder of the history. The patient did not have a history of clinically significant severe and persistent mental illness, and no cardinal symptoms of either acute mania or psychosis were described throughout her hospitalization. No negative symptoms of a major thought disorder were described, either.

Personality vulnerability or frank personality disorders could also be considered, especially given the patient’s history of trauma. However, we do not have the necessary information to support these diagnoses, and her brief hospitalization offers insufficient exposure to allow us to make these diagnoses.

Multiple substance use disorders were noted in this case, and I strongly suspect that substance use is playing a considerable role in this patient’s presentation. Acute intoxication (e.g., with cocaine) may be associated with unusual behavior, but repeated use while under strict observation in the hospital would be unlikely. Withdrawal from alcohol or benzodiazepines can be linked with delirium, but the patient’s behavior appears to be deliberate, methodical, and devoid of acute confusion and of any other signs or symptoms of acute withdrawal from one of these agents, such as tremor or changes in vital signs. She reported recent opioid use, and her initial examination was notable for some signs of early opioid withdrawal. Furthermore, she requested intravenous opioids at the time of the initial presentation and with each episode of self-injurious behavior. Could opioid use disorder be the unifying diagnosis in this case?

In the presence of intentional and repetitive self-harm, a diagnosis in the category of somatic symptom and related disorders could also be explored. A deception syndrome (factitious disorder or malingering) is a strong consideration, given the multiple inconsistencies in the available information and ultimate evidence of deliberate self-infliction of injuries. To rule out an occult medical cause, I performed a literature search for spontaneous and recurrent elbow dislocations. The review offered limited data but provided reassurance that spontaneous elbow dislocation is an uncommon finding outside specific populations (e.g., children and male athletes), and when it occurs, it is often linked with preexisting joint vulnerability.2–4

The patient’s history offers minimal evidence that her behavior reflects an unconscious need to maintain a sick role, a hallmark of factitious disorder. Instead, there appears to be a strong correlation between her behavior and opioid administration, which would reflect secondary gain, a hallmark of malingering. I suspect that the best explanation of this patient’s behavior lies at the intersection of substance use and deception syndrome.

Note: Malingering is the purposeful production of falsely or grossly exaggerated physical and/or psychological symptoms with the goal of receiving a reward. ... Malingering is not a psychiatric disorder. https://www.psychologytoday.com/us/conditions/malingering (Links to an external site.)

Dr. Mladen Nisavic’s Diagnosis

Severe opioid use disorder and malingering (deception syndrome).

Psychiatric Diagnosis

Dr. Nicholas J. Kontos: After multiple psychiatric interviews, the patient reported that she had lied about her suicide attempt and had intentionally dislocated her elbows. She also reported that her goal in both cases was to obtain opioids, confirming the diagnosis of malingering.

The Diagnostic and Statistical Manual of Mental Disorders, fifth edition,5 classifies malingering among “other conditions that may be a focus of clinical attention.” Malingering is not a psychiatric disorder. It can be distinguished from factitious disorder by the presence of behavior that is directed toward tangible gains, as opposed to behavior that is directed toward intangible sick-role gains. Sick-role gains include receiving care, being excused from duties, and being able to place blame on sickness.6 The line between tangible and intangible gains can be blurry; it is sometimes more important to describe and try to address the patient’s goals than to distinguish between factitious disorder and malingering.

There is minimal evidence-based guidance for the identification of clinically significant deception, particularly that involving psychological symptoms. The method for making an actionable diagnosis of malingering is unsettled, even in forensic situations, in which dedicated neuropsychological tests are used.7,8 It is not surprising that underidentification of malingering in the clinical setting is common.9,10

This patient reported a specific suicide attempt, with a motive and associated pain and fear, and she later reported elbow pain and immobility. At face value, this patient’s history warranted concern from clinicians who were making decisions about safety precautions. However, because the patient did not have physical findings (e.g., oropharyngeal lesions) or imaging findings that would support the reported ingestion and because she had disengaged from subjects about which she had initially expressed desperate concern, suspicions appropriately rose. Such suspicions might be inhibited by concerns about stigmatization, doctor–patient rapport, and even liability.11 Allowing suspicion without cynicism or premature closure is an early hurdle in deception assessment.12

Some experts advise and others discourage confrontation of patients who have possible deception syndrome, and approaches to confrontation are seldom defined. An approach that is incremental, honestly poses and compares conflicting points of view, and attends to the ethical implications of a potentially one-sided good-faith relationship13 is consistent with a “feedback model,” in which rapport and attention to reasons for deception are emphasized.14 In this case, confrontation of the patient began with an unreciprocated attempt to engage and a statement of helpful intent. Then, inconsistencies in the available information were addressed with curiosity and met with irritation from the patient. The next day, the patient explained her behavior but otherwise remained irritably disengaged. Continued confrontation was eventually met with meaningful engagement, including participation in motivational interviewing.

Most patients with deceptive behaviors do not readily explain those behaviors. Yet, misrepresented psychological symptoms are strongly suspected in up to 20% of psychiatric emergency department visits15 and reported anonymously by 8 to 10% of psychiatric inpatients.16–18 Nonetheless, it is important for physicians to remain skeptical of their own intuitions about and strong reactions against possible deception. Physicians have no special aptitude for detecting deception in unfamiliar patients.19 Medical records may provide a longitudinal perspective that reveals consistencies across presentations or inconsistencies within reports. A patient who is unfamiliar to an individual physician may be quite familiar at the institutional level. Close review of available records may be valuable when evaluating a patient with possible malingering.

Discussion of Management

Orthopedic Management

Dr. Marilyn Heng: Because the elbow joint has bony stability with a deep ulnohumeral contour and capsular and ligamentous constraints, it is a difficult joint to dislocate.20 Prompt restoration of articular alignment by means of closed reduction is desired to reduce the risk of swelling, damage to the articular cartilage, and neurovascular compromise. Reduction of the dislocated elbow usually results in pain relief for the patient. The administration of narcotic pain medication is not usually continued after reduction for simple elbow dislocation; at most, only a short course (1 to 2 days) is administered. Simple elbow dislocation without associated fracture is usually treated nonoperatively, with treatment followed by a period of immobilization. In this patient, the results of clinical examination and the previous dislocation of the right elbow would lead to a plan for a longer-than-usual period (2 to 3 weeks) of immobilization.

The patient’s active attempts to redislocate her elbow resulted in breakage of her splint. Conversion to a circumferential fiberglass cast prevented her from intentionally dislocating the right elbow but then provoked her to dislocate the left elbow. Closed reduction and long-arm casting of the left elbow was performed. Surgery for recurrent elbow dislocation consists of repair of ligamentous structures, with or without external fixation. However, a cautious approach should be taken for patients who intentionally, habitually dislocate a joint for secondary gain. In such patients, surgical treatment is associated with a high risk of failure due to nonadherence to medical recommendations. In this situation, the general approach of the orthopedic surgeon would be either to maintain prolonged casting or to do nothing while the issues behind the behavior leading to intentional dislocation are addressed.

Management of Deception Syndromes

Dr. Kontos: Only case reports and experience guide the clinical management of malingering. In practice, management occurs in three domains: treatment, shifting of the patient’s strategies, and punishment. Treatment addresses the consequences of self-harm; in this case, it involved casting of the affected limbs. Treating an objective pathologic condition (e.g., an infection or ingestion) must proceed independently of and in parallel with addressing its cause. Psychiatric treatment for malingering focuses on possible coexisting conditions (e.g., substance use or personality disorder).

The confrontation and feedback involved in the detection of malingering can engage the patient in the work of shifting maladaptive life strategies in favor of adaptive ones. The goal is to “move the discussion from the traditional reliance on medical or psychological causes to a consideration of the reasons” behind malingering.14 Common reasons include addiction, legal entanglements, and the need for food, shelter, and safety. In some cases, the health care system is unable to meet these needs other than by directing the patient toward a different path. The application of clinical tools to purely social problems may do more harm than good.

A patient’s inability or unwillingness to reciprocate reasons-based engagement can necessitate interventions with the appearance of punishment or actual punishment. Sometimes, the only good outcome of malingering is the prevention of iatrogenic harm and the nonparticipation of the clinician or institution in reinforcing maladaptive behaviors. A security-facilitated “therapeutic discharge”21,22 may be needed for recalcitrant patients. In extreme cases, criminal prosecution for theft of service might be considered.11

Management of Opioid Use Disorder

Dr. Nadia Quijije: When treating a patient with opioid use disorder and coexisting acute pain in the inpatient setting, I keep three major components in mind: opioid withdrawal, undertreated pain, and longitudinal treatment through medication-assisted strategies (suboxone or methadone maintenance therapy). In this case, I was concerned about the patient’s risk of opioid withdrawal, given her consistent use of heroin. When I met the patient, it had been 3 days since her last opioid use, so she was still within the window for withdrawal symptoms but had been receiving short-acting opioids for pain along with agents for the management of opioid withdrawal symptoms (dicyclomine for abdominal cramps and acetaminophen for muscle aches). In the management of opioid withdrawal, it is important to assess for both subjective symptoms (anxiety, abdominal cramps, and muscle aches) and objective symptoms (diaphoresis, dilated pupils, and piloerection). This patient reported and seemed most distressed about “sweats and anxiety,” for which I recommended the addition of clonidine, which can specifically relieve these symptoms by means of norepinephrine dampening.23

During the treatment of this patient’s pain, she reported feeling comfortable with the prescribed oxycodone, and therefore, we did not recommend changing the agent or adjusting the dose. However, it is important to keep in mind that patients with opioid use disorder are likely to have a high tolerance for opioids and will therefore probably need a high dose of opioids for treatment, especially when they are undergoing surgical or medical procedures, as in this case.24 This is also an opportunity to discuss medication-assisted treatments, such as suboxone and methadone, for both the management of acute pain and the longitudinal treatment of opioid use disorder.25 This patient was not interested in receiving methadone; she was agreeable to the initiation of suboxone as medication-assisted treatment for opioid use disorder but not for the management of acute pain. It was recommended that suboxone be initiated after immediate needs were resolved to allow for adequate pain management and to avoid suboxone-induced opioid withdrawal.26 The inpatient setting is a prime place to set up aftercare treatment with intensive outpatient programs, methadone maintenance clinics, suboxone prescribers, recovery coaches, or Narcotics Anonymous.27 We had planned to transfer this patient to a dual-diagnosis inpatient unit to obtain treatment for acute substance use disorder and to establish aftercare planning.

Dr. Cruz: The patient declined treatment for substance use disorder and social-work assistance with shelter. After discharge from the hospital, she presented to the emergency department five times in the following week. On the final presentation, she asked that the arm casts be removed, and she has not presented to the emergency department in more than 6 months.

Final Diagnosis

Opioid use disorder and malingering.

This case was presented at Psychiatry Grand Rounds.

Disclosure forms provided by the authors are available with the full text of this article at NEJM.org.

We thank Dr. John Taylor for assistance with selection of this case and organization of the conference.