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BRIEF COMMUNICATION
Year : 2019  |  Volume : 7  |  Issue : 1  |  Page : 27-29

Malingering versus dissociative disorder: A clinical dilemma!!


1 Department of Ophthalmology, Kasturba Medical College, Mangalore, Karnataka, India
2 Department of Psychiatry, S R Medical College and Research Centre, Trivandrum, Kerala, India

Date of Submission26-Aug-2017
Date of Acceptance09-Jan-2019
Date of Web Publication12-Mar-2019

Correspondence Address:
Jayanthi Kalary
Department of Ophthalmology, Kasturba Medical College, Mangalore, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jcor.jcor_62_17

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  Abstract 


Malingering and dissociation coincide with the mode of presentation. Dissociation and attention-deficit hyperactivity disorder (ADHD) can coexist due to their similar etiology. We report a case of dissociative disorder in a boy with ADHD presenting with sudden visual diminution. To our knowledge, though common, such case has not been reported in the literature. A 9-year-old boy, a case of ADHD on atomoxetine (25 mg) and risperidone (0.25 mg), was brought by his apprehensive mother, with sudden diminution of vision in his right eye for 1 week. On examination, his visual acuity was 20/120 in the right eye and 20/20 in the left eye, even on repeating with various charts. His anterior segment, fundus, and cycloplegic retinoscopy were normal. Visually evoked potential was normal in both the eyes. With a suspicion of malingering, +20D in front of the left eye. The test was positive for malingering, and the mother was reassured. The kid was sent to the psychiatry department for further counseling. They diagnosed it as a dissociative disorder. Simple tests for malingering still have an important role in ophthalmology. Children cannot be underestimated in their ability to malinger, but at the same time, dissociative disorder should be borne in mind before labeling a patient as a case of malingering. Because once the label of malingering is given, then it is a human tendency to form a prejudice idea about that patient and later that the patient would not get proper medical assistance.

Keywords: Attention-deficit hyperactivity disorder, dissociative disorder, malingering tests


How to cite this article:
Pai SG, Nayak M, Kalary J, Krithishree S S. Malingering versus dissociative disorder: A clinical dilemma!!. J Clin Ophthalmol Res 2019;7:27-9

How to cite this URL:
Pai SG, Nayak M, Kalary J, Krithishree S S. Malingering versus dissociative disorder: A clinical dilemma!!. J Clin Ophthalmol Res [serial online] 2019 [cited 2019 Mar 21];7:27-9. Available from: http://www.jcor.in/text.asp?2019/7/1/27/253992



The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision defines malingering as the intentional production of false or grossly exaggerated physical or psychological symptoms motivated by external gain.[1] This is seen in all age groups. It is not considered as a form of mental illness or psychopathology although it can occur in the context of other mental illnesses.

Previously, dissociation was referred to as hysteria, however, that term remains extinct now. It is a psychological phenomenon which involves disruption in consciousness, memory, identity, and/or perception of the environment. Dissociation in simple language is detachment from reality. Dissociation may be present in general population in nonpathological forms, which is also called “psychological absorption.”[2] It can be used as a coping mechanism or as a defense mechanism to minimize or tolerate stress.

When dissociation is used pathologically and involuntarily, it forms dissociative disorder.

Transient dissociative episodes are considered to be common in childhood, which eventually reduce in frequency by adulthood. Researchers have found a significant association of dissociative episodes with childhood trauma. Dissociation may manifest differently at different age groups. It often goes unnoticed or misdiagnosed. Hence, the purpose of the study is to emphasize the need to explore the psychological angle for visual disturbances.


  Case Report Top


A 9-year-old school-going boy was brought to our outpatient department by his apprehensive mother. He was complaining of sudden, painless diminution of vision in his right eye for 1 week. It was not associated with redness, headache, nausea, vomiting and floaters. The mother did not report any trauma to the eye. He was a case of attention-deficit hyperactivity disorder (ADHD) and on atomexitine (25 mg) and risperidone (0.25 mg) in the past 1 year at the time of presentation in our outpatient department.

On examination, visual acuity was 6/36 for distance and N36 for near in the right eye and 6/6, N6 in the left eye. Visual acuity in the right eye was not improving with pinhole and refraction.

His anterior segment including pupillary reactions and fundi were normal. Cycloplegic retinoscopy was done and was normal. Microtropia was ruled out by 4-prism diopter test. A visually evoked potential (VEP) test was performed to rule out neurological disorders. It was normal.

The child was reviewed after 1 week, and repeat visual acuity testing was done. It was the same even on repeating with various charts. We had a few differential diagnoses in mind.

Amblyopia which went unnoticed and became apparent suddenly as in closure of normal eye or uniocular vision testing. Cortical blindness, optic nerve conduction defects, In view of his medical records rare possibility of malingering, amblyopia could be ruled out here as there was no apparent cause for form or sensory deprivation.

The following malingering tests were performed:

  1. Fogging test – A +20 diopter lens was placed in front of the left eye to blur the image, and the child was encouraged to read from the left eye. Here, the child has to use his right eye to read the charts as the left eye's image is blurred
  2. Prism test.


To our surprise, they were positive.

We explained the condition to his parents and reassured them. The child was referred to the psychiatry department for further counseling. Psychiatrist reported it as a dissociative disorder and was treated accordingly. Now, the child is doing well without any complaints.


  Discussion Top


Pupillary reactions have an important role in ruling in pathology of lesions of the anterior visual pathway. A normal VEP rules out lesions of the anterior visual pathway as well as cortical function. In this case, since pupillary reactions and VEP were normal, malingering tests were performed.

Malingering tests available are as follows:[3] fogging test which can be used to bring out latent hypermetropia and malingering, crossed-cylinder technique, Lytton test, Baudry test, prism up, down test, optokinetic nystagmus test, optical coherence tomography, VEP, and frequency-doubled perimetry which uses sine wave grating of low spatial frequency.

Simple tests for malingering still have an important role in ophthalmology. Children cannot be underestimated in their ability to malinger. Simple malingering tests which can be done in outpatient department are of a value in saving time and resources. However, tests such as VEP, optical coherence tomography, and frequency-doubling perimetry which are of greater significance can be used in doubtful cases.[4],[5] Identifying a malingerer will help focus resources toward patients with genuine symptoms, but at the same time, mislabeling turns out to be unjust to the patient. Because once the label of malingering is given, then it is a human tendency to form a prejudice idea about that patient and later that the patient would not get proper medical assistance. [Table 1] elaborates on main differences between dissociation and malingering.
Table 1: Dissociation vs. Malignering

Click here to view


There is no direct association between ADHD and dissociative disorder. However, trauma experienced in early part of life is associated with psychological and behavioral consequences.[6] Early life trauma forms a common etiological basis for conditions such as dissociative disorders (psychological variant) and ADHD (behavioral variant). In our patient, we were unable to establish the clear evidence of existence of early life trauma; however, it can be hypothesized as a common source for occurrence of both the problems.

Dissociative disorder is a diagnosis of exclusion. Whenever a patient presents with bizarre set of symptoms, a detailed history with thorough physical examination has to be done; in our case, the child presented with sudden, painless diminution of vision of 1-week duration. On examination, there were no associated ocular signs and no precedence of trauma. When a discrepancy was noted in the symptoms and objective tests, a diagnosis of dissociative disorder was made by exclusion.

Since the patient is 9 years old with no evidence of personal gain for such presentation, the motive and mode, the diagnosis of dissociative disorder was given precedence over malingering.

The primary reason for the occurrence of any dissociative symptom in any age group would be an unresolved early life conflict which would be lingering in the unconscious mind. This forms a common etiological platform for the emergence of any mental illness. However, the symptom manifestation and age of onset depend on the psychological integrity, environmental support, and genetic vulnerability.

It is important to know that the treatment of dissociation is not in the resolution of these conflicts because many a times these conflicts remain beyond the reach of clinicians. Thus, it is not always important to probe and disturb the unconscious mind. Further, understanding these conflicts would be important in preventing worsening of the symptoms or preventing further episodes. Treatment mainly lies on empowering the patient in handling such life stressors.

Hence, in our patient on initial probing, the conflict seemed to be the interpersonal disharmony between the child's parents. This was addressed to the caregivers. However, the child was counseled and endowed with problem-solving skills on further follow-ups with the department of psychiatry. The child regained the lost functioning ability and resumed back to normal life.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Richard R. Clinical Assessment of Malingering and Deception. 3rd ed. The Guilford Press, NewYork, London; 2012. p. 69-70.  Back to cited text no. 1
    
2.
Irwin HJ. Pathological and nonpathological dissociation: The relevance of childhood trauma. J Psychol 1999;133:157-64.  Back to cited text no. 2
    
3.
Zia C, Murugesan V. Postgraduate Ophthalmology 2012. p. 1592.  Back to cited text no. 3
    
4.
Sun IT, Lee JJ, Huang HM, Kuo HK. Pattern visual evoked potentials for identifying malingering. Doc Ophthalmol 2015;130:221-9.  Back to cited text no. 4
    
5.
Incesu AI. Tests for malingering in ophthalmology. Int J Ophthalmol 2013;6:708-17.  Back to cited text no. 5
    
6.
Glod CA, Teicher MH. Relationship between early abuse, posttraumatic stress disorder, and activity levels in prepubertal children. J Am Acad Child Adolesc Psychiatry 1996;35:1384-93.  Back to cited text no. 6
    



 
 
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