Psychiatry Case Challenge: A 9-Year-Old With Suicidal Behavior

James Robert Brasic, MD, MPH


January 25, 2022

Hallucinations likely result from excitatory stimulation, such as an excessive phasic release of endogenous dopamine in schizophrenia,[9,10,11,12] although the duration of the hallucinations and delusions (fixed false beliefs) experienced by the patient in this case were insufficient to support that diagnosis here. Hallucinations also result from inhibition or elimination of sensory stimulation,[13] such as visual hallucinations in those who cannot see (the Charles Bonnet syndrome) and sensory perceptions in an amputated extremity (the phantom limb phenomenon).[14]

The differential diagnosis of this child could possibly include malingering, the deliberate fabrication of symptoms by a person, usually to avoid an undesirable outcome, such as going to jail, or to gain benefits, such as compensation for injuries. Both the patient and his mother verified the presence of the symptoms. No evidence suggested that the patient was making up the symptoms that he reported.[15]

Another unlikely possibility for the differential diagnosis is factitious disorder imposed on self, still often referred to as Munchausen syndrome, a condition like malingering, in that the person deliberately reports false symptoms and signs of medical and psychiatric disorders.[16] Usually in this syndrome, the person reports a flamboyant story with many complications. No evidence suggested that the child was fabricating his symptoms. The evidence on history and examination confirmed the veracity of his symptoms and his signs.

A related condition to rule out is factitious disorder imposed on another, still often referred to as Munchausen syndrome by proxy, a condition in which a caregiver, often a parent, falsely reports the symptoms and signs of medical and psychiatric illnesses in a child who actually is healthy.[17] This condition was ruled out in this patient because the symptoms and the signs reported by the patient and his mother were corroborated by history and examination.

The above considerations in the differential diagnosis represent conditions in which a young patient and parent deliberately report symptoms and signs that they know are false. These are fabricated conditions. Because the history and the examination confirmed the information reported by the patient and his mother, fabricated conditions were ruled out.

Another condition in the differential diagnosis is conversion disorder. In this condition, the patient truthfully reports the experienced symptoms and signs. Although the patient believes in a physical basis for the symptoms and signs, no organic pathology is detected. Conversion disorders often occur in people with low socioeconomic status and low education. Conversion disorders may occur in people who have experienced physical, emotional, and sexual abuse. Although conversion disorders can occur in children, the symptoms and signs reported by the patient are not confirmed on interview and examination.[18] Conversion disorder was ruled out in this patient because his symptoms and his signs were confirmed on history and examination.

Although he is too young to have a personality disorder, as diagnosis requires age 18 years or older, he has many of the signs of an antisocial personality. However, based on his behavioral history, he would be diagnosed as having a conduct disorder, prior to showing evidence of a brief psychosis.


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