Cases That Test Your Skills

Is she being abused or ‘acting out’?

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Ms. L says her caretaker is beating her, but the allegation may be suspect. How can you find out the truth and ensure the patient’s safety?


 

References

HISTORY: ‘Unusual behavior’

Ms. L, age 44, has severe cerebral palsy and has used a wheelchair since childhood. Her mother, who had been her primary caretaker, died 12 years ago, and her stepsister has been caring for her since.

Ms. L’s primary care physician reports that the patient has been “acting out” lately and asks us to evaluate her “unusual behavior.” Six months ago, the physician prescribed escitalopram, 30 mg/d, to treat depressive symptoms stemming from her chronic neurologic disorder.

We interview Ms. L and her stepsister together. The patient says she has been depressed, irritable, and moody, and her stepsister confirms this. The patient shows no signs of distress during the interview, and her answers appear short and guarded.

The stepsister says she typically spends her day turning Ms. L to prevent bedsores, feeding and bathing her, replacing her urinary catheter and emptying her urinary bag, and helping her to the bathroom. At day’s end, the stepsister has little time to spend with her husband or for other activities. She says at times she resents tending to Ms. L’s constant needs and feels “stressed out.”

We diagnose Ms. L with a mood disorder caused by a general medical condition. We continue escitalopram, 30 mg/d, and add oxcarbazepine, 150 mg bid, to treat her irritability and lability.

FOLLOW-UP: ‘She’s abusing me’

At Ms. L’s follow-up visit 2 weeks later, we ask her stepsister to leave the examination room and interview the patient alone to gauge her emotional condition and insight.

Seconds later, Ms. L starts crying hysterically, then reports that for 12 years her stepsister has been beating her, usually after she requests something. Yesterday, she says, her stepsister started punching her after she asked to be taken to the park.

Ms. L says the abuse is escalating and now occurs daily. She says she is covered with bruises from the last beating, although no bruises are visible at first glance. Afraid to go home with her stepsister, she pleads for help.

At this point, I would:
  1. call the primary care physician for collateral information
  2. examine Ms. L for bruises
  3. get the stepsister’s side of the story
  4. contact state protective services
  5. all of the above

The authors’ observations

Is Ms. L being physically abused, or is a psychiatric condition driving her to fabricate these allegations?

We saw nothing suspicious during the first interview with the stepsister, although she acknowledged difficulty coping with Ms. L’s constant requests (Box 1).1 Caring for a severely disabled person day in and day out can be trying for both the caregiver and her family, and the stepsister could be taking her frustrations out on Ms. L.

Until proven otherwise, we must assume Ms. L is being harmed and seek more information. We also must watch for signs of a delusional or factitious disorder or malingering—any of which would suggest the allegations are false.

Box 1

An abuser of a vulnerable adult…

Is often a family member

Experiences stress brought on by the strain of caregiving coupled with marital problems, lack of money, overcrowded living conditions, or lack of needed health or social services

Often abuses alcohol and/or drugs

Might have emotional problems:

  • Caregiver often resents patient’s dependency
  • If patient is caregiver’s parent, caregiver might be retaliating for past mistreatment

Depends on vulnerable adult for basic needs such as money or housing

Might come from a family where abusive behavior is normal

Source: Reference 1

HISTORY: A second opinion

We ask Ms. L if we can discuss the allegations with her and her stepsister, but she fears retaliation and insists that we not speak to the caretaker.

We then call Ms. L’s primary care physician, who has been managing her care for several years. He says the patient has begged him numerous times for protection from her stepsister, but adds he has found no evidence of abuse. He notes that he has witnessed tension between the 2 women during office visits and cannot dismiss the possibility of abuse.

The attending psychiatrist performs a brief physical exam with the resident looking on but finds no bruises, excoriations, or unusual scarring on her arms and legs. Because our outpatient clinic lacks an examination room, we do not perform a whole-body exam.

We then notify state protective services. There, an agent tells us that in the past year, Ms. L has made 4 allegations of caretaker abuse, none of which were substantiated after extensive investigation. The agent says her office will assign a case worker but considers the case a low priority.

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