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[Successful treatment of an elderly woman after stubborn resistance].

A 72-year-old depressed woman was admitted by court order after a long history of ¿successful' resistance to any treatment, both at home and in a psychiatric hospital. The nature of her disorder had not been recognised and she was diagnosed elsewhere as suffering from factitious disorder, probably based on intense countertransference. The diagnosis of depression with mood-congruent psychotic features was made. After several unsuccessful combination treatments and refusal of electroshock therapy, she finally responded to combination therapy with tranylcypromine, lithium carbonate and clozapine. Dutch medicolegal regulations need not be an impediment in such cases, intercollegiate consultation is most useful and strict adherence to therapy guidelines is beneficial.

Aged↗

Non-organic hearing loss redefined: understanding, categorizing and managing non-organic behaviour.

Addressing the complex factors that underpin any presentation of non-organic hearing loss (NOHL) is essential to that individual's proper management. The complex and often conflicting approaches taken to date are reviewed. Previous dichotomous models distinguish those assessed as consciously malingering for external benefits from those who generate symptoms unconsciously to meet psychological needs. Incorporating the DSM-IV-TR diagnosis of 'factitious disorder' into a new model bridges the conceptual gap. Three categories (malingering, factitious and conversion) are used distinctly, for the purpose of diagnosis, and on a continuum for the purpose of management. Motivating factors, type of gain, degree of intention and consistency of response during audiological assessment can all be related within the model. Advances in objective measurements have made the detection of NOHL easier. A reinvigoration of interest in effective diagnosis and management of the condition is therefore timely.

Adolescent↗

Disorders of adult personality and behaviour (F6). Results from the ICD-10 field trial of the Diagnostic Criteria for Research in German-speaking countries.

Results of the ICD-10 Diagnostic Criteria for Research (DCR) field trial in German-speaking countries revealed a high level of interrater reliability (kappa = 0.79) for disorders of adult personality and behaviour (section F6) with marked differences between specific diagnoses: borderline personality = 0.76, transsexualism = 0.98, factitious disorder = 0.33. Compared with the results of the field trial concerning the Clinical Guidelines for section F6 of ICD-10, the application of the more precise and restrictive DRC led to an improvement of general kappa values of 0.15.

Factitious Disorders↗

Hypercalcemia and human nature.

Patients on hemodialysis may develop severe and symptomatic hypercalcemia if skeletal buffering is ineffective. We report a case of persistent hypercalcemia with apparent extrarenal vitamin D synthesis. Associated aluminium intoxication was suggested on desferrioxamine challenge and adynamic uremic osteodystrophy confirmed on bone biopsy. Plasma calcitriol did not suppress with corticosteroids but did with ketoconazole. No other evidence for underlying granulomatous disease was found. We discuss our approach to less usual causes of hypercalcemia, and emphasise the pitfalls associated with factitious disorders.

Adult↗

Münchausen syndrome by proxy and sleep disorders medicine.

Münchausen syndrome by proxy is a factitious disorder of childhood in which a parent fabricates medical history or produces signs of illness in a child to keep the child in a sick role. Since approximately half of all cases of Münchausen syndrome by proxy are presentations of central nervous system illness, such as excessive daytime sleepiness and near-miss sudden infant death syndrome, sleep disorders centers are likely diagnostic consultants for the evaluation of children involved in this disorder. We review characteristics that may suggest that a particular case has an increased likelihood of Münchausen syndrome by proxy. The recent presentations of two cases of Münchausen syndrome by proxy to sleep disorders centers are discussed as examples.

Child Abuse↗

Factitious methemoglobinemia.

We report the case of a 26 year-old female who was treated on numerous occasions for methemoglobinemia believed secondary to surreptitious abuse of dapsone as part of a factitious disorder.

Adult↗

Strategic-behavioral intervention in the treatment of chronic nonorganic motor disorders.

Chronic nonorganic motor disorders pose particular difficulties because of a combination of diagnostic confusion and intractability to psychotherapeutic or behavioral interventions. Three cases are presented, all of whom failed a rehabilitation approach that emphasized basic behavioral principles of shaping and reinforcement. Despite this initial failure, all three patients showed dramatic and rapid improvement after implementation of an intervention combing elements of strategic and behavior therapy. The strategic element consisted of placing patients in a double bind by telling them full recovery constituted proof of an organic etiology and failure to recovery constituted conclusive evidence of a nonorganic or psychiatric etiology. These cases also illustrate the difficulty in distinguishing between conversion and factitious disorders.

Adolescent↗

Psychogenic movement disorders.

All varieties of movement disorders may be mimicked by a psychogenic disorder, most commonly tremor, dystonia, and myoclonus. Approximately 3% of patients seen in specialty clinics have a psychogenic movement disorder (PMD). The diagnosis of a PMD depends on not just ruling out an organic movement disorder, but moreover, recognizing features from the history and examination that are inconsistent or incongruous with an organic movement disorder. Most PMDs represent a conversion disorder, sometimes as part of a somatoform disorder; less common diagnoses include a factitious disorder or malingering. Co-morbid psychiatric illness is prevalent in patients with PMD including depression, anxiety, and personality disorders. Many PMDs remain chronic, but a multidisciplinary approach centering on psychiatric intervention can be successful. A shorter duration of symptoms and a co-existent treatable psychiatric disorder portend a better prognosis, whereas compensation and pending litigation are associated with a poorer prognosis.

Female↗

Factitious posttraumatic stress disorder.

A growing number of young men have reported an array of symptoms that suggest a diagnosis of posttraumatic stress disorder. Five such men, all claiming to be Viet Nam veterans, were treated at a VA medical center; three said they were former prisoners of war. In fact, none had been prisoners of war, four had never been in Viet Nam, and two had never even been in the military. Instead, all five suffered factitious disorders. The authors describe the five patients and discuss differential diagnoses; the value of verifying military histories is stressed.

Adult↗

The Ganser syndrome: evidence suggesting its classification as a dissociative disorder.

The past and present nosology of Ganser's syndrome is discussed. The anomaly is defined as the presence of approximate answers with hallucinations, clouded sensorium, somatic conversion, and amnesia. The characteristic symptom of the syndrome, paralogia, is appreciated as an associated feature of Factitious Disorder with Psychological Symptoms. It is suggested that Ganser syndrome may be linked inappropriately with the concept of factitious illness. Two new cases of the Ganser syndrome are presented, and an additional forty-one case reports are reviewed. A high correlation between the presence of paralogia and amnesia is revealed, which suggests that paralogia and related psychological symptoms are better classified as associated features of Atypical Dissociative Disorder.

Adult↗

[Pseudomalabsorption of levothyroxine: a case report].

A 49-year-old woman who had been treated with sodium levothyroxine because of hypothyroidism after diagnosis of Hashimoto thyroiditis and total thyroidectomy for multinodular atoxic goiter was evaluated for persistent hypothyroidism despite the use of large doses of levothyroxine (600 microg/day). The patient showed signs and symptoms of hypothyroidism and her laboratory tests were: TSH of 351 microUI/mL, free thyroxine of 0.20 ng/dL, and total triiodothyronine of 27 ng/dL. She was submitted, under medical supervision, to a levothyroxine overload test with no evidence of malabsorption of the thyroid hormone. Diagnosis of factitious disorder and Munchausen syndrome leading to the pseudomalabsorption of levothyroxine was considered.

Diagnosis, Differential↗

Deceiving others/deceiving oneself: four cases of factitious rape.

Although patients with factitious disorders typically seek the "patient" role through illness portrayals, some instead portray themselves falsely as "victims." We discuss the cases of four women who claimed to have been victims of rape; the allegations ultimately were disproved. Factitious rape may be prompted by a search for nurturance; by dissociation, leading individuals to believe that trauma earlier in life is ongoing; by a need to be rescued from real, current abuse; and by projection of anger onto specific male targets. Although dramatic, factitious rape is rare, we advocate thorough investigation of rape claims even when patients have known histories of deceptive behavior.

Adult↗

Different patterns of extension and recurrence in algodystrophy.

A true recurrence at exactly the same site is quite unusual in algodystrophy. Local or regional extension is possible. The bone scan is an easy way to demonstrate that the areas successively affected are not the same. An apparent local recurrence could in fact be a microscopic compression fracture of trabecular bone or cortical fractures or part of a factitious disorder.

Adult↗

Pseudomalabsorption of levothyroxine.

OBJECTIVE: --The issue of patient compliance with pharmacological therapy vs malabsorption of medication was explored in the context of persistent hypothyroidism despite the administration of large doses of levothyroxine sodium. DESIGN: --Retrospective case series. SETTING: --Referred care in two large tertiary care centers. PATIENTS: --Four patients, seen within two decades, with clinical and biochemical hypothyroidism while receiving levothyroxine, were evaluated for selective malabsorption of this hormone. INTERVENTIONS: --Studies included serial measurements of thyroid hormone levels after a loading dose of levothyroxine or liothyronine sodium or evaluation with a double-labeled thyroxine tracer technique. Results were compared with studies of levothyroxine malabsorption in the medical literature. RESULTS: --All patients were ultimately found to have normal (82% to 100%) absorption of oral levothyroxine. There was no evidence that malabsorption of levothyroxine can occur as an isolated abnormality. CONCLUSIONS: --Some patients exhibit a factitious disorder suggesting malabsorption of levothyroxine. When treating hypothyroidism, psychiatric issues may result in noncompliance with levothyroxine therapy.

Adult↗

Quartz stones: spurious or iatrogenic?

We describe 2 cases of spurious quartz-containing calculi; the first patient-driven and the second iatrogenic. An iatrogenic etiology can occur after the use of holmium:yttrium-aluminum-garnet laser energy because the fiber tip is composed of quartz. To make the diagnosis of a spurious stone, a high degree of suspicion is essential. A quartz stone should prompt the diagnosis of a factitious disorder in the absence of the appropriate surgical history. Psychological counseling and/or referral to a pain management clinic should be considered in such cases.

Citric Acid↗

A case of comorbid anorexia nervosa, bulimia nervosa, and Munchausen's syndrome.

Reports of comorbid eating disorders and Munchausen's syndrome are rare. As part of a follow-up study of the outcome of anorexia nervosa, medical records and direct structured psychiatric interview data were collected on all women treated for anorexia nervosa in Christchurch, New Zealand between 1981-1984. On interview, one participant received diagnoses of anorexia nervosa, bulimia nervosa, and factitious disorder (Munchausen's syndrome). The subject interwove symptoms of her eating disorders with factitious presentations on several occasions. This diagnosis had not been apparent prior to compilation of all medical records.

Adult↗

Factitious hemiplegia and Munchausen's syndrome.

We report a case of a thirty-year-old woman suffering from chronic factitious disorder with hemiplegia. Such a pathomimia is very uncommon in Munchausen's syndrome. Indeed, most often, the clinical picture is characterised by acute abdominal pain, fainting, haemoptysis, precordialgia, hematemesis or dermatological lesions.

Adult↗