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The paper deals with the topical problem of false parasitic diseases (FPD) in patients with various organic (somatic and mental) disorders. A classification of groups of FPD patients is given according to their clinical and social signs. Examples of 6 cases of FPD observed by the authors and those published in the literature are presented. Simple and effective recommendations on the management of FPD patients are given.
The concept of psychosomatic disorders has been undergoing great evolutionary changes during the past 20 to 30 years. There is no longer any significant or reasonable disagreement that the brain and body mutually interact, and the pathways of those interactions are being explored and explained. Enormous amounts of work are being done to unravel the workings of the brain, which is more complex than any other organ because of neural connections and networking of astronomic proportions.
The psychosomatic disorder termed Munchausen's syndrome has gained official recognition in the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, in which it is referred to as a "chronic factitious disorder with physical symptoms." Sporadic case reports have been published over the years. Few patients with this disorder allow themselves to be psychologically evaluated or seek treatment for the disorder itself. We report here an unusual case in which a young woman sought help for her hospital-peregrinating behavior.
The present article contains initial results form systematic psychoanalytic work with patients practicing secret self-mutilation (our term for these is "mimicry patients"). The group we examined was treated on an in-patient basis in a hospital for psychosomatic disorders. The article may be considered as a preliminary report. Up until now the international range of experience is rather limited. We have therefore, made use of this occasion also for developing an applicable clinical definition of the different forms of self-mutilation. This definition is based upon psychological criteria rather than, as has hitherto been the custom, upon the techniques and the morphology of the self-inflicted injuries. Clandestine self-mutilation, in our understanding, is a psychosomatic illness. The self-manipulation has the character of a psychosomatic symptom which, although self-inflicted, is beyond the control of the afflicted individual and is accompanied by extremely reduced consciousness. So far, the experience gained in therapy points to a variety of subconscious conflicts at the back of this symptom, most frequently a severe guilt problem which is not only manifest intrapsychically but also within the family milieu of the patient. On the whole therapeutic results correspond to those observed with other grave psychosomatic disorders accompanied by organic lesions, that is to say improvement sets in slowly after a therapy extending over periods of several months to several years. Initially, a long time before any treatment of the subconscious conflict may be attempted, such therapy must employ supportive ego-consolidating methods and establish a therapeutic alliance. Even so we see no reason for resignation with regard to therapeutic success.
Twenty-five patients without relevant organic disease were examined who complained of long-standing memory disturbance, but were free of relevant organic disease and exhibited a test performance that was normal, or reduced by not more than two standard deviations. Cases of amnesia in the context of dissociative reactions were not considered. Symptoms attributed to memory disturbance were differentiated into deficits of new learning, retrograde memory and attention. Typical complaints were forgetting plans on the way to executing them and temporary blockage of material that had been committed to memory. While sex and age were evenly distributed, there was a clear predominance of professionals compared to manual workers. Relevant psychiatric findings or psychiatric diagnoses were present in all cases. The most frequent diagnoses were chronic stress disorder and depressive syndromes. Accompanying psychosomatic symptoms were present in about half of the cases. Wordlist learning scores were in the normal range in the majority of cases, and psychomotor speed scores were in the normal range in nearly all cases. The discussion addresses symptoms, diagnosis, etiology and therapy of functional memory disturbances and examines the relationship to the syndrome of pseudodementia.
UNLABELLED: Cutaneous pathomimia is a behaviour disorder witch interest the skin. In some cases, self-mutilation can be serious and require a surgical treatment. CASE REPORT: A 60 year old woman consults for extensive scar interesting the face and the scalp and realising the aspect of burn face in cicatricle level. The treatment consisted on excision and skin graft. The patient was addressed to Psychodermatology consultation. Authors show the place of plastic surgery in management of cutaneous pathomimia.
Gilles de la Tourette syndrome (GTS) is a genetic neuropsychiatric disorder, which is more common than previously thought. Ganser syndrome is an uncommon disorder, particularly in children. We present the first report of a young girl aged 7 who was diagnosed independently as having both GTS and Ganser syndrome and who was otherwise well and remained well and improved at follow-up 8 years later. This highlights how the clinicians must always be vigilant when atypical behaviours begin, especially when one diagnosis has already been given. There may well be treatment implications.
Medically unexplained physical symptoms are common in pediatric settings, though little systematic research is available to guide the development of treatment efforts for pediatric somatization and somatoform disorders. This paper presents a management model for pediatric somatization based on principles distilled from the available pediatric and adult literature. Careful assessment, frank presentation of the diagnosis, and a cognitive-behavioral and rehabilitative approach are emphasized, along with aggressive psychiatric treatment of comorbid psychopathology. Well-designed empirical studies of intervention are needed that should examine efficacy as well as the relationship between symptomatic improvement, functional improvement, and comorbid anxiety and depressive symptoms.
Our report describes a 46-year-old woman with self-inflicted oedema of the left leg and the left arm. She induced leg oedema by an elastic bandage tourniquet and arm oedema by holding her arm dependent and immobile. A preexisting disorder of the affected leg (postthrombotic syndrome) and of the affected arm (hypoesthesia subsequent to surgical injury of the plexus brachialis) delayed the diagnostic proceedings. Our case report shows that: Confirmed presence of organic disease does not exclude limb oedema of self-inflicted origin. Oedema resulting from a tourniquet and "hysterical oedema" can be developed by one and the same patient. Effective care of such patients is only possible if dermatologist and psychiatrist work together all the time (liaison psychiatry).
In three patients, two women aged 37 and 20 years and a man aged 46 years, a blistering skin condition was observed. Histopathological examination of the skin lesions revealed a blister level just beneath the stratum granulosum, which is proof of a friction blister. The patients were suffering from bullous dermatitis artefacta or bullous pathomimia. This is a psychiatric disorder characterised by rubbing skin blisters but denying self-infliction. Early diagnosis is important to prevent unnecessary drug therapy and chronic morbidity. The typical histology supports the doctor in his suspected diagnosis. A supportive and empathic dual disciplinary approach (by somatic physician and psychosocial worker) is recommended, avoiding direct confrontation with the self-inflicted nature of the lesions, and using the 'narrow escape' strategy, avoiding loss of face of the patient.
In the first part of this paper we discuss some of the most important areas of progress and of controversy in the field of memory functions and of memory impairment. Three main issues are taken separately into account: (1) the fractionation of memory into a number of sub-systems and the relationships existing among these subsystems; (2) the main theories of amnesia and the mechanisms underlying memory disorders; (3) the main anatomoclinical forms of amnesia and the brain structures subserving various components of the amnesic syndrome. In the second part we shift from the basic research to the clinically oriented investigations, reporting the results of two studies that we have recently conducted on some aspects of memory disorders in dementia. In the first study we have shown that severity and qualitative aspects of amnesia can be used to distinguish the two most frequent clinical forms of dementia, namely the dementia of the Alzheimer's type (DAT) from the vascular forms of dementia. In the second study we have demonstrated that a fine grained analysis of memory impairment can help improving the most difficult differential diagnosis in this field, namely the distinction between DAT and depressive pseudo-dementia.
Our examinations have revealed personality changes in eighteen out of fifty patients with frontal tumour. The changes may be classified to a certain extent in the same symptomatological category as pseudodementia. In view of the site, size and histological structure of the tumours, the existence and severity of the disorders seem to be independent of tumour vascularization. Such personality changes may be the only pathological sign, even in the presence of large tumours. Earlier diagnostic difficulties (the group of patients dates back to the period prior to CAT scanning) may be largely overcome by the use of computerized axial tomography. Thus the duration of a case up to time of surgery can be reduced (hitherto as long as 10 years or more) and tumours may no longer grow to excessive size.
A case report on a patient with Münchhausen syndrome is presented and the psychopathological features are compared to other reports in the literature. Diagnosis and differential diagnosis are discussed with regard to other somatoform disorders such as conversion disorder and somatization disorder as well as to malingering and cenesthesic schizophrenia. The management of Münchhausen syndrome is aggravated by the low compliance in these patients, who expose themselves to serious complications of unnecessary medical and surgical procedures. Early diagnosis could to a considerable extent exclude these iatrogenic risks. We recommend that patients presenting the psychopathological features of a Münchhausen syndrome should be conservatively observed and an attempt to clarify both the medical and the psychiatric diagnosis should be made before any invasive procedure is undertaken.
In general somatic hospital the prevalence of litigious nosogenic reactions (LNR) was 4,3 pro mille. It was examined 52 cases of LNR. Paranoic (overvalued and delirious) disorders were the main ones in clinical picture of LNR. Two forms of motivation were noted: rental disorders (demand of money compensation of the loss resultant from somatic disease) and equitable ones (revelation of the damage due to actions of medical personnel). Among the patients with rental LNR (43 persons) the individuals with hysteric disorders of personality (hysterical psychopathy) were mainly found. Meanwhile among the patients with equitable LNR (9) there were patients with slow-progredient psychopathic-like schizophrenia inclined to the development of paranoic reactions and with litigious-paranoic tendencies. The development of rental LNR was seen in comparatively favourable course of somatic diseases which was not connected with invalidism or considerable loss of ability to work. In somatic diseases, when equitable LNR were formed, it was not possible to reveal a preference in severity of the course of somatic disease.
The knowledge of biological pain mechanisms are not sufficient for the understanding of patients with chronic pain syndromes such as low back, cervicobrachial and muscle pain. Psychological and psychosocial aspects play important roles in the setting and perpetuation of symptoms. Mood and anxiety disorders, secondary gains such as early retirement and financial compensations, must all be acknowledged by the physician as possible contributors to the symptoms. Abnormal illness behavior may better characterize patients with chronic pain syndromes. Behavior observation, which is akin to medical practice, is therefore a powerful tool in the diagnosis and management of these syndromes. Physicians ought be very careful in not reinforcing the patients already strong organic convictions regarding their symptoms, avoiding making decisions based on patients complaints and alleged disabilities, and assigning poorly defined and disputable diagnosis labels. Society needs also to refrain from policies that encourage abnormal illness behaviors.
The concept of pseudodementia was coined in the late XIXth century to refer to a syndrome mimicking dementia, but without underlying neurological lesions. Depressive disorders represent the main etiological factor and may present under two different forms, either "depressive cognitive disorders", or the more severe feature of "Wernicke's pseudodementia". The main issue remains diagnosing pseudodementia form organic dementia, especially from cortical degenerations of the Alzheimer type. Thus, the recognition of this clinical syndrome represents an alternative to the diagnosis of dementia which may lead to earlier and more effective psychiatric treatment. Recently, diagnostic criteria have been proposed to facilitate this distinction. Such criteria include clinical history, neuropsychological features, biological findings (dexamethasone suppression test and plasma MHPG) and electroencephalographic sleep studies. Finally, from a theoretical point of neurological conception of depression as well as for current hypotheses on the relationship of this last one with dementia.
The author reports a case of factitious rape in a psychiatric inpatient. To his knowledge, this is the first case report of this syndrome in the medical literature. This case is related to the signs and symptoms commonly found in Munchausen Syndrome. The question of the relationship of factitious rape to borderline personality disorder and to disturbed sexual identity is raised. Physicians are urged to develop an index of suspicion for factitious disorder.
Medical records were selected from the Danish National Patient Register in order to study individuals between the ages of 17 and 49 years in the general population who, during an 8-year period, were admitted at least 10 times to a general hospital (N = 282). Fifty-six subjects (19%) were found to be persistent somatizers, i.e. they were admitted repeatedly to general hospitals for physical symptoms without an organic basis. This corresponded to a frequency of persistent somatization in the population 0.6 per 1000 men and 3.2 per 1000 women. Seventy-five per cent of the subjects were under 25 years old at the onset of their disorder, and all were under 35. Their illnesses were long-lasting, with one-third having a hospital 'career' of more than 20 years. They had a lifetime median of 22 medical admissions, and had utilized 3% of the general population's admissions to non-psychiatric departments. This investigation shows that persistent somatization is not a rare phenomenon, and that taking the heavy utilization of health-care resources into account it constitutes a considerable problem for the health-care system. The long hospital career and the relatively early start of somatization in some subjects emphasize the importance of an early identification of the condition, and of efforts to try to prevent its persistence.