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PubMed1993

Think of depression--atypical presentations in the elderly.

Depression in the elderly may have many presentations. Skill is required in differentiating clinical depressive conditions from mild reactive states and senile dysphoria. Screening tests are available that may assist the doctor in the diagnosis of depression. One of these, the Geriatric Depression Scale (short form), is easily completed by patients (Table 3). Exclusion of organic causes of depression and sub-typing of the depression are the first steps. Correct matching of type of treatment--medication, electroconvulsive therapy, cognitive-behavioural therapy or other forms of therapy--to the type of depression usually leads to a good outcome. Extra caution is required in prescribing medications to older people because of altered pharmacokinetics and the frequent co-occurrence of physical disorders. For example, the use of tricyclic antidepressants is precluded by the presence of cardiac conduction abnormalities, urinary outflow problems, narrow angle glaucoma or postural hypotension and the subsequent risk of falls and fractures. Depression in the elderly carries a much greater risk of endogenous and psychotic sub-types and of suicide. The proportion of the population who are elderly is increasing. Depression in older persons is very common, may be difficult to diagnose, is treatable and has a prognosis similar to that of middle aged or younger patients. Doctors should think depression in older patients and bear in mind possible atypical presentations. When the correct diagnosis, usually possible by taking a careful history, is followed by correct treatment, the outcome can be very rewarding for patient and doctor.

Aged↗
PubMed2003

Detection of feigned mental disorders: a meta-analysis of the MMPI-2 and malingering.

The validity of test data from multiscale inventories is dependent on self-reports that may be easily distorted by malingering. In examining the Minnesota Multiphasic Personality Inventory-2's (MMPI-2) role in the assessment of feigning, this review provides a conceptual analysis of the detection strategies underlying the MMPI-2 validity scales. The conceptual analysis is augmented by comprehensive meta-analysis of 65 MMPI-2 feigning studies plus 11 MMPI-2 diagnostic studies. For the rare-symptoms strategy, Fp (Cohen's d = 2.02) appears especially effective across diagnostic groups; its cut scores evidence greater consistency than most validity indicators. The data supported the F as an effective scale but questioned the routine use of Fb. Among the specialized scales, Ds appeared especially useful because of its sophisticated strategy, consistent cut score, and minimalfalse-positives. General guidelines are offeredfor specific MMPI-2 validity scales in the assessment of malingering with specific diagnoses.

Factitious Disorders↗
PubMed2005

Dermatitis artefacta: unusual appearance in an older woman.

Dermatitis artefacta is a rare and difficult condition for diagnosis and treatment, with the highest incidence of onset in late adolescence to early adult life. Most patients are young women who have a personality disorder; borderline features are common and the patient's denial of psychological distress makes management and treatment difficult. Patients use a variety of means to cause the skin changes. Clinical presentation of the skin lesions does not conform to those of known dermatoses and are located on easily reached parts of the skin. We report an unusual case of a 72-year-old woman with symmetrical changes under the breasts and in the right inguinal region. The lesions were composed partly of haemorrhagic round lesions and partly of scars. A skin biopsy was taken and consultations with the psychiatrist, internist and the patient's family led to the diagnosis of self-induced dermatitis. The skin lesions were covered by occlusion techniques and the lesions improved very rapidly. The patient was discharged from the hospital under psychiatric and family care.

Aged↗
PubMed1989

[Subcortical dementia syndrome: semiology and physiopathology].

Among the dementia syndromes--that is, disorders of memory associated with a global alteration of cognitive functions sufficient to affect the subject's normal social behaviour--the current trend is to individualize a particular syndrome due to a primary dysfunction of the subcortical structures. The main characteristics of this syndrome are a slowing down of cognitive processes (bradyphrenia), a preferential disturbance of the fundamental processes (memory, motivation, attention, etc.) and a relative preservation of specific functions (speech, praxis, gnosis). Such a syndrome has been described not only in some cases of degeneration of the basal ganglia, but also in other brain diseases, notably vascular diseases, and in severe depressive states. Various recent clinical or fundamental studies have shed some light on the neuronal and neurochemical substrate of the syndrome, thus providing proof of the reality of the subcortical dementia concept which contributes to a better understanding of the relationship between brain and mental functions.

Aged↗
PubMed2006

Clinical and theoretical parallels between desire for limb amputation and gender identity disorder.

Desire for amputation of a healthy limb has usually been regarded as a paraphilia (apotemnophilia), but some researchers propose that it may be a disorder of identity, similar to Gender Identity Disorder (GID) or transsexualism. Similarities between the desire for limb amputation and nonhomosexual male-to-female (MtF) transsexualism include profound dissatisfaction with embodiment, related paraphilias from which the conditions plausibly derive (apotemnophilia and autogynephilia), sexual arousal from simulation of the sought-after status (pretending to be an amputee and transvestism), attraction to persons with the same body type one wants to acquire, and an elevated prevalence of other paraphilic interests. K. Freund and R. Blanchard (1993) proposed that nonhomosexual MtF transsexualism represents an erotic target location error, in which men whose preferred erotic targets are women also eroticize their own feminized bodies. Desire for limb amputation may also reflect an erotic target location error, occurring in combination with an unusual erotic target preference for amputees. This model predicts that persons who desire limb amputation would almost always be attracted to amputees and would display an increased prevalence of gender identity problems, both of which have been observed. Persons who desire limb amputation and nonhomosexual MtF transsexuals often assert that their motives for wanting to change their bodies reflect issues of identity rather than sexuality, but because erotic/romantic orientations contribute significantly to identity, such distinctions may not be meaningful. Experience with nonhomosexual MtF transsexualism suggests possible directions for research and treatment for persons who desire limb amputation.

Amputation, Surgical↗
PubMedDate not supplied

Dermatitis artefacta. Clinical features and approaches to treatment.

In dermatitis artefacta, the patient creates skin lesions to satisfy an internal psychological need, usually a need to be taken care of. The clinical presentation is characteristic, and differs from that of neurotic excoriations, delusional disorders, malingering, and Munchausen's syndrome. Munchausen's syndrome by proxy is a form of dermatitis artefacta. Except where disease is mimicked, lesions that do not conform to those of known dermatoses are shrouded in mystery, appearing fully formed on accessible skin, within the context of a characteristic psychological constellation. The patient is friendly but bewildered, and the relatives, angry and frustrated. Because of lack of diagnostic stringency, quoted female-to-male ratios range from 3:1 to 20:1, with the highest incidence of onset in late adolescence to early adult life. Most patients have a personality disorder; borderline features are common. The patient's denial of psychic distress, and negative feelings aroused in healthcare personnel, make management difficult. Limit-setting for the protection of both the physician and patient; creation of an accepting, empathic, and nonjudgmental environment; and close supervision of symptomatic dermatologic care will permit development of a therapeutic relationship in which psychological issues may gradually be introduced, that may occasionally permit psychiatric referral. Issues of etiology should be sidestepped because confrontation is counter productive. When psychiatric referral is refused by the patient, the use of psychotropic drugs by dermatologists is helpful and appropriate. The upper dose range of selective serotonin reuptake inhibitors (SSRIs), or low dose atypical antipsychotic agents, may be effective. Except in mild transient cases triggered by an immediate stress, the prognosis for cure is poor. The condition tends to wax and wane with the circumstances of the patient's life. Lesions can be kept to a minimum, the patient can be protected from unnecessary and intrusive studies, and society can be protected from escalating and unnecessary expenditure of medical resources if, rather than discharging the patient, the dermatologist continues to see the patient on an ongoing basis for supervision and support, whether or not lesions are present. Research studies are necessary to document more accurately the expectable cause, treatment outcome, and prognosis for this group of patients.

Dermatitis↗
PubMed2000

A green man.

Explore the source record for details and available documents.

Adult↗
PubMed1982

Psychogenic seizures. A study of 42 attacks in six patients, with intensive monitoring.

Intractable complex partial seizures and seizures of unknown type were studied in 78 patients, six of whom were found to have psychogenic seizures. Evaluation by intensive monitoring included simultaneous six-hour telemetered EEG and videotape recordings and daily determination of plasma antiepileptic drug levels. Diagnosis was determined by assessment of four major criteria: deviation of seizures from characteristics of known seizure types, absence of epileptiform activity in the ictal EEG, absence of slowing in the postictal EEG, and relation of seizure frequency to decreasing plasma concentrations of antiepileptic drugs. No single criterion is sufficient for an unequivocal diagnosis of psychogenic seizures.

Adult↗
PubMed1984

Factitious cutaneous bleeding. A case of pseudostigmata.

A 10 1/2-year-old girl had a ten-month history of spontaneous episodes of epistaxis and bleeding from the skin, eyes, and ears. The bizarre nature of the complaint, labeled as stigmata prior to referral, along with the altered family dynamics, led to the conclusion that the origin of the episodes was factitial. A mild case of gingivitis proved to be the source of blood for the bleeding episodes.

Child↗
PubMed1994

Factitious food allergy and failure to thrive.

OBJECTIVE: To examine the relationship between parental beliefs about factitious food allergies and failure to thrive in their children. RESEARCH DESIGN: Retrospective case review. SETTING: Tertiary care referral center in Denver, Colo. SELECTION PROCEDURES: A consecutive sample of more than 700 patients referred for evaluation of food allergies was screened for age; negative results to double-blind, placebo-controlled food challenges; and failure to thrive. MEASUREMENTS/RESULTS: After identifying two probands, we identified nine additional children with failure to thrive in the context of parents' beliefs in allergic reactions to multiple foods. The results of puncture skin tests conducted for foods suspected of causing allergic reactions were negative for seven (64%) of the 11 children. There were no allergic reactions to open challenges (ie, children, staff, and parents knew which food was being tested). Only two patients reacted during double-blind, placebo-controlled food challenges. One reacted to milk (one of 14 suspected foods) and the other reacted to eggs and milk (two of 15 suspected foods). CONCLUSIONS: Parental beliefs about food allergies can lead to dietary restrictions severe enough to cause failure to thrive in their children. Because of the wide-spread belief by parents that children are allergic to food, pediatricians are frequently faced with the question of whether to subject children to food restrictions. Their collaboration with unsubstantiated parental beliefs can have long-term, deleterious consequences.

Attitude to Health↗
PubMed1982

Factitious asthma. Physiological approach to diagnosis.

Three patients with recurrent emergency room visits and hospitalizations for bronchial asthma are described. Although each patient had respiratory distress associated with wheezing and an apparent response to conventional therapy, other features were inconsistent with the pathophysiology of asthma. These included absence of a significantly elevated alveolar-arterial oxygen tension difference, lack of roentgenographic hyperinflation, and normal small airway function soon after clinical response. Furthermore, bronchial hyperreactivity, a constant feature of asthma, was absent in all patients. Each patient demonstrated wheezing that was self-induced and heard loudest over the neck. Two patients had previous psychiatric illness, one of whom had been hospitalized for factitious fever. We believe that these patients had a form of factitious illness not previously described. Recognition of this syndrome may avoid unnecessary medical care and allow initiation of appropriate psychiatric follow-up.

Adult↗
PubMed1998

Responses to unsolicited patient e-mail requests for medical advice on the World Wide Web.

CONTEXT: The Internet is increasingly used by consumers to seek health and medical information, but online medical advice has not been explored systematically. OBJECTIVE: To explore the attitude of physicians and other providers of medical information on the Internet toward unsolicited e-mail from patients and their reaction to a fictitious acute medical problem described in such an e-mail. DESIGN: E-mail in December 1997 and January 1998 to Web sites from a fictitious patient describing an acute dermatological problem. Follow-up questionnaire survey to the same sites. SETTING: World Wide Web. SUBJECTS: Fifty-eight physicians and Web masters. MAIN OUTCOME MEASURES: Response rate and types of responses. RESULTS: Twenty-nine (50%) responded to the fictitious patient request; 9 respondents (31%) refused to give advice without having seen the lesion, 27 (93%) recommended that the patient see a physician, and 17 (59%) explicitly mentioned the correct "diagnosis" in their reply. In response to the questionnaire, 8 (28%) of the 29 respondents said that they tended not to answer any patient e-mail, 7 (24%) said they usually reply with a standard e-mail message, and 7 (24%) said they answer each request individually. CONCLUSIONS: Responses of physicians and Web masters to e-mail requests for medical advice vary as do approaches to handling unsolicited e-mail. Standards for physician response to unsolicited patient e-mail are needed.

Computer Communication Networks↗