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A 25-year-old man with a variety of unusual ocular symptoms was fully investigated and no abnormality discovered. The suspicion of self-medication with a mydriatic was confirmed when homatropine was isolated in his tears. We describe a method for collecting tears which allowed biochemical confirmation at leisure.
The effectiveness of the Sixteen Personality Factor (16PF) motivational distortion correction procedures was investigated with a sample of 212 welfare recipients who completed the 16PF while participating in a mandatory welfare-to-work program. A multiple regression analysis showed that the motivational distortion (MD) score was significantly related to most of the preselected Personality factors. The regression analysis also revealed that primary E (Dominance) was associated with MD, although the manual does not require MD adjustments for this factor. Based on comparisons of mean differences at the various MD correction levels, findings indicated general support for the MD correction procedures described in the manual; however, the magnitude of the correction procedures should be used cautiously as this may overcorrect for MD on some of the 16PF primaries. The relevance of the findings also are discussed in terms of evidence for Cattell's (1968, 1973, 1986) trait-view theory as it applies to response distortions.
Although respondent misrepresentation in many areas of psychological testing has been widely studied, little is available for evaluating misrepresentation during health-related psychological assessments. In this article, I report the empirical development and validation of such scales for 2 screening inventories: the Psychological Screening Inventory (the HPO scale; Lanyon, 1970, 1978) and the Multidimensional Health Profile (the HPE scale; Ruehlman, Lanyon, & Karoly, 1998a, 1998b, 1999). In each case, judges were asked to simulate the misrepresentation of health problems. Items were selected whose frequencies differed from normal responding; these items were screened for marked content irrelevance and further refined using data from additional respondents. Validation data showed that for both scales the group means for persons with genuine health problems were up to 1 SD above the normative mean, and the means for suspected and actual simulators were about 2 SDs higher than the health-problem groups.
A woman with pituitary-dependent Cushing's disease remained hypercortisolemic after bilateral adrenalectomy. A search for an adrenal remnant by venous catheterization study suggested persistent cortisol-secreting tissue in the left adrenal bed. During ACTH stimulation, plasma corticosterone concentrations remained low and cortisol remained high, suggesting the cortisol was of exogenous origin. Cushingoid features resolved after confronting the patient with this evidence. Plasma corticosterone concentrations played a novel role in the diagnosis of factitiously induced Cushing's syndrome in this patient.
Recurrent episodes of spontaneous hypoglycemia developed in a 30-yr-old woman who had received a brief course of insulin therapy 10 yr previously. She denied surreptitious insulin administration, and the autoimmune hypoglycemia syndrome was considered. Her insulin levels could not be reliably measured because of the presence of circulating antiinsulin antibodies, which interfere with standard RIA techniques. Reverse phase high performance liquid chromatographic analysis of serum obtained during a hypoglycemic episode revealed a mixture of beef and pork insulins but no human insulin, firmly establishing the diagnosis of factitious hypoglycemia. This case illustrates the value of reverse phase high performance liquid chromatography in characterizing patients in whom the autoimmune hypoglycemia syndrome is suspected.
A case of factitious hypercortisoluria due to the presumed addition of glucocorticoid to the urine collections is presented. The discrepancy between urine and blood steroid hormone levels first suggested that the patient had tampered with the urine collections. Plasma steroid hormone levels were normal, whereas the urinary free cortisol level fluctuated in a totally random fashion. Urinary 17-hydroxycorticosteroid and urinary free corticosterone levels were normal. Partition chromatography of the urine indicated that the cortisol immunoactivity coeluted with authentic cortisol. This study illustrates the value of multiple urinary and plasma steroid determinations, especially urinary or plasma corticosterone measurements, in suspected cases of factitious Cushing's syndrome.
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Dementia is a frequent cause of memory loss with aging. The incidence of complex partial seizures sharply rises after age 60. Complex partial seizures that occur with subtle clinical signs or loss of awareness, or occur during sleep may defy identification. We report five elderly patients fearing dementia in whom memory dysfunction was due to unrecognized complex partial seizures.
OBJECTIVE: To differentiate the quantitative sensory testing (QST) results of subjects simulating small and large fiber sensory loss from those of normal subjects and subjects with sensory peripheral neuropathy. BACKGROUND: QST is used to measure sensory thresholds in clinical, epidemiologic, and research studies. It is not known whether there are objective test results that characterize the subject seeking to deceive the examiner. METHODS: The Computer Aided Sensory Examination IV 4, 2, and 1 stepping algorithm was used to determine vibration and cold perception in nine naïve subjects. Subjects were asked to simulate sensory loss (on two occasions) and to respond normally on one occasion. Test results were compared to those of subjects with diabetic sensory neuropathy. Each QST trial was performed three times. RESULTS: Reproducibility, measured by the intraclass correlation coefficient, was similar in all groups for the vibration perception test (simulation 1: 0.68 [95% CI 0.31, 0.91], simulation 2: 0.82 [95% CI 0.54, 0.95], normal response: 0.77 [95% CI 0.47, 0.94], and subjects with peripheral neuropathy: 0.76 [95% CI 0.18, 0.95]) and the cold perception test (simulation 1: 0.53 [95% CI 0.12, 0.85], simulation 2: 0.82 [95% CI 0.55, 0.95], normal subjects: 0.67 [95% CI 0.30, 0.90] and subjects with peripheral neuropathy: 0.88 [95% CI 0.57, 0.97]), all just noticeable difference units. There were no differences between performance characteristics in the two simulation trials. Responses to null stimuli did not differentiate between groups. CONCLUSION: Test performance characteristics do not permit discrimination among subjects simulating sensory loss, subjects with normal responses, and subjects with peripheral neuropathy.
The spectrum of conditions associated with self-inflicted wounding and their presenting features were outlined in the first part of this article (Moffatt, 1999). In part two, the assessment and management of self-wounding patients is discussed. Manipulative behaviour can be a barrier to treatment, as well as a disruptive force within the healthcare team. Awareness of its effects are essential to the successful development of a therapeutic relationship. However, the current possibilities for effective treatment of self-wounding are limited, and there is an urgent need for more research into both its causes and the various management options available.
OBJECTIVE: To report a case of dementing syndrome resulting from ibuprofen use. CASE SUMMARY: A 76-year-old white man with normal mental status became confused, was lost in familiar places, and showed short-term memory loss after beginning a therapeutic regimen of ibuprofen 600 mg 3 times daily for osteoarthritis in anticipation of embarking on a foreign trip. Symptoms of dementia began within 1 week after taking ibuprofen and resolved completely within 1 week after the ibuprofen regimen was stopped. This pattern was repeated 6 months later, when the patient again traveled abroad. Consistently before, during, and after these events, the patient took atenolol, clonidine, lisinopril, aspirin, vitamin C, lecithin, vitamin E, and multivitamins. DISCUSSION: Using the Naranjo probability scale, we reasoned that the patient's dementia-like syndrome could be attributed to the use of ibuprofen because pseudodementia appeared after the suspected drug was administered, improved when the drug was discontinued, reappeared when the drug was readministered, had no apparent alternative cause, manifested similarly after each exposure to ibuprofen, and was confirmed by the family's observation after both episodes. Objective causality assessment revealed that the adverse drug reaction was probable. CONCLUSIONS: Use of ibuprofen must be considered during clinical evaluation of any patient with new onset of dementing illness. The Naranjo probability scale may be clinically useful for evaluating other pharmaceutical agents that may be contributing to development of dementia-like conditions.
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BACKGROUND: Surreptitious ingestion of laxatives can lead to serious factitious diseases that are difficult to diagnose. Most cases involve ingestion of bisacodyl or senna. Thin layer chromatography (TLC) of urine or stool is the only commercially available test for these laxatives. Such testing is considered highly reliable, but its accuracy in clinical practice is unknown. Our aim was to evaluate the reliability of TLC laxative testing by a clinical reference laboratory in the United States. METHODS: Diarrhea was induced in healthy volunteers by ingestion of bisacodyl, senna, or a control laxative (n = 11 for each laxative group). Samples of urine and diarrheal stool were sent in blinded fashion to the clinical reference laboratory for bisacodyl and senna analysis. RESULTS: TLC testing for bisacodyl-induced diarrhea revealed a sensitivity of 73% and specificity of 91% when urine was tested and sensitivity and specificity of 91% and 96%, respectively, when stool was analyzed. When diarrhea was induced by senna, the TLC assay for senna failed to identify even a single urine or stool specimen as positive (zero% sensitivity). CONCLUSIONS: Considering the expected prevalence of surreptitious laxative abuse in patients with chronic idiopathic diarrhea (2.4%-25%, depending on the clinical setting), TLC of urine or stool for bisacodyl by this reference laboratory would often produce misleading results, and testing for senna would have no clinical value. The major problems are false-positive tests for bisacodyl and false-negative tests for senna.
A 27-year-old woman with severe vitamin K deficiency presented with hemoptysis and diffuse pulmonary infiltrates. She rapidly developed respiratory failure requiring ventilatory support. Surreptitious ingestion of brodifacoum, a long-acting warfarin derivative, was ultimately found to be the cause of her coagulopathy and DAH.
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BACKGROUND: Chronic oral, facial and head pain is a common clinical problem, and appropriate diagnosis and management are a challenge for health care professionals. Patients often will first seek the care of dentists because of the pain's localization in the oral cavity and surrounding structures. This article emphasizes the importance of establishing accurate diagnoses and conducting appropriate triage of the patient with complex orofacial pain. CASE DESCRIPTIONS: The authors present two case reports illustrating the complex nature of oral, facial and head pain, and the potential and actual pitfalls in management of this condition. These representative cases demonstrate how orofacial pain--which appears to be localized in the peripheral dental and oral structures--can have extremely complex etiologies involving other anatomical structures, the central nervous system and psychological factors. The reports point to the need for the expertise of a number of specialists in such cases. CLINICAL IMPLICATIONS: If the symptoms and clinical findings do not appear to be consistent with typical oral disease, or if standard treatments do not alleviate the pain, the dental clinician must consider other, more complex orofacial pain diagnoses. The dental professional should not hesitate to make referrals to key specialists or to members of an interdisciplinary team at a pain treatment center who have the expertise to appropriately diagnose and manage chronic oral, facial and head pain.