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PubMed1999

Hypoglycemia: factitious and felonious.

Factitious diseases are characterized by physical or psychologic symptoms that are voluntarily self-induced. These diseases are as old as mankind. Once called "malingerers," these patients must be distinguished from hysterics in whom symptoms are produced unconsciously. In factitious diseases, illness is produced by deliberate acts by the patient who when seeking medical help omits to mention them and may continue strenuously to deny them even when confronted with the evidence. Factitious diseases occur in patients who simulate or exaggerate symptoms or disability to obtain some kind of discernible personal gain or avoid an unpleasant situation; however, such actions may only produce disadvantages by exposing the patient to the risk of death or permanent injury. This has been described as Munchausen syndrome, which is probably a manifestation of severe psychiatric disease. The use of medicines or poisons to induce illness in others also produces a type of factitial disease and presents similar or greater difficulties in diagnosis. In both situations, the clinical history, ordinarily the most important clue to the correct diagnosis, is not only incomplete but often misleading. Sometimes referred to as Munchausen by proxy, this form of factitial disease may be impossible to distinguish from attempted murder or grievous bodily harm. The subtle differences between these disorders, if any, have not been discussed herein.

Factitious Disorders↗
PubMed1997

Diseases of the lips.

The vermilion of the lips was conceptualized by Jean Darier as the semi-mucosa. The anatomy of the lips is transitional from skin to mucous membrane. This article emphasizes inflammatory diseases of the lips known as cheilitis. Angular cheilitis is a reactive process with several possible causes, including infections, mechanical, nutritional deficiency, and various dermatoses. Contact cheilitis may be caused by a primary irritant or a delayed hypersensitivity allergic reaction to contactants. Plasma cell cheilitis is a reactive periorificial mucositis. Exfoliative cheilitis is also a reactive process, probably secondary to factitious activity of the patient. Cheilitis glandularis is a chronic inflammatory disorder of the labial salivary glands and their ducts. There are three forms: simple, superficial suppurative, and deep suppurative. A premalignant potential is present in cheilitis glandularis. Cheilitis granulomatosa is one manifestation of orofacial granulomatosis. The granulomatous conditions of Melkersson-Rosenthal syndrome, sarcoidosis, and Crohn's disease may be associated with cheilitis granulomatosa or it may stand alone as Miescher's cheilitis. Actinic cheilitis is another premalignant form of cheilitis that is amenable to a variety of therapeutic modalities.

Allergens↗
PubMed1977

Sulfonylurea-induced factitious hypoglycemia. A growing problem.

Two patients had sulfonylurea-induced factitious hypoglycemia. Both patients demonstrated hyperinsulinism during hypoglycemia suggesting the presence of an insulin-secreting tumor. One patient underwent an exploratory laparotomy with subtotal pancreatectomy before the etiology of the hypoglycemia was discovered. Inboth patients, the diagnosis was made by detecting sulfonylurea agents in blood. A survey of Portland, Ore metropolitan hospitals suggests that factitious hypoglycemia occurs with a frequency similar to the insulinoma syndrome. The biochemical similarity of these disorders and the apparent increasing incidence of factitious hypoglycemia suggests that blood determinations of sulfonylurea agents should be performed prior to exploratory laparotomy for an insulinoma.

Adenoma, Islet Cell↗
PubMed1997

[Psycho-cutaneous disorders in practice. Self-inflicted skin diseases of psychological origin].

Patients with self-inflicted cutaneous lesions often consult practitioners or dermatologists rather than psychiatrists. The factitious skin lesions are pleomorphic, and may range from wounds, abrasions, blisters or burns, to relatively harmless patient-dependent aggravation of known dermatological diseases. The underlying psychopathology is highly divergent, ranging from socially induced stress behaviour to serious psychiatric disease with a high incidence of suicide. The basic psychological mechanisms of these diseases are poorly understood, and psychocutaneous disorders are difficult to treat effectively. The main challenge is to establish a trustful doctor-patient relationship, in which a joint therapeutic strategy can be established. The author describes six different psychocutaneous disorders in two selected cases, showing both the distinctions between the joint disorders and their common features. The need for constructive collaboration between practitioner or dermatologist and psychiatrist is emphasized.

Adolescent↗
PubMed1992

Fourteen cases of imposed upper airway obstruction.

Imposed upper airway obstruction was diagnosed as the cause of recurrent and severe cyanotic episodes in 14 patients. Episodes started between 0.8 and 33 months of age (median 1.4) and occurred over a period of 0.8 to 20 months (median 3.5). Diagnosis was made by covert video surveillance, instituted after either (a) the observation that episodes began only in the presence of one person, or (b) characteristic findings on physiological recordings, lasting between 12 hours and three weeks, performed in hospital or at home. Surveillance was undertaken for between 15 minutes and 12 days (median 24 hours) and resulted in safety for the patient and psychiatric assessment of the parent: mother (n = 12), father (n = 1), and grandmother (n = 1). These revealed histories of sexual, physical, or emotional abuse (n = 11), self harm (n = 9), factitious illness (n = 7), eating disorder (n = 10), and previous involvement with a psychiatrist (n = 7). Management of the abusing parents is complex, but recognition of their psychosocial characteristics may allow earlier diagnosis. Imposed upper airway obstruction should be considered and excluded by physiological recordings in any infant or young child with recurrent cyanotic episodes. If physiological recordings fail to substantiate a natural cause for episodes, covert video surveillance may be essential to protect the child from further injury or death.

Airway Obstruction↗
PubMed1996

Preventing factitious gingival injury in an autistic patient.

A 34-year-old man with a history of autism developed a deep gingival cleft. During clinical evaluation, the patient repeatedly scraped the affected area with his fingernail. The lesion's clinical features were consistent with focal inflammatory hyperplasia, periodontal disease and factitious stomatitis. This article describes the case and discusses diagnostic and behavioral issues important in treating any patient whose mental age is impaired.

Adult↗
PubMed1990

Infected wounds and repeated septicemia in a case of factitious illness.

During 19 years an assistant nurse, now 35 years old, has been repeatedly treated for several malingered and self-induced disorders escalating to self-mutilation. An ulcer of her right leg never epithelialised in spite of various local treatments and surgical intervention. During repeated attacks of self-induced septicemia altogether 11 different bacterial species were isolated; on 8 occasions Rhodococcus equi. The septicemias were successfully treated with antibiotics. The underlying psychiatric problem, a borderline personality disorder, has not been possible to treat in a conventional manner. Probably due to collaboration between the plastic surgeon and the psychiatrist she has had fewer attendances and shorter hospital stays lately. Her prognosis is still dubious as regards further self-mutilation and other expressions of self-destructive behaviour.

Actinomycetales Infections↗
PubMed2003

Factitial oral lesions in an autistic paediatric patient.

Self Injurious Behaviour (SIB) is a deliberate harm to the body that may lead to factitial injuries. Its origin may be functional or biological and it has a higher prevalence in females and in psychologically impaired individuals. Seventy per cent of autistic patients have SIB. Seventy-five per cent of factitial injuries are located in the head and neck region. A paediatric case report concerning a 4-year-old autistic female is presented. Detailed medical history, physical examination, clinical intraoral and radiographic examination, incisional biopsy, neuropaediatrical, psychological and speech evaluation were undertaken. Diagnosis included hypochromic macrocytic anaemia, caries, coronal fracture, factitial ulcer, factitial periodontitis, self-extraction of primary teeth and permanent teeth buds, non-specific oral ulcer with inflammatory reaction, mild mental retardation, speech impairment, autistic syndrome and self injurious behaviour consisting of putting fingers and foreign objects in the gingiva, fingernail biting and hair pulling. Differential diagnosis included hystiocitosis X, prepuberal periodontitis and leukocyte adhesion deficiency. Dental preventive and restorative treatment was performed. Non-contingent reinforcement therapy was successfully used to diminish SIB. Treatment of factitial oral injuries must be interdisciplinary and requires cooperation of the patient, the parents, health care providers, and medical team.

Autistic Disorder↗
PubMed1984

Counterfeit calculi.

We describe two patients whose initial clinical presentation was that of nephrolithiasis. Eventually, an incontrovertible diagnosis of factitious illness was established. We describe this syndrome, review the underlying psychodynamics, and suggest an approach to treatment, with a plea to physicians to recognize the compulsive behavior as a sign of a disordered psyche and the need for some form of psychotherapy.

Acute Disease↗
PubMed1991

How to identify psychogenic disorders of stance and gait. A video study in 37 patients.

Thirty-seven patients with psychogenic disorders of stance and gait were clinically evaluated, recorded on video, and analysed with regard to clinical phenomenology. Characteristic, suggestive and unspecific features were identified. Six characteristic features proved most valuable for diagnosis of psychogenesis, as they occurred alone or in combination in 97% of patients: (1) momentary fluctuations of stance and gait, often in response to suggestion; (2) excessive slowness or hesitation of locomotion incompatible with neurological disease; (3) "psychogenic" Romberg test with a build-up of sway amplitudes after a silent latency or with improvement by distraction; (4) uneconomic postures with wastage of muscular energy; (5) the "walking on ice" gait pattern, which is characterized by small cautious steps with fixed ankle joints; (6) sudden buckling of the knees, usually without falls. Seventy-three percent of patients had additional suggestive features. Classification into characteristic subtypes was not found useful because predominant features varied from patient to patient and occurred in various combinations. Factitious impairment of stance and gait was studied in 13 healthy drama students. Simulated gait dysfunction appeared less conspicuous and more difficult to diagnose than the clinical psychogenic disorders.

Adult↗
PubMed1995

Factitious injury of the oral mucosa: a case series.

Gingival and oral mucosal tissues can be the site of a number of mucocutaneous and ulcerative conditions. Generally, these are not difficult to identify on the basis of clinical characteristics, and diagnosis can be aided by the use of routine histopathological and immunopathological techniques as well as other laboratory investigations. Self-induced or factitious injury (FI) of the oral mucosal tissues may present a confusing clinical picture, and be diagnosed erroneously as a mucocutaneous disorder in spite of the absence of appropriate pathological and immunopathological findings, or a failure to respond to routine treatment. A case series is presented here outlining 4 cases of FI which presented initially as mucocutaneous disease. These cases were investigated to rule out systemic or local causes, in order to establish a diagnosis of FI. Treatment of these conditions was facilitated with placebo or sham procedures which were designed primarily to cover the lesions. In most cases, the self injurious behavior could be linked to secondary gain.

Adult↗
PubMed2006

[Dermatitis artefacta (factitial dermatitis)--an interdisciplinary diagnostic and therapeutic challenge].

Factitial cutaneous lesions result from self-inflicted injury leading to objectifiable clinically relevant damage to the skin. Triggering factors are frequently psychiatric disorders or specific stress situations. Clinical manifestations range from superficial erosions to deep wounds.The establishment of the diagnosis is often a time-consuming and complicated process that precedes acceptance of the underlying pathology by both the therapist and patient. If lasting therapeutic success is to be achieved, the possibility of such cutaneous lesions must be included in differential diagnostic considerations, and early interdisciplinary cooperation is necessary.

Adult↗
PubMed2003

[Disturbed regulation of self-esteem in patients with overt versus covert self-destructive behaviour].

OBJECTIVES: According to psychoanalytic models self-harming patients are characterised by an unstable self-system and a disturbed regulation of self-esteem. This is presumed to be denied or dissociated to a greater degree by those who harm themselves secretly (factitious patients) as compared to those who show open self-harm. It is hypothesised and empirically tested that self-destructive patients have more profound disorders of narcissistic self-regulation than patients without self-destruction, and that this should be more evident in patients with overt self-destructive behaviour. METHODS: The sample consists of 354 psychosomatic patients, 32 of whom demonstrated self-destructive behaviour (18 exclusively overt and 6 exclusively covert types of behaviour, according to Willenberg et al.). The narcissism inventory was applied. RESULTS: Self-destructive patients showed higher levels on the "threatened self"-dimension than psychosomatic patients without self-harm. Overtly self-harming patients showed a higher degree of narcissistic self-regulation than covertly self-destructive patients. CONCLUSIONS: This supports theoretical assumptions of a disturbed regulation of self-esteem in self-destructive patients, especially in overtly self-harming patients.

Adolescent↗
PubMed1993

[Bacteremia and multiple and recurrent skin ulcers due to Brucella melitensis. A new modality of self-induced infection].

Self-induced infections are a special form of factitious disease. They are characterized by the autoinoculation of contaminated substances or bacterial cultures which may lead to cutaneous infections, bacteremias, or arthritis by various germs. The conditions produced are difficult to diagnose and may lead to multiple operations, and sometimes mutilations or death of the patient. Herewith, a patient who, over a period of 10 months, presented 4 episodes of bacteremia and cutaneous abscess in which Brucella melitensis was isolated is described. In addition, during the second admission, the patient had factitious fever. Despite the evidence of self induced infection, the patient denied autoinoculation however, following confrontation with the facts and supportive psychotherapy the patient has not presented any further episodes after 6 months of follow up. Although the microorganisms involved in this type of disorders are various, this is the first case described in the literature of self-induced infections by Brucella melitensis.

Abscess↗
PubMed2005

Autodestructive syndromes.

BACKGROUND: The phenomenon 'autodestructive behaviour' is becoming an increasingly serious disease and cost factor in a wide range of medical fields. The present paper presents a survey of the literature on autodestructive behaviour, excluding psychotic, substance-induced or organic brain disorders. Starting out with a conceptual overview, the paper goes on to look into the epidemiology of autodestructive behaviour and the forms in which it manifests itself. METHOD: A literature search was conducted in Medline, Psycinfo and Psyndex using the search terms 'artifact', 'artificially induced', 'autodestructive', 'self-mutilation', 'factitious', 'self-harm', 'self-induced', 'self-inflicted', 'self-injuring' and 'self-mutilation' for the period from 1977 to 2003. RESULTS: Five of a total of 18 empirical studies describe the simultaneous occurrence of direct and indirect forms of autodestructive behaviour. Reported prevalence rates range from 0.032% to 9.36%. The ratio of females to males was found to be 2:1 (average age: 31.5 years; SD: 9.3 years); in contrast, the gender ratio was reversed for Munchausen's syndrome. The case history data presented are patchy and differ in terms of their priorities. We found a large number of codiagnoses, which seems to indicate that personality and dependence disorders, or substance misuse, are characteristic of both direct and indirect forms of autodestructive behaviour. CONCLUSIONS: The task at hand is to use a yet-to-be-developed nomenclature and adequately operational diagnostic criteria to work out standardised survey instruments that do justice to the heterogeneity of this disorder complex.

Comorbidity↗
PubMed1985

Posttraumatic stress disorder: a thirty-year delay in a World War II veteran.

Some clinicians doubt the validity of a diagnosis of delayed posttraumatic stress disorder for Vietnam veterans. Precombat psychopathology, drug abuse, factitious symptoms, and malingering in pursuit of disability compensation are cited as alternative explanations for the syndrome. The authors discuss the case of a much decorated World War II veteran whose symptoms of posttraumatic stress disorder first occurred more than 30 years after combat. They consider the alternative explanations for his symptoms to be inadequate.

Combat Disorders↗
PubMed1995

Munchausen syndrome by proxy and factitious illness: symptomatology, parent-child interaction, and psychopathology of the parents.

The term Munchausen syndrome by proxy is used to diagnose children presenting symptoms of an organic disorder resulting from manipulations initiated by their caretakers. Even in early infancy it happens that injuries are induced, and that drugs, poisons or medicine are administered in order to provoke and feign clinical symptoms of severe diseases. Exact data on prevalence are not available but it is obvious that Munchausen syndrome by proxy is a rare psychiatric disorder. There is a body of evidence that Munchausen syndrome by proxy is nothing but the extreme of a broader clinical entity for which the term factitious illness has been introduced. In this group children are included whose mothers invent a history of disease in order to produce symptoms without actually damaging their children. It is not well established whether such a distinction is necessary and whether there are differences in long-term outcome. Onset of symptoms is as early as three weeks up to twelve years, and mean age of diagnosis according to a more comprehensive study is 3 1/4 year. The estimated mortality rate of children with Munchausen syndrome by proxy is 9 percent. In three of the four cases of children reported here clinical presentations were dominated by symptoms of central nervous disorders. All mothers showed unsure and inconsistent parental behaviour and inefficient coping. None of them received support from their partners, if present. In interaction the children always wanted to dominate their mothers. The high amount of personality disorders observed in the caretakers might be the reason for the often reported failure of psychotherapeutic interventions.

Child↗
PubMed1995

[Factitious gastrointestinal hemorrhage in 3 school-age girls].

Three female patients aged 9, 13 and 14 years, respectively, seen by the authors over a 1-year period presented with the complaint of recurrent hematemesis (2 patients) or melena (1 patient). The (presumed) bleeding episodes had only been seen by the respective patient and one parent (the mother in two cases and the father in one). In two cases, the other parent was antagonistic with the reported situation. A clear symbiosis had been forged between the index case and the allied parent. Two patients had previously been seen in several hospitals and had undergone various diagnostic tests, including esophagogastroduodenoscopies, all of which had proved normal. Two girls had attempted suicide. Two of the mothers had a depressive disorder. Re-evaluation of the patients by the authors again ruled out any cause for the presumed bleeding or any sequelae originating from it. The patients and their parents were referred to a psychiatric service but this was only complied by one family; the other two repeatedly avoided attending the psychiatric clinic. Awareness of this pattern of presentation and of the psychiatric profiles of the patients and their families is critical for practitioners in order to recognize factitious illness whenever a patient with a history of gastrointestinal bleeding presents with incongruous or illogical medical history and clinical findings.

Adolescent↗