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PubMedDate not supplied

Recognition of factitial hand injuries.

Facitial injuries with various presentations occur with some frequency to the hand because it is a body part that is easily accessible. Methods used to produce wounds included insertion of porcupine quills, application of constrictive rubber bands, mascara injections and excoriation of healing wounds. It is important to recognize the factitial origin in order to avoid needless repetitive surgery and permanent hand disability. No specific pattern of psychopathology was found in our cases. The patients' attitude toward their lesions was one of bland unconcern and stoicism. The patients were resistant to psychiatric referral and persisted in seeking medical responsibility for cure. Successful management requires early suspicion and prompt recognition as well as establishment of non-accusatory relationship with the primary physician. Confrontation should be avoided if possible. Even if reinforced with collaborative evidence, such confrontation will have limited effect on the patient's subsequent behavior.

Adolescent↗

PubMed1977

Factitious Bartter's syndrome.

A 29-year-old man had a six-month history of fatigue and hypokalemia. Gastrointestinal losses of potassium were not judged significant. The patient denied ingestion of licorice, large quantities of laxatives, or diuretics. Clinical and laboratory findings were consistent with Bartter's syndrome in the adult. Normal blood pressure, hypokalemic alkalosis, and hyperaldosteronism, with insensitivity to the pressor effect of angiotensin infusion, were present. Another major finding in Bartter's syndrome, juxtaglomerular hyperplasia, was not demonstrated because plans for renal biopsy were cancelled when thiazide was detected in the urine, utilizing chemical extraction and spectrophotometry. Surreptitious ingestion of diuretics must be excluded in any adult patient in whom a diagnosis of Bartter's syndrome is considered.

Adult↗

PubMedDate not supplied

Hyperthyroidism in patients older than 55 years: an analysis of the etiology and management.

BACKGROUND: Hyperthyroidism is a common disease in the elderly. Although some studies on the prevalence of this thyroid disorder have been performed in the aged population, several aspects of hyperthyroidism, such as etiology and treatment effectiveness, have not been fully characterized in large series of aged patients. OBJECTIVE: The aims of the present study were to determine the frequency of the diverse etiologies of hyperthyroidism, and to assess the effectiveness of therapy in adult patients older than 55 years. METHODS: We performed a descriptive, observational, cross-sectional study in the setting of a hospital endocrinology clinic. We studied a group of 313 patients with hyperthyroidism. There were 246 women (78.6%, age 67.02 +/- 8.35 years) and 67 men (21.4% age 63.34 +/- 7.63 years). Overt hyperthyroidism was diagnosed in 167 patients (53.4%) and subclinical hyperthyroidism in the remaining 146 subjects (46.6%). In every patient we studied: the etiology; presence or absence of goiter; time of evolution from diagnosis; previously and presently used treatments; current thyroid functional status (free thyroxine and thyrotropin concentrations); adequacy of disease control, and thyroid autoimmune status. RESULTS: The different etiologies of hyperthyroidism were as follows: toxic multinodular goiter 43.1%; Graves' disease 21.4%; iatrogenic thyrotoxicosis 16.0%; toxic adenoma 11.8%; iodine-induced thyrotoxicosis 1.2%; subacute thyroiditis 1.0%; painless thyroiditis 0.3%; factitious thyrotoxicosis 0.3%; TSH-secreting pituitary adenoma 0.6%, and unknown etiology 3.8%. Etiology was related to age, sex, presence of goiter, degree of hyperthyroidism and autoimmune status. 77.6% of patients had been diagnosed in the last 5 years, and 91.3% in the last 10 years. Preferred therapies were thionamide drugs in patients with Graves' disease and radioiodine in patients with hyperthyroidism due to nodular disease. Surgery was performed in a limited number of patients. Periodic follow-up was used in patients with subclinical hyperthyroidism. Control of the disease was adequate in 65.3% and inadequate in 34.7% of patients who received any kind of previous therapy. In this group of patients, logistic regression analysis showed that the probability of attaining good control of hyperthyroidism was greater in patients with overt thyrotoxicosis compared to patients with subclinical thyrotoxicosis. CONCLUSION: In patients older than 55 years, toxic multinodular goiter is the most frequent etiology of spontaneous hyperthyroidism, followed by Graves' disease and toxic adenoma. Most patients with thyroid hyperfunction can be adequately controlled, provided that effective therapy is administered. Patients with overt hyperthyroidism seem to have a higher probability of attaining adequate control of their disease than patients with subclinical hyperthyroidism, regardless of age, sex or etiology.

Aged↗

PubMed1979

Factitious diabetes and antibody mediated resistance to beef insulin.

A case of factitious diabetes is reported. The patient gave herself insulin intermittently over a four year period. A high concentration of insulin binding antibody was found with the antibody showing much greater avidity towards beef than human insulin. There was resistance to intravenously administered beef insulin with low concentrations of free insulin and high concentrations of bound insulin. In contrast, in response to a glucose tolerance test, both the free insulin and C-peptide responses were normal as was glucose tolerance. The clinical difference in responsiveness to the human and beef insulins is well illustrated in vitro by insulin binding differences and is probably a function not only of different equilibrium constants of the antibody for human and beef insulins but also of different high affinity binding site concentrations.

Adult↗

PubMed2000

Treatment of self-mutilation with olanzapine.

BACKGROUND: Self-mutilation or dermatitis artefacta is a facet of a much broader spectrum of factitial disease. Three nonpsychotic patients with self-mutilation are presented in this article who were successfully treated with low dose olanzapine when all other modalities of therapy had failed, including trials with numerous antidepressants and antipsychotics. OBJECTIVE: The patients were simultaneously evaluated and treated by a dermatologist and a psychiatrist who run the psychodermatology or consultation-liaison clinic based at McMaster University. After dermatologic conditions had been excluded as a cause of the clinical findings, olanzapine was prescribed on a trial basis due to its low risk of parkinsonian side-effects and its antihistaminic properties. CONCLUSIONS: The excellent clinical response of the patients can be attributed to the low side-effect profile of the drug but also to the anti-impulsive effect which stems not only from antihistaminic properties but also from its antidopamine and serotonin-blocking action.

Adult↗

PubMed1977

Factitious hypoglycemia. Diagnosis by measurement of serum C-peptide immunoreactivity and insulin-binding antibodies.

In seven patients with factitious hypoglycemia due to the surreptitious injection of insulin, we made the diagnosis by measurements of plasma insulin and C-peptide immunoreactivity (in seven patients), facilitated by the finding of circulating insulin-binding antibodies (in two patients). The simultaneous demonstration of low plasma glucose, high immunoreactive insulin and suppressed C-peptide immunoreactivity represents a triad of results pathognomonic of exogenous insulin administration. Determination of plasma free C-peptide and free insulin permitted patients with high titers of insulin antibodies, including those with a history of insulin-treated diabetes, to be studied and diagnosed in a way similar to that in subjects who had no circulating insulin antibodies.

Adenoma, Islet Cell↗

PubMed1983

Attitudes of patients, housestaff, and nurses toward postoperative analgesic care.

A survey was carried out among housestaff and nurses involved with postoperative patient care to assess their knowledge of analgesics and their attitudes toward postoperative analgesic care. Only one-fifth of the respondents prescribed for complete pain relief. There were some misconceptions about adding other drugs to narcotic analgesics as well as fear of the addictive properties of these narcotics. The respondents lacked confidence about their knowledge of narcotic analgesics. Fear of respiratory depression was less prominent. Nine percent of the physicians and 31% of the nurses believed that response to a placebo indicates factitious pain. Fifty-four percent of the physicians and 74% of the nurses believed that patients receive adequate pain relief. Eighty-one patients were questioned on their beliefs about pain and its relief. Sixty-six of these were monitored postoperatively to assess the effectiveness of pain relief, which was judged by the authors to be ineffective (i.e., moderate to severe pain at the peak of analgesia) in 41%. Seventy-five percent of the patients reported that their overall postoperative pain relief had been adequate. There was no correlation between the amount of analgesic required postoperatively and either the degree to which patients believed pain builds character or the degree to which they rated themselves sensitive to pain. This study emphasizes the need for better and more comprehensive training of housestaff and nurses in analgesic care.

Adolescent↗

PubMed2005

Attachment representations in mothers with abnormal illness behaviour by proxy.

BACKGROUND: Abnormal illness behaviour by proxy (also known as factitious illness by proxy or Munchhausen syndrome by proxy) is a type of child maltreatment, the origins of which are poorly understood. AIMS: To describe attachment representations in a cohort of mothers demonstrating abnormal illness behaviour by proxy. METHOD: Sixty-seven mothers who had shown this behaviour took part in a semistructured interview assessing their attachment representations. RESULTS: Only 12 mothers (18%) were rated secure in terms of their own childhood attachments. There was evidence of unresolved trauma or loss reactions in 40 mothers (60%). Eighteen mothers (27%) gave unusually disorganised and incoherent accounts of attachment relationships in their own childhoods. The frequency of these attachment categories is higher than in normal non-clinical samples. CONCLUSIONS: Insecure attachment is a risk factor for this type of child maltreatment. Therapeutic interventions could be offered in relation to unresolved traumatic stress or bereavement responses. Further study of similar groups, such as mothers with sick children or mothers with histories of traumatic experience, would be a useful next step.

Adult↗

PubMed1996

Clinical consequences of the EI/MCS "diagnosis": two paths.

There are two distinct paths down which patients "diagnosed" with environmental illness/multiple chemical sensitivities (EI/MCS) can travel. Along the first path, beliefs about low-level, multiple chemical sensitivities as the cause of physical and psychological symptoms are instilled and reinforced by a host of factors including toxicogenic speculation, iatrogenic influence mediated by unsubstantiated diagnostic and treatment practices, patient support/advocacy networks, and social contagion. Intrapsychic factors also reinforce this path through the motivational mechanism of factitious malingering, or unconscious primary and secondary gain, mediated through psychological defenses, particularly projection of cause of illness onto the physical environment. The second path involves restructuring distorted beliefs about chemical sensitivities. Explanations of the placebo effect, the physiology of the stress response, and the symptoms of anxiety and panic facilitate the direction of EI/MCS patients onto this path. A decision model is presented to discriminate among toxicogenic and psychogenic explanations of the EI/MCS phenomenon, based on appraisal of reaction and physiologic and cognitive responses during provocation chamber challenges under double-blind, placebo-controlled conditions. These studies have been helpful therapeutically for some patients in selecting the path that leads to wellness. This paper suggests how various therapeutic techniques can be employed with difficult patients. Often, supportive psychotherapy establishes a therapeutic alliance which facilitates cognitive therapy to restructure distorted beliefs. In the process of finding alternative explanations to chemical sensitivities, the etiology of symptoms is related to stressful life events, including childhood experiences which may have disrupted normal personality development and coping capacity. Furthermore, biological and physiological sequelae stemming from early, chronic trauma have been identified which could explain many of the multisystem complaints. The incidence of childhood abuse reported by EI/MCS patients is strikingly high, and it is recollection of trauma that many EI/MCS patients avoid by displacing the psychologic and physiologic adults sequelae onto the physical environment. The reenactment of these experiences may be necessary in the therapy of some affected individuals. Despite the significant therapeutic effort expanded, some patients who are imprisoned by a closed belief system about the harmful effects of chemical sensitivities are resigned to travel down the path which ultimately leads to despair and depression, social isolation, and even death.

Child↗