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[Artificially-induced disorders and dissociation].
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Comments on case report--self-castration.
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[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.
[Management of trauma to the male external genitalia].
Male genital injury, although rarely life-threatening, demands prompt, appropriate management to prevent long-term sexual and psychological damage. However, because of the rarity and disparity of severe genital injuries, there is still no universal therapeutic strategy. Urethral injury, although rare, may be associated with substantial long-term morbidity such as fistulas and strictures. Injuries to the scrotum and its contents may cause impaired fertility, chronic pain, hypogonadism, and altered self-image. Penile injury may lead to pain, curvature, and erectile dysfunction. This article concentrates on reviewing the major etiologies and mechanisms of urethral and genital injuries in men and summarizes principles and strategies of treatment based on the guidelines of the European Association of Urology.
[Artifactual illness in plastic surgery].
The therapy of factitious disorders is a challenge for the treating surgeon. Only a clear understanding of the underlying causes and a good doctor-patient relationship make a successful outcome possible. Discussion about a confrontation of the patient with the diagnosis and the best made of treatment is still in progress. Early diagnosis and the cooperation between surgeons and psychiatrists are the most important parts of dealing with factitious disorders. This article gives an overview of symptoms and therapies. Six case reports demonstrate possibilities of the disorder's appearance.
[Self-induced illness in ENT medical practice. Artefacts as a contribution to differential diagnosis of unusual illness courses].
Until now reports of factitious disease have not been found in the ENT literature. In contrast, the dermatologic literature estimates an incidence from 0.01 to 0.26%. In order to achieve effective treatment for these patients, knowledge of the characteristic symptoms is fundamental. The present paper describes the variety of disease possible, using three cases treated between 1992 and 1994 in the ENT Department of Cologne. According to the literature, females are involved in a ratio of 9:1, with the majority working in medically related professions. Depression and anorexia are typical symptoms. When a factitious disease is suspected, psychiatric consultation is essential. Confrontation of a suspect patient by the otolaryngologist is not often considered because several reports quote suicidal behavior in up to 25% of self-manipulating patients and tendencies to refuse to follow psychiatric treatment are considerable.
Chronic perforation of the urinary bladder by self-inserted foreign body.
We report on a 14-year-old girl with pyelonephritis, secondary to a foreign body, in her urinary bladder. A self-inserted pencil led to stone formation and bladder perforation at two sites. Eighteen months after insertion, the pencil was removed by suprapubic cystotomy.
Evidence that spinal endogenous opioidergic systems control the expression of chronic pain-related behaviors in spinally injured rats.
We have previously reported that ischemic spinal cord injury in rats leads to chronic pain-related behaviors. Thus, rats exhibited aversive reactions to innocuous mechanical stimuli (mechanical allodynia) applied to a body area at or rostral to the dermatomes innervated by the injured spinal segments. The responses of the rats to cold are also markedly enhanced (cold allodynia). Interestingly, more than 50% of spinally injured rats did not develop these abnormal pain-related behaviors after spinal cord injury. In the present study, we showed that the extent of injury is similar between allodynic and non-allodynic rats. Furthermore, intrathecal (i.t.) naloxone, a broad-spectrum opioid receptor antagonist, reversibly provoked mechanical and cold allodynia-like responses in spinally injured rats that did not develop such behaviors spontaneously. However, naloxone did not elicit such reactions in normal rats and did not alter the tail-flick latency in normal or spinally injured rats. Furthermore, i.t. D-Phe-Cys-Tyr-D-Trp-Orn-Thr-Pen-Thr-NH2 (CTOP) or naltridole, selective antagonists of mu and delta opioid receptors, respectively, also triggered pain-related behaviors similarly to naloxone. Although norbinaltorphimine (nor-BIN), a selective kappa-receptor antagonist, also elicited such responses, the time course of the effect makes it unlikely that spinal kappa-receptors were involved. These results suggested that the expression of abnormal pain-related behaviors in some spinally injured rats is tonically suppressed by the spinal opioidergic system. Interindividual differences that lead to lack or dysfunction of such inhibition may underly the appearence of pain-related behavior in some, but not all, spinally injured rats. It is suggested that such inhibition is exerted through spinal mu and delta, but not kappa, opioid receptors. The endogenous opioidergic control appears to be only active against abnormal painrelated behaviors in spinally injured rats. Our results are relevant for the clinical observation that only a subgroup of patients with nerve injury suffers from neuropathic pain.
[Therapy refractory unilateral chronic blepharokeratoconjunctivitis as the chief manifestation of auto-aggression syndrome. Clinico-histopathologic findings].
UNLABELLED: Autoaggressive syndromes as causes of diseases underlying chronic blepharitis and keratoconjunctivitis that are refractory to treatment are often difficult to recognize. PATIENTS: Three female patients (age 21, 25, 41 years) and one male patient (age 42 years) had suffered from a right-(4x) or left-(1x) handed treatment-refractory blepharokeratoconjunctivitis for 1, 2, 11 and 30 months prior to admission. In each case more than 5 ophthalmologists and 2-6 eye hospitals had been consulted, and extraocular surgery had been performed 1-4 times. RESULTS: Patients presented with a visual acuity of 0.3 p (1x), 0.1 (1x), FC (1x), HM (1x). In three patients contact eczema of the facial skin and lids and a corneal pannus were observed; in two patients we saw purulent pseudomembranous and in two patients chronic cicatrizing keratoconjunctivitis. Conjunctival smears grew P. aeruginosa, and S. aureus; impression cytology showed infiltration with neutrophils and epithelial keratinization; histopathology indicated chronic inflammatory, partly purulent subepithelial and stromal conjunctival infiltrate with hyper- and parakeratosis fibrous strands and epithelial cell loss; the lower lids showed parakeratosis, focal necrosis, intercellular edema and a lymphohistiocytic round-cell infiltrate. Furthermore, multiple allergies to antibiotics and preservatives (4x), lacerations of the arms and legs (2x) and an irritative-toxic dermatitis (1x) were substantiated. In the patients who agreed to a psychiatric consultation, somatized-agitated longing for care combined with a dependent and infantile personality (1x) and reactive depression (2x) were verified. CONCLUSIONS: In patients suffering from treatment-refractory unilateral chronic blepharokeratoconjunctivitis correlated with the hand, one must take into consideration the fact that other factors may be involved: possible exacerbation prior to examinations; multiple inpatient diagnostic and surgical procedures in different locations; histopathological mixed inflammatory patterns; and psychiatric syndromes.
Self-amputation of penis and tongue after use of Angel's Trumpet.
This case report draws attention to the dramatic consequences of the consumption of Angel's Trumpet. Angel's Trumpet contains alkaloids (especially scopolamine, as well as hyoscyamine, atropine and other alkaloids) in a relatively high concentration. When intoxicated with Angel's Trumpet, patients can suffer hallucinations, motoric restlessness, overtalkativeness, convulsive sobbing and sexual excitement, as well as aggressive and autoaggressive behaviour. Somatic symptoms are tachycardia, mydriasis, hypertonia, respiratory disturbances and vomiting, as well as a potentially life-threatening anticholinerg syndrome. In this paper, we report on a young man who amputated his penis and his tongue after having consumed Angel's Trumpet tea, illustrating that consuming this beautiful flower with the name of an angel and the poison of the devil can be very dangerous.
Investigation of an alleged mechanism of finger injury in an automobile crash.
This investigation centers on the case of an adult male whose finger was allegedly amputated by the steering wheel of his car during a crash. The subject claimed to have been driving with his left index finger inserted through a hole in the spoke of his steering wheel and was subsequently involved in an offset frontal collision with a tree. The finger was found to be cleanly severed at the mid-shaft of the proximal phalanx after the crash. This injury was alleged to have been caused by inertial loading from the rotation of the steering wheel during the crash. To determine whether this injury mechanism was plausible, three laboratory tests representing distinct loading scenarios were carried out with postmortem human surrogates loaded dynamically by the subject's steering wheel. It was found that the inertial loads generated in this loading scenario are insufficient to amputate the finger. Additionally, artificially constraining the finger to force an amputation to occur revealed that a separation at the proximal interphalangeal joint occurs rather than a bony fracture of the proximal phalanx. Based on these biomechanical tests, it can be concluded that the subject's injury did not occur during the automobile crash in question. Furthermore, it can be shown that the injury was self-inflicted to fraudulently claim on an insurance policy.
Self-implanted subcutaneous penile balls--a new phenomenon in western Europe. M. A. Rothschild et al. Int J Legal Med (1997) 110: 88-91.
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An unusual case of self-inflicted penetrating needle injury to both eyes.
BACKGROUND: To describe an unusual case of non-accidental, penetrating needle injury to both eyes. METHODS: Case report. RESULTS: The patient was a 12-year-old girl with no medical or psychiatric problems detected during regular school health screenings. She presented with sudden bilateral eye pain with severe visual loss, but denied any prior trauma. She was was found to have central, penetrating corneal wounds in both eyes, which extended to the fovea in the left eye. The penetrating needle track involved the mid-cornea to the fovea, suggesting that the patient had intentionally aimed the needle into the eye while directly focusing on the needle. She subsequently underwent bilateral cataract operations; and an associated tractional retinal detachment in the left eye remained stable. Postoperatively, her visual acuity improved from perception of light to 6/9 in the right; 6/30 in the left eye. Psychological evaluations and clinical assessments did not suggest any evidence of child abuse or sexual assault. It is thus highly possible that these needle injuries could be self-inflicted. CONCLUSIONS: This is an unusual case of self-inflicted needle injury to the eyes in a pediatric patient.
Factitious disorders encountered in patients with the diagnosis of reflex sympathetic dystrophy.
Reflex sympathetic dystrophy (RSD) may be a misdiagnosis or at least not descriptive enough in patients with atypical hand posture and atypical edema. Seven patients with the previous diagnosis of RSD were investigated further because of inconsistent clinical picture with the underlying pathology and bizarre course of the disease. Four patients had clenched fist and three had factitious edema. These seven patients underwent psychological examination, and MMPI was applied to all. In two of these no psychological disorder was obtained according to DSM-IV. One patient could not adapt to MMPI. In two anxiety disorders, in one depression, and in one patient conversion disorder was diagnosed. We suggest that these patients are not motivated enough to improve their conditions and expectations of such patients may show some differences depending on the environment.
Gynecologic problems in an institution for the management of juvenile delinquency. Some general experiences at Juvenile Hall.
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Self-induced solar retinopathy by patients in a psychiatric hospital.
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Gentian violet keratoconjunctivitis.
A case of bilateral keratoconjunctivitis caused by self-instillation of a 1% aqueous solution of gentian violet was complicated by a secondary uveitis and gram-negative conjunctivitis. The patient was treated with cycloplegics and specific antibiotics and after resolution of the bacterial infection, a mild topical corticosteroid was used. After six months the patient had completely recovered from the keratitis, but bilateral corneal vascularization, had unilateral posterior synechiae, corneal scarring, and cataract formation were present. Cationic dyes such as gentian violet appear to be toxic to the ocular surfaces and tend to produce severe intraocular inflammation.