Monday, January 17, 2011

Factitious Disorder?

Updated 3/2017-- photos and all links removed as many are no longer active and it was easier than checking each one.

Have you ever seen a case of factitious disorder?  Ever had a patient who’s wound just wouldn’t heal in spite of all the good care you gave them, all the blood work you checked (ie nutrition, infection, etc)?  Ever wondered if perhaps this nice patient was doing something to themselves?
This recent case report in the December issue of the Journal of Plastic, Reconstructive & Aesthetic Surgery prompted me to look up the diagnosis of “factitious disorder.”  Here is the abstract summary (full reference below):
This case report presents the history of a 43-year-old man who sustained a relatively minor burn to his face but who subsequently suffered significant morbidity. Although the wound was grafted on a number of occasions, it failed to heal. Multiple investigations were carried out to determine the cause of recurrent wound breakdown. It had been suspected that the patient was interfering with the wound but this could not be proven initially. He was eventually diagnosed with factitious disorder and it was only when this was managed in the multi-disciplinary setting that his wound finally healed.
I don’t have access to the full article, but what I found when I looked up factitious disorder makes me wonder
The Cleveland Clinic has a nice overview of factitious disorder aka Ganser Syndrome aka Munchausen Syndrome (bold emphasis is mine).
Factitious disorders are mental disorders in which a person acts as if he or she has a physical or mental illness when, in fact, he or she has consciously created his or her symptoms. (The name factitious comes from the Latin word for "artificial.")
People with factitious disorders deliberately create or exaggerate symptoms of an illness in several ways.
The Cleveland Clinic website list the possible warning signs of factitious disorders include the following:
  • Dramatic but inconsistent medical history
  • Unclear symptoms that are not controllable, become more severe, or change once treatment has begun
  • Predictable relapses following improvement in the condition
  • Extensive knowledge of hospitals and/or medical terminology, as well as the textbook descriptions of illness
  • Presence of many surgical scars
  • Appearance of new or additional symptoms following negative test results
  • Presence of symptoms only when the patient is alone or not being observed
  • Willingness or eagerness to have medical tests, operations, or other procedures
  • History of seeking treatment at many hospitals, clinics, and doctors’ offices, possibly even in different cities
  • Reluctance by the patient to allow health care professionals to meet with or talk to family members, friends, and prior health care provider

I’ll pick on myself here.  In fact that is exactly why a small area in my left eyebrow has failed to heal as quickly as it should.  I keep picking at it, picking off the scab before it’s ready to fall off.  I don’t do it to create or exaggerate the problem.  It’s a nervous tick.  I’ve always been a scab picker (and, yes, I tell my patients not to pick at theirs).  It’s a trait that comes in handy as a surgeon who gets to debride wounds.
Don’t forget that some patients are simply like me.  Don’t forget that some may have a issue like this (Trigeminal Trophic Syndrome).  All these other possibilities must be ruled out before giving the patient the diagnosis of factitious disorder.

Factitious Disorder as a differential diagnosis for recurrent skin graft failure; D.M. Seoighe, M. Dempsey, C. Lawlor, A.M. O’Dwyer;  
Journal of Plastic, Reconstructive & Aesthetic Surgery - 27 December 2010 (10.1016/j.bjps.2010.11.004)
Factitious Disorder; eMedicine Article, October 22, 2009; Todd S Elwyn, MD and Iqbal Ahmed, MBBS

1 comment:

Anonymous said...

I know of a patient that had a chronic wound that wouldn't heal until it was discovered that they were rubbing heroin into their wound rather than shooting it. The wound healed once they got some inpatient wound care and were started on methadone.