Factitious disorders of the upper limb

"Extensive necrosis following extravasation of alkali in the crease of the elbow after voluntary intravenous injection: A case report"

Chemical burns are often deep with difficult initial clinical evaluation, especially those due to alkalic agents, which have a strong penetrating power. They therefore require specialized care in a Burn Unit. Self-inflicted burns are infrequent but their management represents a real challenge. We report the case of a 47-year-old referred to our Burn Center for the evaluation of a self-inflicted corrosion with an alkalic agent (soda), injected at the crease of the left elbow. The patient, right handed, was a nurse and had notably a psychiatric history of depressive syndrome. We observed a deep, well-defined necrosis area, associated with intense peri-lesional inflammation and extensive cellulitis. Faced with this unusual clinical appearance for a chemical burn, the patient's questioning was repeated and the patient finally admitted to having injected himself with a basic caustic product intravenously. Surgical treatment was carried out in two stages: debridement with exposure of vascular and neural structures then coverage with a free anterolateral thigh flap. The postoperative consequences were uneventful with a satisfactory functional result. Factitious disorders are underestimated and often misleading. Among factitious disorders, self-inflicted wounds remain a real challenge requiring multidisciplinary management. Many etiologies exist, among which injection of drugs or substances, in any anatomical localization, leading to variable loss of substance. The use of a free flap for acute extravasation is rare but sometimes essential. The anterolateral thigh flap allows good resurfacing on areas with important functional requirements.

The clinical relevance of complex regional pain syndrome type I: The Emperor's New Clothes

The management of patients with chronic pain is a nearly daily challenge to rheumatologists, neurologists, orthopedic surgeons, pain specialists and indeed a issue in nearly every clinical practice. Among the myriad of causes of pain are often included a unique syndrome, generally referred to as complex regional pain syndrome type I (CRPS). Unfortunately CRPS I has become a catch all phase and there are serious questions on whether it exists at all; this has led to an extraordinary number of poorly defined diagnostic criteria. It has also led to an etiologic quagmire that includes features as diverse as autoimmunity to simple trauma. These, in turn, have led to overdiagnosis and often overzealous use of pain medications, including narcotics. In a previous paper, we raised the issue of whether CRPS type I reflected a valid diagnosis. Indeed, the diagnostic criteria for CRPS I, and therefore the diagnosis itself, is unreliable for a number of reasons: 1) the underlying pathophysiology of the signs and symptoms of CPRS I are not biologically plausible; 2) there are no consistent laboratory or imaging testing available; 3) the signs and symptoms fluctuate over time without a medical explanation; 4) the definitions of most studies are derived from statistical analysis with little consideration to required sample size, i.e. power calculations; 5) interobserver reliability in the assessment of the signs and symptoms are often only fair to moderate, and agreement on the diagnosis of "CRPS I" is poor. Even physicians who still believe in the concept of "CRPS I" admit that it is vastly overdiagnosed and has become a diagnosis of last resort, often without a complete differential diagnosis and an alternative explanation. Finally, one of the most convincing arguments that there is no clinical entity as "CRPS I" comes from the enormous heterogeneity in sign and symptom profiles and the heterogeneity of pathophysiological mechanisms postulated. This observation is underscored by the diversity of responses among "CRPS I" patients to essentially all treatment modalities. It has even led to the concept that the signs and symptoms of CRPS can spread throughout the body, as if it is an infectious disease, without any medical plausible explanation. If true progress is to be made in helping patients with pain, it will require entirely new and different concepts and abandoning CRPS I as a legitimate diagnosis.

[The phenomenon of covert self-mutilation in the surgical routine]

Factitious disorders are conditions which are unknown to many physicians but have a prevalence of 1-5 % in outpatient departments and hospitals. In order to avoid prolonged and complicated (false) treatment in surgery this article gives a review of the definition, epidemiology and pathogenesis of factitious disorders as well as clinical symptoms and therapy options. A focus is placed on the identification of patients, treatment strategies and the prevention of malpractice. Additionally, clinical features of the disorder are illustrated with the description of some characteristic cases.

Factitious disorders and malingering: challenges for clinical assessment and management

Compared with other psychiatric disorders, diagnosis of factitious disorders is rare, with identification largely dependent on the systematic collection of relevant information, including a detailed chronology and scrutiny of the patient's medical record. Management of such disorders ideally requires a team-based approach and close involvement of the primary care doctor. As deception is a key defining component of factitious disorders, diagnosis has important implications for young children, particularly when identified in women and health-care workers. Malingering is considered to be rare in clinical practice, whereas simulation of symptoms, motivated by financial rewards, is regarded as more common in medicolegal settings. Although psychometric investigations (eg, symptom validity testing) can inform the detection of illness deception, such tests need support from converging evidence sources, including detailed interview assessments, medical notes, and relevant non-medical investigations. A key challenge in any discussion of abnormal health-care-seeking behaviour is the extent to which a person's reported symptoms are considered to be a product of choice, or psychopathology beyond volitional control, or perhaps both. Clinical skills alone are not typically sufficient for diagnosis or to detect malingering. Medical education needs to provide doctors with the conceptual, developmental, and management frameworks to understand and deal with patients whose symptoms appear to be simulated. Central to the understanding of factitious disorders and malingering are the explanatory models and beliefs used to provide meaning for both patients and doctors. Future progress in management will benefit from an increased appreciation of the contribution of non-medical factors and a greater awareness of the conceptual and clinical findings from social neuroscience, occupational health, and clinical psychology.

Factitious lesions of the hand

The presence of a lesion with atypical presentation, obscure clinical history, which does not improve with classic treatments, shall raise the red flag of the medical team. In such cases, the hypothesis of a factitious lesion shall be considered. Many times the correct diagnosis on the initial assessment may avoid high-cost diagnostic tests, unnecessary treatments, and time consumption of the medical team. We present here two classic cases of factitious lesions that, similar to those described in the literature, is difficult to diagnose and difficult to treat.

Factitious hand disorders: review of 29 years of multidisciplinary care

PURPOSE

To improve our understanding of factitious hand disorders with a review of our experience over 29 years in a multidisciplinary hand center.

METHODS

A retrospective chart review was performed to identify workers' compensation patients treated for factitious hand disorders in the multidisciplinary hand center between January 1981 and September 2010. Multidisciplinary evaluation at this center involved evaluation by hand surgeons, occupational therapists, and psychologists. Data collected include age, sex, race, educational level, clinical presentation, number of diagnostic tests, number of surgeries, time to referral to the multidisciplinary center, direct cost of care, psychological diagnosis, Minnesota Multiphasic Personality Inventory, treatment modalities, and work status.

RESULTS

We identified 174 workers' compensation patients with factitious hand disorders. Presentation was used to classify patients into 1 of 4 categories: psychopathological dystonia, factitious edema, psychopathological complex regional pain syndrome, and factitious wound creation and manipulation. There were statistically significant differences between the 4 categories in demographics, utilization of medical resources, psychopathology, treatment modalities, and return-to-work status. Patients with factitious wounds were more educated, used more medical resources, demonstrated an angry or hostile profile, and experienced a lower return-to-work rate. Patients with dystonia were less educated, used less medical resources, demonstrated a hypochondriasis or depressed profile, and experienced a higher return-to-work rate.

CONCLUSIONS

Treatment of factitious hand disorders remains frustrating and costly due to failure or recurrence after traditional approaches. This review is a large-scale examination of the factitious hand disorder population that demonstrates the unique pathology involved in each of the 4 categories. There is a specific association between the category of hand disorder and the underlying pathology and prognosis.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic IV.