做作性障碍 —— 一例不明原因的鼻出血的罕见病因

概述:鼻衄或鼻出血是一种常见的疾病,有可能会严重到需要紧急医疗或手术治疗.人为的鼻出血是一种罕见的案例.对患者复杂的行为问题,在大学阶段的培训较少,因此,外科医生常常错过患者一些隐藏的心理问题.在这里,我们给出一例做作性障碍的病例,该案例由于鼻出血而进行手术.经过适当的评估并于耳鼻咽喉科会诊之后,我们采用抗抑郁药物和认知行为治疗成功治愈该患者.     

Factitious disorder as repeated diabetic ketoacidosis: a case report

Factitious disorder is a challenging entity, both in diagnosis and treatment. The clinical presentation is variable in feigned symptoms and spans virtually all organ systems. The diagnostic criteria are simple, yet making the diagnosis is often complicated and can be delayed by focusing on the urgent or readily observable diagnosis. In this article, the authors present a case of factitious diabetic ketoacidosis resulting from the deliberate withholding of exogenous insulin. This particular case is dissected in order to portray the underlying psychopathology. In doing so, the authors illustrate how a patient with factitious disorder might fulfill unmet, presumably unrealized needs. The authors also discuss the diagnostic criteria and treatment strategies of factitious disorder, both of which are of considerable debate within the psychiatric community.     

The factitious/malingering continuum and its burden on public health costs: a review and experience in an Italian neurology setting

Neurological Sciences - Factitious disorder is classified as one of the five aspects of somatic symptom disorders. The fundamental element of factitious disorder is deception, i.e., pretending to...     

Psychogenic "HIV infection"

The case of a man who falsely represented himself as being HIV positive is reported. In less than one year he was admitted twice with symptoms suggestive of HIV infection. The diagnoses malingering and factitious disorder were consecutively made. Early recognition of Factitious Disorder is essential to prevent patients from harmful diagnostic procedures or surgical treatments. Psychiatric treatment is best focused on management and care rather than cure. Psychogenic "HIV infection" might become more common than acknowledged up to now. Physicians should consider the occurrence of psychogenic "HIV infection," part of the symptomatology may be psychogenically determined, or indeed frankly simulated.     

Factitious disorders with psychological symptoms.

BACKGROUND: Factitious disorders with psychological symptoms have been underdiagnosed and hence undertreated. Historically, the literature has focused on factitious disorder with physical symptoms, particularly Munchausen's syndrome. METHOD: The authors report three cases of factitious disorder with psychological symptoms that had diverse clinical presentations. RESULTS: Two of the patients had features of a psychiatric Munchausen's syndrome--being middle-aged, aggressive men who falsified their symptoms, treatments, and backgrounds. The third patient was a younger woman with comorbid substance abuse, dysthymia, and borderline personality disorder. CONCLUSION: The authors feel that there is a need for refinement of diagnostic criteria, greater awareness, and evaluation of treatment approaches for this condition.     

Patients who strive to be ill: factitious disorder with physical symptoms

OBJECTIVE: Factitious disorder with physical symptoms characterizes patients who strive to appear medically ill and assume the sick role. Clinical suspicion is highest for female health care workers in the fourth decade of life. This study was designed to analyze the diagnosis of factitious disorder, the demographics of affected patients, and intervention and treatment. METHOD: Retrospective examination was of 93 patients diagnosed during 21 years. Two raters agreed on subject eligibility on the basis of DSM-IV criteria and absence of a somatoform disorder and a plausible medical explanation. RESULTS: The group included 67 women (72.0%); mean age was 30.7 years (SD=8.0) for women and 40.0 years (SD=13.3) for men. Mean age at onset was 25.0 years (SD=7.4). Health care training or jobs were more common for women (65.7%) than men (11.5%). Most often, inexplicable laboratory results established the diagnosis. Eighty had psychiatric consultations; 71 were confronted about their role in the illness. Only 16 acknowledged factitious behavior. Follow-up data were available for only 28 patients (30.1%); maximum duration of follow-up was 156 months. Two patients were known to have died. Few patients pursued psychiatric treatment. Eighteen left the hospital against medical advice. CONCLUSIONS: Factitious disorder affects men and women with different demographic profiles. Diagnosis must be based on careful examination of behavior, motivation, and medical history and not on a stereotype. Laboratory data and outside medical records help identify suspicious circumstances and inconsistencies. Confrontation does not appear to lead to patient acknowledgment and should not be considered necessary for management.     

Factitious torsion dystonia in rehabilitation: a singular new case and literature review

We report a case of a 29-year-old woman suffering from chronic factitious disorder (FD) with torsion dystonia. For nearly five years, she traveled widely over the country, going from one hospital to another, taking serious medical risk in order to prolong her illness. After several admissions to Rehabilitation Units and multiple explorations, we find convincing evidence for factitious origin and the diagnosis of Munchausen syndrome was evoked. Such a clinical presentation is infrequent in Munchausen's syndrome. Indeed, most often the clinical picture is characterized by acute abdominal pain, fainting, hemoptysis, precordialgia, hematemesis or dermatological lesions. Physicians should be aware of this rare and potentially critical form of FD. Awareness in identifying these patients may lead to prevent unnecessary medical and/or surgical interventions.     

A case of factitious disorder involving menstrual blood smeared on the face

This article presents a case of factitious disorder in which a female smeared menstrual blood on her face. The patient was admitted to our otolaryngology clinic complaining of bleeding from the mouth, nose, ears and eyes. This event reportedly occurred three to four times on a daily basis. She acknowledged nine prior admissions to different specialists over the last two years. Following psychiatric consultation, we diagnosed factitious disorder with predominantly physical signs and symptoms. She was started on Fluoxetine 20 mg/day and supportive interviews were organized. After diagnosis, we observed that her symptoms decreased over two months. The symptoms did not reoccur three to nine months after treatment. This case report outlines two important features. The first is that a case of this type has not been reported before, and the second feature is that this case demonstrates the effect of cultural factors greatly different from those seen in classical factitious disorder.     

Factitious disorder in a manic patient: case report and treatment considerations

A case of factitious disorder with physical symptoms is described in a patient with manic-depressive illness. The coexistence of factitious disorder and bipolar disorder has not been previously reported. Clinicians should search for an underlying affective disorder in patients who fabricate signs and symptoms of physical illness, since mania may simulate or contribute to the production of factitious behavior.     

Munchhausen patients in general hospitals--Clinical features and treatment approaches in C-L psychiatry settings

Factitious disorders have been reported in 0.5 - 1 % of general hospital patients. It often takes several years until the disorder is detected. During this period, enormous health care cost can arise not least out of iatrogenic self-induced mutilations and related secondary somatic complications. Apart from surgeons and physicians, consultation-liaison (C-L) psychiatrists are particularly called on to diagnose factitious disorders at an early stage in order to avoid unnecessary diagnostic and therapeutic procedures, treatment dropout and doctor shopping. This article gives an overview of clinical features and treatment approaches in C-L psychiatry settings.     

Artificial diseases (self-induced diseases)--a review]

Factitious disorders have gained greater significance in all medical specialties during recent years, and continue to pose difficult problems. At present factitious disorders can be divided into four sub-types, the pretence and/or production of somatic and/or psychic medical symptoms being central to all. Apart from disturbance of ego structure the self and the body image (self) a specific disturbance of the doctor-patient relationship is of pathognomonic value. An integrated therapeutic approach (combination of palliative measures, somatic therapy and psychotherapy) seems to be most successful. In the differential diagnosis, factitious diseases have to be delineated from many other diseases in which self-destructive behaviour may occur.     

Factitious disorder and factitious disorder by proxy

Similar to the adult patient, a child or adolescent may actively feign or produce artificial symptoms (synonymous: Munchausen syndrome). The more frequent case is that the child suffers from being an object of symptom fabrication induced by a close person caring for the child, regularly the mother (Munchausen syndrome by proxy). This review focuses on psychopathological aspects of the clinically more relevant factitious disorder by proxy. Typical behaviour and personality characteristics are presented that can be taken as clinical warning signs. Doctor-mother-interaction is affectively challenging due to conflicting tasks imposed on the physician. Complementary to pediatric exclusion of genuine disease, psychopathological assessment is required to exclude other sources of deviant illness behaviour. Factious disorder shares particular features (active violation of the child, false report of history, aggravated symptom presentation and increased doctor-hopping, difficulties in conforming maternal report in biomedical data) with other psychopathological entities (child abuse, simulation, dissociative disorders, somatoform disorders including hypochondria, variants of maternal overprotection and infantilization, psychosis or delusion in the mother). Criteria for differentiation are presented. Three concepts on the psychopathological etiology of factitious disorder by proxy are relevant: In some cases, it may be conceived as secondary manifestation of a primary psychopathological entity or personality disorder. Learning theory emphasises operant rewards received from vicarious sick role. Attachment theory provides possible explanations concerning the traumatic impact on the child, early sources of psychopathology in the fabricating mother and risks for intergenerational transmission of factitious disorders.     

A case of factitious homicidal ideation

Homicidal ideation is often fabricated or embellished by psychiatric patients in both the emergency room and inpatient settings. Typically, this symptom is malingered to achieve short-term hospital admission and temporary relief from complications of substance abuse, homelessness, and illicit activities. Very rarely, a patient may feign homicidal intent for the primary purpose of remaining in the role of patient (factitious disorder). Although factitious disorder with psychological symptoms has been described in a variety of circumstances, the psychiatric literature lacks any reports of factitious homicidal ideation. This is a report on the case of a patient who was civilly committed on numerous occasions for protracted periods based solely on his self-professed homicidal ideation. The case raises both forensic and clinical questions and reinforces the authors' belief that further investigation is needed to develop more sophisticated methods of detection, evaluation, and treatment of factitious disorder with psychological symptoms.     

Factitious disorders in civil litigation: twenty cases illustrating the spectrum of abnormal illness-affirming behavior

Physical symptoms are commonly alleged in civil litigation. In some instances these symptoms are originally produced by psychological factors and antedate the alleged injury being claimed as a tort. These cases reflect abnormal illness-affirming behavior. Factitious physical disorders represent a special category of these individuals because they produce their signs and symptoms consciously. This article reviews common features of 20 cases of factitious disorder in which the patients were involved in civil litigation. Attention to these factors can facilitate differential diagnosis, which can lead to improved understanding of causation and appropriate clinical interventions. The authors discuss how the actions of such individuals often shift along the entire spectrum of abnormal illness-affirming behavior over time.     

Insulin-induced factitious hypoglycemic coma

Hypoglycemia due to the ingestion of oral hypoglycemic agents or injection of insulin is a common way for chronic factitious disorder to present to physicians. Despite this fact, factitious hypoglycemic coma is rare. Because hypoglycemia is potentially fatal, with numerous sequelae, physicians need to be aware of its occurrence and method of detection. A case of chronic factitious disorder presenting as hypoglycemic coma is presented and its implications discussed.     

Munchausen's syndrome: a reconceptualization of the disorder

The American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, third edition (DSM-III) delineates three categories of factitious disorders: chronic with physical symptoms (Munchausen's syndrome); factitious disorder with psychological symptoms; and other factitious disorders with physical symptoms. Munchausen's syndrome served as the prototype for all factitious disorders at the time DSM-III was drafted, partly due to the disproportionate attention given to this variant of the disorder. Clinical experience suggests that existing categories do not adequately provide for commonly seen forms of factitious illness. It is now recognized that factitious disorder is the result of a complex interaction of personality factors and psychosocial stressors that often present with both medical and psychiatric symptomatology. Proposed changes in the revised edition of the diagnostic manual DSM-III-R include separate categories of factitious disorder with psychological, physical, and both psychological and physical symptoms. A case report of a patient for whom extensive records and thorough psychological assessment were available is exemplary of a more common course of the disorder (both psychological and physical symptoms) that by current classification would be considered "atypical." A reconceptualization of the disorder that gives emphasis to course and clinical features is suggested.     

Characteristics of psychosis in borderline personality disorder

Comparing a sample of 88 inpatients with borderline personality disorder (BPD) to inpatients with borderline traits, this paper addresses four hypotheses regarding the association between BPD and psychotic symptoms: (1) narrowly defined psychotic symptoms are rare in BPD; (2) broadly defined psychotic symptoms are often reported in BPD; (3) narrowly defined psychotic symptoms are due to concomitant disorders, and (4) psychotic symptoms may be factitious. Consecutive admissions to acute inpatient services were screened for borderline features and patients were examined using the Diagnostic Interview for Borderlines and the Schedule for Affective Disorders and Schizophrenia. The results generally supported the proposed explanations for the association between BPD and psychotic symptoms. Factitious psychotic symptoms were found in only 13% of the BPD sample.     

Phenomenology and outcome of factitious disorders in otolaryngology clinic in Oman

The phenomenology of factitious disorders from the Arab part of the world has been lacking in the medical literature and few reports have emerged from otolaryngology. Using an observational prospective case series study (n = 19) with long-term follow-up (two to six years), the present study reports the magnitude and mode of clinical profile of factitious disorders in a tertiary care hospital in Oman, an Arab-Islamic country. The outcome was operationalized as prognosis following culturally sensitive intervention akin to confrontation technique. The present observation suggests the prevalence of factitious disorders in the otolaryngology tertiary care setting was 0.2%. Approximately 42.1% (n = 8) had hemorrhagic factitious disorders, 15.8% (n = 3) were those who feigned for multiple surgical interventions. Approximately 15.8% (n = 3) presented neurological factitious disorders while the remaining 26.3% (n = 5) clinical profile suggested minor feigned illnesses. Objective "evidence factitia" was present in 68.4% (n = 13) of the cases. On subsequent follow-up, nine patients with chronic forms became asymptomatic, three patients had fewer episodes, four patients were unchanged, and three patients were lost to follow-up. The prognosis was good in patients who did not have associated psychiatric illnesses as compared to those with psychiatric disorders. Factitious disorders are often incorrectly diagnosed, with all consequences in terms of adverse sequels. The observed good prognostic outcomes are discussed in the context of socio-cultural patterning and the factors that may shape the presentation of factitious disorders in Oman.     

The Ganser syndrome: evidence suggesting its classification as a dissociative disorder

The past and present nosology of Ganser's syndrome is discussed. The anomaly is defined as the presence of approximate answers with hallucinations, clouded sensorium, somatic conversion, and amnesia. The characteristic symptom of the syndrome, paralogia, is appreciated as an associated feature of Factitious Disorder with Psychological Symptoms. It is suggested that Ganser syndrome may be linked inappropriately with the concept of factitious illness. Two new cases of the Ganser syndrome are presented, and an additional forty-one case reports are reviewed. A high correlation between the presence of paralogia and amnesia is revealed, which suggests that paralogia and related psychological symptoms are better classified as associated features of Atypical Dissociative Disorder.     

Pseudologia fantastica and factitious disorder: review of the literature and a case report

Pseudologia fantastica is sparsely defined in the psychiatric literature, and has not been reviewed in the English-language psychiatric literature since 1988. To redefine the role of pseudologia fantastica in factitious disorder, the case of a 56-year-old man with factitious disorder is discussed.