Ointment Pseudo-Cheilitis: A Disease Distinct From Factitial Cheilitis. A Series of 13 Patients From São Paulo, Brazil.

BACKGROUND: The terms exfoliative cheilitis, factitial cheilitis, and morsicatio labiorum are used to describe self-inflicted lesions of the lip. OBJECTIVE: Here we report and analyze clinical, pathological, and therapeutic data on 13 patients with a form of factitial cheilitis that we believe should be considered a separate entity. RESULTS: Eight patients were male and 5 patients were female. All patients reported pain and presented with crusts consisting of dried saliva and topical medications adherent to the surface of the lips. These patients expressed great concern with their condition, and reported several previous, ineffective treatments. Simple reassurance only was not effective; saline compresses alleviated symptoms for a few patients. Most patients were lost to follow-up. Biopsies were not performed on all patients. CONCLUSION: This particular type of cheilitis artefacta has been previously described, but some features described herein are new and allow a specific approach: patient's behavior, the "protrusion sign," and possible improvement with antidepressants. For these cases, we propose the term ointment pseudo-cheilitis because it comprises the nature of the attached material and the lack of true inflammation. Further psychiatric characterization is a logical next step in further characterizing this difficult-to-treat condition.

Conversion, Factitious Disorder and Malingering: A Distinct Pattern or a Continuum?

This chapter is aimed at highlighting the recent findings concerning physiopathology, diagnosis, and management of conversion, factitious disorder, and malingering. Conversion disorder is the unintentional production of neurological symptom, whereas malingering and factitious disorder represent the voluntary production of symptoms with internal or external incentives. They have a close history and this has been frequently confounded. Practitioners are often confronted to medically unexplained symptoms; they represent almost 30% of neurologist's consultation. The first challenge is to detect them, and recent studies have confirmed the importance of "positive" clinical bedside signs based on incoherence and discordance, such as the Hoover's sign for the diagnosis of conversion disorder. Functional neuroimaging has allowed a better understanding of the pathophysiology, and highlighted abnormal cerebral activation patterns in conversion disorder in relation to motor, emotional, and limbic networks, different from feigners. This supports the theory evoked by Charcot of a "psychodynamic lesion," which is also reflected by the new term introduced in the DSM-5: functional neurological disorder. Multidisciplinary therapy is recommended with behavioral cognitive therapy, antidepressant to treat frequent comorbid anxiety or depression, and physiotherapy. Factitious disorder and malingering should be clearly delineated from conversion disorder. Factitious disorder should be considered as a mental illness and more research on its physiopathology and treatment is needed, when malingering is a non-medical condition encountered in medico-legal cases.

The clinical inadequacy of the DSM-5 classification of somatic symptom and related disorders: an alternative trans-diagnostic model.

The Diagnostic and Statistical of Mental Disorders, Fifth Edition (DSM-5) somatic symptom and related disorders chapter has a limited clinical utility. In addition to the problems that the single diagnostic rubrics and the deletion of the diagnosis of hypochondriasis entail, there are 2 major ambiguities: (1) the use of the term "somatic symptoms" reflects an ill-defined concept of somatization and (2) abnormal illness behavior is included in all diagnostic rubrics, but it is never conceptually defined. In the present review of the literature, we will attempt to approach the clinical issue from a different angle, by introducing the trans-diagnostic viewpoint of illness behavior and propose an alternative clinimetric classification system, based on the Diagnostic Criteria for Psychosomatic Research.

[DSM-5: from 'somatoform disorders' to 'somatic symptom and related disorders']. / DSM-5: van somatoforme stoornissen naar 'somatic symptom and related disorders'

BACKGROUND: The DSM-IV somatoform disorder category was controversial and has undergone major changes in DSM-5. AIM: To provide a critical description of DSM-5 somatic symptoms and related disorders (SSD). METHOD: To review the new classification system for somatic symptom and related disorders (SSD) as set out in DSM-5 RESULTS: Whereas the symptoms of somatoform disorder were always considered to be medically unexplained, in DSM-5 the symptoms of somatic symptom disorder can now sometimes be explained by a medical condition. The criterion is that the individual has a maladaptive reaction to a somatic symptom. In DSM-5 the terms somatisation disorder, pain disorder and undifferentiated somatoform disorder have been discarded, whereas factitious disorder as well as psychological factors affecting other medical conditions have been added to somatic symptom disorder and other disorders. Conversion disorder remains as it was in DSM-IV. Hypochondriasis has been renamed 'illness anxiety disorder'. CONCLUSION: The new description of somatic symptom disorder in DSM-5 represents a big step forwards, because the decision has been made to use, for classification, a positive criterion, namely maladaptive reaction to a somatic symptom, instead of the earlier negative criterion, namely that the symptoms should be medically unexplained. Before attaching the ssd label to an illness, the clinician will have to weigh up the clinical consequences of this psychiatric diagnosis.

A review of somatoform disorders in DSM-IV and somatic symptom disorders in proposed DSM-V.

Psychiatric care providers should be trained to use current changes in the somatoform disorders criteria. New diagnostic criteria for Somatic Symptom disorders in the proposed DSM-V is discussed and compared with its older counterpart in DSM-IV. A new category called Somatic Syndrome Disorders is suggested. It includes new subcategories such as "Complex Somatic Symptom Disorder" (CSSD) and "Simple Somatic Symptom Disorder" (SSSD). Some of the subcategories of DSM-IV derived disorders are included in CSSD. While there are some changes in diagnostic criteria, there are concerns and limitations about the new classification needed to be more discussed before implementation. Functional somatic disturbance, the counterpart of converion disorder in DSM-IV, can be highly dependet on the developmental level of children. However, the role of developmental level needs to be considered.

Physician-based estimates of medically unexplained symptoms: a comparison of four case definitions.

BACKGROUND: Medically unexplained symptoms (MUS) are considered a common occurrence in medical settings, although definitions, methodologies and resulting prevalence rates for MUS vary widely between studies. OBJECTIVES: The objective of the present study was to characterize physicians' estimates of MUS, including clinically significant MUS, and to demonstrate in a single study how estimates vary based on the definition used. METHODS: Two hundred and thirteen physicians completed an online questionnaire regarding the number of patients who present to their clinic with MUS. To reduce memory biases, participants reported on the number of patient seen in their most recent clinic day who met increasingly restrictive case definitions for MUS. Weekly estimates were also obtained. RESULTS: The least restrictive definition yielded an estimate of 11%. When certainty criteria were added to the definition of MUS, the estimate decreased considerably to 4%. Approximately 3% of patients were estimated to have chronic MUS that affected their daily functioning or caused significant distress (i.e. psychologically significant MUS), and only half of these, 1.5%, were assigned a diagnosis of somatoform disorder or factitious disorder. The proportion of MUS cases accounted for by malingering was 18%. CONCLUSIONS: The present study documents significantly lower estimates of MUS than chart review studies. However, our results suggest that a significant proportion of the total number of patients who present with MUS have abnormal illness behaviour associated with significant impairment or distress. Despite physicians' recognizing significant distress and dysfunction in these cases, formal diagnoses of somatoform or factitious disorder are rarely assigned.

The A, B, C's of factitious disorder: a response to Turner.

The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-V) is being prepared, but little attention has been accorded the category of factitious disorder, despite its presence in the manual for almost 30 years. Among relevant articles that have appeared, Turner's publication advocates retention of the category, but with new criteria. In the current paper, we reject Turner's reformulation but use the identified diagnostic dilemmas to illuminate the phenomenology of factitious disorder. We also offer a reconceptualization of the diagnosis that should better inform the preparations for DSM-V.

[Pseudologia fantastica: definition and position in relation to axis I and axis II psychiatric disorders]. / Pseudologia fantastica: definiëring en situering ten aanzien van as I- en as II-stoornissen.

Pseudologia fantastica, also known as mythomania or pathological lying, is a psychiatric phenomenon that has been recognised for over a hundred years. By analysing two case studies and by searching the literature for relevant articles we aim to define the concept clearly and to ascertain whether pseudologia fantastica should be considered as a symptom of a psychiatric disorder or whether it should be considered as a separate entity.

Looking toward DSM-V: should factitious disorder become a subtype of somatoform disorder?

BACKGROUND: Factitious and somatoform-disorder patients are alike in that they both organize their lives around seeking medical services in spite of having primarily a psychiatric condition. In DSM-IV, the key difference is that factitious-disorder patients feign illness, and somatoform-disorder patients actually believe they are ill. Although patients may not be conscious of their motivation or even their behaviors, deliberately embellishing history or inducing symptoms exemplifies behaviors designed to enhance a self-concept of being ill. CONCLUSION: For DSM-V, we propose reclassifying factitious disorder as a subtype within the somatoform-spectrum disorders or the proposed physical-symptom disorder, premised on our belief that deliberate deceptions serve primarily to portray to treaters the sense of being ill.

[Psychopathology of Ganser's syndrome. Literature review and case report]. / Psychopathologie des Ganser-Syndroms. Literaturübersicht und Falldiskussion.

The key feature of Ganser's syndrome includes approximate answers to simple questions. The cause of this rare syndrome remains uncertain. Current classification systems categorise it as a dissociative disorder, the symptoms of which are judged as psychogenic in origin. Our review of the literature (n=151) demonstrates however that Ganser's syndrome is frequently associated with brain injury, although detailed imaging, neuropsychological, and neurological data of this for the most part do not exist. We describe a right-handed patient with Ganser's syndrome after a large left-hemispheric middle cerebral artery infarction. Detailed neuropsychological examination showed atypical lateralisation of cognitive functions with so-called crossed nonaphasia and pronounced frontal-executive dysfunctions. Regarding both psychiatric and neuropsychological aspects, we discuss how the key feature of approximate answers may be associated with frontal-executive cerebral dysfunctions.

Feigned and factitious diseases in the British Forces c.1830-1840: a forgotton medical classic.

Soldiers and seamen were remarkably inventive in their methods of feigning disease; I know of few cases where soldiers today have gone to such determined efforts to simulate a disease. All of us have encountered malingerers in the course of our work but the extent and array to which they extend in their attempts is greatly surpassed by the tales of effort and guile reported by Gavin. Fit, content men have always been at the centre of the military capability and in the forces of the present day the driving concerns to discharge oneself from the army or navy are no longer quite as pressing. However, medical officers should always be alert to the art of feigning. I will leave the last word to Hector Gavin: "As long as soldiers have the idea that they can impose upon officers, and that the result will be for their advantage, so long will examples of imposition occur in the army. "

Factitious disorders: reformulating the DSM-IV criteria.

The author criticizes and reformulates the DSM-IV criteria in a clinically and nosologically sensitive way. Criterion A, the intentional production of physical or psychological signs or symptoms, emphasizes symptoms and cannot accommodate pseudologia fantastica, voluntary false confessions, and impersonations. Criterion B, the motivation is to assume the "sick role," has no empirical content and fulfills no diagnostic function. The two criteria need reformulating in terms of lies and self-harm, respectively. Criterion C causes misdiagnosis by pushing factitious disorders into the somatoform and malingering categories and should be abandoned. The author discusses the implications for the etiology of conversion disorders and the classification of factitious disorders.

[Psychogenic disorders: concepts, terminology and classification]. / Trastornos psicógenos: concepto, terminología y clasificación.

The neurological interest on functional or psychogenic disorders (mental or physical disturbances with no organic basis, generally unleashed by stressful situations) has been receiving increasingly more interest over the last few years. In this article we review concepts, terms and classifications of these disorders, very different over time and among different authors. Psychogenic disorders are divided into: a) dissociation (with memory, consciousness and self-identity impairment), and b) disturbances with somatizations, divided into somatoform (unconscious), factitious (voluntary search for patient's role) and malingering (searching for material gain). Special emphasis is placed on conversion or hysteria, included in somatoform disorders. New findings in functional neuroimaging are analyzed. These new data suggest an important role of unconscious and involuntary inhibition in loss of volition (similar to hypnosis and different from malingering). Normal activity in certain brain areas (motor or sensory cortex) is blocked by other areas related to emotional integration (anterior cingular and orbitofrontal cortex). The neurologist's role is important to achieve an early diagnosis of psychogenic disturbances, particularly conversive ones. This means the use of fewer economic resources and better prognosis for the patient.

Non-organic hearing loss redefined: understanding, categorizing and managing non-organic behaviour.

Addressing the complex factors that underpin any presentation of non-organic hearing loss (NOHL) is essential to that individual's proper management. The complex and often conflicting approaches taken to date are reviewed. Previous dichotomous models distinguish those assessed as consciously malingering for external benefits from those who generate symptoms unconsciously to meet psychological needs. Incorporating the DSM-IV-TR diagnosis of 'factitious disorder' into a new model bridges the conceptual gap. Three categories (malingering, factitious and conversion) are used distinctly, for the purpose of diagnosis, and on a continuum for the purpose of management. Motivating factors, type of gain, degree of intention and consistency of response during audiological assessment can all be related within the model. Advances in objective measurements have made the detection of NOHL easier. A reinvigoration of interest in effective diagnosis and management of the condition is therefore timely.

Different interpretations of Munchausen Syndrome by Proxy.

The definition of Munchausen Syndrome by Proxy is reviewed and considered in the context of the overlap with other harmful behaviors of parents. The high incidence of personal abnormal illness behavior in the perpetrators is leading to increasing concern about the safety of children who are cared for by parents who have abnormal illness behavior.

Factitious disorders of the upper limb in Saudi Arabia.

This prospective study investigated 28 patients with factitious disorders of the upper limb. Several cases did not fit any of the well-known factitious syndromes such as SHAFT or Münchhausen syndrome. Patients were divided into five groups, three of which comprised active mutilators who either induced wounds, introduced foreign bodies or induced arm swelling and oedema. Passive mutilators were considered in a separate group and were defined as those who complained of factitious pain or numbness of the limb, for which there was no secondary gain regarding employment or compensation: these patients underwent surgery and hence persuaded the surgeon to do the mutilation. The fifth group of patients exhibited hand posturing and were divided into two subgroups: patients with psychological hand posturing and those seeking secondary gain (malingerers). The clinical presentation, diagnosis and outcome are described for each group.

Factitious disorders.

Reports of factitious disorders, Munchausen's syndrome, and self-induced illness exist throughout medical history. In practice, disease simulation represents a spectrum of behaviors that range from relatively common and benign (e.g., pleading illness to avoid an unwanted social obligation) to rare and malignant forms (e.g., Munchausen's syndrome and factitious disorder by proxy). Factitious disorders are differentiated from malingering by the goal that motivates the individual's behavior. The only apparent goal in factitious illness is to gain the sick role; the goal in malingering is to gain rewards, such as compensation, or to avoid the unwanted, such as military service or jail. This article summarizes clinically relevant information on factitious disorders for primary care physicians.