FACTITIOUS DISORDER


FACTITIOUS DISORDER IN SAUDI ARABIA: A REPORT OF TWO CASES

Tariq A. Al-Habeeb, KSUF (Psych), College of Medicine, King Khalid University Hospital, Riyadh, Saudi Arabia

تتصف الاضرابات المصطنعة بوجود أعراض عضوية أو نفسية يتظاهر بها الفرد قصدا أو يختلقها دون وجود بواعث جلية سوى رغبته في انتحال الدور المرضي. ولم تدرس هذه الاضطرابات في مرضى سعوديين إلا نادرا. وفي هذه المقالة نعرض حالتين مرضيتين لرجل وامرأة سعوديين مصابين بهذا الاضطراب، وأظهر كل منهما ملامح متلازمة منشوسن. وقد نشد كل منهما –مثلهم مثل كثير من المرضى النفسيين –العلاج عند المعالجين الشعبيين قبل مراجعتهم للمستشفي. وعلى الرغم من اختلاف العوامل الاجتماعية والحضارية فإنه من الواضح أن الوعي والقبول لدى الأطباء بإمكانية حدوث الاضطرابات المصطنعة هو مطلب مهم لتشخيصها.

Factitious disorders are characterized by physical or psychological manifestations that are intentionally produced or feigned with no apparent external incentives in order to assume the sick role. These disorders are rarely reported or may be under-reported in Saudi patients. We describe here two male and female Saudi cases of such disorders. Both presented  predominantly  with  features of Munchausen’s syndrome. Like most psychiatric patients both had sought help from traditional healers prior to their reporting to the hospitals. Inspite of the socio-cultural factors, it is clear that doctors’ awareness and acceptance of the possibility of factitious disorders is a prerequisite to making the diagnosis.

Key Words:Factitious disorders, cultural factors.

INTRODUCTION

Socio-cultural factors are important in the epidemiology and psychopathology of various psychiatric disorders1,2 including factitious ones. They have an influence on the pathways to seeking medical help.3 In addition, illness behavior has cultural overtones in Arab patients.4

Factitious disorders are characterized by physical, and psychological signs or symptoms that are intentionally produced with no external incentives to feign illness.5 These disorders have been reported from various cultures.6,7

A distinction should  be  made  between factitious disorders and malingering. In the latter, the patient produces symptoms with an obvious goal. In factitious disorders, the motivation to be a patient is vague and obscure.

Munchausen’s syndrome, in its classic description, is an uncommon subtype of factitious disorder which has received great attention.7,8 This syndrome is the earliest description of a factitious disorder with predominantly physical signs and symptoms. Although factitious disorders are common among males, recent reviews indicated a

Correspondence to:

Dr. Tariq A. Al-Habeeb, Assistant Professor and Consultant, Head, Division of Psychiatry, College of Medicine, King Khalid University Hospital, P.O. Box 7805, Riyadh 11472, Saudi Arabia

preponderance of female patients.9 The probable judgement that a particular symptom is produced intentionally is made both by direct evidence and with the exclusion of other causes of the symptoms. Almost in all reported cases of factitious disorders with physical symptoms, no obvious major mental disorder has been found. However, many such patients have been described as  having  underlying  masochistic, borderline or dependent personality traits.9 Although the prognosis is usually poor, patients who have adequate psychosocial support with less severe personality pathology can do better. In this article, two patients who suffered from such disorders are described.

CASE 1

A 45-year-old, illiterate, Saudi housewife was referred from a medical ward for psychiatric consultation. During her stay in the medical ward, she was investigated for skin lesions distributed mainly on the abdomen and both thighs, but not on her back or other areas of the body inaccessible to the hand. The dermatologist suspected factitious dermatosis (dermatitis artefacta).

Her case history revealed that two years prior to her current psychiatric consultation, she was hospitalized for vague abdominal pain, but all investigations were normal. After discharge from the hospital, she consulted a traditional healer who treated her by cauterization. During the following two years, she presented with recurrent skin lesions on the abdomen, arms and both thighs. Some of the lesions were new, others were exacerbations of old lesions. The lesions were incapacitating and prevented her from performing her usual household choices. Her family background showed that she had four growing children. Her illness had created marital discord but there was no family history of mental illness. Furthermore, she had no past history of serious physical or mental illness. Her premorbid personality revealed underlying dependent personality traits. The examination of the mental state did not show any major disorder.

During her stay in the psychiatric ward for observation, the  lesions  were  dressed properly. Evidence of intentional production of skin lesions on healed sites and on new areas was reported. When confronted with evidence of  their factitious nature, she  denied  doing herself any harm. Surprisingly, she did not demand discharge.

The judgement that the skin lesions were produced intentionally was made by direct evidence from the staff in the ward and by excluding other causes of these lesions. She was discharged from the psychiatric ward after three months and given a follow-up appointment in the psychiatric clinic but she never showed up.

CASE 2

A 39-year-old, single, illiterate and unemployed Saudi male presented with dramatic severe abdominal pain. He was vague and inconsistent when questioned in detail about the nature of the pain. When  all  of the investigations proved negative, he started to complain of chest pain. Intentional production of physical symptoms was suspected and he was referred for psychiatric assessment.

His past history showed that he had been admitted to different general hospitals in Saudi Arabia, some of which were far from his hometown. The information received from some of these hospitals showed that repeated medical and surgical consultations, including extensive investigations, did not reveal any physical disorder. In addition, psychiatric assessment showed no evidence of mental disorders either.

During his stay in the psychiatric unit, he presented with acute renal pain, hematuria and evidence of self-induced blood tinged stool. On confronting the patient about the factitious nature of his complaints after organic causes had been ruled out, he became angry and discharged himself. Two months later, he presented to the hospital in a deaf-mute state but left the hospital when again confronted. Similarly, he did not benefit from traditional healers whom he had visited many times, on the advice of his relatives. He continued to appear in the hospital with different symptoms. Once he simulated the symptoms of acute asthma. We managed him by confronting his symptoms but remaining supportive.

DISCUSSION

One of the essential clinical features of the above two cases is the intentional production of physical symptoms. The first case is that of factitious dermatosis, the second is  of  chronic  physical symptoms associated with multiple hospitalizations. The first case of dermatitis artefacta was preceded by cauterization from a traditional healer which might have acted as a predisposing factor. The second case is similar in presentation to other classic cases of Munchausen’s syndrome10 described in several cultures.

It is  important for clinicians to remember that with factitious disorder there could be some real physical illnesses that need appropriate management.11

The behavior of these two patients has cultural dimensions. To travel, females in the Saudi culture need “mahram” (a person whom they cannot legally marry) who might not always be available.12 This requirement restricts their travel creates an important feature of what was known as wandering  type of  Munchausen’s syndrome.13 In  females, the type of   Munchausen’s syndrome that is characterized by less severe psychopathology, a higher functioning level and less frequent factitious behavior is classified as non-prototypical.14 This classification seems to be justified as revealed in case 1, though it has recently been criticized8 because the criteria for classification are not applicable in a good number of factitious disorder cases.

New modern hospitals are common in Saudi Arabia. For submissive female and male patients, falling sick is a means of receiving attention, avoiding responsibility and preserving their integrity. This might be incorporated  into  the psychopathology of factitious disorders in Saudi culture.

In spite of socio-cultural factors, it is clear that doctors’ awareness and acceptance of the possibility of factitious disorders is a prerequisite to making the diagnosis. Once factitious disorder is diagnosed, it  is  important to confront the patient but remain supportive. Confrontation should be carefully planned. In Saudi culture, it would be inappropriate to inform the relatives that the patient is feigning the  symptoms, since this may precipitate psychotic breakdown of the patient.

Interestingly, both patients consulted traditional healers during their factitious behavior. Although consulting traditional healers could be explained partially by the religious background of the Saudi culture, it is interesting that in spite of the modern treatment available in Saudi Arabia, patients including those with factitious disorder, still consult traditional healers with their somatic and psychological symptoms.

REFERENCES

1.     Kleiman A, Good B. Culture and depression. Berkly: University Press; 1985.

2.     Chakraborty A. Cultural perscpectives in Indian psychiatry (Editorial). Indian J Psychiatry 1992;34:1-2.

3.     Roglers LH, Cortes  DE. Help seeking pathways: A unifying concept in mental health care. Am J Psyciatry 1993; 150:554-61.

4.     El-Islam F. Cultural aspects of illness behaviour. Arab J Psychiatry 1995; 6:13-18.

5.     American Psychiatric Association (1994): Diagnostic and Statistical Manual of Mental Disorders (4th ed) Washington DC: Author.

6.     Bhatia RS. Pseudosickness. J Assoc Physcians India1990;38:514.

7.     Folk DG. Munchausen’s syndrome and other factitous disorders. Neurologics Clinic 1995; 13(2):267-81.

8.     Sutherland AJ, Rodin RM. Factitous disorders in General Hospital settings: clinical features and a review of literature. Psychosomatics 1990;31:392-9.

9.     Rebecaa MJ. Factitious disorders. In: Kaplan HI, Sadock BJ, editors. Comprehensive Textbook of Psychiatry, 5th ed. Baltimore: Williams & Wilkins; 1995. 1271-9.

10.   Asther R. Munchausen’s syndrome. Lancet 1951;1:339-41.

11.   Jeffrey D. Munchausen’s syndrome and substance abuse. J Subst Abuse Treat 1994;11(3): 247-51.

12.   Qureshi NA, Hegazy IS. Munchausen’s syndrome and trihexyphenidyl dependence. Indian J Psychiatry 1993;35:187-8.

13.   Carney MWP, Brown JP. Clincial features and motives among 42 artifactual illness patients. Br J Med Psychol 1983;56:57-66.

14.   Nadelson T. False patients/real patients: A spectrum of disease presentation. Psychotherapy and Psychosomatic 1985;44: 175-84.


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TUBERCULOUS SPLENIC


AN UNUSUAL PRESENTATION OF TUBERCULOUS SPLENIC ABSCESS

Mohammed Y. Al-Naami, FRCSC, Department of Surgery, Asir Central Hospital, Saudi Arabia

حضر هذا المريض البالغ من العمر 55 عاما يشكو من ألم بالجانب الأيسر الخارجي لأسفل الصدر وأعلى البطن نتيجة ورم مفصص. أوضح التقييم الطبي أن هذا الورم عبارة عن خراج تحت الجلد ومتصل حتى منشأ خراج بالطحال. تم علاج المريض عن طريق جراحة فتح وتصريف للخراج تحت الجلد مع استئصال الطحال وعلاج بأدوية طبية مضادة للدرن. أكد وأوضح الفحص النسيجي المرضي للطحال وجود درن بالطحال.

تحسنت حالة المريض بعد الجراحة وتم إخراجه من المستشفى بعد عشرة أيام على العلاج بالأدوية المضادة للدرن.

بعد مضي عام أصبح المريض لا يشكو من أي أعراض مرضية وتحسنت حالته بصورة مطردة.

الكلمات المرجعية: الدرن، الطحال، خراج.

A 55-year-old male presented with painful lobulated mass on the left lateral lower chest and upper abdomen. Evaluation revealed the mass as a subcutaneous abscess originating from and communicating with a splenic abscess. The patient was treated by incision and drainage of the subcutaneous abscess along with splenectomy, and antituberculous therapy. Histopathological examination of the spleen confirmed the diagnosis of splenic tuberculosis. Postoperatively, the patient improved, and was discharged ten days later on antituberculous drugs. One year later, the patient remains asymptomatic and shows progressive improvement.

Key Words:Tuberculous, Spleen, Abscess.


 

INTRODUCTION

One-third of the population of the world is infected with mycobacterium tuberculosis. Eight million people, ninety-five percent of whom live in developing countries develop this disease each year. These figures increase annually and will certainly continue to increase.1 This worldwide increase is  also  attributable  to its interaction with the human immuno-deficiency virus (HIV) epidemics.1,2 Tuberculosis of the spleen is not uncommon, but splenic abscess formation as a result of tuberculosis is rare.3,4 Presented here is a case of tuberculous splenic abscess presenting as a subcutaneous abscess. Also discussed are the management options of tuberculous splenic abscess.


 

Correspondence to:

Dr. Mohammed Y. Al-Naami, Assistant Professor, Department of

CASE REPORT

A 55-year-old male presented with a gradually increasing mass on the left lateral lower chest and upper abdomen over a period of one year. He had no other medical problems and no history of contact with a tuberculous patient. On examination, a lobulated subcutaneous mass measuring about 7 cm in diameter, soft to cystic in consistency, immobile and attached to the skin which was tense and slightly red, tender but not warm, not pulsating, and with no bruit was found on the left lower chest and upper abdomen laterally. The spleen was enlarged 8 cm below the costal margin. Other systems were normal.

Chest X-rays showed a calcified lesion near the hilum of the right lung suggestive of an old pulmonary tuberculosis. Abdominal radiographs showed calcified lesions in the left upper quadrant (Figure 1). Ultrasound of the abdomen indicated an enlarged spleen with areas of calcification. CT scan of the abdomen revealed a splenic abscess communicating with another subcutaneous abscess through the lower chest wall (Figure 2). Based on these data, a complicated tuberculous splenic abscess was the most probable diagnosis.

Under general anesthesia, the subcutaneous abscess was incised and drained, and splenectomy was performed simultaneously. The spleen was found to be enlarged, fibrotic, and adherent to the lower chest wall. There was an abscess cavity within the spleen communicating with the subcutaneous abscess through a small tract in the lower chest wall below the insertion of the diaphragm. The abscesses contained thick pus and necrotic material. Histopathology of the spleen revealed the characteristic tuberculoid granuloma with epithelioid cells, Langhans’ multinucleated giant cells, and caseation necrosis (Figure 3). Acid fast bacilli staining, tuberculous and bacterial cultures were all negative.

The patient was started on Isoniazid (INH) 300 mg OD, Rifampin 600 mg OD, Ethambutol 600 mg OD and Pyrazinamide 500 mg OD for 5 weeks, then maintained on the former two drugs. The patient’s condition improved on anti-tuberculous medications and showed good clinical progress at one-year follow-up.

DISCUSSION

Though the prevalence of tuberculosis in the developed countries declined significantly over the last few decades, in the developing countries it remains a major public health problem.5 The decline in the developed world can be attributed to mass vaccination and the advanced health care systems, whereas in developing countries poor socioeconomic status, overcrowding, poor nutrition, and lack of medical care all contribute towards the increased incidence of tuberculosis.

Tuberculosis is usually caused by Mycobacterium tuberculosis through airborne transmission. Tubercle bacilli thrive best in tissues with a high oxygen tension. Consequently, certain organs of the body such as the lungs, renal cortex, and growing ends of bones are more commonly involved than other organs, such as the liver and spleen, where the oxygen tension is low.5 Splenic involvement is usually associated with disseminated (miliary) tuberculosis, and tuberculous abscess formation in the spleen is attributed to the over-reaction of the host immune response with the formation of caseation necrosis. Splenic tuberculosis cases are usually asymptomatic and in less than half of cases with abscess formation, they may present with the classic symptoms of fever, chills, tenderness in the left upper quadrant, and splenomegaly.6 The diagnosis of splenic tuberculosis can be reached by a high index of suspicion especially in endemic areas. Calcifications in the spleen is an important radiological sign of tuberculosis.6 Isolation of tubercle bacilli by the Ziehl-Neelsen staining and culture techniques of aspirates from the splenic abscess, and the characteristic histopathologic finding of tubercle granuloma of the spleen establishes the diagnosis of tuberculosis.

Splenic tuberculosis without abscess formation is usually managed medically with anti-tuberculous drugs. Tuberculous splenic abscess has been successfully treated with anti-tuberculous drugs7,8 alone, and by splenectomy.6,9 However, surgical treatment is preferred in a solitary tuberculous splenic abscess in otherwise fit patients,9 and in such complicated cases as this case. Penetration of tuberculous splenic abscess into the subcutaneous tissues or to the outside is extremely rare. This patient was managed surgically, and treated with anti-tuberculous drugs for almost a year, as splenic tuberculosis is usually associated with a disseminated disease.

In conclusion, because of the rising incidence of tuberculosis,1 unusual presentation of tuberculosis should be suspected as the disease is becoming increasingly more common.

ACKNOWLEDGMENT

The author is grateful to Dr. Abdur Rauf Khan (Consultant Pathologist) for photographic preparation and interpretation.

REFERENCES

1.Raviglione MC, Snider DE jr, Kochi A. Global epidemiology of tuberculosis. Morbidity and mortality of a worldwide epidemic. JAMA 1995; 273 : 220-6.

2. Odhiambo JA. Unusual presentation of tuberculosis {editorial }. E Afr Med J 1993;  70: 605.

3. Huang CT, Leu HS, Lee MH. Tuberculous splenic abscess. Chang Keng I Hsueh 1995; 18:77-81.

4.Kao PF, Tzen KY, Chou YH, Lu SY, You DL.  Accumulation of Ga-67 citrate in a tuberculous  splenic abscess. Clin Nucl Med 1996; 21: 49-52.

5.  Fox E. Tuberculosis. In: Srickland  GT, editors. Hunter’s Tropical Medicine. 7th ed. Philadelphia:  W.B. Saunders; 1991. p.458-83.

6.  Al-Salem AH, Mallapa KK, Qaisaruddin S. Tuberculous abscess of the spleen. Trop Geogr Med 1993; 45(6): 304-5.

7.Gotor MA, Mur M, Guerrero L, Aspiroz C, Romero D, Gimeno E. Tuberculous Splenic Abscess in an immunocompetent patient. Gastroenterol Hepatol 1995; 18:15-7.

8.Abitbol V, Paupard T, Etienney I, Patey O, Guez C, Oberlin P, et al. Clinical and radiological aspects of tuberculous splenic abscesses. Gastroenterol Clin Biol 1996; 20:597-600.

9. Wu P. Diagnosis and treatment of solitary tuberculosis of the spleen. Chung Hua Chieh Ho Ho Hu  Hsi Tsa Chih 1989;  12: 292-3 , 319.


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