A 45-year-old woman comes to the office with multiple scratches, small sores, and abscesses on her left arm. She is worried because the sores have been present for the past month and have not healed. The patient has no idea how the sores developed and is concerned that they will spread. She is a nurse who is well known to the staff from a similar presentation 2 years ago. At that time, she had similar skin lesions, many of which were severely infected and did not respond to usual treatment. Fecal bacteria were found in one of the sores. On another occasion, the patient had a spreading infection and cellulitis that required a prolonged hospitalization and intravenous antibiotics. She has no other medical problems. Which of the following is the most likely cause of this patient's condition?

Question

A 45-year-old woman comes to the office with multiple scratches, small sores, and abscesses on her left arm.  She is worried because the sores have been present for the past month and have not healed.  The patient has no idea how the sores developed and is concerned that they will spread.  She is a nurse who is well known to the staff from a similar presentation 2 years ago.  At that time, she had similar skin lesions, many of which were severely infected and did not respond to usual treatment.  Fecal bacteria were found in one of the sores.  On another occasion, the patient had a spreading infection and cellulitis that required a prolonged hospitalization and intravenous antibiotics.  She has no other medical problems.  Which of the following is the most likely cause of this patient's condition?

Quizplus · Accepted Answer

11ec160b_3625_7ae8_9249_7df36fe9e1ab_MD0001_00 This patient's likely deliberate induction of infection in the absence of obvious external rewards is consistent with factitious disorder. In factitious disorder, patients deceptively produce signs and symptoms of a medical or psychiatric illness or induce injury to obtain attention and receive protracted care (ie, to assume the "sick role"). Behaviors may include deceptive reporting of symptoms, manipulating laboratory samples, ingesting a substance (eg, insulin), altering medical records, or inducing illness (eg, injecting fecal matter to produce an abscess). These patients are aware of their symptoms and conceal their attempts to simulate or cause them, but they lack conscious awareness of why they do it. When confronted with the possibility of feigning or producing symptoms, they typically respond with denial and may reject medical and psychiatric care (eg, sign out against medical advice). The presentation is often episodic and more likely to occur in women and health care workers. When an individual falsifies illness in someone else (eg, child), the diagnosis is factitious disorder imposed on another. (Choice A) This patient has insufficient symptoms to diagnose borderline personality disorder (eg, unstable mood and relationships, impulsivity, suicidality). Patients with borderline personality disorder may engage in deliberate self-harm (eg, cutting), but it is not associated with deceiving medical caregivers. (Choices B, D, and F) Factitious disorder can be differentiated from other somatic symptom disorders by the presence of deliberate falsification of symptoms or illness (Table). In conversion, illness anxiety, and somatic symptom disorders, patients are concerned with genuine symptoms and are not attempting to deceive. (Choice E) Malingering is differentiated from factitious disorder by the intentional falsification of symptoms for personal gain (eg, financial benefits, time off from work). In contrast, factitious disorder requires the absence of obvious rewards. Educational objective: Factitious disorder involves the conscious and deceptive feigning or self-production of physical or psychological symptoms to obtain attention and medical care from health care personnel. __________ References: Factitious disorders and malingering: challenges for clinical assessment and management. (http://www.ncbi.nlm.nih.gov/pubmed/24612861)

A 45-Year-Old Woman Comes to the Office with Multiple Scratches