Kaplan and Sadocks Comprehensive Textbook of Psychiatry, 11e

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Chapter 19. Factitious Disorder

Table 19–2. Methods of Factitious Symptom Production, Suggestive Signs, and Confirmatory Tests by Systems ( Continued )

Method of Factitious Symptom Manufacture Spitting into urine sample (salivary amylase) Injection of blood from transfusions Ingestion of NSAIDs/salicylates Ingestion of loperamide

Symptom

Signs Suggestive of Factitiousness

Test for Factitious Method Obtain monitored sample

Pancreatitis

Hyperamylasuria with normal serum amylase Nasogastric tube shows blood despite normal endoscopy Single-stripe sign-on colonoscopy

GI bleeding

Radiolabeling transfusions

Obstruction

HPLC of serum/stool for motility slowing agent

Renal Diuresis

Diuretic abuse

High urine potassium concentration

Detection of diuretics by chromatography

Bartter syndrome

Loop diuretic abuse

Hypokalemia, urine chloride low or variable

Renal biopsy for juxtaglomerular hyperplasia Screen urine for diuretics

Self-induced vomiting

Metabolic Hypervitaminosis A Vitamin A abuse

Increased gamma-glutamyltransferase

Increased serum/tissue levels vitamin A, retinoic acid derivatives

Increased bilirubin

Hypokalemia Hyperkalemia

Laxative abuse

See above

Injection of urine into blood sample

Potassium level incompatible with life

Monitoring sample gathering yields normal result

Hypernatremia

Salt load

Fractional excretion of sodium high Gastric aspirate salt concentration > 200 mmol/L

Urologic Hematuria

Adding blood from another wound/meat Traumatizing urethra Inserting foreign bodies into the bladder Ingestion of anticoagulants Addition of coloring to urine Injection of egg protein in bladder

Lack of red blood cell/hemoglobin casts

“3-tube” urinalysis (more blood in first tube if urethral trauma)

Lack of distorted red blood cells

Physical examination

Radiography

Proteinuria

Large day-to-day variations in urine protein concentration Serum albumin concentration remains in normal range

Electrophoresis of urine protein/pure albumin Large albumin band on UPEP without transferrin increase Antibody confirmation of human albumin

Lack of other signs of nephrotic syndrome

Bacteriuria

Injecting bacteria into bladder or urine specimens Adding pepper grains to urine Inserting stones into bladder Submitting quartz, feldspar as samples

Urinary calculi

Infrared spectrophotometry

Chemical analysis X-ray diffraction X-ray crystallography

Hematologic Anemia

Self-bloodletting

Decreased serum iron, ferritin, iron binding capacity Decreased bone marrow iron concentration

Iron 59 elimination studies

Urine/stool iron levels

No evidence of bleeding

Blood typing

Sickle cell crisis

Serum protein electrophoresis normal

Genetic testing Hemoglobin electrophoresis

Pancytopenia Ingestion of chemotherapy Hemorrhage/purpura Ingestion of anticoagulant (rodenticide/coumadin)

Prolonged prothrombin time (PT)

Warfarin/brodifacoum/heparin assay

Heparin injection

Prolonged partial thromboplastin time (PTT) with normal PT

PTT measured every 2 hours under observation Reversal with protamine sulfate Normal reptilase time Failure of PTT to correct in 1:1 mixture with normal plasma Correction of PTT with heparin removal measures Detection of quinidine-dependent antiplatelet antibodies

Ingestion of quinidine

Purpura with thrombocytopenia

Endocrine Hypoglycemia

Serum insulin concentration > 100 mU/L Normal proinsulin levels (increased in insulinoma)

Injection of insulin

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