Kaplan and Sadocks Comprehensive Textbook of Psychiatry, 11e

1914

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 Ingestion of oral hypoglycemic (sulfonylurea) Ingestion of tolbutamide Manipulation of testing strips

Symptom

Signs Suggestive of Factitiousness

Test for Factitious Method

High insulin/low C-peptide levels

Insulin/C-peptide ratio > 1.0

Extreme elevations in insulin levels Insulin antibodies (less reliable with human recombinant insulin) Failure of glucagon to produce C-peptide Glyburide assay in serum/urine Tolbutamide assay in serum

Hyperglycemia Insufficient administration of insulin Hyperthyroidism Ingestion of thyroid hormone

Goiter/eye findings absent Serum thyroglobulin low-normal or undetectable Increased thyroxine or liothyronine levels Radioactive iodine uptake low Low TSH in thyroid storm

Cushing syndrome

Injecting/ingesting glucocorticoid Plasma/urinary cortisol increased

Detection of synthetic glucocorticoids in serum/urine Serum cortisol and corticosterone levels Epinephrine/norepinephrine levels in serum/urine Metanephrine/normetanephrine levels in serum/urine Provocative (glucagon)/suppression (clonidine) tests 44-metaiodobenzylguanidine nuclear scan

Adding glucocorticoid to urine

Plasma ACTH low/undetectable Normal corticosterone/high cortisol Normal chromogranin A level Lack of metabolites of epinephrine (metanephrines) Lack of norepinephrine increase after glucagon Normal response to clonidine suppression test Treatment-resistant hypokalemia

Pheochromocytoma Injection of epinephrine, isoproterenol

Ingestion of stimulant

Injection of epinephrine into urine sample

Hyperaldosteronism Ingestion of black licorice/ glycyrrhizic acid

Serum glycyrrhizic acid level

Metabolic alkalosis Hypernatremia

Cardiovascular Arrhythmia

Rearranging of EKG leads Ingestion of digitalis, beta-blockers, calcium channel blockers

Unusual pattern on EKG

Supervise placement of EKG leads Serum levels of drugs Electrochemiluminescence assays detect BBs in urine

Hypertension

Valsalva maneuver Ingestion of stimulants

Office BPs normal, home BPs high

Observe BP checks

Serum/urine assay for pseudoephedrine

Infarction

Beating self with towel to raise creatine kinase

EKGs don’t change

Repeat EKGs

Enzymes do not rise appropriately

Repeat troponins

Dermatologic Cheilitis

Self-inoculation with polyvinylpyrrolidone (PVP)

Liver/lymph node biopsies show PVP in histiocytes

granulomatosa

Dermatitis artefacta Self-mutilation

Distribution of lesions in reachable areas Skin biopsy shows mechanical trauma, necrosis, blood

Erythematous lesion Applying alcohol to lesion Nonhealing wounds Injection of air/contaminants/ foreign bodies

Heal when casted

Apply fluorescein to wound, examine hands/nails for fluorescence

Resistant to treatment Subcutaneous emphysema

Obstetrical Ectopic pregnancy

Injection of hCG

Negative urine b-hCG Widely varying b-hCG levels Inconsistent pH Vaginal wall shows abrasion/denies intercourse

Negative ultrasound

Vaginal discharge

Intravaginal insertion

Neurologic Movement disorders Ingestion of neuroleptics to induce parkinsonism

MRI/EEG/EMG inconsistent

Serum levels of neuroleptic

Hoover sign/tremor entrainable/ distractable Prolactin elevated with antipsychotics

Multiple sclerosis Pseudoseizures

Examination inconsistent History inconsistent

CSF protein electrophoresis

Video EEG

Semiology inconsistent Never observed seizing by others

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