Wires in the body: a case of factitious disorder.

Factitious disorder can present with a wide variety of symptomatology. We present a case of a young girl presenting with spontaneous extrusion of wires from her limbs. These metallic wires were present in both her upper and lower limbs in the muscle bulk and were visible on X-ray. She sought repeated surgical removal of these wires, but the wires would invariably reappear. The patient could not be engaged in a therapeutic relationship and the family took premature discharge against medical advice, as they believed in supernatural causation for the phenomenon and were afraid that medical intervention might bring further ill fortune. The case highlights the importance of belief systems of family members as a barrier in managing such cases.

INTRODUCTION

Factitious disorder can present with a myriad variety of symptoms which baffle the physicians. Patients have been found to produce bizarre symptoms, including non-healing wounds caused by mouthwash and self-insertion of needles in finger joints[1] among many others. Medical implausibility of symptoms or inexplicable findings in the laboratory data[2] at times lead to suspicion of the diagnosis. We report case of a young girl presenting with recurrent spontaneous extrusion of wires from her body and discuss the difficulties faced in management due to the family's belief of supernatural causation of the phenomenon.

CASE REPORT

Ms. S, a female aged 16 years, hailing from rural background in northern India, with lower socio-economic status, presented with recurrent spontaneous extrusion of copper wires from all of her limbs for the past 1½ years. The patient initially reported pain and development of pustules in the posterior aspect of the left hand which took a long time to heal when an X-ray revealed thin metallic wires in the muscle bulk. These wires were removed by a surgeon, but the problems recurred after a couple of days. Subsequently these wires would be removed every week or two at a clinic in a nearby town, but they would soon recur. The copper wires extracted from the patient surgically would be entrusted to the family members, who would dispose them off near home. The patient and the family members sought treatment at many places in nearby towns but there would be recurrence in a few days. The family members had also taken her to many faith healers for cessation of extrusion of these wires, who told them that she was afflicted by a powerful jinn causing the presence of the wires. Faith healers had suggested rituals which the patient did not follow meticulously. She had also received brief media attention for her symptoms, which she liked and the family members would often talk about it with pride during the interview. The patient presented to our center after she was refused surgery for extraction of wires by local surgeons, who referred her to a tertiary care center. She was admitted in the psychiatry ward for management. In past history, the family members reported that the patient had difficulty with affect regulation since childhood. She would be stubborn and inconsiderate toward younger siblings, would get angry easily, and refuse food. She would refuse to do the delegated household chores, sought attention of others and would go out of the house without informing the family members. Physical examination of the patient revealed multiple scars and wounds bilaterally, in the forearms, arm, thighs and knees. However, no scars or wounds were present in any inaccessible areas like back. On interview the patient was guarded. She appeared tidy and kempt with normal speech, had euthymic affect and no perceptual and thought abnormalities. Higher mental functions were within normal limits. She expressed displeasure on being asked about any psychological stressors and focused primarily on her physical complaints. When asked nonjudgmentally about the possible source of such wires in the body she became verbally aggressive and assumed a challenging stance toward the ward team. Engaging her into a therapeutic relationship was very difficult. She refused psychometric and personality testing and did not cooperate for the same on repeated attempts. X-rays of multiple body areas were obtained [Figures 1 and 2] and a surgery consultation was sought. The surgical team decided against operation as it was considered unnecessary with risk of further tissue scarring, and advised regular dressing of the wounds.

Figure 1

X-rays of hands

Figure 2

X-ray of thigh

The diagnosis of factitious disorder was made due to the presentation of repeated healthcare seeking for metallic wires in the body parts. Malingering was ruled out due to absence of a definite external incentive occurring from the act. Repeat X-rays confirmed the diagnosis as no new wire formation occurred during the ward stay.

The patient became disappointed when surgery was refused and started requesting for discharge. When all attempts to gain confidence of the patient failed, the patient was confronted in a supportive manner in a way that redefines the patient's illness from that of a physical disease to that of psychological distress, and with the assurance that the information will not be communicated to any family member. However, the patient became aggressive, and stopped communicating altogether with the treating team. Family intervention also failed as family members vehemently declined the possibility of the patient inserting the wires herself and were quite insistent that it be due to supernatural powers. Understanding the plurality of the belief system of the family, where they believed that the causation was by “jinn” but the treatment needed was surgical, the family was also allowed to visit faith healers during hospitalisation. Ultimately a therapeutic contract was drafted between the family members, the psychiatry team and the surgical team, whereby it was agreed that all wires from one limb will be removed by surgery, and a soft bandage with tamper protection seal will be made in the same limb. If no new wires developed in the protected limb after a month, family members will come back for psychiatric treatment. Although family members initially agreed, they refused the contract subsequently fearing that the “jinn” will be angered and may cause further damage, and left the hospital against medical advice

DISCUSSION

As in our case, insertion of metallic foreign bodies has been described in patients with factitious disorder. These have included cases wherein needles have been inserted in the joints,[3] metallic objects have been inserted in the wounds,[4] and even sewing needles being inserted into the chest[5] causing pneumothorax. The quest for seeking medical attention may cause significant bodily distress.

Also, difficulty in establishing therapeutic relationship has been documented in patients with factitious disorder and they tend to leave treatment process prematurely[6] as has been in the present case. The case brings forth a situation where the family members ascribe the occurrence of wires to supernatural powers, introducing further complexity in enlisting co-operation of significant others. The case highlights, that inspite of multidisciplinary approach to treatment by a team of psychologist, surgeons and psychiatrist with acceptance of indigenous belief system of family members and letting them visit faith healers, the patient could not be retained in the treatment. In retrospect, we feel the magico-religious belief system of the family members was the most significant barrier to treatment in this case. This case highlights the need for understanding socio-cultural contexts while managing such cases.