The Girl Shedding Glass Pieces from Her Body Parts: Unfolding the Mystery Behind Dermatitis Artefacta.

Patients presenting with unusual symptoms are uncommon. Unusual symptoms often catch the attention of the public including the health professionals. Atypicality in the symptoms is usually seen in patients with factitious disorder. In patients with factitious disorder, there occurs conscious production of symptoms with an unconscious motive, irrespective of the fact whether they are ill or not. Self-inflicted injuries to skin often give rise to typical skin lesions known as dermatitis artefacta, which many a times simulate other dermatological conditions. Patients with factitious disorder often have a narrow line of demarcation from malingering. We present a case of an adolescent girl presenting with spontaneous extrusion of glass pieces from her body parts with focus on diagnostic dilemma and management.

What was known?

Dermatitis artefacta is common in females in their adolescence to early adulthood

The pursuit of seeking medical attention may cause significant bodily distress, which might attribute to self-inflicted injury and development of dermatitis artefacta

The presentation is often characterized by nonhealing skin lesions, may be in the form of abrasions, scratching, exfoliation, cutting, or burning.

Introduction

The term “Factitious” means artificial or false. Factitious disorder can present with different type of symptoms which often mystify the physicians. Physicians may get frustrated and feel that the patient is inducing the symptoms, which may lead to the development of countertransference causing problem in treatment of these patients. Patients have been found to produce weird symptoms, including nonhealing wounds caused by mouthwash and by insertion of needles in finger joints among several other symptoms.[1] Medical probability of symptoms or inexplicable findings in the laboratory data[2] lead to suspicion in the diagnosis. Factitious disorder is separated from malingering by the motive for feigning of symptoms. A person, who is malingering is motivated to feign symptoms for some material gain such as monetary compensation, excuse from work, avoiding punishment, or getting disability benefits whereas an individual with factitious disorder feigns illness to assume a sick role, not for secondary gain such as monetary compensation or avoiding of obligations. Hence, it is considered as an abnormal illness behavior of conscious symptom exacerbation.[3] Their motives are to seek attention that comes from being a patient or being ill. The exact etiology of factitious disorder is not known but the two factors associated with most cases of factitious disorder are an affinity for the medical system and poor and maladaptive coping skills.[4]

Case Report

A 16-year-old high-school dropout, unmarried girl belonging to a joint family of lower socioeconomic status from rural background was referred from the Department of Surgery for the evaluation of her problem of recurrent spontaneous release of glass pieces from her body parts (upper and lower limbs) for the past 1 year. The patient had initially reported pain and development of abrasions due to the extrusion of glass pieces from her limbs in succession, which started from the left foot, and then from the left hand and forearm followed by the right foot and hand. As informed by the family members, every day, about 10–15 glass pieces of size ranging up to approximately 6 mm × 3 mm were taken out from patient's body parts by a doctor in the village. The glass pieces extracted from the patient would be given to the family members. Patient and family members sought treatment at many places in nearby towns. As per the patient and her family members, there was cessation in the release of glass pieces for about 3 months, after she had received some homeopathic treatment. However, when homeopathic treatment was stopped, again her symptoms reappeared. Family members had also visited many faith healers for her problems.

Patient and her family members denied about any obvious psychosocial stressors. Premorbid temperament did not reveal any abnormality.

The patient was initially guarded, so attempts were made to engage her in an interview by establishing rapport. She was sent to the recreational therapist regularly. Sessions were taken by the clinical psychologist. Later during the sessions, she had expressed about some interpersonal conflicts with her elder brother's wife. She was also disappointed by the denial of her marriage proposal in an influential family of her village. Physical examination of the patient revealed multiple abrasion of the skin of both hands and feet, predominantly on the left side suggestive of dermatitis artefacta [Figure 1]. On palpation of her forearm, some impacted glass pieces were felt under the abraded skin and patient used to take out the impacted glass pieces with her own hand. However, no abrasions were present in any inaccessible areas of the body or face. Her hematological investigations were within normal limits, except hemoglobin level of 10.6 g%.

Figure 1

Multiple abrasion of the skin of hands (prominent in left hand than right one) and feet suggestive of dermatitis artefacta

X-ray of the upper and lower limbs revealed radio-opaque foreign bodies (glass pieces) underneath the skin of her left forearm and at the heel of left foot [Figure 2]. Psychometric assessment (Rorschach inkblot test)[5] revealed intact human empathy, increased form-based responses indicative of rigidity and concrete thinking. The presence of dysphoric emotion, anxiety and negative self-worth, and feelings of inferiority were also evident from the psychometric assessment. A wide range of contact indicated that she showed wide range of interests in her environment. Assessment on Structured Clinical Interview for DSM-IV Axis II Personality Disorders[6] for personality disorder was noncontributory.

Figure 2

X-ray showing radio-opaque foreign bodies (glass pieces) underneath the skin of her left forearm and at the heel of her left foot

During ward behavior observation, once, it was found that she was hiding something by putting her hands across her chest. During physical examination, glass pieces were recovered from patient's clothes.

The diagnosis of factitious disorder was made due to the presentation of repeated healthcare seeking for glass pieces extruding from the body parts. Malingering was ruled out due to the absence of definite external motive/incentive. Old, impacted glass pieces were removed surgically from patient's body. Patient and family members were psycho-educated about the nature of illness. The patient stopped reporting the release of glass pieces from her body parts and remained symptom free for three months following discharge.

One pharmacist from the patient's village had maintained her fear by suggesting that this clinical presentation might be possible in some rare clinical disorder which caused lot of difficulty in convincing the patient and her family members about it, which was subsequently taken up in the sessions and was addressed by the treating team.

Discussion

The self-inflicted trauma in patients with factitious disorder may have many adverse consequences of varied severity. Sharp object insertion is associated with severe sequel. Evidence depicts the deadliest consequences of insertion of sharp foreign bodies causing pneumothorax, empyema, injury to joints, and wounds.[789]

The term “Dermatitis artefacta” was interchangeably used with the term “Factitial Dermatitis.”[10] It is more common in females than in males with peak age of presentation during second to the third decade of life.[10] In our case, dermatitis artefacta was due to self-inflicted repeated trauma of the skin of palms and soles by sharp glass pieces. The self-inflicted trauma was severe enough to cause retention of foreign bodies in the subcutaneous tissues of volar forearm. In this patient, the severity of harm was not much but the amount of stress her family members encountered was enormous. The pursuit of seeking medical attention may cause significant bodily distress. Early life adversities including abuse and neglect during childhood increase the risk to develop factitious disorders.[4]

Hospitalization results in an escape from traumatic home situations. Patients get more attention from the family members and a number of other care providers (doctors, nurses, and hospital workers). In case of our patient, predominant involvement of the left foot and left hand also gave the clue that these sites were more approachable for a right-handed person to inflict lesions. The thick skin of sole and palm also make them preferred sites for inserting sharp glass pieces as it is relatively less painful. Management involves avoiding direct confrontation (as there is possibility of loss of self-repute), which was the focus in our treatment.

Poor information and magico-religious beliefs influence the management and need to be dealt with cautiously. In our patient's case also, her family members’ beliefs and attitude towards her illness resorted to faith healing. Lack of proper information in traditional healers and even general practitioners as well as the myths and attitudes associated with such type of symptoms in the society leads to ambivalence among family members. It facilitates the maintenance of symptoms by their feedback and causes an inadvertent delay in proper treatment of the patient at a proper facility at the right time. For atypical or medically unexplained symptoms encountered in clinical practice, psychological causation should be kept in mind.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

What is new?

The clinical presentation of shedding of glass pieces is unique and is not reported in the literature before.