Religious stigmata as malingering artifact: Report of a case and review of the literature.

RATIONALE: Artifacts or simulated diseases are self-inflicted conditions caused by various means and for different purposes. Disease simulation can be motivated, among other things, by illegal purposes, to escape from civil duties or prison sentences, for example, or to exploit specific situations in order to receive a range of benefits. In such cases, the simulator is fully aware of his or her actions and intentions. DIAGNOSES, INTERVENTIONS AND OUTCOMES: We report the case of a 42-year-old woman who, for 3 consecutive years, showed religious stigmata on the forehead and on the dorsal surface of hands and feet immediately before Easter. Lesions showed an acute onset, manifested as erosions and ulcerations, and healed a few days after Easter. Stigmata were immediately made public and every year faithful and curious people went in procession to the house of the patient, offering different kinds of gifts. After intervention of the police authority in the early days of the third episode, the patient and her family repented of their actions. Cutaneous lesions healed in few days and similar events did not occur during the following 2 years. LESSONS: Regardless of personal beliefs, the possibility that stigmata could be self-inflicted for illegal or profit purposes should always be considered.

Introduction

The issue about self-inflicted skin lesions (SISL)[ has been critically discussed in a recent position paper of the European Society for Dermatology and Psychiatry. SISL are divided into 2 main groups: the first group is represented by syndromes associated with a denied or hidden pathological behavior, with (malingering) or without (factitious disorders) external incentives; the second group is represented by syndromes associated with a nondenied and nonhidden pathological behavior (compulsive and impulsive disorders). Our case of religious stigmata belongs to the first group of SISL, associated with external incentives and profit purposes.

Case presentation

A 42-year-old woman, originally from a small town in Calabria (South of Italy), showed, for the third consecutive year, cutaneous lesions during Easter holidays. Such lesions appeared every year on the forehead and on the dorsal surface of hands and feet (Figs. 1–3). Lesions suddenly become manifest on Holy Monday and healed spontaneously within a few weeks. These alleged stigmata were made public, causing a steady flow of devotees and curious onlookers to the patient's house, offering gifts of various kinds. The year before the local ecclesiastical and police authorities had become interested in the singular event, but legal or religious actions were not undertaken as the stigmata had rapidly disappeared some days after Easter.

Figure 1

Irregularly round erythematous-ulcerated lesion on hands dorsum.

Figure 3

Multiple erosions following the hairline. Notice the consistent diameter and spacing.

Similar elements involving symmetrically feet dorsum.

The patient came to our attention on the third day of clinical manifestations of the third year, accompanied by her general practitioner. At physical examination, a dozen mildly exudative erosions were present on the forehead, along the hairline, measuring 0.5 cm in diameter, regularly spaced 1 cm from each other. On the dorsal surface of the hands, halfway between carpus and metacarpus, an irregularly round erythematous-ulcerated lesion, swollen and moderately bleeding, was noticeable. The left-hand lesion was larger and more infiltrated. Similar erythematous-ulcerated elements (measuring 1.5 × 1 cm) involved symmetrically the central dorsum of the feet. No lesions were present on wrists, palms, soles, or elsewhere.

During consultation the patient was silent; she gave no specifics on time and mode of onset of lesions, and did not complain of any subjective symptoms. She also showed a wary and absent attitude, occasionally speaking in a detached manner about her religious faith. The psychiatric consultation, which had been refused at the time of the previous episodes, described a hysterical personality with attention-seeking behavior and excessive need for approval of her family. Moreover, her general practitioner reported us that the intervention of the police, the day before, had stopped the people pilgrimage to the house and had changed the attitude of the patient and her relatives; they showed fear and discretion, diminished the episode, and argued that most likely it would not have occurred again. The patient refused hospitalization but promised she would return for follow-up, but actually never showed up. Her general practitioner later reported us that lesions were already healing 3 days after our consultation, with complete healing after 3 weeks. Stigmata no longer recurred during Easter holidays on the following 2 years. The time-related milestones concerning the case are summarized in Table 1.

Table 1

Time-related milestones of the presented case.

Discussion

Different causes and purposes underlie SISL associated with denied or hidden pathological behaviors. Most of the time disease simulations are due to psychiatric problems, such as psychosis and personality disorders. The intrinsic motive of these lesions is a request for family and society attention, as a reaction to difficulties or adverse situations with involuntary cutaneous somatization, masochism with physical pain, and guilt or spiritual responses. As showed by the literature,[ cases of unconscious simulators, mainly women with chronic cutaneous diseases, belong to this group. Such patients always deny self-induced illness and seem unconcerned about the disease.

However, disease simulation can be motivated by illegal purposes, for example, to escape from specific types of duties (military duty, draft), to avoid detention, and to acquire benefits in an occupational environment (sickness leave extension, recognition as an occupational disease, higher class of disability). In these cases, simulators are aware of their actions and purposes.[ In our long-term practice, we have directly observed 46 patients affected by SISL with illegal purposes in occupational environments. These patients, overwhelmingly male, are affected by morphologically bizarre lesions, more so than those provoked by unaware pathomimia patients. Besides hands and forearms, unusual areas are involved and the most peculiar and unlikely causative agents are implicated.[ The certainty of conscious simulation, suspected by a positive history for job uneasiness, by lesions’ particular morphology, and by repeated diagnostic tests’ negativity, came from patients’ admission after repeated friendly and confidential consultations.

Herein we report a rare case of religious stigmata. Affected sites, morphology, acute onset, and duration led to suspicion of an artificially induced disease. As a matter of fact, in our case hands and feet dorsum were affected without the involvement of palms and soles. Moreover, in religious texts, the originally described sites of upper limb involvement are the wrist and not the hands. Stigmata were also immediately made public by the patient and her family in this case. Our hypothesis was indirectly confirmed by quick resolution of the dermatosis and no recurrence of the lesions during the following 2 years. Moreover, the patient's absent attitude, as though she was living in her inner world, could also underlie a hysterical personality that could be easily exploited by her relatives. This was confirmed by the psychiatric consultation. Skin lesions were probably caused by metal objects, by a mechanism of scraping (on the forehead), or overheating (most likely on the dorsal surface of hands and feet); however, the use of caustic chemicals cannot be excluded.

Differential diagnosis with dermatologic conditions, when singularly considering a lesion among those affecting hands and feet, included contact dermatitis, mycosis, and infective and noninfective granulomatosis; contact dermatitis to a hair accessory such as a frontlet or headband (perhaps with spaced metallic inserts) could have been responsible for the hairline manifestations. However, when assessing the clinical presentation as a whole, together with patient history, we believe that a differential diagnosis is not needed, as there is no single dermatologic condition that could justify the morphology, localization, symmetry, and evolution of such lesions.

To our knowledge, the topic of malingering religious stigmatization has rarely been treated in the medical literature. Kluger and Cribier thoroughly discussed the subject in light of modern medicine,[ and a few other cases similar to our own have been reported. In particular, a case of a 42-year-old man with a 5-month history of palmar ulcers at different healing stages has been described.[ During consultation the patient theatrically explained how he had been blessed by God with Christ's stigmata. However, the patient's partner revealed that such lesions were autoinflicted with a knife. Another case of a 23-year-old male patient with stigmata on the hands has been reported in a small town of Sicily. He showed some erosion on the dorsal surface of hands, and small bullous lesions arranged to create the word “pax” on the left palm. Previously, other odd events, promoted as divine, had occurred in the house of the young man (weeping of an effigy depicting the Madonna, weeping and bleeding of a Jesus Christ's picture, lugubrious sounds at night). Accordingly, a prayer hall in the garage of the house had been set up, complete of an altar and iconography of the Stations of the Cross. A flock of people brought gifts and pledges. The patient later turned out to be hysterical, with an easily swayed personality, and easily manipulated by relatives and acquaintances for profit aim. The intervention of the law authority stopped the lucrative affair.[ Early and Lifschutz observed a 10-year-old black Baptist girl during a 3-week period immediately preceding Easter Sunday.[ Psychiatric examination did not evidence psychological alterations except an indifference toward bleeding and auditory hallucinations of religious nature.

The issue concerning religious stigmata has always been of particular interest,[ given the complexity of interpretation and discussion. Stigmatized people present bleeding lesions in 5 distinct body sites: hands and feet because of nails (not on wrists, as evidenced by the Shroud of Turin), the ribs in relation to the thrust of the spear, the back (site of flagellation and pressure of the cross), and the forehead because of the crown of thorns. These are all known signs of the passion of Christ. Besides the visible ones, invisible stigmata, such as intense pain affecting the above-mentioned sites, should be considered. The latter could precede or represent the outcome of visible stigmata, but may also be isolated, without any means to ascertain their presence.[

Saint Francis of Assisi (1182–1226) was the first person to receive stigmata, unless Saint Paul implied that he had them when he wrote, “I bear the marks of the Lord Jesus in my body.”[ Saint Francis developed the stigmata during an ecstatic vision in 1224[; these were described 2 years later in his first biography.[ The Saint Francis's stigmata were immediately acknowledged by the papacy, despite minor opposition among the clergy, which accused the Saint of heresy.[ Kluger and Cribier reported 3 other cases of autoinflicted stigmata, which dated back to the XIII century.[ During the following centuries, >300 cases of stigmatization were described, most of which were fervent Roman Catholics.[ In 1908, Imbert-Gourbeyre found that of the 321 people with stigmata described afterwards Saint Francis, 41 were men and 280 were women during their reproductive years.[

They mainly came from Italy (229 cases), and then France, Spain, Germany, Belgium, Portugal, Switzerland, Holland, Hungary, and Peru.

Among the most famous stigmatized of the XIX century, Louise Lateam (1850–1883) stands out, a Belgian girl who bled every Friday except for 2 from 1868 to 1883; she was visited by various eminent Belgian doctors.[ Also Thérese Neumann (1898–1962), a German peasant girl, developed the stigmata in 1926 during an ecstatic vision; her hands and feet bled regularly on Fridays until her death.[ Finally Saint Pio of Petralcina (1887–1968) had his hands bleeding continually from 1918; however, the lesions faded at the time of his death.[

As shown by the above-mentioned data, stigmata have been manifesting for centuries in the context of Catholic Europe. In the USA, similar episodes were unheard of until the spreading of Catholicism.[ In the XX century, stigmata were reported among other religious contexts (e.g., Muslim ascetics developed lesions in the same sites of injuries endured by the Prophet in his battles).[ Cases in America and Australia were also reported.[ Kluger and Cribier in 2013 compiled a list of the most praised stigmatized. However, few people with stigmata have been beatified or canonized, and the Catholic Church does not allow for mandatory association between stigmata and sanctity, declining the conventional belief that stigmata represent a supernatural event, and are granted by God as a sign of piety. A proclaim by Pope Urban VIII instructs Catholic writers to attribute a purely human nature to this phenomenon.[

The question of the etiological interpretation of stigmata remains controversial; as a matter of fact, there is no reason to presume that all stigmata should have the same etiology. Excluding ascertained cases of voluntary self-harm for malingering, as our case and few others (Table 2), stigmatization is generally referred to as unconscious self-harm during hysteria, autosuggestion, and hypnotism; these are all characteristic factors that can be associated with “mystical delirium.”[

Table 2

Cases of religious stigmata due to self-harm for malingering purposes.

According to various authors, however, cases of “inexplicable” stigmata with spontaneous onset and absence of external triggering factors have been described.[ Discrete exceptional clinical entities, not fully understood in their pathogenesis, could possibly constitute the underlying condition to some of these cases, for example, autoerythrocyte sensitization syndrome (Gardner–Diamond syndrome, or psychogenic purpura), vicarious menstruation (various organs possibly affected), hematidrosis (blood cells in sweat), and hemolacria (secondary to ophthalmic conditions).[ Such conditions usually affect young women, although often presenting variable features of psychosomatic personality, and are certainly considered “natural.”

Given all the earlier discussion, religious stigmata are progressively shifting from medieval mysteries to distinct psychiatric and psychosomatic disorders. In studying stigmata, however, we should always consider the possibility that they could be self-inflicted for illegal and/or profit purposes.

Women of catholic faith are mainly affected. In the context of a state of trance, bleeding lesions appear, overlapping those suffered by Jesus Christ, on hands and feet (not on wrists, as evidenced by the Shroud of Turin in relation to the spikes), sometimes on the ribs (in relation to the thrust of the spear), or on the back (site of flagellation), and less often on the forehead (in relation to the crown of thorns) or on the shoulders (in relation to the pressure areas of the cross).

In conclusion, regardless of personal beliefs, we should always consider the possibility that stigmata, whose study “does typify the fascinating relation between physical, psychological and spiritual phenomena,” could be self-inflicted for illegal and/or profit purposes.