Factitious Decompression?

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ckenedi

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Hi,

I'm putting together a review article on factitious decompression illness for an international meeting after having been involved in the treatment of a confirmed factitious patient. I've completed a formal systematic review of the medical literature and only found 3 published cases in medline/pubmed.

As a non-dive physician with previous research in factitious disorder I was quite surprised. Are factitious presentations that rare? Or are they recognized by the underwater medicine community and not considered worth noting? Or is there another source of communication about cases?

Thank you,

Chris Kenedi
 
Hi,

I'm putting together a review article on factitious decompression illness for an international meeting after having been involved in the treatment of a confirmed factitious patient. I've completed a formal systematic review of the medical literature and only found 3 published cases in medline/pubmed.

(bold mine)

I'm curious how you determine this?

Finding actual bubbles would certainly confirm it's existence, but does the absence of observable bubbles actually confirm it's not real?

If someone complains of symptoms, receives treatment, and then stops complaining how would you know whether it was "real" or not?

Or for that matter, how can you tell the difference between someone who is faking DCS, with someone who isn't sure, but believes they have the symptoms?

Are factitious presentations that rare? Or are they recognized by the underwater medicine community and not considered worth noting? Or is there another source of communication about cases?

Considering that treatment will generally ruin a vacation, I have a really hard time imagining anybody wanting to fake DCS. In fact, it tends to go the other way, with people who quite plainly have DCS, attributing symptoms to all sorts of other things.

flots.
 
I believe they are rare --factitious disorders in Decompression Sickness Syndrome-- because most of us who have suffered "ordinary type I DCS" are usually in denial of initial real symptoms --which can present as vague or diffuse immediately post-dive on the surface (i.e. "not feeling right"; slight nausea; mild muscle-skeletal joint pain), but then develop into acute signs & symptoms over time (i.g. shortness of breath; sharp throbbing joint pain) before admitting the problem and seeking treatment.

Interestingly though, you might get such socially factitious behavior with a diver who is exhibiting real signs & symptoms of DCS, if the patient presents at a medical clinic in which none of the attending physicians have any experience in Emergency Hyperbaric Medicine, and the patient is progressing from latent or nascent symptomatology to acute physical distress over an hour to several hours time without treatment.

. . .In sum, realize that you, as a diver, can be your own best advocate if you think you have developed DCS. By having organized information for the ER physician, you make his job easier. By KNOWING you should be on oxygen and politely but adamantly insisting on it, you aid your own treatment. If you have DAN in your pocket, you bring another resource to bear. And if you have done your homework, and know where hyperbaric treatment is available, you can shorten the time course to effective therapy.

DCS: Surviving the Emergency Room
 
(bold mine)

I'm curious how you determine this?

Finding actual bubbles would certainly confirm it's existence, but does the absence of observable bubbles actually confirm it's not real?

If someone complains of symptoms, receives treatment, and then stops complaining how would you know whether it was "real" or not?

Or for that matter, how can you tell the difference between someone who is faking DCS, with someone who isn't sure, but believes they have the symptoms?



Considering that treatment will generally ruin a vacation, I have a really hard time imagining anybody wanting to fake DCS. In fact, it tends to go the other way, with people who quite plainly have DCS, attributing symptoms to all sorts of other things.

flots.


In this case the patient's symptoms were vague, but consistent with possible AGE. He was treated at a hyperbaric center and did not improve. His behavior was severely unusual for a number of reasons and noted by staff at the Hyperbaric facility as well as the referring facility. He told an extraordinary story. However none of this generated a diagnosis of factitious disorder, although treatment personnel were concerned that something was wrong.

The same patient was confirmed to be factitious based on a subsequent medical admission for an unrelated reason 3 weeks later, under a different name at a different hospital. He was identified by a doctor who had treated him at a 3rd, unrelated hospital for a completely different condition under a different name. A medical investigation (test) in fact showed that he had fabricated the laboratory result (using an identified toxic substance) which led to him being admitted in that case.

Based on this, a retrospective review of records came up with a series of identities that had a clear connection (were the same person based on physical description, demographic features and biomedical data). The diving story came up when the 3rd team followed the paper trail and with the retrospectoscope, the unusual dive story fit the rest of his factitious behavior. Closer investigation confirmed that he was elsewhere during the supposed dive trip and also showed that features of his story were patently false (they involved people who were supposedly deceased, who were in fact living).

So the dive medicine team did the absolute right thing by not second guessing; it was only later that the nature of the presentation became clear. We presume this person has presented to other centres in Australasia and possibly North America (where he says he did his dive training, most likely true).

Several articles in the peer-reviewed medical literature on factitious disorder have suggested the incidence to be between 3% and 9% of medical/surgical admissions. (Note that factitious disorder is a specific diagnosis with specific criteria, where people fabricate disease to obtain "the sick role." It is NOT the same as malingering where someone fabricates disease (like a neck injury) for legal/financial reasons (i.e. an insurance settlement). People with factitious disorder are often in real distress; patients with the disorder who have been confronted and who have admitted to the behavior report having a real sense of pain/distress that they couldn't express in words, so they engaged in behavior to seek care/treatment that they felt they truly needed, even if it was not for their actual distress/pain. It's a complex issue and the people who suffer from it have complex reasoning.

Regardless, it is universally seen across every other field of medicine without exception. So It's quite interesting that it is not reported in the underwater/dive medicine literature.
 
What you are saying about the patient also sounds very similar to cases of munchausen's syndrome. I think I spelled that right.
 
. . .
Based on this, a retrospective review of records came up with a series of identities that had a clear connection (were the same person based on physical description, demographic features and biomedical data). The diving story came up when the 3rd team followed the paper trail and with the retrospectoscope, the unusual dive story fit the rest of his factitious behavior. Closer investigation confirmed that he was elsewhere during the supposed dive trip and also showed that features of his story were patently false (they involved people who were supposedly deceased, who were in fact living).

That's all very weird and fascinating!

Regardless, it is universally seen across every other field of medicine without exception. So It's quite interesting that it is not reported in the underwater/dive medicine literature.

Denial is very common. This is the first time I've heard of anybody faking symptoms, but is very interesting. Thanks for posting.

Does the guy get a footnote with his name in a medical text somewhere for being the first? :cool:

flots.
 
To deliberately create a DCS/AGE condition secondary to a Factitious Disorder can result in painful disabling injury, paralysis, or even suicidal death. Therefore IMO, you won't see many cases of these unfortunate individuals motivating themselves to use this mode of self-injurious, attention seeking behavior.
 
What you are saying about the patient also sounds very similar to cases of munchausen's syndrome. I think I spelled that right.

Hi Nielsent,

The family of psychiatric disorders involving the deliberate production, feigning or exaggeration of symptoms/signs (e.g., Factitious Disorder, Somatoform Disorder, Malingering) can be quite confusing to the lay person.

To put it simply, a Factitious Disorder involves the intentional production or feigning of physical or psychological signs or symptoms. The motivation for the behavior is to assume the sick role & external incentives for the behavior (such as economic gain, avoiding legal responsibility, or improving physical well-being) are absent. The elicitation of attention, compassion & the like is what drives these behaviors. Munchausen Syndrome is an older term that is now subsumed under the Factitious Disorder classification.

These patients have a very long history in the annals of medicine and I can assure you that they can be quite challenging, troublesome & trying, not mention expensive to the health care system, to diagnose & treat.

Regards,

DocVikingo

---------- Post added ----------

Considering that treatment will generally ruin a vacation, I have a really hard time imagining anybody wanting to fake DCS.flots.

Hi flots am,

Yes, I suspect that you do. However, we're talking potentially very serious psychiatric disease here and patients in this general classification are known to ruin far more important situations than dive vacations, such as careers, marriages & their health. Self-inflicted wounds, self-induced disease & indirect self-harm from medical & surgical treatment occasioned by feigned symptoms are frequent in certain cases of Factitious Disorder.

Regards,

DocVikingo

---------- Post added ----------

To deliberately create a DCS/AGE condition secondary to a Factitious Disorder can result in painful disabling injury, paralysis, or even suicidal death. Therefore IMO, you won't see many cases of these unfortunate individuals motivating themselves to use this mode of self-injurious, attention seeking behavior.

Hey Kev,

Obtaining meaningful estimates of the incidence & prevalence of Factitious Disorder is complicated by the dishonesty inherent in the condition, not to mention that these folks tend to seek treatment from many different doctors & facilities.

But, you are correct in that it does appear to be rare in the general population (almost certainly <0.5%). Within large general hospital populations, ~1% of patients are diagnosed as such upon psychiatric consultation.

However, I can show you case studies where patients diagnosed with Factitious Disorder intentionally poisoned themselves with toxic chemicals/medications; infected themselves with pathogens; punctured their ear drum, eye & even skull; interfered with/exacerbated medical conditions to prevent recovery; and ignored a bona fide medical issue until it become very grave.

Regards,

DocVikingo
 
Sheer speculation, but a lower rate of factitious DCS (and most disorders) might be expected among divers simply because we are a population somewhat healthier than the norm. We&#8217;re screened before training; and even after training, significant health issues reduce the likelihood that we&#8217;ll dive.
 
Finding actual bubbles would certainly confirm it's existence, but does the absence of observable bubbles actually confirm it's not real?

Not at all. It's extremely rare to find an in situ bubble in DCS, even with radiologic studies.

If someone complains of symptoms, receives treatment, and then stops complaining how would you know whether it was "real" or not?

You wouldn't necessarily be able to tell. I haven't seen factitious DCS, but I've seen factitious disorder in other cases and it's not always apparent during a short course of treatment.

DCS is a diagnosis based on clinical presentation and dive history, and reinforced by the patient's response to hyperbaric treatment. There are no radiologic or laboratory studies that confirm it or rule it out, so it wouldn't be hard to fake it if you had the knowledge. DocV knows a heck of a lot more about this than I do, but some factitious patients can be pretty sophisticated so fakery would potentially be very difficult to detect, especially in an acute setting. I'd imagine that only the egregious cases like Dr. Kenedi is working with would draw any type of attention.
 
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