Gaslighting in alleged assault ascertained as Munchausen syndrome transcending to malingering in highly counterintuitive self inflicted acid burns

A factitious disorder leading to the self-infliction of highly counter-intuitive burns was diagnosed in a middle-aged female. The injuries were otherwise alleged to have been sustained by assault inflicted upon her by an unknown person. The case was diagnosed by medico-legal interpretation of injuries, in spite of a highly deceptive and concocted history by the patient and her husband. The entity was unique in being associated with magnificent primary, secondary and tertiary gains. The exploitation of the morbid sequel to malinger by the patient, and the involvement of the husband for the prolongation of the illness of his wife for financial gains as gaslighting was highly unusual. The self-infliction of injuries over hands is seen in factitious disorder. However, a combination of a guarded self-immersion of the hands and feet in a corrosive by an illiterate female, followed by malingering to earn livelihood is unprecedented in factitious disorders. The delayed presentation which required amputation of all the limbs to save the life of the patient is a glaring highlight of this case.

Administration of 5-HT-1B agonist ameliorates pseudodementia induced by depression in rats

Major depressive disorder (MDD) is the leading cause of memory impairment in general population. The serotonin hypothesis provides a target model for the treatment of depression and depression-associated memory loss. 5-HT-1B receptor is suggested as a potential candidate in the pathophysiology of depressive illness. Dysfunction of 5-HT-1B receptors has been observed previously in depressive patients. Zolmitriptan, 5-HT-1B agonist is clinically recommended for the treatment of migraine. However, in present study this drug was tested as a potential treatment for depression and associated memory loss by altering the serotonergic function at receptor level. Rats (n=24) were equally divided into unstressed and stressed groups. Depression was induced by 19 days of restraint stress for 4 h which was followed by forced swim test and pattern separation test to assess depressive symptoms and memory impairment, respectively. The initial sign of depression-associated memory loss involves impaired pattern separation which is regarded as pseudodementia. In this study stressed rats showed depression- and pseudodementia-like symptoms. After the induction of depression, rats were treated with zolmitriptan at a dose of 0.3 mg/kg which resulted in a significant attenuation of depression and depression-associated memory impairment. Results are discussed with reference to the modulation of function of 5-HT-1B receptor following the administration of exogenous agonist.

Uncommon and/or bizarre features of dementia

This study aimed at describing uncommon or bizarre symptoms observed in patients suffering from dementia. Medline and Google scholar searches were conducted for relevant articles, chapters, and books published since 1967. Search terms used included uncommon presentation, behavioural and psychological symptoms, dementia, Alzheimer's disease, and fronto-temporal dementia. Publications found through this indexed search were reviewed for further relevant references. The uncommon symptoms are described as case-reports and there are no systematic investigations. Bizarre behaviours arising late in life should be thoroughly investigated as symptoms of dementia.

Pseudodementia caused by severe depression

The diagnosis of pseudodementia may be difficult in a patient with a history of major depressive disorder. Clinical case history. A 70-year-old man with a history of major depressive disorder, in remission for 3 years, presented with confusion, agitation and cognitive disorder. The differential diagnosis included depression with pseudodementia, drug-induced dementia or Alzheimer disease. Mild cognitive improvement was noted after discontinuation of simvastatin. After 9 months of treatment for depression, the patient had remission that was sustained for >1 year, with mild residual difficulty remembering words of songs. The differential diagnosis of dementia includes major depressive disorder and adverse events from simvastatin.

An approach to the patient with multiple physical symptoms or chronic disease

Doctors diagnose and treat disease; illness is the experience of, and response to, a disease by patients and the people in their lives. Discrepancies between disease and illness (eg, adjustment to the sick role, treatment-related difficulties, denial of medical illness, and psychiatric comorbidity) are prevalent, as are somatoform disorders and other conditions in which patients are invested in being understood as medically ill. This article reviews suggestions for physicians' responses to these patients and their dilemmas.

Ganser Symptoms in a Case of Frontal-Temporal Lobe Dementia: Is There a Common Neural Substrate?

Neuropsychological testing was completed in a patient who showed cognitive decline of mental functions, unusual answers to questions, and other characteristics of what has typically been described in the literature as the "Ganser Syndrome." Clear evidence of malingering on a memory test seemed to confirm that this patient was exaggerating deficits for psychiatric reasons or secondary gain, yet the patient showed evidence of mild organic impairment on MRI and continued to deteriorate in cognitive functions and basic self-care. Although an initial SPECT scan had suggested a pattern inconsistent with dementia, a second scan showed frontal-temporal perfusion deficits. Based on this scan and the clinical picture of progressive deterioration, a diagnosis of frontal-temporal lobe dementia was made. This case illustrates that the seemingly deliberate selection of incorrect responses may occur in the early stages of an organic dementia, and that a diagnosis of frontal-temporal lobe dementia should be considered in cases where symptoms appear to be psychiatric or nonorganic. The case further raises the question of whether the reported symptoms of Ganser Syndrome may be accounted for by frontal-temporal lobe dysfunction, since there appears to be some overlap between symptoms of Ganser Syndrome and frontal-temporal lobe dementia. It is also important to note that many reported cases of Ganser Syndrome had a history of head injury.

Self-induced skin lesions: a review of dermatitis artefacta

Psychocutaneous conditions are difficult to diagnose and a challenge to treat. Clinical manifestations can be caused by diverse and creative methods from garlic to deodorant. This review discusses the literature on dermatitis artefacta (DA). Although the overall incidence of DA is not known, the importance is emphasized by a strong association with borderline personality disorder (BPD) and dissociation disorders as well as a prevalence of 33% in patients diagnosed with anorexia and bulimia. Furthermore, DA is frustrating for physicians and family members, with a differential diagnosis that includes severely morbid medical conditions. Thus, recognizing and correctly diagnosing DA is critical to avert unnecessary tests, treatments, and frustrations, ultimately allowing for more efficient management and better healing.

[Usefulness of cognitive plasticity evaluation in the differential diagnosis of cognitive impairment and depression-induced pseudo-dementia]

INTRODUCTION

A major challenge for gerontological research is to differentiate adequately between old adults with poor performance on cognitive tasks due to depression, and those who present cognitive impairment associated with dementia. In view of the fact that cognitive plasticity has already proved to be efficient in the diagnosis of age-associated cognitive impairment, mild cognitive impairment and dementia, the objective of this study is to investigate the possibility that it may also prove useful in the differential diagnosis of these two disorders.

MATERIALS AND METHODS

A total of 50 old adults participated in the study. These completed the Positions Test (PT) and the Auditory Verbal Learning Test of Learning Potential (AVLT-LP) as measures of cognitive plasticity. Participants also undertook the Spanish version of Mini Mental State (MEC), Life Satisfaction Questionnaire (LSQ) and Geriatric Depression Scale (GDS). Socio-demographic data were also collected.

RESULTS

With regard to cognitive plasticity, depressed old adults do not differ from those without depression. On the other hand, old adults with cognitive impairment present less cognitive plasticity than those without cognitive impairment.

CONCLUSION

Cognitive plasticity appears to be a relevant variable in the differentiation between old people with low cognitive performance due to depression and old people with cognitive impairment.

Dermatitis artefacta in a patient with paranoid syndrome

It is well recognized that psychosomatic factors play an important role in many skin diseases. Dermatitis artefacta coexists with quite an extensive number of psychopathologic conditions. In women, it is regarded as a ''cry for help'', especially when the patient is faced with psychosocial stressors. We present the case of a 40-year-old woman with long lasting self-inflicted excoriations and ulcerations of the skin located within easy reach of her hands. We discuss the reasons for such behavior and the possibilities of dermatological and general interventions.

Recurrent Subcutaneous Emphysema of the Face

In the neck or face, there are different causes for subcutaneous emphysema such as injury to the sinuses, the hypopharynx, the laryngotracheal complex, the pulmonary parenchyma, the esophagus or the presence of gas-forming organisms. However, factitious subcutaneous emphysema, a rare cause, must be considered in the differential diagnosis. In this clinical report, we discuss a 20-year-old girl who was under follow-up because of recurrent subcutaneous emphysema of the face and periorbital area. After 2 years of work-ups, including a period of close observation in the intensive care unit, self air injection by syringe was found as the cause of recurrent subcutaneous emphysema of the face, and the patient was labeled as having factitious recurrent subcutaneous emphysema. Therefore, when a patient presents with unexplained recurrent subcutaneous emphysema, one should suspect self-infliction and examine for puncture marks.

Factitious buccal lesion secondary to bruxism in a child with cerebral palsy

Children with cerebral palsy are at greater risk of a whole range of oral conditions than their peers. These include bruxism (tooth grinding), oral skill dysfunction, gross malocclusion due to effects of the abnormal orofacial muscle tone on tooth eruption, drooling of saliva, and poor oral hygiene. A challenging case of a painful buccal lesion in a 2 year old girl with cerebral palsy (CP) that did not respond to antifungal, antiviral or antibiotic treatment is presented as a factitious lesion. The recognition and significance of self-injurious behaviour and factitious lesions in children are discussed.

Factitious disorder and malingering in adolescent girls: case series and literature review

Six cases of factitious disease and malingering in pediatric patients referred to an infectious diseases practice in a tertiary care children's hospital are described, and implications for general clinical practice are reviewed. All patients were girls aged 9-15 years. Two patients were malingering with the secondary gain of avoiding attendance at school. The other 4 patients presented with factitious illness without clear link to secondary gain, but rather for a psychological purpose. Three of the subjects admitted to self-induced or feigned illness. The 2 patients diagnosed with malingering did very well with early parental support, psychotherapy, and attention paid to school difficulties. The outcomes of the others with underlying psychological conflicts were less resolved. Factitious disorders and malingering occur in the pediatric population. A high index of suspicion is needed for prompt diagnosis and care.

Syndrome pseudo-démentiel révélateur d’une fistule artério-veineuse durale

We describe a case of a 70-Year-old man who presented subacute pseudo-dementia due to a dural fistula. Neurological assessment and the reversibility of the symptoms after embolization support the originality of this observation.

Corneal toxicity: the epithelium and stroma in iatrogenic and factitious disease

Corneal toxicity is caused by chemical trauma and by iatrogenic and factitious disease, which are often overlooked, and which are reviewed here. The clinical signs of iatrogenic disease are usually nonspecific and identical to those resulting from other causes of surface disease. Factitious disease is either the result of mechanical trauma or the abuse of toxic eye drops. One epidemiological study, in a tertiary setting, identified 13% of keratoconjunctivitis cases as iatrogenic. Healing was prolonged taking 7-93 (median 28.5) days. Pathogenic mechanisms vary widely with different drugs and include subclinical scarring, pseudopemphigoid, drug-induced ocular cicatricial pemphigoid, and toxic follicular reactions. There is little readily available data either on the probability of the development of adverse reactions or for the comparison of different drugs. The assessment of the toxicity of topical drugs is currently by the Draize test in rabbits. New in vitro tests on human corneal epithelial cell cultures include ATP assays for cell viability, scanning EM of epithelial microvilli, and vital staining to assess cell membrane permeability and intracellular esterase. Despite their simplicity, these test systems can correlate well with clinical toxicity and provide a toxicity index for drug comparisons. Treatment requires drug withdrawal or substitution by non-preserved and less toxic preparations. Factitious injury is rare, difficult to diagnose, and should only be considered when all other diagnoses have been excluded. Prevention requires a high level of awareness of the potential for iatrogenic disease, particularly in the high-risk setting of chronic ocular surface disease.

Factitial oral lesions in an autistic paediatric patient

Self Injurious Behaviour (SIB) is a deliberate harm to the body that may lead to factitial injuries. Its origin may be functional or biological and it has a higher prevalence in females and in psychologically impaired individuals. Seventy per cent of autistic patients have SIB. Seventy-five per cent of factitial injuries are located in the head and neck region. A paediatric case report concerning a 4-year-old autistic female is presented. Detailed medical history, physical examination, clinical intraoral and radiographic examination, incisional biopsy, neuropaediatrical, psychological and speech evaluation were undertaken. Diagnosis included hypochromic macrocytic anaemia, caries, coronal fracture, factitial ulcer, factitial periodontitis, self-extraction of primary teeth and permanent teeth buds, non-specific oral ulcer with inflammatory reaction, mild mental retardation, speech impairment, autistic syndrome and self injurious behaviour consisting of putting fingers and foreign objects in the gingiva, fingernail biting and hair pulling. Differential diagnosis included hystiocitosis X, prepuberal periodontitis and leukocyte adhesion deficiency. Dental preventive and restorative treatment was performed. Non-contingent reinforcement therapy was successfully used to diminish SIB. Treatment of factitial oral injuries must be interdisciplinary and requires cooperation of the patient, the parents, health care providers, and medical team.

Beyond collusion: active illness falsification

OBJECTIVE

This article explores the relationship between factitious disorder by proxy victimization and the genesis of factitious disorder in young people. It is hoped that this will aid in our understanding of how some illness falsification behaviors may be learned and transmitted within the family system.

METHOD

A discussion of the origins of adult factitious disorder and recent findings on the phenomenon of illness falsification in children and adolescents is integrated with some of the more ambiguous or "blended" cases which combine primary falsification by the youngster with caregiver collusion. Those less easily classified cases of factitious illness which fall in the gray areas, containing elements of both independent illness falsification by a child or adolescent with an earlier history of collusion with a parent's Munchausen by Proxy disorder, are proposed as a type of transitional case which may help us better understand the process by which illness falsification is learned.

RESULTS

The literature on illness falsification in adults supports the possibility that adult factitious disorder may have its origins in adolescence or perhaps even earlier. Several cases are identified which suggest that some youngsters independently falsifying illness may have had earlier experiences of Munchausen by Proxy victimization or perhaps experienced the modeling or encouragement of illness falsification by a caregiver. Certain elements of the child victim experience, including efforts to overcome feelings of powerlessness, chronic lack of control, and disappointment in the physician are suggested as possible dynamics in the eventual development of independent illness falsification behaviors.

CONCLUSIONS

The many unanswered questions in our understanding of the development of factitious illness in children and adolescents suggest avenues for further research. It is hoped that increased understanding will eventually allow more rapid, reliable identification of these patients and more effective interventions within the family system, with positive implications for future generations.

Self-inflicted anterior scleritis

PURPOSE

To describe and clinically characterize a syndrome of self-inflicted scleritis.

STUDY DESIGN

Case reports and literature review.

METHODS

Two patients had persistent scleritis at presentation. Both did not respond to prescribed therapy, including systemic corticosteroids and immunosuppression. The first had unexplained, diffuse anterior scleritis and persistent linear keratoconjunctival abrasions after a work-related injury. Several objective indicators pointed to concealed noncompliance with medications. The second patient was a medical assistant with diffuse, unilateral anterior scleritis and unexplained visual loss. Systemic work-up was negative. She had pharmacologic mydriasis and keratoconjunctival abrasions at presentation.

RESULTS

Systemic therapy was stopped in both patients. The first patient, who was in the process of requesting permanent disability status, showed persistent inflammation on each follow-up visit. The second patient improved with no further therapy after she was confronted with objective indicators of a self-inflicted condition.

CONCLUSIONS

Although the presentation of self-inflicted scleritis can be similar to that of idiopathic or autoimmune anterior scleritis, the former may show additional findings of traumatic conjunctival and corneal abrasions. Indicators of self-inflicted etiology, of which malingering is one such entity, include evidence of concealed noncompliance with prescribed treatments and lack of response to potent antiinflammatory and immunosuppressive agents. Correct diagnosis including early psychiatric evaluation in all such cases, may help prevent unnecessary treatment and unjustified work-related compensation.

Dermatitis artefacta. Clinical features and approaches to treatment

In dermatitis artefacta, the patient creates skin lesions to satisfy an internal psychological need, usually a need to be taken care of. The clinical presentation is characteristic, and differs from that of neurotic excoriations, delusional disorders, malingering, and Munchausen's syndrome. Munchausen's syndrome by proxy is a form of dermatitis artefacta. Except where disease is mimicked, lesions that do not conform to those of known dermatoses are shrouded in mystery, appearing fully formed on accessible skin, within the context of a characteristic psychological constellation. The patient is friendly but bewildered, and the relatives, angry and frustrated. Because of lack of diagnostic stringency, quoted female-to-male ratios range from 3:1 to 20:1, with the highest incidence of onset in late adolescence to early adult life. Most patients have a personality disorder; borderline features are common. The patient's denial of psychic distress, and negative feelings aroused in healthcare personnel, make management difficult. Limit-setting for the protection of both the physician and patient; creation of an accepting, empathic, and nonjudgmental environment; and close supervision of symptomatic dermatologic care will permit development of a therapeutic relationship in which psychological issues may gradually be introduced, that may occasionally permit psychiatric referral. Issues of etiology should be sidestepped because confrontation is counter productive. When psychiatric referral is refused by the patient, the use of psychotropic drugs by dermatologists is helpful and appropriate. The upper dose range of selective serotonin reuptake inhibitors (SSRIs), or low dose atypical antipsychotic agents, may be effective. Except in mild transient cases triggered by an immediate stress, the prognosis for cure is poor. The condition tends to wax and wane with the circumstances of the patient's life. Lesions can be kept to a minimum, the patient can be protected from unnecessary and intrusive studies, and society can be protected from escalating and unnecessary expenditure of medical resources if, rather than discharging the patient, the dermatologist continues to see the patient on an ongoing basis for supervision and support, whether or not lesions are present. Research studies are necessary to document more accurately the expectable cause, treatment outcome, and prognosis for this group of patients.

Chronic factitial ulcer of chin cured by endodontic (root-canal) surgery for underlying periapical abscess

In a determined search for the cause of a "factitial" ulcer of the jaw, consultation with 3 dentists was required before an underlying periapical abscess was discovered. Within 3 months of endodontic surgery, this ulcer of 12 years duration had completely healed and remains healed. Too often dental infection is neither suspected nor detected as a cause of skin disease.

A case report: recognizing factitious injuries secondary to multiple eating disorders

This report describes the uncommon problem of a female patient diagnosed with an eating disorder, bulimia nervosa, who reported self-mutilating dental factitious behavior. The case presents a serious diagnostic and management problem. Notwithstanding the clinical appearance of the dentition, a thorough medical-dental history was essential for this uncommon diagnosis.

Identification and classification of factitious disorders: an analysis of cases reported during a ten year period

OBJECTIVE

The current article offers a new conceptualization of factitious disorders based on cases reported in the literature.

METHOD

The current analysis examines twenty-nine cases of factitious disorder patients over the course of ten years (1986-1996). Cases were found through PSYCHLIT and MEDLINE searches. Patient variables examined include: demographics, occupational status, marital status, childhood history, extent of medical history, the presence of a borderline personality disorder, and presence of a psychosocial stressor prior to the onset of the factitious disorder.

RESULTS

An examination of the cases found demographic patterns of illness presentation consistent with previous reviews of the disorder. From the examination emerged two distinct types of factitious presentations-one acute, one chronic. A two-dimensional approach is introduced in an attempt to understand various disease presentations. Cases were classified based on proposed Current Life Stress and Chronic Life Pattern dimensions. These dimensions are measures of the extent to which the patient's factitious presentation is in response to an immediate psychosocial stressor, or an action consistent with a long-term maladaptive behavior pattern resulting from an underlying character pathology. Three patient groups were identified based on estimated patient levels of each dimension. The three groups are: Stress Response, Life Response, and Mixed Response.

CONCLUSION

Recommendations are made to increase the role of physicians in the detection of factitious patients, as well as to move toward a more uniform reporting of cases of factitious disorders in the literature.

Problems of differential diagnosis between depressive pseudodementia and Alzheimer's disease

Today, pseudodementia seems to be a blurred and misleading term. It is more precise to speak about cognitive disorders which can be observed in both depressed and demented patients. Guidelines which can help to differentiate between depression and dementia are proposed for both the history and the course of the disorders. Additional brain imaging can give further indications. Ergopsychometric setting, which obeys directed burden under speed conditions may be helpful. SSRIs may reduce the HPA axis hyperactivity in depressive patients with Alzheimer disease. Therefore this medication can help to improve the state of these patients.

[Reversible dementia]

A 65 year old woman, referred for differential diagnosis of dementia, presented with cognitive and mnestic deficits. Typical signs and symptoms of hypothyroidism led to the diagnosis of severe autoimmune thyroiditis. After six months of treatment with thyroid hormone, dementia, myopathy and ataxia had disappeared. The neurologic and neuropsychologic manifestations of hypothyroidism are discussed. In dementia the diagnosis of secondary and reversible forms is of great importance with regard to prognosis and treatment. Hypothyroidism is known to be a common and treatable cause of pseudodementia. Early diagnosis and adequate treatment are important to prevent further permanent deterioration of cerebral function.

Epileptic pseudodementia

Dementia is a frequent cause of memory loss with aging. The incidence of complex partial seizures sharply rises after age 60. Complex partial seizures that occur with subtle clinical signs or loss of awareness, or occur during sleep may defy identification. We report five elderly patients fearing dementia in whom memory dysfunction was due to unrecognized complex partial seizures.

Role of psychiatric disorders in self-inflicted periodontal injury: a case report

Self-inflicted or factitious injuries (FI) are not uncommon in psychiatric patients. In general, this kind of behavior is linked to secondary gain. However, the role of underlying psychiatric illness should not be overlooked. Usually, the diagnosis of factitious injury can be confirmed by a careful medical-dental history, clinical appearance of the lesion, laboratory investigations, and response to established treatment protocol. A case is presented in which repetitive injurious behavior resulted in rapid periodontal attachment loss. The lesion responded well to conservative periodontal treatment. The role of underlying psychiatric morbidity leading to repetitive self-injurious behavior is discussed.

Case study: Ganser syndrome in children and adolescents

Six cases of the Ganser syndrome have been previously described in the literature and are reviewed here. They are imperfect representations of the originally described syndrome. This article describes a case of the Ganser syndrome in a 12-year-old boy who, after a mild head injury, presented with three of four of the core symptoms. The nature of the Ganser syndrome remains unclear, but this case study highlights dissociation and abnormal illness behavior as being important in the production of the symptoms. Classically the course is short-lived, although this report raises the possibilities of a much more chronic course.

Factitious disorders and the 'professional patient'

Factitious disorders are fabricated illnesses. Conceptually, these disorders lie in the gray zone between malingering and real diseases. Clinical awareness will prevent unnecessary diagnostic and therapeutic interventions. The author profiles those patients and symptoms that accompany factitious disorders as well as factitious disorders by proxy. In the case of the latter, child abuse may be uncovered as well. Although rare, factitious disorders will be present in a busy primary care practice. Clinical detection based on patient profiles can aide discovery. Early recognition and management may prevent a chronic and debilitating course from culminating into one in which the person becomes a "professional patient."

Preventing factitious gingival injury in an autistic patient

A 34-year-old man with a history of autism developed a deep gingival cleft. During clinical evaluation, the patient repeatedly scraped the affected area with his fingernail. The lesion's clinical features were consistent with focal inflammatory hyperplasia, periodontal disease and factitious stomatitis. This article describes the case and discusses diagnostic and behavioral issues important in treating any patient whose mental age is impaired.

Concepts of neurotic and personality disorders in ICD-10: results of the Research Criteria Study

A discussion on personality disorders (F6) is conducted within the framework of the Research Criteria Study on the basis of one case each of borderline syndrome (F60.31), transsexualism (F64.0), and factitious disorder (F68.1). In the Research Criteria Study the main agreement achieved about personality disorders was 77%, for borderline disorders 94%, transsexualism 91%, and factitious disorders 53%. Additional diagnoses were given in the case of factitious disorder by 43%, for borderline disorders in 15%, and for transsexualism in only 3%. Alternative diagnoses improved the overall agreement about factitious disorders by 21%, about borderline disorders and about transsexualism by 3%. It appears justified to introduce a coding for an alternative main diagnosis. The diagnostic concepts are discussed with respect to practicality, suitability, adequacy and reliability. The raters felt fairly secure about the classification. The research diagnostic criteria proved to be very practical. The raters attributed a high reliability to ICD-10 and, with the exception of factitious disorders, a very valid image of patients.

Pseudodementia: a slow death

The clinical term "pseudodementia" has remained a permanent nosological entity in the literature for over 100 years. Indeed, recognition of the fact that clinical symptoms associated with reversible neuropsychiatric conditions can mimic irreversible disorders was known as early as the middle of the 19th century. The importance of the term lies in the inherent assumption that the presenting dementia is not real, or is at least reversible, and therefore treatable. Nonetheless, there continues to be controversy regarding the validity and appropriate clinical use of the term. This article reviews the evolution and clinical utility of the term pseudodementia and attempts to redirect investigative efforts toward an understanding of the neuroanatomical substrates that underlie depression and cognitive impairment in the elderly. Based on a critical analysis of the relevant literatures, a subcortical-frontal neuroanatomical substrate of late-life depression is supported. Further, the presence of leukoaraiosis, as measured by magnetic resonance imaging, is proposed as a potential neurobiological marker that contributes to the depressed mood, cognitive impairment, and later cognitive deterioration of some elderly depressed.

Think of depression--atypical presentations in the elderly

Depression in the elderly may have many presentations. Skill is required in differentiating clinical depressive conditions from mild reactive states and senile dysphoria. Screening tests are available that may assist the doctor in the diagnosis of depression. One of these, the Geriatric Depression Scale (short form), is easily completed by patients (Table 3). Exclusion of organic causes of depression and sub-typing of the depression are the first steps. Correct matching of type of treatment--medication, electroconvulsive therapy, cognitive-behavioural therapy or other forms of therapy--to the type of depression usually leads to a good outcome. Extra caution is required in prescribing medications to older people because of altered pharmacokinetics and the frequent co-occurrence of physical disorders. For example, the use of tricyclic antidepressants is precluded by the presence of cardiac conduction abnormalities, urinary outflow problems, narrow angle glaucoma or postural hypotension and the subsequent risk of falls and fractures. Depression in the elderly carries a much greater risk of endogenous and psychotic sub-types and of suicide. The proportion of the population who are elderly is increasing. Depression in older persons is very common, may be difficult to diagnose, is treatable and has a prognosis similar to that of middle aged or younger patients. Doctors should think depression in older patients and bear in mind possible atypical presentations. When the correct diagnosis, usually possible by taking a careful history, is followed by correct treatment, the outcome can be very rewarding for patient and doctor.

The Ganser syndrome in two adolescent brothers

The Ganser syndrome is rare in children and adolescents. Two cases of Ganser syndrome in adolescent brothers, both of whom developed the syndrome while in jail and awaiting trial, are presented. Both brothers subsequently developed signs and symptoms indicative of affective disorder. The differential diagnosis and the management of these two patients are discussed in the light of the nosological controversies surrounding this clinical entity.

[Bacteremia and multiple and recurrent skin ulcers due to Brucella melitensis. A new modality of self-induced infection]

Self-induced infections are a special form of factitious disease. They are characterized by the autoinoculation of contaminated substances or bacterial cultures which may lead to cutaneous infections, bacteremias, or arthritis by various germs. The conditions produced are difficult to diagnose and may lead to multiple operations, and sometimes mutilations or death of the patient. Herewith, a patient who, over a period of 10 months, presented 4 episodes of bacteremia and cutaneous abscess in which Brucella melitensis was isolated is described. In addition, during the second admission, the patient had factitious fever. Despite the evidence of self induced infection, the patient denied autoinoculation however, following confrontation with the facts and supportive psychotherapy the patient has not presented any further episodes after 6 months of follow up. Although the microorganisms involved in this type of disorders are various, this is the first case described in the literature of self-induced infections by Brucella melitensis.

Automatic and effortful memory processes in depressed persons

Clinical lore has held that depression results in memory dysfunction, particularly in older adults. Some believe that memory loss due to depression is indistinguishable from an organic dementia and label such dysfunction pseudodementia. Previous literature has inconclusively supported the relation between depression and memory deficits. This research assessed three groups of subjects: (a) 30 depressed patients, (b) 20 psychiatric controls, and (c) 30 normal controls. Dependent memory tasks were designed to vary along the automatic and effortful memory encoding continuum defined by Hasher and Zacks (1979). Two tasks were designed to be effortful (free recall and paired associates) and two tasks were designed to be automatic (memory for frequency and location). Contrary to predictions, depression was not related to memory deficits. However, post-hoc analyses indicated that psychiatric hospitalization and psychotropic medication had a greater negative impact on memory than did depression. As predicted, age resulted in effortful encoding deficits whereas age resulted in minimal deficits on the automatic tasks. There was no evidence of an interaction between depression and age that would be consistent with the descriptive label of pseudodementia.