26 de diciembre de 2011

Mastectomía bilateral profiláctica radical resultante de un trastorno facticio

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Psychosomatics 42:519-521, December 2001 © 2001 The Academy of Psychosomatic Medicine FUENTE ORIGINAL http://psy.psychiatryonline.org/cgi/content/full/42/6/519
Case Report

Prophylactic Bilateral Radical Mastectomy Resulting From Factitious Disorder

Marc D. Feldman, M.D.

Received March 30, 2001; revised July 16, 2001; accepted July 20, 2001. From the Department of Psychiatry and Behavioral Neurobiology, University of Alabama at Birmingham, Birmingham, AL. Address correspondence and reprint requests to Dr. Feldman, Center for Psychiatric Medicine, 1713 Sixth Avenue South, UAB Station, Birmingham, AL 35294-0018.
Key Words: Other Personality Disorder • Mastectomy
As awareness of hereditary cancers grows, individuals who may be at risk on the basis of a family history are pursuing risk determination and, as appropriate, prophylactic medical or surgical intervention. Through news outlets and health-related Internet Web sites, the public is increasingly aware of the importance of genetic transmission and the possibilities of attenuating heritable risk factors. One point emphasized is that heritable cancers tend to arise in several close relatives and in multiple generations within the same family.

Considering that the expression of factitious disorders is limited only by an individual's creativity and motivation, it is perhaps not surprising that alarming genetic histories would be invoked by some individuals who seek the intangible benefits of the "sick role."1 Unlike individuals who malinger for external benefits such as money or abusable medications, patients with factitious disorder deliberately produce or falsify illness to secure the attention, sympathy, nurturance, and lenience of others. They may also manufacture illness to manipulate and control others, to enhance their own self-esteem through association with medical professionals, and to organize and preserve their sense of identity.2
This case report discusses a woman who chose to present herself as a member of a family ravaged by a history of cancer. Like many individuals with factitious disorders, she obtained unnecessary surgical intervention, this time in the dramatic form of a prophylactic bilateral radical mastectomy. She meets criteria for the diagnosis of factitious disorder in that she engaged in a pattern of deliberately misleading health professionals about her background while lacking any evident motivation beyond assuming the mantle of "patienthood."

Searches of MEDLINE (1966 to present), CancerLit (1975 to present), HealthSTAR (1975 to present), and ISI Science Citation (1995 to present) computer databases failed to uncover any previously published reports of prophylactic radical mastectomy prompted by a false family history. However, one case of prophylactic subcutaneous mastectomy based on a spurious family history has been reported.3
Case Report

Ms. A., a 40-year-old married medical paraprofessional, sought counseling at a genetics clinic. She expounded on the successful battle she had waged against ovarian cancer, first diagnosed a decade earlier. She went on to claim that her mother had died of breast and ovarian cancer several years earlier and that three of her sisters had breast cancer, one of whom had undergone a bilateral mastectomy. Ms. A stated that her maternal grandmother, two maternal aunts, a niece, and a cousin had also had bilateral mastectomies necessitated by cancer, and that a paternal aunt was suffering from ovarian cancer. She also claimed to have had five miscarriages. Relatives, a review of records, and ultimately the patient herself confirmed that all of this information was false.

On the basis of Ms. A.'s professed history, the examiner concluded that there was a strong hereditary predisposition to breast and ovarian cancer and that Ms. A.'s chance of carrying a corresponding genetic mutation (BRCA1 or BRCA2) approached 90 percent. Prophylactic mastectomy, about which the patient had inquired, was endorsed as an option. She was cautioned that outside records would need to be obtained to ensure that there were no misunderstandings about the various cancer diagnoses, but apparently this task was not completed. Ms. A was advised to undergo DNA testing but declined, invoking limited financial resources to pay for the part not covered by insurance.
Subsequently, Ms. A. was seen by a cancer specialist who, armed with the genetic clinic report, agreed with her decision to proceed with prophylactic mastectomy. He noted that several previous breast biopsies had revealed only fibrocystic disease and that a radionuclide-enhanced mammogram was negative. Regardless, Ms. A. affirmed her preference for mastectomy over anti-estrogen medication and close follow-up. A bilateral radical mastectomy took place during the following month.

A subsequent review of Ms. A.'s history disclosed a long history of misinforming others that she had illnesses such as diabetes mellitus. Over time, these assertions had been met with increasing disinterest and complacency. She had also manufactured stories of personal crisis, ostensibly intended to mobilize friends' support. However, she was not known to have undergone any unwarranted surgery. There was little evidence for pursuit of external goals such as obtaining financial compensation or evading criminal prosecution, and Ms. A. had never engaged in litigation involving medical or other matters. Although she had chronically solicited opioids for personal use from multiple physicians, she did not request medication in the context of her concerns about cancer. She had never been diagnosed with a mental disorder. Her family was unaware until after the operation that it had taken place because she had imparted false information. During a 4-hour "intervention" by her family and friends and her priest, Ms. A. could not offer any consistent or convincing explanation for her behavior; for instance, she claimed at one point that she hoped the surgery would induce her husband to divorce her but could not elaborate. At the end of the meeting, she agreed to psychiatric care but changed her mind the next day.
Factitious breast ailments have been reported in the literature several times, but they remain a relatively esoteric manifestation of factitious disorder. When it does occur, factitious breast disease usually involves women who have deliberately induced or aggravated dermatoses, infection, mastitis, ulceration, or bleeding of the breast.4–8 One male patient mechanically constricted his nipple to cause inflammation.9 In such cases, a perplexing disease pattern or the lack of a consistent treatment response can suggest that medical deception is involved,5 as can an unusual history, histology, and localization.6 The presence of benign breast disease can make the diagnostic process more complex, but false claims of primary cancers in each breast, as described by Evans et al.3 in two cases, are much more readily disproved.
When factitious breast cancer itself has been observed, it often appears in association with other false medical claims. For instance, Arteaga-Rodriguez et al.10 described a woman who pretended to have paraplegia, tuberculosis, and malignant tumors of the breast and other bodily sites, but each was disconfirmed following a thorough work-up. Ultimately, she was diagnosed with Munchausen syndrome, the most severe and chronic form of factitious disorder.11 As illustrated by Feldman and Escalona's patient,12 claims of having breast cancer are sometimes supplemented by self-induced medical signs, such as severe weight loss due to surreptitious dieting and alopecia from head-shaving rather than purported chemotherapy.
Kerr et al.13 encountered five women whose false family or personal histories led to erroneous estimates of breast cancer risk. Of the five, several had sincerely supplied information that was later shown to have been falsified by a family member. The one patient who underwent mastectomy did have an authenticated family history of breast cancer in numerous relatives, though she also reported a personal cancer history that could not be confirmed. The type of mastectomy performed was not described, and it is not clear whether any of the patients or family members actually qualified for a diagnosis of factitious disorder as opposed to malingering or a somatoform disorder. Regardless, factors that enhanced detection in these cases, such as the patients' surprising lack of knowledge about the particular treatments received by close relatives, were not evident in the case of Ms. A. As a result of her compelling reports, and the unlikelihood that a woman would seek the unnecessary removal of her breasts, Ms. A.'s physicians took her reports at face value and did not carry out the process of objective corroboration and confirmation. The false premise under which surgery occurred—the report that there was a deeply troubling family history of cancer—was not discovered until afterward. In contrast, Grenga and Dowden14 discuss a patient who, like Ms. A., sought bilateral prophylactic mastectomy because of a strongly positive family history of breast cancer; however, the fabricated history was exposed prior to the operation, which was then canceled. In a unique case report that led to concern and disappointment among invited respondents, a patient who massively exaggerated her personal and family medical histories was granted prophylactic bilateral simple mastectomy even after the ruse was exposed.15 Although a psychiatrist had deemed her competent to make this decision and physicians perceived that her anxiety about cancer risk was genuine, one respondent pointed out that "informed consent, a component of autonomy, is not upheld simply because the patient is receiving the treatment she requests."
"Disease forgery" can be achieved through one or more of several methods. Individuals can provide false symptom reports, exaggerate symptoms, simulate medical signs (e.g., seizures), falsify test results and other data, aggravate spontaneous signs, or self-induce actual illness. In addition to its other lessons, Ms. A.'s outcome illustrates that, even at the comparatively mild level of inventing a family history, individuals may procure medical/surgical intervention that proves irreversible. Medical and surgical caregivers should be educated to the fact that there is peril in performing a drastic procedure based solely on a patient's report of his/her family or personal history. In addition, caregivers should view with concern a patient whose request for mastectomy or other dramatic surgery appears premature or overeager and liberally seek psychiatric consultation in such a case. Verification of the history is invaluable and should be routine,16 though the acquisition of releases of information and the records themselves can be laborious even when the patient fully cooperates. Finally, psychiatrists can help educate other physicians that unwarranted interventions, even when a patient has successfully lied about his or her history, are potentially compensable through the legal system.17
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