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.
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
American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, 4th Edition. Washington, DC, American Psychiatric Association, 2000, pp 513-517
Ford CV: Lies! Lies!! Lies!!! The Psychology of Deceit. Washington, DC, American Psychiatric Press, 1996, pp 164-166
Evans DG, Kerr B, Cade D, et al: Fictitious breast cancer family history (letter). Lancet 1996; 348:1034
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Peters F, Neulen J, Schuth W, et al: Self-inflicted necroses (mastitis factitia) as an unusual course of non-puerperal mastitis. Geburtshilfe Frauenheilkd 1988; 48:816-818[Medline]
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Reich P, Gottfried LA: Factitious disorders in a teaching hospital. Ann Intern Med 1983; 99:240-247
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Goetsch CM, Smith SM, Olopade OI, et al: Multidisciplinary rounds. Assessing hereditary breast cancer risk. Cancer Practice: A Multidisciplinary Journal of Cancer Care 1999; 7:279-284
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