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Three cases of suspected artefactual conditions of the breast are presented, one case each of recurrent bleeding, recurrent infection and atypical eczema. Involvement of the breast is rare, but may go undiagnosed in many cases. Patients are usually married and in the second half of their reproductive life. An unusual pattern of disease appearance and behavior, lack of response to treatment, inappropriate affect and a request for mastectomy are helpful in suggesting the diagnosis. A disturbance in personal relationships can often be elucidated by psychiatric assessment. Treatment is difficult and may be limited to suspecting the diagnosis, excluding organic disease and avoiding unnecessary and repetitive surgery.

There has been a groundswell of reaction, mostly favorable, to the most recent edition of the Diagnostic and Statistical Manual. In this paper the author attempts to evaluate the Manual, which purports to provide an atheoretical and descriptive diagnostic model on its own ground, as well as from a psychodynamic and ego-psychological point of view. More specifically, the Manual is evaluated in terms of its usefulness in the diagnosis and management of the Somatoform Disorders, as well as other typical general hospital problems. This assessment raises many questions about the basic tenets of DSM III in general. Concomitantly, suggestions are made to enhance the reliability, validity, and clinical relevance of the Manual.

Different presentations of depression may occur in the elderly. Complaints of physical illness are especially common and pseudodementia may be the presenting picture. Overtreated hypertension which can be well controlled with diuretics is a common cause of depression in the elderly. Taking the patient off the drug known to cause depression will often solve the problem.

Intractable complex partial seizures and seizures of unknown type were studied in 78 patients, six of whom were found to have psychogenic seizures. Evaluation by intensive monitoring included simultaneous six-hour telemetered EEG and videotape recordings and daily determination of plasma antiepileptic drug levels. Diagnosis was determined by assessment of four major criteria: deviation of seizures from characteristics of known seizure types, absence of epileptiform activity in the ictal EEG, absence of slowing in the postictal EEG, and relation of seizure frequency to decreasing plasma concentrations of antiepileptic drugs. No single criterion is sufficient for an unequivocal diagnosis of psychogenic seizures.

The paper discusses further cases of somatization (somatization disease, conversion, chronic pains) as distinct from simulation. Views of the somatization disease and conversion are based on a classification of psychopathology which has not been generally used in Czechoslovakia. The paper gives a hypothetical explanation of today's more frequent occurrence of somatization. It describes a simple screening test used for diagnosing somatization (hysteria), and suggests principles of elementary procedure to be applied in patients with subjective somatic complaints.

The neurological problems in elderly patients are dominated by cerebral vascular accidents and dementias. The incidence and the prevalence of cerebral vascular accidents has greatly decreased following measures of primary, secondary and tertiary prevention. The problem raised by dementias is one of a positive diagnosis (presently according to DSM III criteria) and mostly the problem of the differential diagnosis, i.e. the diagnosis of curable dementias or "false dementias".

A brief review is given of the incidence and nature of psychiatric symptoms, particularly depression, that are associated with chronic physical diseases common in the elderly. A discussion of medical illnesses that mimic depression, and depression presenting as somatic disease, illustrates the challenge of differential diagnosis. Guidelines are presented for the treatment of depression in patients with central nervous system, cardiovascular, hepatic and renal, and gastrointestinal disorders. Pharmacokinetic factors relevant to the use of cyclic and monoamine oxidase inhibitor antidepressants in the elderly are reviewed.

We report five cases of factitial panniculitis produced by blunt trauma. Localized forms include Secrétan's syndrome and l'oedeme bleu, which are usually unilateral and involve the hand and forearm, respectively. When the lesions are more generally distributed, the self-induced nature may be less apparent. These patients may have been diagnosed as having Weber-Christian disease, pancreatic fat necrosis, or superficial thrombophlebitis. The microscopic picture of organizing hematoma may be supplemented by the appearance of amorphous polysaccharide masses commingled with iron pigment.

The authors present a case illustrating factitious illness with a coexisting depressive disorder. The factitial presentation involved self-mutilation that served to procure and prolong patient status, while obscuring the recognition of a major depressive episode. The importance of accurate assessment and prompt recognition of factitious illness is discussed, with emphasis upon the identification of contributing psychodynamics, underlying psychopathology and ongoing psychosocial stressors. Psychiatric consultation efforts were successful, but in the context of considerable morbidity. Psychotherapeutic gains occurred only after vigorous antidepressant drug therapy and substantial psychotherapeutic efforts that empathically addressed the patient's masochism and dependency.

Evaluating the clinical significance of cognitive dysfunction in patients who exhibit signs of both depression and dementia is one of the more formidable challenges in psychiatry. This article reviews cognitive dysfunction associated with depression, the concept of "pseudodementia," and the syndromal phenomenology of coexisting depression and Alzheimer's-type dementia. The state of the art in neuropsychologic, electroencephalographic, metabolic, and neuroradiographic techniques for evaluating dementia and depression syndromes will be discussed, as will implications for the treatment of such patients.

A patient whose peculiar and painful purpura seemed to be strongly related to psychogenic factors is described. The skin bleeding pattern in this patient was consistent with the diagnosis of psychogenic purpura (autoerythrocyte sensitization). In addition, idiopathic thrombocytopenic purpura and platelet storage pool deficiency were present. These somatic conditions are considered to be of minor importance in the pathogenesis of this hemorrhagic syndrome. The association of these various types of bleeding disorders in the same patient has not been previously described.

Surreptitious self-administration of insulin is an important cause of hypoglycemia. A 28-year-old female hospital ward clerk presented with hypoglycemia associated with an elevated plasma insulin level and a low plasma C-peptide concentration. Factitious illness was denied by the patient until it was definitively proven by using a species-specific insulin radioimmunoassay that the type of insulin circulating at the time of hypoglycemia was of animal rather than of human origin. The differential diagnosis of hypoglycemia associated with hyperinsulinemia and the current laboratory methods which may be employed to distinguish between factitious hypoglycemia and endogenous hyperinsulinism are discussed.

Eleven clinical and behavioral syndromes that can result in self-inflicted injury in childhood and adolescence are reviewed and classified. The causes and remedies of such injuries vary both among and within these 11 classes. Pediatricians should be alert to the possible presence and meaning of self-injury.

A case of Ganser syndrome occurring in an 11 year-old Indian boy is described, and the psychodynamics and nosological status of the syndrome discussed. Ganser syndrome should be regarded as a hysterical state, and should not be confused with the similar picture observed in organic brain syndromes and psychoses.

Factitious hypoglycemia is similar in presentation to insulinoma and occurs most commonly in persons with ready access to insulin. Diagnosis previously was based on circumstantial evidence but now can be confirmed by demonstration of high insulin levels and low C-peptide levels in the presence of hypoglycemia. Treatment is primarily psychiatric, and success so far is limited.

Six patients (four male and two female) with factitious cheilitis are described. All had personality disturbances as well as crusted lip lesions that varied in severity from thin serous crusts to thick hemorrhagic crusts. This entity must be distinguished from infectious cheilitis, contact cheilitis, actinic cheilitis, photosensitivity dermatoses, exfoliative cheilitis, and cheilitis glandularis on the basis of the history and laboratory evaluation.

A case of pseudodementia in a 10 year old boy was first reported in 1981. When reviewed 8 years after initial presentation, his symptoms were largely unchanged. The case continues to be complicated by claims for compensation and a successful appeal against the initial compensation judgment.

The authors report a second visually impaired, mentally retarded male who presents with symptoms consistent with atypical pervasive developmental disorder, Tourette disorder, and a syndrome of approximate answers (Ganser's syndrome). Both this case and an earlier reported case are significant in that they identify two children with strikingly similar long-standing symptoms and developmental histories. Since these findings may have broader relevance to children with multiple coexisting disorders, diagnostic and intervention strategies in this population are reviewed.

We describe the case of a young woman presenting with deaf mutism and self-damaging behaviour. We emphasize the active investigation of psychological and physical symptoms, combined with gradual and gentle confrontation in a supportive setting.

Factitious or self-induced illness has rarely been mentioned in gynecologic literature. Described herein are 4 nonpregnant women, 3 of whom had vaginal bleeding of unknown origin and 1 who had recurrent fevers and an acute abdomen. In gynecologic practice, factitious illness should be suspected whenever a patient presents with a protracted illness that has eluded diagnosis. Furthermore, the index of suspicion for factitious illness should be high whenever a patient has an abnormal psychiatric history or has worked in a paramedical field.

Over the last seven years self-inflicted diarrhoea was diagnosed in seven patients with chronic diarrhoea which was deliberately induced by the secret intake of laxatives. Six of the patients were female, four of them in paramedical occupations. All also had loss of weight and hypokalaemia between 2.1 and 2.9 mmol/l. All had accepted extensive and interventional procedures during a mean of five hospital admissions, with minimal pathological findings and no aetiological diagnosis. They had undergone numerous therapeutic measures, in one instance even several operations and parenteral feedings. Making the correct diagnosis was decisively impeded and delayed by the patients' seeming cooperativeness. In four patients the diagnosis was finally made by demonstrating laxatives in the urine, in two others by finding hidden tablets in the room, in one by demonstrating melanosis of the colon. A factitious cause of chronic diarrhoea should be excluded if no other cause can be established.

Recent literature on the relationships among dementia, depression, and social support was reviewed, with particular emphasis on the diagnostic differentiation of dementia and depression, and the role of these three entities in elderly individuals with cognitive impairment. Dementia-like symptoms arising in depression and the coexistence of dementia and depression are discussed. Research is necessary to determine more objective criteria for depression and dementia, to provide cognitive and psychiatric testing for elderly individuals, to clarify the diagnostic or prognostic value of the term pseudodementia, and to further elucidate relationships between depression, dementia, and social support.

The DSM-III classification of factitious disorders encourages artificial separation into disorders with physical and those with psychologic symptoms. Despite documented examples of similar patients who present with psychiatric complaints, Munchausen's syndrome is usually considered a form of chronic factitious physical disorder. Three patients with both factitious physical and psychologic symptoms are presented. These patients illustrate the importance of focusing on the fundamental behavior of assuming the patient role, rather than on the specific category of symptoms. We recommend that the category of symptoms be used as a modifying statement, rather than defining separate disorders.

Of 200 diagnosed cases of alcoholic delirium 5 (= 2.5%) involved, from the differential diagnostic viewpoint, simulation of alcoholic delirium with all the symptoms involved. The symptoms of the simulation case are compared with the acute symptoms, and points in common to all simulation cases are presented: Definite alcoholic anamnesis, wide experience of treatment for alcohol abuse, dynamics of a pronounced purposeful action when social complications are imminent and course of the symptoms when the interview turns to simulation. In connection with therapy, special attention is drawn to Distraneurin treatment, which is not indicated in such cases.

The most common features of cognitive impairment due to pseudodementia are a relatively acute onset, symptoms of six to 12 months duration; past psychiatric history, particularly depressive illness; age over 50; frequent "don't know" as opposed to "near miss" answers; normal electroencephalogram and computed tomographic scan of the brain, and absence of nocturnal worsening. With this profile, or three or four of these clinical features, a carefully monitored, aggressive trial of an antidepressant regimen is justified.