Ann Thorac Surg 2001;72:280-281
© 2001 The Society of Thoracic Surgeons
Case report
Self-inflicted pneumothoraces
John D. Urschel, MDa,
John D. Miller, MDa,
W. Frederick Bennett, MDa
a Department of Surgery, McMaster University, Hamilton, Ontario, Canada
Accepted for publication June 26, 2000.
Address reprint requests to Dr Urschel, Department of Surgery, St. Joseph’s Hospital, 50 Charlton Ave E, Hamilton ON L8N 4A6, Canada
e-mail: urschelj{at}fhs.mcmaster.ca
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Abstract
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Self-inflicted pneumothoraces are rare manifestations of psychiatric illness. Two patients with self-inflicted pneumothoraces are reported, and the typical clinical features of factitious disorders are described. If thoracic surgeons are aware of these conditions, inappropriate surgery—and poor outcomes—can be avoided.
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Introduction
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Recurrent spontaneous pneumothoraces are a common thoracic surgical condition [1]. We report on 2 patients with repetitive self-inflicted pneumothoraces as the presenting feature of a psychiatric illness. Thoracic surgeons should be aware of these psychiatric illnesses [2] and their implications for thoracic surgical management. Diagnostic clues and typical clinical patterns are described.
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Case reports
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Patient 1
A 30-year-old male student complained of dyspnea and right-sided chest pain. His chest radiograph showed a small right pneumothorax. The patient had previously undergone multiple chest-tube insertions and bilateral operations (left pleurectomy and right apical bullectomy) for recurrent spontaneous pneumothoraces. Treatments had been rendered at hospitals in three different cities. We advised against immediate chest-tube insertion and instead repeated the radiograph after several hours. This second radiograph showed a larger right pneumothorax and a new foreign body (a hypodermic needle) in the chest (Fig 1). When confronted, the patient suggested that a needle had been carelessly left on his stretcher and had entered his chest by accident. He expressed concern about the hospital’s sloppiness. Self-inflicted injury seemed more plausible, but operative removal was nevertheless indicated. The broken hypodermic needle was removed thoracoscopically, and a parietal pleurectomy was done. A blunt postoperative discussion followed, and the patient reluctantly admitted to having induced many pneumothoraces in the past. Psychiatric consultation yielded a diagnosis of mixed personality disorder with a variant of Munchausen syndrome. A dispute over narcotic theft prompted chest-tube removal and discharge on the second postoperative day.
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Fig 1. Chest radiograph of patient 1 shows a pneumothorax from a self-inflicted penetrating foreign body (hypodermic needle) injury.
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Patient 2
A 33-year-old former ambulance attendant complained of dyspnea and left-sided chest pain; her chest radiograph showed a pneumothorax. Past history included chest-tube insertions for pneumothoraces and at least one laparotomy for unexplainable pneumoperitoneum. Treatment had been rendered at several different hospitals. A left thoracoscopic pleurectomy was done. Several months later, the patient was treated at another hospital for a right pneumothorax and a pneumoperitoneum. A series of hospitalizations (at different institutions) for pneumothorax, pneumoperitoneum, collections of air in her liver (Fig 2), and various soft-tissue gas collections ensued. Self-injection of air was suspected. The patient eventually underwent a right parietal pleurectomy and apical wedge resection by an unsuspecting surgeon. The wedge resection specimen showed cotton-fiber emboli consistent with intravenous drug abuse.
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Comment
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A variety of psychiatric illnesses produce physical symptoms. Thoracic surgeons should have a basic understanding of these illnesses and their implications for surgical management. Mental illnesses that produce physical symptoms fall into two broad categories: somatoform disorders and factitious disorders [2]. In somatoform disorders, physical symptoms are not under a person’s control. Somatoform disorders can be subdivided into somatization disorder (historically known as hysteria), conversion disorder, pain disorder, and hypochondriasis [2]. Thoracic surgeons with a special interest in thoracic outlet syndrome and benign esophageal disease frequently encounter patients with somatization disorder [3, 4]. These patients have multiple complaints, describe their symptoms in exaggerated terms, seek many medical opinions, and have a propensity to undergo diagnostic procedures and operations [3].
Unlike patients with somatoform disorders, individuals suffering from factitious disorders intentionally feign or produce symptoms [2, 5]. Important factitious disorders include true factitious disorder (Munchausen syndrome) and malingering. The disorders are distinguished by the motivation for deceit. Assuming the "sick role" is the motivation in Munchausen syndrome, and external gain (narcotic administration or avoidance of work or military service) is what motivates the malingerer.
This is a report of self-inflicted pneumothoraces as a manifestation of factitious disorders. The clinical pattern is very similar to that of other reported self-inflicted illnesses [2, 5]. Diagnostic clues include admissions at multiple hospitals, multiple surgical procedures, bizarre illnesses in multiple organ systems (hematuria, pneumoperitoneum, soft-tissue abscesses, wound infections), unusual eagerness to submit to invasive procedures, extensive knowledge of medical terminology and routines, and an occupational background in health care. Noncompliance with medical care is common, and these patients frequently discharge themselves when the factitious nature of their illness is recognized.
Thoracic surgeons should be wary of patients with self-inflicted pneumothoraces. Surgical therapy may be inappropriate. In addition, patients with factitious disorders may deliberately create their own surgical complications and then seek malpractice compensation from hospitals and physicians [6].
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References
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Urschel J.D. Thoracoscopic treatment of spontaneous pneumothorax. J Cardiovasc Surg 1993;34:535-537.[Medline]
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American Psychiatric Association Task Force on Nomenclature and Statistics. Diagnostic and statistical manual of mental disorders, 4th ed. Washington, DC: American Psychiatric Association, 1994.
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Hameed S.M., Grewal R.P., Urschel J.D. Somatization tendencies in surgically treated neurogenic thoracic outlet syndrome patients. Vasc Surg 1995;29:185-188.
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Tew S., Jamieson G.G., Pilowsky I., Myers J. The illness behavior of patients with gastroesophageal reflux disease with and without endoscopic esophagitis. Dis Esophagus 1997;10:9-15.[Medline]
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Robertson M.M., Cervilla J.A. Munchausen’s syndrome. Br J Hosp Med 1997;58:308-312.[Medline]
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Sousa J.A., Cline D.M., Stout R.C., Allison E.J., Jr Extortion in the emergency department. J Emerg Med 1997;15:537-541.[Medline]
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Abstract
Introduction
