BRITISH MEDICAL JOURNAL 30 AUGUST 1975

Clinical Problems

Self-inflicted Injury: A Follow-up Study of 43 Patients

IAN SNEDDON, JOAN SNEDDON

British Medical J7ournal, 1975, 3, 527-530

Summary

Forty-three patients, 38 women and 5 men, with self-inflicted skin lesions were studied. Thirty-three werefollowed up for up to 22 years. In most cases dermatitisartefacta was only one incident in a long history ofpsychogenic illness. Of the 43 patients, 13 (30%), 12women and one man, continued to produce lesions orwere disabled with other psychiatric disorders morethan 12 years after the onset ofsymptoms. Prognosis wasdifficult but recovery seemed to occur when the patient'slife circumstances changed rather than as a result oftreatment.

Introduction

Skin disease is never simple to treat even when the patientwishes to recover. It becomes far more difficult when the patient(usually female) deliberately manufactures lesions. Suchpatients present a double challenge-that of diagnosis, andthat of management, since once detected they usually refuseto discuss the underlying problem and cease to attend. Asearly as 1907, Towle' described 49 cases of gangrena cutishysterica, and in 1917 Simpson2 pointed out the need to recog-nize such lesions in young girls. The shape of artefact lesionsis usually bizarre3; they have linear or geometric outlines, andsuperficial necrosis is common. The handedness of the patientsis a factor determining the sites of the lesions. Many patientshave a "Mona-Lisa-like" expression of artful innocence.4 Lyell5reviewed the whole problem of the diagnosis of self-inflicteddisease.Though much has been written about the diagnosis few

attempts have been made to discover the ultimate fate of thepatients. McCormack6 sent a questionnaire to 10 patients butonly five replied, this being too few to allow any definiteconclusion. He suggested, however, that the rarity of thecondition after the age of 25 indicated that it did not persist.Seville7 recorded nine cases, in all but one of which the patientsappeared to recover.

Relatively little has been written on the subject by psychia-trists, possibly because since patients wish to remain ill, patientsoften refuse psychiatric help or appear to comply and then failto keep appointments with the psychiatrist. Hawkings et al.,8

Rupert Hallam Department of Dermatology, Hallamshire Hospital,Sheffield S10 J2F

IAN SNEDDON, M.B., F.R.C.P., Consultant Dermatologist

The Royal Hospital, Sheffield S1 3SRJOAN SNEDDON, M.D., Senior Casualty Officer (Now Lecturer in

Psychiatry, University of Sheffield)

however, studied 19 patients with simulated disease, not alldermatitis artefacta, and concluded that it is a self-rightingcondition with a close similarity to anorexia nervosa. Ourexperience resembles that of Battle and Pollitt,9 who describedsix patients, three of whom continued to produce fresh lesionsfor over 20 years despite plastic surgery and psychotherapy.We have studied 43 patients and succeeded in following up33 of them for up to 22 years.

FindingsThe details of the patients are given in the table; 14 of the 38 womenand three of the five men were married. Zaidens'0 believed thatdermatitis artefacta is a disease of middle age, but in our experienceit is very much a disorder of young women. The different types ofartefacts and the numbers of cases in which they were found wereas follows: excoriations, linear or square, 25; heat, acid, or alkalineburns 6; bruising 4; nail piercing 3; rubber bands 2; ligatures roundhands and legs 2; and conjunctivitis 1. In some cases the lesion wastrivial; in fact, in case 7 it could be removed with ether. Few of ourpatients, unlike those of Hawkings et al.,8 worked in hospitals.In case 24 the patient, an occupational therapist, produced a skilfulimitation of psoriasis (fig. 1) by means of a corrosive which would haveremained undetected but for an accident when the corrosive trickleddown her forearm, leaving a tell-tale straight line. One can also

..

FIG. 1-Case 24. Appearances of lesion simulating psoriasis.

FIG. 2-Case 32. Granulomatous appearance of lesion above cuticle.

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528

Details of Cases Studied

BRITISH MEDICAL jouRNAL 30 AUGUST 1975

Case Marital Age when Duration of Duration ofNo. Sex State First Seen Symptoms Type of Lesion Possible Related Factors Follow-up Present State

(Y ears)_ __

11 F. Single

12 M. Married

Qedemna of hand due toligature round wrist

Linear excoriations

Linear excoriations

Linear excoriationsScarred alopeciaPossible acid burn of face

Rash on face removableby solvent

Blister on faceFacial scratchesNecrotic lesions of legs

suggestive of alkalineburns

Linear lesion of face

Sewlling of leg caused byligature

Cheilitis and conjunctivitis

Blister on legLinear scratchesLinear erosions for 3 years

Square erosions of face

Burn blistersBruising left thigh

Ulceration of breast

Linear excoriations of face

Crush injury to left hand.Recurrent bruising ofleft hand. Frequentlinear cuts elsewhere

Linear excoriations onhands

Superficial chemical burns

Recurrent bruising oflimbs. Nohaemnatologicalabnormality oraultoerythrocytesensitivity

Rmaa on knee after trivialinjury at work

Linear excoriations of face

Traumatic lesions offinger nails

Produced skin lesionwhile in hospital afterlobectomy for bronchitis.Excoriations, failure ofwounds to heal

Forgotten rubber bandround leg

Superficial blisters andblack streaks-? silvernitrate

Nail damage above cuticle

Bruises on thighsNail damage above cuticle

Excoriation of left shin

Over-anxious, dominantmother

Stutters badly. Solitaryeidstence

Drug eruption 6 monthspreviously. Donunantmother suffers frommental illness

Receiving war pensionfor nerves

Dominant, rigld, andstrict stepmother

Mother aggressive. Patienthad weakness of legs2 years previously

Failed exams on nursingand lost relgigous falth

Laboratory technician,jealous of sister

Marital quarrels. Wiferefused to share bed solong as leg was bad

Recurrent soreness ofeyes since aged 7.Police charge forchnigprescriptions.

Unsubtantiated historyof being raped bySunday-school teacherat 12 years

Quarrelled with boyfriendRecurrent depressionJealous of older brother

Under psychiatric carefor episodes of pseudo-coma and recurrentabdominal pain sinceage 15

Recurrent abdominal pain,hysterical coma, anddepression. Severalattempts at self-poisoning

Depression and repeatedsuicidal attemptsfollowed by anorexianervosa

Hysterical aphonia.Admnission for overdoseon several occasions.Falling attacks, nottrue epilepsy.Dominant mother

Recurrent hospitaladmission for abdominalpain. Laparotomy 1970,no abnormality found.Eight children byhusband withHuntingdon's chorea

Occupational therapist inmental hospital. Wasdivorcing husband atonset. Recurrence oferuption during divorcehearing

Onset at death of mother.Has care of incontinentadult brother. Attacksof depression.Exacerbation on deathof husband 1 year ago

Coincided with mother'sdeath, her divorce, andbrother's suicide

Coincided with fatherrunning away to S.America. Youngest of 6children. Shy andinsecure

None found

Broken home. Said tohave been sexuallyassaulted at 16.Hysterical paraplegiaand retention of urine.Persistent back pain.Artificial pyrexia andhaemoptysis

Senile dementia

Inadequate personality,low intelligence. Sullenand unco-operative.Refused psychiatrichelp

None known

None known

Dominant mother

Mentally subnormal

5 Years

13 Years

13 Years

13 Years

11 Years10 Years

11 Years

6 Months

12 Years

2.Years

9 Years

9 Years

4 Years3 Years

15 Years

6 Years

22 Years

13 Years

5 Years

7 Years

9 Years

7 Years

3 Montha

17 Years

7 Years

6 Months

3 Months

6 Years

11 Years

Recovered after 3 years

Still producing artefactlesions

Recovered after 1 yearWell

UntracedRecovered. Well

Untraced

Untraced

UntracedCleared rapidly. Still ciearPossibly epileptic with

diabetes insipiduaWell. Married with 1 child

Untraced

Blind, disabled

WellUntracedHealed after 3 year whenmoved house

Happily married. Nofurther lesions

Healed for past 3 yearsHysterical episodes, pain,and pseudocoma

Depressed and hearingvoices

Skin clear. Working.Stil under psychiatriccare for depression

Unable to work. Walkswith a stick

Still producing artefacts

Well, happily remarried

Continues to bruise

Well

Unmnarried, pregnant

Untraced recentlyRecovered after 14 yearswhen she married. Nowhas two children

Healed

Mild depressive state.Continues to haveartefact

Untraced. Nails recoveredduring 6 months

Recovered in 3 months.Untraced

Recovered after marriageon leaving home

One recurrence but now

1

2

3

45

6

7

8910

F.

F.

F.

F.

M.

F.

F.

F.

F.

F.

Single

Single

Single

Single

Married

Single

Single

SingleSingleSingle

F.

M.F.

M.

F.F.

Single

SingleSingleMlarried

SingleMlarriedMarried

F. Married

F. ISingle

18

55

14

2047

18

18

159

25

18

41

27

141531

19

3919

55

16

20

24

21

43

54

10

16

14

81

29

12

49

18

41

2 years

3 Weeks

1 Year

6 Years4 Year

3 Months

3 Months

6 Months6 Months

1 Month

6 Montha

12 Years

3 MonthsI Week3 Months

1 Year

3 Months1 Month

4 Months

7 Days

1 Year

2 Months

3 Years

3 Years

3 Weeks

2 Months

Unknown

4 Months

1 Year

2 Years

6 Months

6 Months

13

141516

17

1819

20

21

22

23

24

25

26

27

28

29

30

31

32

33

34

35

F.

F.

F.

F.

F.

F.

F.

F.

F.

F.

F.

F.

F.

F.

Single

Married

Married

Married

Married

Single

Single

Single

Married

Married

SingleMlarried

SingleMarried

-11-

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BRITISH MEDICAL JOURNAL 30 AUGUST 1975

Type of Lesion Possible Related FactorsDuration ofFollow-up

I. I . 1-Bruised hand

Linear facial excoriations.Burns on fingers

Rubber band underwedding ring

Superficial abrasions.Dental burr hole inforearm. Artefact ulcerin mouth

Excoriated nose

Superficial linear blisters,possibly fromcorrosive.

Extensive ulcer of leftside of face and neckrecurring for 20 years.Started after trivialburn

Bruise on left leg aftertwisting ankle. Unableto walk and attendcollege

Unable to keep up withothers at school

Unhappy, came frombroken home

No reason found.Forgetfulness ?

Recurrent falling attackstreated by psychiatristfor 4 years before skinlesions appeared.Dominant mother andalcoholic father

Anorexia nervosa at 20years. Active lesbianbefore marriage. Sleepsin chair downstairs toavoid sharing bed withhusband

Lifelong bed wetter. Shyof getting undressed.Avoided P.T. as long asshe had skin lesion

Depression; 10 years ofpsychiatric care

Dominant and anxiousmother. Leg in plasterunder care oforthopaedic surgeon for18 months

1 Month

4 Weeks

2 Years

8 Years

5 Years

7 Years

6 Months

Present State

Untraced

Untraced

Recovered

Still producing lesions

Continues to produceartefacts despite 8 yearsof psychotherapy

Well

Healed for 3 months.Working

Well and back at college

be easily misled by young girls who produce a granuloma of thenail bed, probably by piercing the nail with a heated needle. In cases

28, 32, and 34, all of young girls at different schools, identical lesionswere produced (fig. 2), suggesting some common source of informa-tion. Though two patients (cases 1 and 12) deliberately appliedbandages around their limbs to make them swell, the rubber-bandinjuries in the two old ladies (cases 30 and 38) were produced byforgetfulness. We have excluded patients with neurotic and acneexcoriations from our series.

Prognosis

Of the 43 patients, 33 were traced. Details of their progress were

obtained from hospital notes and information on their present statewas derived from personal knowledge or family doctors. Severalof the young patients clearly used an artefact to draw attention totheir particular problem, and when that was solved they recovered-for example, cases 3, 11, 17, and 41. In most cases, however, theartefact was only one incident in a long history of psychogenic illnessand was often accompanied by abdominal pain, episodes of pseudo-coma, self-poisoning, or depression.Twelve women and one man continued to produce lesions or were

severely disabled in other ways an average of 12-4 years after theonset of symptoms. Twenty were known to have recovered. Evenif the 10 who were untraced are assumed to be well, this means that30% of all our patients with self-inflicted lesions failed to recover,which is a much poorer prognosis than previous surveys have sug-gested. The difficulty of giving a prognosis is illustrated by thefollowing two case histories. The first patient recovered; the seconddid not.

Case 29-At the age of 14 this girl, already a problem child from a brokenhome, underwent a lobectomy for bronchiectasis. Before leaving hospitalshe developed an artefact skin lesion. She also had unexplained fever.Two years later her normal appendix was removed at another hospital tocure abdominal pain; the wound broke down, however, and she was seen

by a psychiatrist. She then went to live with an aunt in the south of England.She claimed that at the age of 16 she was sexually assaulted, but there wasno proof of this. At age 18 she returned to Sheffield and became a traineenurse. Soon after her training began she was admitted for investigation ofhaemoptysis, but no cause was found, and while on the ward developedlesions on her legs (fig. 3). These healed under occlusive dressings but it wasnoticed that her oral temperature was raised, and this occurred even whenthe nurse stood by and watched. On every occasion that her oral temperaturewas raised her rectal temperature was normal. How she raised the mercurythermometer remained a mystery. She refused totalk to a psychiatrist.Shortly after resuming her nursing duties she fell and her legs became

paralysed and she developed retention of urine. Despite her history myelog-raphy was carried out to exclude a spinal tumour. None was found. A

psychiatrist was again called and she was detained in a mental hospital on a

compulsory order. There she demanded her clothes, recovered the function

of her legs and bladder, and was discharged after three days. She continued

to complain of pain in her back and was given a plaster jacket at a nearby

hospital. At the age of 28, after 14 years of continuous invalidism, shemarried and subsequently had two children. She has not consulted herdoctor for two years and is known to be well.

FIG. 3-Case 29. Characteristic linear superficial abrasions.

Case 22-A 20-year-old woman sustained a minor crush injury to her lefthand when working in a canning factory. A blue swelling appeared on theback of the hand, though this subsided when the hand was occluded inplaster. It was soon suspected that a haematoma artefact was responsibleand, much against her mother's wishes, she was seen by several psychiatristsand a neurologist. After five years the back of the hand was still troublingher. The area was explored by an orthopaedic surgeon. For a short timeshe resumed work but soon cut a finger on her right hand, which wouldnot heal. She was then seen in the skin department, and when the woundhealed under an occlusive dressing she developed hysterical aphonia. Shewas interviewed by a medical social worker, who felt that the patient'smother dominated her and that any attempt to refer her for psychotherapywould be resisted. Her mother died at that time, and the following year,

when 31, the patient was admitted with an overdose of barbiturates, anda hysterical personality was diagnosed. She subsequently attended thepsychiatric department for 11 years, during which she learnt to dislocate

MaritalState

Age whenFirst Seen(Years)

Duration ofSymptoms

12

17

80

20

CaseNo.

36

37

38

39

40

41

42

43

529

Sex

F.

F.

F.

F.

F.

F.

M.

F.

Single

Single

Married

Single

Married

Single

Married

Single

3 Months

1 Day

2 Weeks

3 Months

2 Years

10 Days

20 Years

1 Years

30

12

55

19

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530 BRITISH MEDICAL JOURNAL 30 AUGUST 1975

her patella and now walks with a stick. She had occasional fit-like attacksbut electroencephalography showed no evidence of epilepsy. She wasregistered as disabled, a total invalid with a 21-year history.

Comment

These patients present a considerable problem. They are notdeliberate malingerers, nor are they psychopaths with Mun-chausen's syndrome. We agree with Hawkings et al.8 thatthere are similarities between these patients and those withanorexia nervosa, in that the condition affects particularlyyoung girls who have immature personalities; however, of the13 patients who failed to recover, four of the 12 women weremarried and three were over the age of 40 at the onset of symp-toms, and there was one man of 27.

In the management of these patients one cannot betterLyell's5 dictum that one has to indicate indirectly that youknow of their activities but sympathize. They should be givenan opportunity to talk but many do not do so. Direct con-frontation with the patient or relatives leads to the patient ceasingto attend. Though isolation and failure to communicate makesthem difficult to help, we have recently obtained slightly moreencouraging results from relaxing exercises taught by a clinicalpsychologist. It must be admitted that essentially the patientswho have recovered have done so when they have matured or

when their life situation has changed and not as a result ofmedical intervention.

We are grateful to Dr. R. E. Church for allowing us to include hispatients in the study. We thank all those family doctors who sokindly and efficiently supplied up-to-date information on theirpatients, and the numerous medical social workers for the hours spenton interviews. We are indebted to Miss Morag Melvyn for her helpwith the psychological management of several patients, and to Dr.Lawton Tonge for his psychiatric assessments and advice. We shouldalso like to thank Miss Wendy Spencer, of the photographic depart-ment.

References1 Towle, H. P., Journal of Cutaneous Diseases, 1907, 25, 477.2 Simpson, C. A., Journal of Cutaneous Diseases, 1917, 35, 493.3 Stokes, J. H., and Garner, V. C., Journal of the American Medical Associa-

tion, 1929, 93, 438.4 O'Donovan, W. J., Dermatological Neuroses. London, Kegan Paul, 1927.5 Lyell, A., Scottish Medical Journal, 1972, 17, 187.6 McCormack, H., British Journal of Dermatology and Syphilis, 1926, 38,

371.7Kitchen, I. D., McGibbon, C., and Seville, R. H., British Medical_Journal,

1967, 2, 218.8 Hawkings, J. R., et al., British Medical Journal, 1956, 1, 361.9 Battle, R. J. V., and Pollitt, J. D., British Journal of Plastic Surgery, 1964,

17, 400.10 Zaidens, S. H., Journal of Nervous and Mental Disease, 1951, 113, 395.

Hospital Topics

Occupational Hazards in Window Cleaning

B. F. RIBEIRO

British Medical Journal, 1975, 3, 530-532

Summary

Accidental falls involving window cleaners treated atthe Middlesex Hospital over five years are reviewed.Failure to use safety belts and the lack of suitableanchorage points were contributary factors in all 20patients. The use of protective equipment and the provi-sion of anchorage points should be enforced. While thedoctor's duty is to treat injuries he also has the oppor-tunity to draw attention to their prevention.

Introduction

During six months in 1972 as an accident officer at the MiddlesexHospital I treated seven window cleaners who had been injuredby falls. Four were permanently disabled and unable to returnto their occupation. In view of the disabilities produced by theinjuries and to review the safety standards used by window

Department of Surgical Studies, Middlesex Hospital, LondonWiN 8AA

B. F. RIBEIRO, M.B., F.R.C.S., Surgical Registrar

cleaners I undertook a retrospective survey of a further 13patients with similar injuries presenting during 1967-7-2.

Types of InjuriesAll the injuries resulted from falls from ladders or window sills andthe patients fell into two groups: group 1 consisted of nine patientswith minor fractures or soft tissue injuries requiring outpatienttreatment, and group 2 consisted of 11 patients with multiple injuries,who were all admitted to hospital; four required emergency surgery.Falls from heights below 6-1 m (20 ft) produced relatively minorinjuries to the arms in seven of the nine patients in group 1, whilefalls from greater heights produced multiple injuries to the legsor trunk in 10 of the 11 patients in group 2 (see table). In the armfractures around the wrist joint predominated. In the leg injuriesinvolving'the ankle joint and calcaneum were most common; in threepatients the injury was bilateral. In three patients compressionfractures of the vertebrae complicated leg fractures. Joint dislocationsoccurred in four patients and in one (case 15) involved three separatejoints. Internal injuries occurred in only one patient and proved fatal(case 20).

Effects ofInjuryThere were no disabilities reported among the patients in group 1.The most common disability in group 2 resulted from fractures of thecalcaneum. When the fracture involved the subtalar joint the resulting

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