Intentional Simulation of Illness

Hello Piper Allyn Ranallo Elaine Wooler

Can I request a review into the intersection of psychiatry and dermatology?  An initial look into a potential duplication between Artefactual skin disease and Dermatitis factitia came from https://prod-request.ihtsdotools.org/#/requests/preview/760735?fromList=true.  The reference from the Australasian Journal of Dermatology (2001) says, “Many of the presentations are not as dermatitis and hence the term ‘artefactual skin disease’, rather than ‘dermatitis artefacta’, is used to describe factitious disorders with dermatological features. The condition may be self-induced or produced by another, in which case it represents a form of ‘Munchausen syndrome by proxy’. Rarely, the lesions are produced by another person with the assent of the patient.” So is this a supertype/subtype relationship?  The literature is unclear. Must Dermatitis factitia be modeled with inflammation since there are other possible presentations such as circular blisters or erosions, burns, scratching, cryodamage, excoriations, urticarial lesions, hemorrhages, indurations, or necrosis?  The causative agent is physical force, but could it also be foreign body or chemical - topical or injected?

Variations may be determined by the individual’s

• denial or admission to the acts
• motive (to exclude malingering, Munchausen)
• propulsion to injure
• pattern to seek or shy away from treatment

There may be further duplication or misrepresentation among the subtypes of 274949005 |Self-inflicted skin lesions (disorder)|.  Should the subtypes be limited to skin only as in this FSN?  Otherwise ‘Dermatitis factitia’ and other terms that may have ‘derm-’ in the name actually encompass skin, hair, nails, and/or mucosae.  

There may also be errors in these psychocutaneous disorders and their synonyms. For example, Dermatitis factitia and Dermatitis simulata are synonymous in SCT but separate codes in ICD-11.  Also, here is a case of Dermatitis artefacts vs. Dermatitis Factitia: https://www.karger.com/Article/Pdf/73996#:~:text=The%20skin%20lesions%20in%20dermatitis,malingerers%20%5BKalivas%2C%201996%5D. 

For 403589005 |Non-accidental injury to skin (disorder)|, should this be termed ‘purposeful’ ‘intentional’ or ‘intended’ instead of ‘non-accidental’?  The injury could be from self or someone else, so its supertype of |Artefactual skin disease inflicted by others| is incorrect.  

Slide 10 of http://www.psychodermatology.us/resources/Documents/DSM%205%20Equivalents%20of%20Current%20Psychocutaneous%20diseases%20[Autosaved].pptx lists the many dermatology terms used to explain factitious disorder imposed on self. 

Thanks for your attention,

Copying this here from Michael First:

It’s never ben clear to me how to respond to these queries within the confines of the Confluence site (Piper—please enlighten me) …so I’ll respond in this e-mail instead.

This is yet another example of two different fields of medicine using the same terminology is slightly different ways. Dermatitis factitia is essentially self-induced skin lesions; “factitial” in this sense means artificial, i.e, not caused by dermatological disease.  Factitious disorder in DSM shares the fact that the skin lesions are self-induced with  dermatitis factitia, but a core feature of factitious disorder in DSM is that the self-induced symptoms are associated with identified deception, i.e, the lesions have been created with the goal of deceiving someone (usually health care professionals) as to their true origin.  Other DSM disorders that may be characterized by self-induced skin lesions are excoriation (skin-picking) disorder, in which the skin-picking results from a failure to control an impulse to pick the skin,  as well as disorders associated with self-mutilation (e.g. borderline personality disorder).  Malingering, not a mental disorder, may also present as self-induced skin lesions if the goal of the behavior is personal gain.   S0 there is no one-to-one relationship between dermatitis factitia and any DSM condition.

-- Michael

Hi Krista LillyHas this discussion been resolved? I'm not really clear yet on how to interpret these concepts. Which of the SNOMED concepts stem from DSM, which from dermatology? 

From your first post, I understand an (at least theoretical) difference between 27720003 | Dermatitis factitia (disorder) | and 402736003 | Factitious skin disease (disorder) |; but what distinguishes  402737007 | Artefactual skin disease (disorder) | from its parent 402736003 | Factitious skin disease (disorder) |?