• Jena Martin MD

Do Know Harm

Dermatopathologists sometimes see mental illness. 

Actually, all pathologists can occasionally see mental illness.  Skin specialists just happen to see these particular diseases the most frequently.  The skin, readily accessible to all people, is the most commonly affected organ.

Patients hurt themselves on purpose.  They do things to themselves that cause pain and physical damage.  Then, they bring the evidence of that pain to their doctor.  In this, they experience some relief, or perhaps knowing that someone is trying to address their concerns is soothing. 

The patients may not be conscious of this dynamic - they truly see their physical pain as real.  The pain is something they have made manifest to others rather than created wholesale.   They may be conscious of the entire process of intentional harm and solace in health care.  Or perhaps they are only intermittently aware of what they are doing. 

These are called Facticial conditions.

Definition :  factitious: induced by deliberate human action with or without intention to produce a lesion or disease

This is not the same thing as faking.  Some patients do fake conditions (to get time off of work, for example).  That is called malingering and it is not a mental illness.

From my position behind the microscope I tell the providing physician what I see, and they know that the conditions I describe are a manifestation of a mental disorder.  I know what happens, but not why. 

Here are some examples from cases I have seen.

A teenager comes in with her mother and her mom is concerned about her bald spots.  Under the microscope, we can tell - she is pulling her hair out.  

A hair follicle without a hair - one clue to to the diagnosis.

Something is wrong with this hair.  It has an irregular brown material inside it, the result of trauma to the hair itself.  The name for this is a pigment cast. 

The normal hair shaft is bright pink; the abnormal dark pigment means only one thing - the hair has been pulled on and damaged.

This is a cross section of the scalp, where we usually count hairs to evaluate the kind of alopecia (balding).  Here we see a fairly normal number of hairs, but what's that?  6 hairs with dark brown irregular centers.

For an example of another clue, called the Hamburger sign, please see these images: https://goo.gl/images/9EFBQM

All of these clues add up to only one explanation - this patient is pulling out her hair.  This is called Trichotillomania. Some authors now recommend using the term neuro-mechanical alopecia.  

A middle aged woman brings in an old baggie of band-aids and skin scrapings. 

The woman knows these are the bugs that bother her and she has brought them from home to her dermatologist appointment so that we can examine them under the microscope.  The band-aids are stained with pink serum and skin crusts.  There are tiny hairs and skin flakes.  The pathology technician scrapes and collects these to be processed in the lab, and we look at them under the microscope.  We see plant debris, hair shafts and the surface of dead skin.  There are no bugs, only the intricate histology of seeds and plant rinds.

Inflamed serum crust and fragments of keratin (what you would call a scab).

Plant material, of unknown type, can be very beautiful.  Fragments like these can also be seen in fecal material.

This is also plant material, likely a fragment of wood.

This patient suffers from a condition called Morgellons**. This is a delusional disorder that there are parasites or foreign material moving in or out of the skin.   There are no parasites.

A young woman complains of bruising and thickening of the skin on her thighs.  The dermatologist performs a deep biopsy so we can look down to the fatty layer of the skin. 

She has some changes to this layer, what we would place broadly in the category of panniculitis (inflammation of the fat layer), but none of our usual diagnostic algorithms make sense. 

For panniculitis we examine the pattern of inflammation in the fatty lobules at the base of the biopsy.

Here are the fat cells with mostly histiocytes, also called macrophages.

It looks most like what we call fat necrosis - a common reaction pattern in fat to physical trauma.  After many stains and much review, we sign out the case with vague terminology and suggest to the dermatologist that this may be a facitical panniculitis.  The patient could have injected something into the area, applied pressure, hot or cold items, or otherwise traumatized the area.

Some factitial pathologies are accidental, but nevertheless self-inflicted.

A young man visits the doctor with mysterious erosions on his penis.  They are red and painful.  He has no explanation for it.  The doctor biopsies one, and under the microscope we see tiny chunks of the material - some sort of filler - he has injected into his penis.  Instead of making his penis larger it has left him with a lifetime of scarring.

 This is a very thin shave biopsy because no one wants to biopsy the penis.

Polarized light highlights the foreign material, in the center of the previous photograph (it works because foreign material is highly ordered, and polarizes in the light). 

This diagnosis - Lipogranuloma on the penis -  is not uncommon.

Dermatologists at large institutions see many patients with facticial disorders.  These patients will seek expert opinion and care after all of their local doctors have failed them*.   They travel to large medical centers because they believe something is wrong with them.  Part of assessing and assuaging their conditions means ruling out a serious illness.  This means blood tests, images and biopsies.  

When I was a dermatopathologist in training, I saw many of these patients. They were all distressing and tragic.  The young woman with large gashes in her forehead and blood under her fingernails.  The couple where the woman sat, obese and mute in her wheelchair, while her husband excitedly talked about the organisms emerging from her wounds.  

Several times we saw a woman who injected saline to produce large and spreading blisters; she repeatedly returned to undergo rounds of hospitalization for infections.  She had suffered a surgical error as a young adult and this victimization had damaged more than her colon; she was enraged by and yet drawn to interactions with doctors.

Facticial conditions can present as a real mystery to physicians. The symptoms don't 'add up' and don't fit our typical lists and hypotheses. Once they are perceived as a mental health issue, these patients emerge as true tragedies. Until the mental disorder emerges as the real diagnosis though, these patients are difficult, challenging, and sometimes the situation seems even absurd. One non-dermatological case is my favorite example of this dynamic.  

One of my teachers in pathology told of us a perplexing case from the obstetrician-gynecologist.   A woman came into the emergency department and said she had miscarried.  The obstetrician removed the tissues from the vaginal canal and brought them to the pathology lab where he awaited the pathologist's answer.   The pathologist examined the maroon-colored tissues and sampled parts to look at under the microscope.  There, things were just not making sense.  He saw degenerated and enlarged cells within strange structures.  Could it be an odd tumor?  Pathologists don't like it when things don't make sense.  The tension was rising.

Sensing the pathologists dilemma, the surgeon offered up his assessment. "Honestly", the surgeon said, "I thought it looked kind of like chicken gizzards."

And it turns out, that's exactly what it was. The patient had inserted these gizzards into her vaginal canal before going to the emergency department.

Pathologists have lots of evidence to share about how patient's harm themselves, for a variety of reasons.  For a great video tutorial on the pulmonary pathology of injected drugs, watch  Dr. Mukhopadhyay's talk 'What happens to your lungs when you shoot up pain pills'  at https://youtu.be/b8GEqeV2B0o

* This kind of 'splitting' between good doctors and bad doctors is part of a borderline personality disorder.  Patients will at first lionize their new wonderful physician who can save them.  Their disappointment will be just as strong in the opposite direction.

**For more information about Morgellons, this most recent and comprehensive study is available in full-text (link below).  From the article's concluding paragraph:

  • "To our knowledge, this represents the most comprehensive, and the first population-based, study of persons who have symptoms consistent with the unexplained dermopathy referred to as Morgellons. We were not able to conclude based on this study whether this unexplained dermopathy represents a new condition, as has been proposed by those who use the term Morgellons, or wider recognition of an existing condition such as delusional infestation, with which it shares a number of clinical and epidemiologic features.  We found little on biopsy that was treatable, suggesting that the diagnostic yield of skin biopsy, without other supporting clinical evidence, may be low. However, we did find among our study population co-existing conditions for which there are currently available therapies (drug use, somatization). These data should assist clinicians in tailoring their diagnostic and treatment approaches to patients who may be affected. In the absence of an established cause or treatment, patients with this unexplained dermopathy may benefit from receipt of standard therapies for co-existing medical conditions and/or those recommended for similar conditions such delusions infestation."


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