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5 Factitious Skin Disorders withExternal Incentives
Fig. 5.22 Dermatitis artefacta induced by chromic mixture. (Reproduced with permission by
Bonamonte etal. [62])
109
Fig. 5.23 The same patient as in Fig.5.21. (Reproduced with permission by Bonamonte etal. [62])
personality, whereas his wife showed major depressive symptoms and had a histrionic personality [71].
Both of the above described cases can be considered as forms of dermatitis artefacta imposed on another person, caused by intentional “psychological” malingering without any venal incentive.
110
Fig. 5.24 Self-artefact induced by incandescent metal object on pre-existing spontaneous contact
dermatitis. (Reproduced with permission by Bonamonte etal. [62])
D. Bonamonte et al.
Fig. 5.25 Dermatitis artefacta induced by chromic mixture. (Reproduced with permission by
Bonamonte etal. [62])
5.5 Secrétan Syndrome
Secrétan syndrome is characterized by a hard and sometimes cyanotic oedema
(Charcot’s “edema bleu”) on the back of one or both hands and forearms. The afiction can be induced by applying a haemostatic ligature or tight bandaging around
the forearms.
5 Factitious Skin Disorders withExternal Incentives
Fig. 5.26 Woody and ulcerative plaque on the right rotular region after 20years by the subcutaneous injection of liquid parafn as attempt to obtain a disability pension. (Reproduced with permission by Bonamonte etal. [10])
111
This picture, rst described in 1901 by Henry Secrétan, a Swiss doctor [72], and
experimentally reproduced in monkeys by means of repeated injuries [73], has been
observed in professional environments in simulators aiming to gain an occupational
disease pension. The oedema is likely to be of a lymphatic nature and may be associated with pain and limited exion of the metacarpal-phalangeal joints. Oedema
from a haemostatic ligature can sometimes present, with clear-cut margins and a
fairly regular, horizontal, erythematous ring.
The diagnosis of self-inicted injury was not suggested by Secrétan in his original work, but by authors who reported subsequent, similar cases [74–76]. In all
cases the patients were workers who had sustained minor injuries at work and hence
were expecting compensation. In all cases, the syndrome was apparently induced
either by application of a tourniquet or by repeated self-inicted contusion of the
dorsum of the hand.
Angelini and Coll. observed a case of Secrétan syndrome unrelated to external
incentives in a girl aged 16. She had presented six episodes of hard oedema on the
dorsum of the left hand that had lasted 10–20days [77] (Fig.5.29). The complaint
consisted of indurated oedema of the back of the hand, associated with cyanosis,
tenderness and limited exion of the metacarpal-phalangeal joint. A large number
of clinical and laboratory investigations were carried out. Examinations by the
orthopaedic surgeon and a vascular surgeon proved unhelpful. Repeated X-rays of
the left hand and wrist showed no abnormality. Morpho-oscillographic examination
of the forearm demonstrated a slowed venous return, an altered vasomotor tone and
112
Fig. 5.27 Self-induced
ulcerative lesions on dorsal
right hand and coccyx.
(Reproduced from
Meneghini and Angelini
[53]. All rights reserved)
D. Bonamonte et al.
Table 5.2 Clinical differential diagnosis between occupational dermatitis artefacta (ODA) and
dermatitis artefacta (DA)
Criteria ODA DA
Gender Generally male Generally female
Age Young and adult Young and adult
History Episodic afiction with acute
Cutaneous
sites
Morphology More bizarre lesions Less bizarre lesions
Causal agents Highly varied, strange and
onset
Hands, arms, and unusual sites Generally face and arms
unthinkable
Chronic history of complaint
Common mechanical objects or chemical
agents
a relative hyposphygmia on the left side. This latter parameter returned to normal
after resolution of the oedema. Arteriography and lymphography of the left upper
limb showed no abnormality. On the occasion of her last admission to the clinic, the
patient presented with atrophic scars on the dorsum of the left hand and excoriated
acne on the cheeks (Fig.5.30). The psychiatric assessment produced evidence of a
marked hysterical personality with a “belle indifference” to the primary disease.
This led to the suspicion of a self-inicted aetiology. The patient was enlightened as
5 Factitious Skin Disorders withExternal Incentives
Fig. 5.28 Self-induced irritant bullous patch test. (Reproduced with permission by Foti etal. [66])
113
Fig. 5.29 A 16-year-old girl with oedema of the dorsum of the left hand. (Reproduced with permission by Angelini etal. [77])
to the signicance of the diagnosis of oedema artefacta and no further lesions were
recorded at follow-up examinations. The self-inicted injury had been induced by
repeated contusion of the area using various different hard objects.
Secrétan syndrome must be differentiated from the spontaneous chronic “occupational traumatic lymphoedema of the hands and forearms” described by members
114
Fig. 5.30 The same patient as in Fig.5.29. Atrophic scars on the dorsum of the left hand and
excoriated acne. (Reproduced with permission by Angelini etal. [77])
D. Bonamonte et al.
of our team in shermen [78, 79]. This complaint is due to various causes and particularly to repeated trauma from sea urchin spines and the tight cuffs of the wetsuit.
In spontaneous, chronic professional cases, lymphography may show alterations of
the lymph vessels [79].
Secrétan syndrome must also be differentiated from other types of acute or
chronic oedema, such as lymphatic aplasia, recurrent erysipelas, deep thrombophlebitis, angioedema, lariasis, venous obstruction post-surgical disturbances, and
carcinoma or other tumours of the breast.
5.6 Religious Stigmata
5.6.1 General Remarks
“Stigma” (the Greek term was originally referred to a wound or sign inicted on a
slave) refers to the reproduction of wounds like those inicted on Christ during the
crucixion, on the palms of the hands, soles of the feet and head (in lieu of the
Crown of Thorns), as well as the chest, the lips (in contact with a vinegar-soaked
sponge), and the back (marks of lashing) [80–88]. Over the centuries, stigmata have
appeared in saints, priests, nuns, and fraudsters, as well as in subjects suffering from
dermatological diseases, such as haematidrosis, and psychiatric disorders [89, 90].
Besides the visible ones, invisible stigmata, such as intense pain affecting the abovementioned sites, should be considered. The latter could precede the outcome of
visible stigmata or be a result of them, but may also be isolated, without any means
to ascertain their presence [91, 92]. Whether they are genuine or artefacts, stigmata
5 Factitious Skin Disorders withExternal Incentives
115
are still considered a medical enigma; they represent a complex model of interaction
between the skin and the psyche.
The wounds can bleed permanently or only just on Fridays or near special
Catholic holidays, such as Easter Sunday [85]. They differ in number (from 1 to 10),
size and body part affected. Usually, the stigmata are observed on the palms; however, after Barbet reported that contrary to popular belief, nails would have been
implanted at the level of the wrists in order to hold the weight of the body on the
cross, lesions started also to appear on the wrists [88, 93, 94].
Crucixion was practised in ancient Rome until the fourth century A.D. as a
punishment of criminals. A passage in the Bible (Galatians 6:17) suggests that Saint
Paul might have been the rst to receive stigmata, since he writes “I bear the marks
of the Lord Jesus in my body” [95]. Stigmatization was not then mentioned in the
west or east until the beginning of the thirteenth century.
Saint Francis of Assisi (1182–1226) was the rst person to receive stigmata during an ecstatic vision in September 1224; these were described 2years later in his
rst biography [85, 86, 96]. Saint Francis’ stigmata were immediately acknowledged by the papacy, despite minor opposition among the clergy, which accused the
Saint of heresy [88, 97].
Kluger and Cribier reported three other cases of self-inicted stigmata dating
back to the thirteenth century [88]. During the following centuries, more than 300
cases of stigmatization were described, most of them in fervent Roman Catholics
[88]. In 1908, Imbert-Gourbeyre found that 321 people with stigmata had been
described after Saint Francis, 41 were men and 280 were women during their reproductive years [98]. They were mostly from Italy (229 cases) and then France, Spain,
Germany, Belgium, Portugal, Switzerland, Holland, Hungary, and Peru.
Among the most famous stigmatized subjects in the nineteenth century, Louise
Lateam (1850–1883) stands out, a Belgian girl who bled every Friday from 1868 to
1883, except for two; she was visited by various eminent Belgian doctors [99].
Therese Neumann (1898–1962), a German peasant girl, also developed stigmata in
1926 during an ecstatic vision; her hands and feet bled regularly on Fridays until her
death [100]. Finally, in Saint Pius of Petralcina (1887–1968; Apulia, Italy), his
hands bled continually from 1918 onwards; however, the lesions faded at the time
of his death [85].
As shown by the above-mentioned data, stigmata have been manifesting for centuries in the context of Catholic Europe. In the United States, similar episodes were
unheard of until the spread of Catholicism [84]. In the twentieth century, stigmata
were reported in other religious contexts (e.g. Muslim ascetics developed lesions in
the same sites of injuries suffered by the Prophet in his battles) [84, 101]. Cases in
America and Australia were also reported [88].
In 2013, Kluger and Criber compiled a list of the most highly praised stigmatized
people [88]. However, few people with stigmata have been beatied or canonized,
and the Catholic Church does not allow a mandatory association between stigmata
and sanctity, denying the conventional belief that stigmata represent a supernatural
event, and are granted by God as a sign of piety. A proclamation by Pope Urban VIII
116
D. Bonamonte et al.
instructs Catholic writers to attribute a purely human nature to this phenomenon [102].
The issue concerning religious stigmata has always been of particular interest,
given the complexity of any interpretation and discussion. The question of the etiological interpretation of stigmata remains controversial; indeed, there is no reason
to presume that all stigmata should have the same aetiology. Excluding ascertained
cases of voluntary self-harm due to malingering, stigmatization is generally referred
to as unconscious self-harm during periods of hysteria, autosuggestion, and hypnotism; these are all characteristic factors that can be associated with “mystical delirium” [85, 88, 103].
According to various authors, however, cases of “inexplicable” stigmata with a
spontaneous onset and no external triggering factors have been described [85, 88].
Discrete exceptional clinical entities, whose pathogenesis is not fully understood,
could possibly constitute the condition underlying some of these cases: for example,
autoerythrocyte sensitization syndrome (Gardner-Diamond syndrome or psychogenic purpura), vicarious menstruation (various organs possibly affected), haematidrosis (blood cells in sweat), bloody otorrhea and hemolacria (secondary to
ophthalmic conditions) [89, 104–119]. Such conditions usually affect young
women; although they often present variable features of a psychosomatic personality, they are considered “natural”.
Owing to all the relative debate, the view of religious stigmata is progressively
shifting from medieval mysteries to distinct psychiatric and psychosomatic disorders. In studying stigmata, however, we should always consider the possibility that
they could be self-inicted for illegal and/or prot purposes.
5.6.2 Religious Stigmata asMalingering Artefacts
The topic of malingering in the form of religious stigmatization has rarely been
treated in the medical literature. Kluger and Cribier treated the subject thoroughly
in the light of modern medicine [88].
A case of a 42-year-old Brazilian man with a 5-month history of irregular, nonpainful palmar ulcers at different healing stages has been described [120]. During
consultation, the patient theatrically explained how he had been blessed by God
with Christ’s stigmata. However, the patient’s partner revealed that such lesions
were self-inicted using a pocketknife.
The case of a 23-year-old man with stigmata of the hands was reported in a small
town in Sicily. He showed some erosions on the dorsal surface of the hands, and
small bullous lesions arranged to create the word “pax” on the left palm. Previously,
other odd events, promoted as divine, had occurred in the house of the young man
(weeping over an efgy depicting the Madonna, weeping and bleeding over a picture of Jesus Christ, lugubrious sounds at night). Accordingly, a prayer hall in the
garage of the house had been set up, complete with an altar and iconography of the
Stations of the Cross. A ock of people brought gifts and pledges. The patient later
5 Factitious Skin Disorders withExternal Incentives
117
turned out to be hysterical, with an easily swayed personality, and easily manipulated by relatives and acquaintances with the aim of making a prot. Intervention by
legal authorities stopped the lucrative affair [121]. This case could be considered as
a case of malingering stigmatization by proxy.
Fisher and Kollar reported the case of a 23-year-old Mexican-American woman
who presented with bleeding on her palms, feet, sides, and head, as well as the oozing of oil from her body. Aside from one video recording, no bloody or oily discharge was directly observed; furthermore, a vial of the said oil, that had a slightly
sweet odour, was found. Meanwhile, at the time of the study, the woman’s 2-weekold daughter also presented with stigmata [122]. Here, too, the suspicion of a malingering disorder and malingering disorder by proxy is high.
A doubtful case of religious stigmata was reported by Early and Lifschutz [123].
A 10-year-old black Baptist girl experienced religious stigmata periodically over a
3-week period immediately preceding Easter Sunday, 1972. The child, who was
intensely religious, came from a large, lower-middle class family in a large city. Her
physical examination results were normal. The authors were unable to detect any
psychopathology, except within the range of her religious experience, and she
showed indifference towards the bleeding and auditory hallucinations of a religious nature.
We observed a case of religious stigmata in a 42-year-old woman, originally
from a small town of Calabria (South of Italy) [124]. The patient showed, for the
third consecutive year, cutaneous lesions during Easter holidays. Such lesions
appeared every year on her forehead and the dorsal surface of hands and feet. The
lesions would suddenly manifest on Easter Monday and healed spontaneously
within a few weeks. These alleged stigmata were made public, causing a steady ow
of devotees and curious onlookers to the patient’s house, offering gifts of various
kinds. The year before, the local ecclesiastic and police authorities had become
interested in the singular event, but legal or religious actions were not undertaken as
the stigmata rapidly disappeared some days after Easter. The patient came to our
attention on the third day of the clinical manifestation in the third year, accompanied by her general practitioner. At physical examination, a dozen mildly exudative
erosions were present on the forehead, along the hairline, measuring 0.5 cm in
diameter, regularly spaced at 1cm from each other (Fig.5.31). On the dorsal surface
of the hands, halfway between the carpus and metacarpus, an irregular, round
erythematous- ulcerated lesion, swollen and moderately bleeding, was evident. The
left-hand lesion was larger and more inltrated. Similar erythematous-ulcerated elements (measuring 1.5×1cm) symmetrically involved the central dorsum of the feet
(Figs.5.32 and 5.33). No lesions were present on her wrists, palms, soles, or elsewhere. During consultation, the patient was silent; she gave no specics about the
time and mode of onset of the lesions, and she did not complain of any subjective
symptoms. She also showed a wary and absent attitude, occasionally speaking in a
detached manner about her religious faith. Psychiatric consultation, which had been
refused at the time of the previous episodes, described a hysterical personality with
attention-seeking behaviour and an excessive need of approval by her family.
Moreover, her general practitioner reported that intervention by the police, the day
118
Fig. 5.31 Religious stigmata: multiple erosions following hairline. Notice the consistent diameter
and spacing. (Reproduced with permission by Bonamonte etal. [124])
D. Bonamonte et al.
Fig. 5.32 The same patient as in Fig.5.31. Irregular rounded ulcerative lesions on back of hands.
(Reproduced with permission by Bonamonte etal. [10])
before, had stopped people making pilgrimages to the house and had changed the
attitude of the patient and her relatives. They showed fear and discretion, diminished the importance of the episode, and argued that most likely it would not occur
again. The patient refused hospitalization but promised she would return for follow up although she never actually showed up. Her general practitioner later reported to
us that the lesions were already healing 3days after our consultation, and there had
been complete healing after 3weeks. Stigmata no longer recurred during the Easter
holidays in the following 2years [124].
This case, because of the affected sites, morphology, acute onset, and duration of
the lesions, easily led to the suspicion of an articially induced disease. As a matter
of fact, in this case only the dorsum of the hands and feet were affected, without
involvement of the palms and soles. Moreover, in religious texts, the originally
described sites of upper limb involvement are the wrists and not the hands. In this