Available online at
ScienceDirect www.sciencedirect.com Chirurgie de la main 32 (2013) 413–415
Clinical case
The psychotic mummified hand: An unusual hand injury complication La main momifiée psychotique : une complication inhabituelle d’un traumatisme de la main L. Mathieu a, E. Guillibert b, W. Mamane a, E.H. Masmejean a,* a
Hand Surgery Unit, Orthopaedics and Trauma Department, Paris-Descartes University, Sorbonne Paris-Cité, Georges-Pompidou European Hospital (HEGP), AP–HP, 20, rue Leblanc, 75908 Paris cedex 15, France b Department of psychiatry, Paris-Descartes University, Sorbonne Paris-Cité, Georges-Pompidou European Hospital (HEGP), AP–HP, 20, rue Leblanc, 75908 Paris cedex 15, France Received 8 July 2013; received in revised form 7 September 2013; accepted 15 September 2013 Available online 1 October 2013
Abstract The authors report the case of a patient with psychotic symptoms secondary to a posttraumatic stress disorder following a work-related hand injury. The somatic presentation was a ‘‘mummified’’ hand neglected for several years in a splint without any care. The psychiatric analysis concluded that this was part of a delusion of persecution expressing a conflict against the patient’s employer and insurance company. Surgical treatment was limited to a hand cleaning with hardware removal. Despite 3 years of antipsychotic medication the patient was still suffering from delusion and the hand remained neglected at the last follow-up. # 2013 Elsevier Masson SAS. All rights reserved. Keywords: Hand injury; Posttraumatic stress disorder; Depression; Psychosis
Résumé Les auteurs rapportent le cas d’un patient présentant des troubles psychotiques secondaires à un syndrome de stress post-traumatique survenu à la suite d’un accident du travail intéressant la main. La présentation somatique était celle d’une main « momifiée » négligée depuis plusieurs années dans une attelle sans aucun soin. L’analyse psychiatrique a révélé que ce tableau s’intégrait dans un délire de persécution lié à un conflit avec l’employeur et la compagnie d’assurance du patient. Le traitement chirurgical s’est limité à un nettoyage de la main et à une ablation de matériel d’ostéosynthèse exposé. Trois ans plus tard, le patient restait délirant avec une main exclue en dépit d’un traitement antipsychotique et d’un suivi psychiatrique prolongé. # 2013 Elsevier Masson SAS. Tous droits réservés. Mots clés : Traumatisme de la main ; Syndrome de stress post-traumatique ; Dépression ; Psychose
1. Introduction An acute injury to a hand can be a disturbing event that might influence patient’s physical, psychological and social equilibrium [1]. Patients may experience loss of hand function and in addition they may experience pain, cosmetic disfigurement, and traumatic related distress [2]. Psychotic features have been described in patients with combat-related Post-
* Corresponding author. E-mail address: [email protected] (E.H. Masmejean). URL: http://www.handsurgery.fr/
traumatic Stress Disorder (PTSD) [3], but never after a hand injury in civilian practice. We describe a case of posttraumatic abnormal posture of the hand due to a persecution delusion combined with a PTSD and a major depressive episode.
2. Case report A 31-year-old right-handed man from North Africa was referred for a deformity of his right hand. Five years ago, when he was working in a foreign country, he sustained a workrelated near-amputation of his right middle finger by a saw. He
1297-3203/$ – see front matter # 2013 Elsevier Masson SAS. All rights reserved. http://dx.doi.org/10.1016/j.main.2013.09.003
414
[(Fig._2)TD$IG] main 32 (2013) 413–415 L. Mathieu et al. / Chirurgie de la
underwent bone grafting and fixation of the proximal phalanx, extensor and flexor tendon repair, and a cross finger flap. Postoperative cares included pain medication and physiotherapy. When we saw him for the first time, his hand was still immobilized in a dirty dorsal splint, and he seemed to have ignored it for several years. The patient and his family asked for corrective surgery for this hand deformity. Examination revealed a dysfunctional posture of the hand induced by the splint, with static positioning in extension at the metacarpophalangeal joints and flexion at the wrist and interphalangeal joints. The thumb and the fifth finger were adducted with atrophy of the intrinsic muscles. Hygiene had been neglected: the nails were several centimeters long, the skin was macerated, and a screw protruded from the dorsal side of the middle finger (Fig. 1). Neurologic examination was difficult to perform because of a poor patient cooperation. Active range in motion was painful and the patient would not permit passive range of motion. X-rays showed diffuse osteopenia and healing of the middle finger fracture (Fig. 2). Nerve conduction studies revealed slightly decreased amplitudes of the sensory action potential in all fingers of the right hand, but motor conduction was normal in median, ulnar and radial nerves. There were no sign of denervation in intrinsic muscles of the hand. The patient was scheduled for cleaning and screw removal (Fig. 3). Under general anesthesia the fingers and wrist could be fully mobilized, except for the proximal interphalangeal joint of the middle finger, which was fixed at 308 flexion. The absence of stiffness in the wrist and non-operated fingers joints indicated likely mobilization despite splinting during the last years. Psychiatric assessment revealed a history of Posttraumatic Stress Disorder (PTSD), depression and paranoia following the accident. The patient had never returned to work, and had entered into a conflict with his employer and insurance
[(Fig._1)TD$IG]
Fig. 2. X-ray showing internal fixation of the proximal phalanx of the middle finger with the protruding screw.
company after their refusal to grant him financial compensation. He had also complained about frequent pain for about 2 years, and believed that his insurance company had implanted an electronic capsule in his body in order to control his mind and make him sick. Then, the patient was transferred to a psychiatric hospital where antipsychotic medication was initiated. A rehabilitation program was associated but his lack of cooperation made it difficult to achieve. Using Diagnosis and Statistical Manual of Mental Disorders (DSM) – IV criteria [4], the diagnosis was a chronic psychotic feature comorbid with a PTSD and a major depressive episode on the axis I, without a personality disorder on the axis II. Finally, he was referred to a psychiatrist in his country of origin, and a long-term antipsychotic treatment was prescribed. At the last follow-up, 3 years later, the patient still showed a delusion of persecution and a total neglect of his hand.
[(Fig._3)TD$IG]
Fig. 1. Initial aspect of the hand after 5 years of permanent splinting: volar view (a), radial view (b) and dorsal view (c).
Fig. 3. Aspect of the hand after cleaning.
L. Mathieu et al. / Chirurgie de la main 32 (2013) 413–415
3. Discussion The influence of psychological factors on the hand is well known and not uncommon. Many clinical cases have been described including malingering, factitious or somatoform disorders [5–8]. In this case report a psychogenic etiology was first considered because of the dramatic appearance of the hand, but an organic etiology had to be ruled out. The history of single digital injury and electrodiagnostic studies were not in favor of a neurological lesion. Reduced amplitudes of sensory action potentials in all digits were difficult to explain, but could be related to chronic flexion posturing of the wrist inside the splint. A factitious disorder was initially suspected, but psychiatric assessment revealed psychotic features. Our analysis was that this ‘‘neglected hand’’ was not the result of malingering, but was a part of the chronic posttraumatic delusion. Patients who sustain a hand trauma frequently develop symptoms of PTSD, especially after work-related injuries [1]. Symptoms of PTSD include reexperiencing of the trauma, hyperarousal and avoidance of stimuli associated with the trauma [4]. Intrusive symptoms (i.e. re-experience of the trauma in dreams and flashback) and avoidance symptoms are present in the early stage, but are also reported after the first year [2]. The initial psychological distress of this patient was unclear because no assessment was performed in the months following the accident. However, 5 years later, he described persistent intrusive and avoidance symptoms with somatization in favor of a PTSD: the chronic pain was a constant reminder of the trauma, and the splint was a mean to avoid the sight of the traumatized hand [1,2]. Comorbidity between PTSD and psychotic symptoms has been reported in number of clinical studies, particularly in veteran soldiers, but it is relatively uncommon [3,9,10]. The co-occurrence between posttraumatic and psychotic symptoms is well described in the immediate suites of a trauma, but can also be chronic [11]. A PTSD subtype termed PTSD with secondary psychotic symptoms (PTSD-SP) has been recently described. In PTSD-SP the onset of PTSD predates the onset of psychosis, excluding patients with schizophrenia [9]. The links between psychotic and psycho-traumatic symptoms are complex and multidirectional. A personality of psychotic structure increases the risk of PTSD, and a trauma can test a latent psychotic structure to reveal its existence [11]. According to his family this patient did not seem to have personality disorder or psychiatric diagnosis prior to the injury. Psychotic symptoms in PTSD are different from flashbacks, but have strong symbolic relation to the trauma [10,12]. In this case, the dramatic aspect of the hand was a reminder of the severity of the trauma for the patient, and a part of the persecution delusion, which was expressive of the conflict against his employer and insurance company. Persistent delusion and hand exclusion after 3 years of therapy indicates a PTSD-SP resistant to antipsychotics. The efficiency of chronic antipsychotic drug treatment remains controversial in this indication [3,12,13]. Finally, it is important to identify patients with trauma-related distress in its early stage after a hand injury. Pain and aesthetics are statistical predictors
415
of symptoms of PTSD in acute hand-injured patients [1]. According to Gustafsson et al. [14] negative reactions to the sight of the hand are associated with both trauma-related distress and mood disorders. These patients must receive psychotherapy with the dual objectives of symptom reduction and return to former work activities when possible [15,16]. 4. Conclusion This extreme clinical situation underlines that severe psychotic features can complicated PTSD after hand injuries. Patients with trauma-related distress should be identify in the early stage, and require a psychological support to prevent progression. Disclosure of interest The authors declare that they have no conflicts of interest concerning this article. References [1] Opsteegh L, Reinders-Messelink HA, Groothoff JW, Posterna K, Dijkstra PU, van der Sluis CK. Symptoms of acute posttraumatic stress disorder in patients with acute hand injuries. J Hand Surg Am 2010;35:961–7. [2] Gustafsson M, Windahl J, Blomberg K. Ten years follow-up of traumarelated psychological distress in a cohort of patients with acute traumatic hand injury. Int J Orthop Trauma Nurs 2012;16:128–35. [3] Hamner MB, Frueh BC, Ulmer HG, Arana GW. Psychotic features and illness severity in combat veteran with chronic posttraumatic stress disorder. Biol Psychiatry 1999;45:846–52. [4] American Psychiatric Association. Diagnostic and statistical manual of mental disorders, 4th ed., Washington, DC: American Psychiatric Association; 1994. [5] Kasdan ML, Stutts JT. Factitious injuries of the upper extremity. J Hand Surg Am 1995;20:S57–60. [6] Krahn LE, Bostwick JM, Stonnington CM. Looking toward DSM-V: should factitious disorder become a subtype of Somatoform disorder? Psychosomatics 2008;49:277–82. [7] Batra S, Sarasin SM, Gul A, Kanvinde R. Psychoflexed hand: a forgotten entity. A case report and review of the literature. Int J Clin Pract 2008;62:1634–6. [8] Cuénod P, Smaga D, Degive C, Della Santa DR. Psychogenic spastic hand. Ann Chir Main Memb Super 1996;15:100–8. [9] Sautter FJ, Brailey K, Uddo MM, Hamilton MF, Beard MG, Borges AH. PTSD and comorbid psychotic disorders: comparisons of veterans diagnosed with PTSD or with psychotic disorder. J Trauma Stress 1999;12:73–88. [10] Butler RW, Mueser KT, Sprock J, Braff DL. Positive symptoms of psychosis in posttraumatic stress disorder. Biol Psychiatry 1996;39:839–44. [11] Auxéméry Y, Fidelle G. Psychosis and trauma. Theoretical links between posttraumatic and psychotic symptoms. Encephale 2011;37:433–8. [12] Ivezic´ S, Bagaric´ A, Oruc´ L, Mimica N, Ljubin T. Psychotic symptoms and comorbid psychiatric disorders in Croatian combat-related posttraumatic stress disorder patients. Croat Med J 2000;41:179–83. [13] Bleich A, Moskowits L. Posttraumatic stress disorder with psychotic features. Croat Med J 2000;41:442–5. [14] Gustafsson M, Amilon A, Ahlström G. Trauma-related distress and mood disorders in the early stage of an acute traumatic hand injury. J Hand Surg Br 2003;28:332–8. [15] Rusch MD. Psychological response to trauma. Plast Surg Nurs 1998;18: 147–53. [16] Rusch MD, Dzwierzynski WW, Sanger JR, Pruit NT, Siewert AD. Return to work outcomes after work-related hand trauma: the role of causal attributions. J Hand Surg Am 2003;28:673–7.
ScienceDirect www.sciencedirect.com Chirurgie de la main 32 (2013) 413–415
Clinical case
The psychotic mummified hand: An unusual hand injury complication La main momifiée psychotique : une complication inhabituelle d’un traumatisme de la main L. Mathieu a, E. Guillibert b, W. Mamane a, E.H. Masmejean a,* a
Hand Surgery Unit, Orthopaedics and Trauma Department, Paris-Descartes University, Sorbonne Paris-Cité, Georges-Pompidou European Hospital (HEGP), AP–HP, 20, rue Leblanc, 75908 Paris cedex 15, France b Department of psychiatry, Paris-Descartes University, Sorbonne Paris-Cité, Georges-Pompidou European Hospital (HEGP), AP–HP, 20, rue Leblanc, 75908 Paris cedex 15, France Received 8 July 2013; received in revised form 7 September 2013; accepted 15 September 2013 Available online 1 October 2013
Abstract The authors report the case of a patient with psychotic symptoms secondary to a posttraumatic stress disorder following a work-related hand injury. The somatic presentation was a ‘‘mummified’’ hand neglected for several years in a splint without any care. The psychiatric analysis concluded that this was part of a delusion of persecution expressing a conflict against the patient’s employer and insurance company. Surgical treatment was limited to a hand cleaning with hardware removal. Despite 3 years of antipsychotic medication the patient was still suffering from delusion and the hand remained neglected at the last follow-up. # 2013 Elsevier Masson SAS. All rights reserved. Keywords: Hand injury; Posttraumatic stress disorder; Depression; Psychosis
Résumé Les auteurs rapportent le cas d’un patient présentant des troubles psychotiques secondaires à un syndrome de stress post-traumatique survenu à la suite d’un accident du travail intéressant la main. La présentation somatique était celle d’une main « momifiée » négligée depuis plusieurs années dans une attelle sans aucun soin. L’analyse psychiatrique a révélé que ce tableau s’intégrait dans un délire de persécution lié à un conflit avec l’employeur et la compagnie d’assurance du patient. Le traitement chirurgical s’est limité à un nettoyage de la main et à une ablation de matériel d’ostéosynthèse exposé. Trois ans plus tard, le patient restait délirant avec une main exclue en dépit d’un traitement antipsychotique et d’un suivi psychiatrique prolongé. # 2013 Elsevier Masson SAS. Tous droits réservés. Mots clés : Traumatisme de la main ; Syndrome de stress post-traumatique ; Dépression ; Psychose
1. Introduction An acute injury to a hand can be a disturbing event that might influence patient’s physical, psychological and social equilibrium [1]. Patients may experience loss of hand function and in addition they may experience pain, cosmetic disfigurement, and traumatic related distress [2]. Psychotic features have been described in patients with combat-related Post-
* Corresponding author. E-mail address: [email protected] (E.H. Masmejean). URL: http://www.handsurgery.fr/
traumatic Stress Disorder (PTSD) [3], but never after a hand injury in civilian practice. We describe a case of posttraumatic abnormal posture of the hand due to a persecution delusion combined with a PTSD and a major depressive episode.
2. Case report A 31-year-old right-handed man from North Africa was referred for a deformity of his right hand. Five years ago, when he was working in a foreign country, he sustained a workrelated near-amputation of his right middle finger by a saw. He
1297-3203/$ – see front matter # 2013 Elsevier Masson SAS. All rights reserved. http://dx.doi.org/10.1016/j.main.2013.09.003
414
[(Fig._2)TD$IG] main 32 (2013) 413–415 L. Mathieu et al. / Chirurgie de la
underwent bone grafting and fixation of the proximal phalanx, extensor and flexor tendon repair, and a cross finger flap. Postoperative cares included pain medication and physiotherapy. When we saw him for the first time, his hand was still immobilized in a dirty dorsal splint, and he seemed to have ignored it for several years. The patient and his family asked for corrective surgery for this hand deformity. Examination revealed a dysfunctional posture of the hand induced by the splint, with static positioning in extension at the metacarpophalangeal joints and flexion at the wrist and interphalangeal joints. The thumb and the fifth finger were adducted with atrophy of the intrinsic muscles. Hygiene had been neglected: the nails were several centimeters long, the skin was macerated, and a screw protruded from the dorsal side of the middle finger (Fig. 1). Neurologic examination was difficult to perform because of a poor patient cooperation. Active range in motion was painful and the patient would not permit passive range of motion. X-rays showed diffuse osteopenia and healing of the middle finger fracture (Fig. 2). Nerve conduction studies revealed slightly decreased amplitudes of the sensory action potential in all fingers of the right hand, but motor conduction was normal in median, ulnar and radial nerves. There were no sign of denervation in intrinsic muscles of the hand. The patient was scheduled for cleaning and screw removal (Fig. 3). Under general anesthesia the fingers and wrist could be fully mobilized, except for the proximal interphalangeal joint of the middle finger, which was fixed at 308 flexion. The absence of stiffness in the wrist and non-operated fingers joints indicated likely mobilization despite splinting during the last years. Psychiatric assessment revealed a history of Posttraumatic Stress Disorder (PTSD), depression and paranoia following the accident. The patient had never returned to work, and had entered into a conflict with his employer and insurance
[(Fig._1)TD$IG]
Fig. 2. X-ray showing internal fixation of the proximal phalanx of the middle finger with the protruding screw.
company after their refusal to grant him financial compensation. He had also complained about frequent pain for about 2 years, and believed that his insurance company had implanted an electronic capsule in his body in order to control his mind and make him sick. Then, the patient was transferred to a psychiatric hospital where antipsychotic medication was initiated. A rehabilitation program was associated but his lack of cooperation made it difficult to achieve. Using Diagnosis and Statistical Manual of Mental Disorders (DSM) – IV criteria [4], the diagnosis was a chronic psychotic feature comorbid with a PTSD and a major depressive episode on the axis I, without a personality disorder on the axis II. Finally, he was referred to a psychiatrist in his country of origin, and a long-term antipsychotic treatment was prescribed. At the last follow-up, 3 years later, the patient still showed a delusion of persecution and a total neglect of his hand.
[(Fig._3)TD$IG]
Fig. 1. Initial aspect of the hand after 5 years of permanent splinting: volar view (a), radial view (b) and dorsal view (c).
Fig. 3. Aspect of the hand after cleaning.
L. Mathieu et al. / Chirurgie de la main 32 (2013) 413–415
3. Discussion The influence of psychological factors on the hand is well known and not uncommon. Many clinical cases have been described including malingering, factitious or somatoform disorders [5–8]. In this case report a psychogenic etiology was first considered because of the dramatic appearance of the hand, but an organic etiology had to be ruled out. The history of single digital injury and electrodiagnostic studies were not in favor of a neurological lesion. Reduced amplitudes of sensory action potentials in all digits were difficult to explain, but could be related to chronic flexion posturing of the wrist inside the splint. A factitious disorder was initially suspected, but psychiatric assessment revealed psychotic features. Our analysis was that this ‘‘neglected hand’’ was not the result of malingering, but was a part of the chronic posttraumatic delusion. Patients who sustain a hand trauma frequently develop symptoms of PTSD, especially after work-related injuries [1]. Symptoms of PTSD include reexperiencing of the trauma, hyperarousal and avoidance of stimuli associated with the trauma [4]. Intrusive symptoms (i.e. re-experience of the trauma in dreams and flashback) and avoidance symptoms are present in the early stage, but are also reported after the first year [2]. The initial psychological distress of this patient was unclear because no assessment was performed in the months following the accident. However, 5 years later, he described persistent intrusive and avoidance symptoms with somatization in favor of a PTSD: the chronic pain was a constant reminder of the trauma, and the splint was a mean to avoid the sight of the traumatized hand [1,2]. Comorbidity between PTSD and psychotic symptoms has been reported in number of clinical studies, particularly in veteran soldiers, but it is relatively uncommon [3,9,10]. The co-occurrence between posttraumatic and psychotic symptoms is well described in the immediate suites of a trauma, but can also be chronic [11]. A PTSD subtype termed PTSD with secondary psychotic symptoms (PTSD-SP) has been recently described. In PTSD-SP the onset of PTSD predates the onset of psychosis, excluding patients with schizophrenia [9]. The links between psychotic and psycho-traumatic symptoms are complex and multidirectional. A personality of psychotic structure increases the risk of PTSD, and a trauma can test a latent psychotic structure to reveal its existence [11]. According to his family this patient did not seem to have personality disorder or psychiatric diagnosis prior to the injury. Psychotic symptoms in PTSD are different from flashbacks, but have strong symbolic relation to the trauma [10,12]. In this case, the dramatic aspect of the hand was a reminder of the severity of the trauma for the patient, and a part of the persecution delusion, which was expressive of the conflict against his employer and insurance company. Persistent delusion and hand exclusion after 3 years of therapy indicates a PTSD-SP resistant to antipsychotics. The efficiency of chronic antipsychotic drug treatment remains controversial in this indication [3,12,13]. Finally, it is important to identify patients with trauma-related distress in its early stage after a hand injury. Pain and aesthetics are statistical predictors
415
of symptoms of PTSD in acute hand-injured patients [1]. According to Gustafsson et al. [14] negative reactions to the sight of the hand are associated with both trauma-related distress and mood disorders. These patients must receive psychotherapy with the dual objectives of symptom reduction and return to former work activities when possible [15,16]. 4. Conclusion This extreme clinical situation underlines that severe psychotic features can complicated PTSD after hand injuries. Patients with trauma-related distress should be identify in the early stage, and require a psychological support to prevent progression. Disclosure of interest The authors declare that they have no conflicts of interest concerning this article. References [1] Opsteegh L, Reinders-Messelink HA, Groothoff JW, Posterna K, Dijkstra PU, van der Sluis CK. Symptoms of acute posttraumatic stress disorder in patients with acute hand injuries. J Hand Surg Am 2010;35:961–7. [2] Gustafsson M, Windahl J, Blomberg K. Ten years follow-up of traumarelated psychological distress in a cohort of patients with acute traumatic hand injury. Int J Orthop Trauma Nurs 2012;16:128–35. [3] Hamner MB, Frueh BC, Ulmer HG, Arana GW. Psychotic features and illness severity in combat veteran with chronic posttraumatic stress disorder. Biol Psychiatry 1999;45:846–52. [4] American Psychiatric Association. Diagnostic and statistical manual of mental disorders, 4th ed., Washington, DC: American Psychiatric Association; 1994. [5] Kasdan ML, Stutts JT. Factitious injuries of the upper extremity. J Hand Surg Am 1995;20:S57–60. [6] Krahn LE, Bostwick JM, Stonnington CM. Looking toward DSM-V: should factitious disorder become a subtype of Somatoform disorder? Psychosomatics 2008;49:277–82. [7] Batra S, Sarasin SM, Gul A, Kanvinde R. Psychoflexed hand: a forgotten entity. A case report and review of the literature. Int J Clin Pract 2008;62:1634–6. [8] Cuénod P, Smaga D, Degive C, Della Santa DR. Psychogenic spastic hand. Ann Chir Main Memb Super 1996;15:100–8. [9] Sautter FJ, Brailey K, Uddo MM, Hamilton MF, Beard MG, Borges AH. PTSD and comorbid psychotic disorders: comparisons of veterans diagnosed with PTSD or with psychotic disorder. J Trauma Stress 1999;12:73–88. [10] Butler RW, Mueser KT, Sprock J, Braff DL. Positive symptoms of psychosis in posttraumatic stress disorder. Biol Psychiatry 1996;39:839–44. [11] Auxéméry Y, Fidelle G. Psychosis and trauma. Theoretical links between posttraumatic and psychotic symptoms. Encephale 2011;37:433–8. [12] Ivezic´ S, Bagaric´ A, Oruc´ L, Mimica N, Ljubin T. Psychotic symptoms and comorbid psychiatric disorders in Croatian combat-related posttraumatic stress disorder patients. Croat Med J 2000;41:179–83. [13] Bleich A, Moskowits L. Posttraumatic stress disorder with psychotic features. Croat Med J 2000;41:442–5. [14] Gustafsson M, Amilon A, Ahlström G. Trauma-related distress and mood disorders in the early stage of an acute traumatic hand injury. J Hand Surg Br 2003;28:332–8. [15] Rusch MD. Psychological response to trauma. Plast Surg Nurs 1998;18: 147–53. [16] Rusch MD, Dzwierzynski WW, Sanger JR, Pruit NT, Siewert AD. Return to work outcomes after work-related hand trauma: the role of causal attributions. J Hand Surg Am 2003;28:673–7.
