Article
During dental school, we are taught to take a thorough history, assess appropriately, carry out special investigations before considering differential diagnoses and formulating a treatment plan. However, there are cases where the history does not correlate with the clinical symptoms, or when special investigations reveal nothing abnormal, and it is a struggle to decide where to refer.
I witnessed such a case unfold. A 17-year-old female patient presented with a 10-day history of a locked jaw and frequent episodes described as seizures. This was a particular point of interest as the ‘seizures’ were described as sudden jerking movements of the limbs with no loss of consciousness, incontinence or loss of reflexes. In fact, the patient would remain conscious and responsive throughout. The patient's past medical history revealed an eating disorder and multiple hospital admissions, while the social history provided by the family described a stress-free teenager embarking on a highly sought-after first job. The patient had undergone a wide range of special investigations to rule out neurological disorders, tetanus and the possibility of a stroke, while the use of muscle relaxant was unsuccessful in releasing the clenched jaw. Our assessment revealed no signs of an anterior disc displacement without reduction of the temporomandibular joint, which may cause a locked jaw.
After a bold suggestion that the symptoms may be voluntary, the patient underwent psychological analysis to reveal the likelihood of a subconscious functional disorder and a differential diagnosis of Munchausen's syndrome. Munchausen's syndrome is a psychiatric factitious disorder wherein those affected feign disease, illness, or psychological trauma to draw attention, sympathy, or comfort to themselves.1
This case demonstrates that, in some rare scenarios, reaching a diagnosis may require a health professional to think laterally (once all logical and likely diagnoses have been considered). As dentists, we may be exposed to similar patients complaining of atypical facial pain, TMJ issues and even toothache. Without suggesting that we become sceptical, it is important to consider psychological contributors and the use of Cognitive Behavioural Therapy.1