Factitial Leg Ulcers Associated With an Unusual Sleep Disorder

To the Editor.—  In their article entitled "Factitial Leg Ulcers Associated With an Unusual Sleep Disorder," I believe that Brodland et al¹ recommend polysomnographic studies in patients with factitious disease on the basis of a faulty assumption of causality.Their patient experienced symptoms of erythromelalgia of the feet for 2 years before presentation. After 10 months, nighttime wakefulness and frequent brief naps during the day were noted, giving the patient only 2 to 3 hours of sleep every 24 hours. Six months later she presented with extensive and deep cutaneous ulcerations that were located on sites primarily accessible to the hands; their "linear and angular qualities" would suggest the digging and gouging that was described more cogently than the rubbing that was impugned.The patient was observed "removing her dressings, and scratching and digging at the ulcers." Behavioral regression, flat affect, and preoccupation with her legs was noted; she