Letters to the Editor
Involuntary Treatment of a Patient with Factitious Disorder: A Paradox?
Dear Editor:
We recently undertook a chart review on a challenging patient. Aside from the statistical aspects, the review shed light on the factitious component of her presentation. We report an uncommon approach to the management of this patient, whose factitious disorder compromises the treatment of her bona fide illnesses: long-term involuntary inpatient treatment.
Case Report
FD is a 35-year-old single, childless white woman on social assistance. Her extensive psychiatric history began at age 14 years with the diagnosis of panic disorder. Anorexia nervosa was diagnosed 2 years later but soon revised to bulimia nervosa. At age 17 years, bipolar affective disorder type I was added. FD also engages in polydipsia, consuming as much as 84 cans of cola during a weekend. This has been manifested independently of bulimia. A borderline level of integration underlies her histrionic and narcissistic behaviour.
FD’s family is highly enmeshed. Her father retired early from farming, owing to his rheumatoid arthritis and his struggle with alcoholism. Her mother was a nurse and worked night shifts so she could “babysit” FD’s father. Prestigious awards for academic brilliance and ballet dancing marked FD’s early development. However, she pursued high marks as an end. FD once admitted that, in Grade 3, she injured her foot deliberately to be excused from a rare slip in her marks. Corresponding documentation indicates that the orthopedic surgeon found FD had changing symptoms, which he attributed to chronic ankle strain. She was unable to complete the second year of university or maintain employment for more than a few months. Clinical records aside, FD’s charts are littered with writings that discuss her engrossment with the pursuit of youth, beauty, and prestige. They reflect frequent resort to denial, to acting out, to externalization, and to intellectualization, as well as to erotic transference to male psychiatrists. Subtle suggestions of deception abound. In fact, in one letter, she detailed reasons for maintaining her bulimia, one of which was the freedom from responsibility.
Her medical records show 91 hospitalizations between 1981 and 2001. FD was certified for at least part of 30 admissions. There were numerous examples of noncompliance and of premature discharges against medical advice, many of which were facilitated by her mother. Hospital fees alone totalled $1.6 million, overshadowing the costs of other health care use, including her 175 emergency room visits that did not lead to admission. Inconsistencies on several levels insinuate a factitious component in FD’s presentation: 1) her frequent calls for attention to her symptoms contrast sharply with her habitual defences; 2) rarely does one encounter a patient with bulimia who frequents the emergency room demanding specific blood work and intravenous therapy; and most informative, 3) mental status examinations contradicted her complaints on many occasions.
It seems paradoxical to apply long-term certification in treating a patient with factitious disorder. FD’s case, however, is complicated by comorbidity with Axis I diagnoses. Periods of relative stability followed previous involuntary hospitalizations. Lasting gains are likely possible only in a setting where her treatment cannot be sabotaged by her impulsivity and her mother’s interference. The outcome remains to be evaluated.
Bienca Lau, Resident
Eugene Marcoux, Consultant
Saskatoon, Saskatchewan
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