Caffeine III

This post is a continuation of the story from the last two posts.

Over the next few days, her creatine kinase peaked and returned to normal. As a healthy 35 year old woman, her kidneys did well in excreting all the caffeine. But her troubles extended to her relationships with the staff. She loved some nurses, she hated the others. She opened up to me, but wouldn't say a thing to my resident. She expressed both love and hate for her mother and step-father. She wanted them to vacate her life and then wanted them to visit and when they visited, refused to talk to them. She said she was suicidal any time we brought up the possibility of sending her home, but the staff claimed the more they interacted with her, the happier she seemed to be.

I met her parents. I was afraid given all I'd heard, but they struck me as perfectly normal people. I learned that they had adopted her at age 5. Since age 16, she has had difficulty getting along with others (though the patient insisted that the voices and paranoia began at age 8). They denied any maltreatment of the patient despite the patient's allegations of harm and rape. Since the patient brandished a knife at them, they needed to call 911 every few months for psychiatric emergency services. The family went through counseling and multiple psychiatrists to no avail. "We just don't know what to do anymore," the mother said. "Her schizophrenia is so severe and it's ruined my husband's and my life. But nobody believes us. One psychiatrist says she's a paranoid schizophrenic and another says she's not. One says she's schizoaffective bipolar and another says she's just bipolar and another says there's nothing wrong at all, she simply has a borderline personality disorder. But I've taken care of her since she was little. She hears voices. She can't sleep at night without her step-dad in the room, then claims her step-dad wants to rape and kill her. She thinks she has special powers. She's never held down a job. She just can't function."

"Wow," I said. I'm not sure if that's what I should have said, but it's how I felt.

The mother continued. "We need you to make this diagnosis clear. She tried to kill herself. She drove out to the store, bought a bottle of pills, and swallowed them all. She's suicidal, she has a mental illness, and she needs help. We need you to transfer her to the psychiatric inpatient facility. Otherwise, she'll continue ruining her life and ours as well."

The psychiatry resident finessed the situation with the patient. The patient didn't deny any of this, but the psych resident was just a little skeptical. He talked to the outpatient psychiatrist, who also had his reservations. The outpatient psychiatrist felt that the patient and her parents exaggerated the symptoms and demanded medications; when medications failed, the patient wasn't complaining of the usual side effects. He had been trying to minimize medications and work on cognitive-behavioral therapy.

When the patient was medically "cleared" after the caffeine overdose, I asked psychiatry whether she should be admitted to the inpatient service. Both she and her parents demanded this. But psychiatry was reluctant to do so. They felt that the patient's mental illness was compounded by both a component of Munchausen syndrome and Munchausen-by-proxy. In the psychiatric factitious disorder of Munchausen syndrome, patients will feign illness or psychological trauma to draw attention or sympathy to themselves. They want to be in the role of the patient, dependent and comforting; this psychological need drives them to hurt themselves or fake illness. Munchausen-by-proxy is a similar syndrome in which a parent fakes or afflicts a disease on their child to get them medical attention. This is a form of child abuse, but I'd never heard of it described for someone in their 30s. In essence, the thought was that both parent and patient had a psychological need to be in the "patient role" and thus fabricated or deliberately induced medical and psychological illness to get us to see her.

The patient had been seen by the same outpatient psychiatrist for three years and been seen at that office for six years, and the outpatient physicians strongly felt there was a component of a factitious disorder. She had chosen to overdose on caffeine, something that is not very lethal but dangerous enough to get her hospitalized. Her parents were irrationally committed to hospitalizing her at a locked facility. Her borderline personality disorder fed off of attention in the hospital. The psychiatry consult team reviewed notes from past hospitalizations which were all consistent with factitious disorder. They recommended discharging her with close outpatient follow-up to balance feeding her psychological addiction to attention with the possibility of suicide. This was one of my most interesting patients as a medicine sub-i.