Treatment refusal in adolescents with severe chronic illness and borderline personality disorder.

Introduction: The aim of this study is to address the complex psychopathologic factors involved in treatment refusal observed in adolescents suffering from a severe chronic illness.

Method: We report on five chronically ill adolescents (2 diabetes mellitus, 1 maple syrup urine disease, 1 bird fancier's lung, 1 HIV infection) who were consecutively admitted to an inpatient psychiatric service as a result of a life-threatening refusal to comply with outpatient management of their medical illness. Case material is analyzed and discussed in the context of a review of the literature.

Results: Each subject was further characterized by: (1) the diagnosis of Borderline Personality Disorder; (2) severe family dysfunction (e.g. abuse, neglect and abandonment); and (3) frequent and prolonged pediatric hospitalizations. During their psychiatric hospitalization, the patients' initial opposition to treatment shifted to mentalization and psychological questioning. From a psychodynamic perspective (attachment theory), we hypothesized that this behavior represented an attack on parental figures as embodied in the suicidal comportment.

Conclusion: Case material is presented to underline the possibility of co-occurring Borderline Personality Disorder when treating youths suffering from chronic illness and refusing treatment. Awareness of Borderline Personality Disorder may help pediatric staff when dealing with this refusal.