title: Treatment refusal in adolescents with severe chronic illness and borderline personality disorder.
abstract: BACKGROUND
  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.
  
  
  METHODS
  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.
  
  
  CONCLUSIONS
  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.
authors.affiliation: Department of Child and Adolescent Psychiatry, Université Pierre et Marie Curie Hôpital Pitié-Salpétrière, APHP, Paris, France.
authors.forename: Emmanuel
authors.initials: E
authors.lastname: Jaunay
authors.forename: Angèle
authors.initials: A
authors.lastname: Consoli
authors.forename: Brian
authors.initials: B
authors.lastname: Greenfield
authors.forename: Jean-Marc
authors.initials: JM
authors.lastname: Guilé
authors.forename: Philippe
authors.initials: P
authors.lastname: Mazet
authors.forename: David
authors.initials: D
authors.lastname: Cohen