Fatal cardiac failure due to myocardial microthrombi in systemic lupus erythematosus.

Our patients had typical features of factitious disease,1 2 three of them developing anorexia nervosa. They had been bleeding themselves for four to 11 years and were well adapted to severe chronic anaemia with haemoglobin concentrations rarely above 60 gll. Their physical fitness was remarkable, and, notably, they tailored their bleeding such that it did not jeopardise an active life. Although our patients showed little overt psychopathological behaviour, all had a borderline personality disorder.2 Psychotherapy seems to be of little value in such disorders, and only one patient with factitious anaemia has been successfully treated with psychotherapy.4 Nevertheless, such patients should be offered regular medical and psychiatric care; psychiatric consultation at an early stage in somatisation disorders reduces the costs of health care considerably, although it does not improve mental, physical, or social health.' Similarly, our patients appreciated regular meetings with doctors or psychotherapists to discuss their problems, although such meetings did not result in a cure.