A Challenging 'Disease'

Mrs. L kept me busy all week on call. A patient with type 1 diabetes, and like many others, pretty brittle. Has been in the hospital for 7 weeks now, from complications of GI surgery.
Despite stable doses of insulin, her glucose levels would swing wildly, from very, very lows, to very very highs, with no clear change in intake, or insulin.
Over the weekend, she was transferred to the ICU for septicemia. Ultimately her blood cultures grew all kinds of weird bugs. But during the emergent transfer, when the nurses were packing up her stuff, they found a bag stashed in her room.
A bagful of medicines, insulins, syringes, even meth. Many dirty needles. The surgeon then confronted her (and I'm glad this was a no-nonsense, pig-headed, God-complex surgeon) and got it out of her. While the medical and surgical team have been trying to help her, she was doing drugs, and also injecting all kinds of things into her, even deliberately contaminating needles with fecal matter, and pricking herself. She was also alternating injections of insulin and dextrose into her IV port, which probably explains the swings.
Munchausen Syndrome.

Munchausen syndrome is a type of factitious disorder, or mental illness, in which a person repeatedly acts as if he or she has a physical or mental disorder when, in truth, he or she has caused the symptoms. People with factitious disorders act this way because of an inner need to be seen as ill or injured, not to achieve a concrete benefit, such as financial gain. They are even willing to undergo painful or risky tests and operations in order to get the sympathy and special attention given to people who are truly ill. Some will secretively injure themselves to cause signs like blood in the urine or cyanosis of a limb. Munchausen syndrome is a mental illness associated with severe emotional difficulties.

Munchausen syndrome—named for Baron von Munchausen, an 18th century German officer who was known for embellishing the stories of his life and experiences—is the most severe type of factitious disorder. Most symptoms in people with Munchausen syndrome are related to physical illness—symptoms such as chest pain, stomach problems, or fever—rather than those of a mental disorder. Reference: clevelandclinic.org

I've seen perhaps 5 or 6 of these in the last 10 years. Always difficult to prove, unless you catch someone red handed. After all, how can you confront someone and accuse them of lying? Though that gal I saw in residency was making it pretty obvious when her skin abscesses grew enteric bacteria, but these occured ONLY in areas of her body where she could physically reach (frontal body, trunk, none in the back).
Always a challenge to treat- as doctors we are trained to treat the medical problem at hand. With care and concern, medicines, invasive therapy. But that is always with the assumption that the patient's on your side. But how do you treat someone, when that someone is working against you, trying to sabotage things?