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I felt a desperate desire to save him--a danger sign in therapy. I could affirm his suffering but not his fierce self-punishment, which I insisted had to cease. Near the end of the year, I realized he was having difficulty telling me that he had begun again to exact his terrible revenge. When I confronted him with my suspicions, Gus became angry. He told me he would not be dependent on our relationship, but would independently decide when he would stop. After telling me this, he simply did not come again and I lost contact with him entirely. For Gus Echeverra chronic illness had deeply idiosyncratic meaning that can be understood only in the alienating context of his extraordinary intrapsychic life. I see him at the deeply tragic end of a continuum. The personal significance of illness is always important, but often it is dominated by the kinds of social and cultural significance I have illustrated in the preceding articles. Yes, anything. Jude starts to walk around the shop. I point out his options. I show him shelves of board games, remote control trucks and cars. I walk him over to a glass cabinet filled with electronics, saying, Look, Jude. You can even get an iPad. He continues to walk around, eventually lifting his eyes to the top shelf that borders the entire shop. Along this shelf are giant stuffed animals, many of which are bigger than he is. You can probably imagine what we're looking at. He gradually works his way over to the corner where there's a giant, fluffy white unicorn with a hot pink mane and a golden horn. In 2008, replied Ken.

When in 2008? February what? February 13th he said. I'll never forget the date. Branden died on February 12th. Oh, no, it's not the same, Ken quickly said. My donor was a 21-year-old who died in a car accident. Oh, said Gail, as she went back to packing and Ken went back to painting. After a little while, Gail needed to run an errand, and she left Ken alone in her apartment with one wall painted yellow. Stop preventing yourself from living the life you've laid out for yourself as the ideal. You are not a lazy person, you're acting lazy, and it's your own thoughts that are making the lazy choices. Stop listening to them. Stop giving them breath and life. Move forward. When you have set out to do something, when you have a day planned, stick to that plan. Don't think. You've already thought, that's where the plan came from. You no longer need to think. You need to do. However, in many individuals the psychological meanings are the most powerful influence on the course of the illness.

Even among this group of patients, self-inflicted illness is very uncommon. I have encountered fifty cases of factitious illness in a career devoted to chronic illness. Only a few were as strange as that of Gus Echeverra. His story may have sent chills through my body and challenged my own sense of reality, yet it taught me that compassion can overcome revulsion to bridge, however fragilely and incompletely, radically different life worlds. That is a lesson clinicians learn in one way or another, usually through the more mundane reality of caring for ordinary lives lived with illness. Factitious illness points to something darker, more driven, less appeasable, less given to reinterpretation as simply cognitive or affective reaction to illness. Each case of factitious illness discloses deep fissures in our inner world, a scarred soul who demands terrifying reenactment of the felt experience of suffering. The words depression, anxiety, guilt, and anger do not do justice to the deeply indwelling, self-defeating psychic forces that create and intensify the experience of illness. There is still something important left unsaid, an aspect of our unique character usually hidden even from us, that can make of life a living hell and of illness a life. And then he speaks. Dad, do I have enough tickets to get that unicorn? What do you say in that moment? Here's what I say: You could. Or you could get an iPad. Jude says, I want to get that unicorn. In that moment, I had a moment. As a dad, I wasn't sure what to do. Sure, we'd recently watched the Minion movies as a family and laughed at the little girl who fell in love with the same stuffed unicorn that sat on the top shelf of Dave & Buster's that day, but I didn't expect my son to want one too. I wasn't sure what to do. When she returned, she found him standing right where she had left him.

He hadn't made any progress. Is there something wrong? Gail asked. I lied to you. You're not a painter? No, not about that. I do have Branden's kidney. When you told me that Branden was your son's name and you were Gail, I immediately realized that I'd received a note from you after I had the transplant. I was given the option to write back to you, and I'm so ashamed that I never did. Persistence We have too many options. We also feel as though we're entitled to the things we want in life because we've spent much of our lives hearing how important and special we are. We are the center of the universe. But, really, all too rarely do we view our lives from afar. Imagine viewing yourself right now from high overhead. Around you can see other people working at their jobs, dealing with problems, taking care of their families. You'd see that whatever you're dealing with right now is one of many issues in your neighborhood. The higher your perspective, the more people you'll see juggling an ever-greater number of problems of increasing complexity. When you see yourself as one of seven billion people on the planet, you are forced to acknowledge that you're not special, that you have a lot of competition, and that whatever you want in life you're going to have to earn it. Factitious illness can also be grouped under syndromes of deliberate self-harm, which include as well repetitive self-mutilating behaviors such as cutting and burning the skin (see Favazza 1987).

These syndromes may occur in the context of serious mental disorders, like schizophrenia or borderline personality disorder, or as autonomous disorders; Hypochondriasis The Ironic Disease It is the copying that originates. By definition, hypochondriasis is that disease in which there is no disease. In contemporary psychiatry it is classified as a chronic condition in which the patient persists in his nosophobia (fear of disease) in spite of medical evidence to the contrary: the patient fears he has a disease, but the physician finds no evidence that the patient's fears are based on the existence of a pathological process. In the dualistic terminology of biomedicine, the patient has an illness experience without the biological pathology of disease. To diagnose hypochondriasis, the practitioner must become convinced that the disease the patient fears he is suffering from is not present. For hypochondriasis to become chronic, the practitioner must also be unable to convince the patient of this fact, because if the patient comes to accept the medical evidence that he is not suffering from the disease he fears he is experiencing, then he no longer has the disease hypochondriasis. I paused, then proceeded to say, Yes, if that's what you really want. But you can have just about anything else too. As we leave the building and walk across the parking lot toward our car to head home, Jude beams. I, on the other hand, am not. I'm not upset; I'm still perplexed. I ask, Are you excited about your unicorn, buddy? With a huge smile on his face, he looks up at me and says, Yeah, Dad. Sissy is going to love her unicorn so much. Instantly, I take a deep breath, and it's as if it resets my whole system. Gail, stunned, immediately picked up the phone and called the transplant center.