Wednesday, April 15, 2009
Two complex cases
Just finished a teleconference with a 'cast of hundreds' from one of our community clinics and also the inpatient service. 10 year old girl with school refusal from time to time, who has incredible anxiety attacks with screaming, serious upset, and occasional lashing out. The diagnosis is unclear, although the consensus is that she has a vestige of a separation anxiety with ongoing worries about mother's mental wellness and relationships; the precise nature of these has been obscure despite much detailed work by several therapists over a couple of years. We all feel that spending a lot of time worrying about the formal 'diagnosis' has not been useful, and that what works better is to take each little problem and work towards a solution, so that eventually all the little solutions will fit together into a clear jigsaw picture.
However, a distant family member is a doctor, and their reading of the symptom constellation is that the girl has juvenile bipolar disorder - a contentious diagnosis in Australia. Added to this the local education department will not provide extra in school support unless there is a clear diagnosis, and someone in the department has developed a nice little list of symptoms for bipolar, with the implication that if we sign a form to say she has bipolar then the girl will get extra help. She certainly has 7 of the criteria, but from my point of view, these could fit with at least 3 other issues. However, over a barrel, I accepted that we need extra help, so I signed the form last year..... Now of course everyone outside our service thinks the answer to getting change is some miniscule tweaking of medication. We, on the other hand, have tried many times to get change going for this girl - with medication as an inpatient and an outpatient used to target symptoms. This means she has been on one of the prime medications for bipolar for some time - with no success.
What has worked over the last few months is a clear and careful plan, focusing on one symptom at a time, with careful grading and practice of solutions. And our patient has attended school for a whole term. There is still a way to go, and we still need to focus better on mum and her problems, and possibly the mum and dad's relationship. I made the point today that about 5-6 years down the track the jigsaw will be much clearer, and we will all look back with the retrospectoscope, and say: "Oh, is that what was going on?" In the meantime we just have to keep plodding on (and try to avoid labels and medication). Sometimes life is very complex, and you just have to keep putting one foot in front of the other in the sure knowledge you will get to a destination.
The other case happened last night. As you will see if you visit our suicide prevention studies site, one major interest is in self-injury and its complex relationship with suicidality, and occasionally completed suicide. I received a phone call from a young woman who has been cutting herself, and also been in and out of anorexia nervosa over many years. She was at the casualty department waiting and waiting to have a cut sewn up. As is usual she had been treated with contempt, and then was sewn up without anaesthetic. Why is it that perfectly reasonable health staff turn into vengeful angels when faced with self-injury? "You are not really a patient (or perhaps even a person) if what you do is self injury!"
I am not the prime therapist for this woman, but we have presented on the same platform at conferences on self-injury. She phoned because there is a plan in place, and in the notes, which says she is not to be admitted unless 'in extremis'. She just wanted to go home to her family. The emergency staff wanted to take blood to see whether she had also taken an overdose (she had not), then they wanted to admit her on the grounds that this time the cut was deep and took 20 stitches. She was waiting to see a psychiatric registrar. She wondered whether I would speak to the registrar, and explain what I knew of her history, and the written plan, and see whether that would keep her out of hospital. I did, and the registrar was very pleasant. My young colleague told me later the registrar "was horrible. Rude. Short. Grumpy." And these are the so called 'helping professionals'!