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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'!

1 comment:

  1. Re: Your acquaintance who is anorexic & self-harms. There seems to be so much contempt in the medical professional for these poor souls who are merely trying to "feel" or counteract another feeling with the self-injury pain. Many friends & acquaintances have been cruelly handled & verbally abused in A&E for anti depressant overdoses, various cutting activities & allowing sadistic sexual partners to injure them. Most recently, I have been blamed for the suicide death of a friend who ended up hanging himself shortly after I was chatting with him on Facebook. He was a gorgeous-looking fellow, brilliant in the computing field & when younger had been very athletic- climbing moderate, snow-covered peaks all over the world with his twin brother. His dad had been a cruel taskmaster- rarely home & constantly changing the kids' schools while chasing big mining engineering jobs around the world. I don't know how my friend became the way he was at 40, but I can imagine it. It was clear from his self-injury attempts that he had no desire other than to experience the pain & see the blood, but he also thought these things might be life threatening as he would call the ambulance or drive himself to A&E. Usually he was sewn up, no anaesthetic, and verbally abused, thrown out on the streets with no appointments organised at 2am. Prior to killing himself he did this 3 times in one week. He didn't like his appointed therapist & wasn't "allowed" to try another, didn't attend groups regularly, kept up his alcohol abuse & still managed to go and live with a "girlfriend" for 6 month before being thrown out. I used to spend time with him- "baby-sitting" was the term his age-congruent friends used- I would take him for walks & photography trips around the city, talk about current things & mutual friends & events. Meanwhile, if he mentioned his cutting etc, I would try to explain what he had done anatomically and why the nurses/doctors weren't taking him seriously. I encouraged him to continue to try & find a suitable therapist and to persist with suggested treatments for a few weeks to give them a decent try. We also discussed that if either of us felt that life really wasn't worth living any more, we would kill ourselves in a "foolproof"way- but we never discussed details- just that sometimes things were painful, where he had his cutting & I had social withdrawal & no sleep. If only the psychiatric/psychological/medical/social work professions could just "work with" people like my friend, there would be less suicide. Just because someone is labeled "borderline" or "narcissistic" doesn't mean they fall outside the bounds of humanity. Real human beings live inside these people and the world lost a lovely one with my friend.