A difficult case

A colleague writes in . . .

 I’m a therapist working with an adolescent with a rapid cycling bi-polar, and the episodes of suicidal thoughts are not improving, the psychiatrist is working on the meds, we seem to have a good week and a bad week, where episodes of deep depression hit most days and last about 1-2 hours, then they ease and the thoughts go. I’m teaching her to use distraction, we’re using cbt, the ocd is improving but the self harm stuff is worrying, any suggestions for manageing these suicidal episodes? also has aspergers .I’ve talked about referral to a more experienced clinician but the family want me to continue as we seem to have a good rapport even though we have only recently started working together, I’m not sure if I’m really not up to this or if I’m just stressing too much but I and want to do the best I can for this client.

This certainly sounds like a very difficult case with many areas of difficulty competing for your attention.  I think that we all have had cases like this where we feel out of our league.  Despite this, the family is clueing you in on one of the most important aspects of treatment . . . the relationship.  This is especially true if that kid in question has Asperger’s Syndrome.  For kids like that, relationships can be very difficult to establish.  The establishment of that relationship is key to any progress in treatment.  I’m sure you have had kids in your practice that had difficulties completely within your comfort zone . . . you understood them and knew how to treat them . . . only to have the lack of good relationship with them prevent any progress.  So, don’t underestimate the power of your relationship with this kid.

Let’s start with the meds, for which there is no information here.  So I will be a bit general, and you can talk to the psychiatrist yourself (or refer the parents to this site so they can talk to the psychiatrist).  Assuming the diagnosis to be accurate, Bipolar Disorder in kids tend to be of the rapid cycling variety.  Rapid cycling means that they have more than 4 cycles per year.  Ultra-rapid cycling means they have between 4 and 365 cycles per year.  Ultradian cycling means that they have more than 365 cycles per year . . . quite a roller coaster.  Kids who experience frequent cycles in their mood have great difficulty in their life sustaining consistency in their relationships with others.  Kids like this frequently have suicidal thoughts or thoughts of self injury.  Sometimes it is thoughts to kill themselves, and sometimes the self injury is just to provide some grounding for themselves.  To relieve pain and stress.  In any case, it is an attempt to provide some relief from an internal state that is felt to be intolerable.  The medicine that is best at managing the rapid cycling seen in kids is Depakote . . . BUT, the medicine that is typically best at reducing suicidal thoughts is Lithium.  The psychiatrist must therefore weigh the potential benefits of each and consider the options.  Which would I use?  Probably neither to start with.  Again, I have no idea what has been used here.  In a nutshell, I would probably try Abilify as the mood stabilizer.  I would give no antidepressants to this kid if at all possible.  To address the depressive-spectrum of this disorder, I would try Lamictal.  If suicidal/self-injury continues to be an issue I would add Lithium.  Again, these thoughts about medicine are given in a complete vacuum. 

How ’bout the therapy part of this?  I am also operating in a vacuum here so I will be general.  First off, you have an advantage.  You have established the relationship.  That done, you must make sure that your office is a safe place for this kid to discuss the thoughts of self injury.  It might scare the bejeepers out of you, but if this kid has to hold all these thoughts and feelings in, they will only get worse.  Let him or her dump them on you (lucky you!!).  The next important part here is to try to get the kid to not want to follow through on these thoughts.  The first step is to separate the thought from the action.  We all have thoughts that we don’t follow through on, Hurting yourself falls into that category.  We have all thought of hurting ourselves at times.  Most of us don’t do anything about it.  As John Irving wrote in The Hotel New Hampshire . . . “keep passing the open windows”.  You must, however, create a plan with him/her on managing these feelings when they do come.  Are they predictable . . . do they come at the same time each day?  Do they last a predictable length of time?  If the answer to these is yes, you can make very specific safety plans for those times.  If they are more unpredictable, then you must be more inventive.  But you must still be very, very specific.  The idea, of course, is to give them something to occupy themselves with cognitively while the feeling aspect of this works its way out.  Nobody feels suicidal forever, the feeling comes and goes.  As a patient begins to manage these episodes in a safe manner, they can gain confidence in that concept of diverting attention during the episode.  The management plan should be concrete and specific.  It should be written down and available to the patient.  If at all possible, there should be point-people for the kid to go to when they feel that way.  That person’s job is to reinforce follow through on the plan, not to judge or discipline the kid.  In addition to those cognitive interventions, you might also look into the process of Dialectical Behavior Therapy.  This is a relatively new line of treatment that was developed by Marsha Linehan specifically to address patients with suicidal and self-injurious behaviors.  It utilizes skills such as mindfulness (attentive to the present moment without judgement) and opposite action (purposefully behaving in a manner opposite to the urges of an unjustified emotion to avoid reinforcing the link between emotion and self-injury) to get a patient through difficult periods.  The age of the patient will, of course, require you to tailor your approach to these interventions.  

Hope these thoughts have been helpful.

–Dan Hartman, MD

1 comment to A difficult case

  • Lorraine Landers

    This is an excellent overview of the issues that arise in treating a child who has bipolar disorder. My only comment concerns the difficulty of practicing in a state where we would give our eye teeth, a few arms and some legs to have a psychiatrist in our facility. Things are so bad here in Alaska, most of the agencies, such as the one I work in, resort to the relentless use of traveling physicians who appear and disappear in a few days. While we can appreciate the desire to see Alaska and earn some bucks along the way, we are desperate for consistency in handling the medication problems that often arise once a child has started psychotropic meds. We end up sending them to their primary care physician each time we have no doc here. Frustrating to say the least. We have just barely begun to diagnose youth with bipolar disorders. We have no expertise available to us on diagnosing dissociative disorders but we see many youth with these symptoms. We are at the whims of travelers who have reasons for their choices in diagnosis and medication as well as therapies but children need to have care that involves a team approach due to the complexity of the issues. All that said, I didn’t want to go on a rant here, I am glad I found this blog and will continue to read it, but I may just resort to asking questions due to the paucity of resources here in rural Alaska. Thanks for the thorough answers to the questions.