A Little Girl With Bipolar “Deserves” A Trial of Lithium

This is a Two-Part Post:

Dave:  This illustration gives a picture of how the use of a psychiatric diagnosis and treatment with medication can affect a family’s living over a long range of experience. It demonstrates the cost of characterizing behavior as disease and ignoring the broader unnamed illness of the family. I recommend you keep the philosophical component of your mind turned on as you read the clinical story.

The Maher’s were referred because Trish, 18, a high school senior, was “completely out-of-control.” Four months earlier, she quit taking her medications, Tegretol and Prozac. She had started taking medications at age four when she was diagnosed with bipolar disorder. When they called for an appointment, I told them that though a psychiatrist, I wasn’t much of a medication man and that they would need to bring the whole family. They took a day to think it over then decided to come in.

Based on my phone call with the father, I expected a very disturbed, probably manic, young woman. A different Trish arrived from what I expected. Instead of disturbed and chaotic, she was composed and for the most part thoughtful in an appealing way. She was a self-owning young woman who agreed she had been difficult of late. She was annoyed with what she viewed as her parents’ over-reactions. The pediatric neurologist who had taken care of Trish for 12 years sent the clinical records, which began with her diagnosis at age 4.

The notes included the initial evaluation by a child psychiatrist that ended with an indefinite conclusion, she “might” have bipolar disorder. The diagnosis was made at a point in cultural time when child psychiatry researchers were newly interested in the possibility of bipolar disorder in children and articles were appearing in the child psychiatry journals. In keeping with the new standard of practice for the time, he thought she “deserved” a trial of lithium. However, the trial was a one-way street, and never ended. She was later changed to Tegretol and Prozac by the neurologist.

Those were the medications she quit taking fourteen years later, in October 1998, four months before they came to see me in February 1999.  A month before she quit taking the medications her father, an executive in a large corporation, was “down-sized”.  He was let go with a six-month severance package. He acted as if it was not a big deal (only a business decision). He felt certain he would soon find a new executive level position. The mother on the other hand, was upset by his nonchalance. She felt that the ship of the family had been torpedoed and was slowly sinking. I found the parents discouraging.

These were polite, upper middle class suburbanites with little capacity or language for self-observation. But they were clear about Trish and what was wrong with her.  Father was conservative and repressed. Mother, who was very hesitant when she spoke about her own life, was very articulate about her daughter. There were times when she was sadistic and smirking when it came to describing Trish. I thought of Trish as having been an unnaturally compliant child most of her life. At 18 she had become mildly, but appropriately rebellious. She was trying to figure out a way to be more than her mother’s little girl.

At one point, the parents felt as though I should see Trish alone. I did, for two visits. Trish was thoughtful about herself. Of her friends she said, “I like these people, I am having fun; I never knew how to have fun before. I can see my parents have never been happy. I don’t want to turn out like them.” She was concerned her mother was trapped and didn’t have any friends. She was trying to get her mother connected to the mother of one of her girl friends who lived on a farm. This mother had a wonderful sense of humor, and seemed to enjoy her life. She thought this mother could be a good influence on her own mother. Trish was worried about her parents. She was trying to help her mother grow up a little, to become more of a person. Ultimately, Trish graduated from high school and went away to college.