Case presentation: 15-year-old Linda

Team maximizes program resources & expertise throughout Menninger

Flynn O’Malley, PhD
Program Director, Menninger Compass Program for Young Adults
Suzanne Robinson, LSCSW
Former staff member, Menninger Adolescent Treatment Program

Linda (not her real real name), a 15-year old female from a large Midwestern city, was admitted to the Menninger Adolescent Treatment Program. From the beginning, the diagnostic assessment of her problems and the provision of treatment were fraught with complications.

First, Linda and her divorced parents each differed somewhat in their reporting of Linda’s difficulties. Clearly, however, Linda had engaged in multiple and potentially quite dangerous behaviors. There was a history of depression and suicidal behavior. Just a few days before her admission Linda ingested a number of acetaminophen and other medicines, and there were other instances of suicidal behavior. A more frequent and pervasive problem was Linda’s pattern of self-injury by inflicting cuts on herself. Most of the cutting was superficial, but she had literally dozens of scars on her arms and legs. On admission Linda stated that her anxiety and depression got so unbearable at times that she felt hopeless, and on several occasions this led to her cutting and parasuicidal behavior. Linda reported some experiences of depression and anxiety beginning as early as the fourth grade, but these problems became more severe in seventh grade. Her cutting started in seventh grade and was finally discovered by her parents who then entered her into outpatient psychiatric treatment.

Linda’s severe anxiety was persistent and particularly debilitating. This was complicated because it seemed related to multiple issues, and it manifested itself in various forms and venues. For example, Linda was exceedingly anxious about having to complete tasks and perform at school; she was extraordinarily self-conscious about her appearance, including her weight; and she worried about her social acceptability to peers and often felt that she didn’t know what to say to them. Linda developed a number of compulsive rituals that had increased over time and made her seem odd to others. Her ability to concentrate at school was a longstanding problem that had become worse recently and seriously compromised her ability to function at school. A number of medications for these multiple problems had been tried with minimal and variable success.

This array of problems, manifesting themselves prominently at varying times, led to many diagnoses and treatment approaches. At various times she was seen as having major depression, generalized anxiety disorder, attention-deficit/hyperactivity disorder (ADHD), obsessive-compulsive disorder (OCD) and borderline personality disorder. To make things even more complicated, upon admission Linda also disclosed in a private interview, her long history of bulimic symptoms, which she had never conveyed to her parents or other treaters, and that had intensified over the last few months.

In the two years prior to her admission at The Menninger Clinic, various attempts at outpatient treatment, as well as three brief hospitalizations and placements at a residential treatment program and a therapeutic boarding school, had not been sufficient to reverse or stem the tide of her worsening pattern of crippling symptoms and potentially self-destructive behavior.

Diagnostic assessment and early treatment
The treatment team met to discuss Linda’s diagnostic process and initial treatment program. The complexities of the case presentation were obvious, and it was agreed that establishing an overall understanding of Linda’s problems, how they related to each other and the prioritization of problems for initial focus, would take the collaboration of all members of the team, as well as additional specialty support. It was necessary to not get derailed by the likely vacillation in the occurrence of Linda’s problems and concerns, and yet it was necessary to remain responsive to her immediate needs, as well as those of her parents. The importance of creating some sense of hopefulness seemed to rest on helping Linda and her parents believe that, despite the complexities, we could move toward a systematic understanding of her problems and that treatment was possible with their help and cooperation.

Linda began in a full range of diagnostic and therapeutic modalities including eating disorders and OCD evaluations, review of previous psychological and educational evaluations, individual psychotherapy, group therapy, full educational program in the accredited, on-site school program and program-based therapeutic groups and activities. Her treatment plan established initial prioritized problems based on their severity and potential for harm, including suicidality, deliberate self-harm, eating problems, depression, anxiety, patient conflict and hostility with family.

A Diagnostic and Treatment Planning Conference was held approximately two weeks after Linda’s admission. Basically, Linda was seen as polysymptomatic, and there was a need for a more refined understanding of the central issues related to her multiple symptoms. Partial psychological testing (Rorschach and MMPI-A) revealed severe anxiety and some odd thinking, especially related to complicated ideas and personal/ emotional issues, but there was no evidence of psychotic thinking or bleak and unrelenting depression. Linda’s distractibility revealed itself to be quite debilitating. She received an OCD evaluation and was referred for specific OCD program elements, including cognitive therapy and response prevention groups. The focus of the OCD work was initially on the patient’s ritualistic behaviors. The patient’s overt eating disorder symptoms began to abate shortly after admission (initially, she had said she would be compelled to purge), but she continued to have body image issues and was referred to the Eating Disorders Program for such problems. Linda’s medications were reviewed and initial trials were begun. Family history and the nature of her relationships with family members were discussed in terms of their contribution to Linda’s functioning.

Following Linda’s conference she was referred for and received a complete psychoeducational evaluation. Results of that process were reviewed in a special meeting, and Linda was seen as having well above average intelligence, good long-term memory and executive functions, but with difficulties in short-term memory and auditory attention.

Self-injurious behavior
Within the support of the milieu and her relationships with staff and other patients, Linda’s affect brightened somewhat. She no longer reported suicidal ideation, urges or intent. She reported frequent urges to cut and some urges to purge. She purged very early on, but then was able to refrain from purging during the rest of her treatment. During Linda’s course of treatment she engaged in one episode of serious self-cutting. This was relatively late in her treatment and was associated with struggles over attempts by staff to help control her compulsive rituals, her anger at the staff members and her reported “wish” to cut.

After a cutting episode, Linda agreed to stop cutting while in the hospital. She participated actively in self-harm groups, addictions track elements focused on self-harm and other elements of treatment that supported her acquisition of alternative skills for managing her frustration, anxiety and periodic despair. She found these helpful. However, even at discharge, Linda’s potential for cutting remained as a “last resort” for managing her emotional difficulties. She could not promise to never cut again, but like other addiction processes, she agreed to continue working on this problem day by day. Linda’s management of emotions, including communicating about them, became the central focus of her treatment.

Management of emotions
A problem identified in Linda’s treatment was how hard and painful it was for her to try and articulate her difficulties concentrating, her volatile emotions and other problems. She complained that she couldn’t keep thoughts in her head, that she was distracted by both inner and outer stimuli and that she just couldn’t “think.” She often became overwhelmed by the frustration of trying to put her thoughts into words when she was in the midst of mental confusion or emotional upset. Focusing on helping her communicate in small, manageable doses proved to be very helpful to her.

Linda’s level of experienced day-to-day depression improved, as did the severity and frequency of “spikes” of more serious depression and despair. She was noticeably more social, enjoyed activities and success in various endeavors and recovered more quickly from minor setbacks. Her self-esteem improved. She wasn’t always sure that she liked herself, but she acknowledged that she felt emotionally “stronger,” and this was evident to others. 

Linda’s anxiety and OCD problems proceeded through a complicated course. Her initial issues centered on her rituals and a generalized sense of anxiety, which she had great difficulty explaining in a coherent manner. She often became even more anxious when asked to talk about it. As time went on, Linda became more able to communicate about specific sources of her anxiety. She reported a great deal of social anxiety. She was certain that she was unattractive. She often felt humiliated by things she said or did and assumed that others also held a low opinion of her. She also had “task” anxiety, which was often related to expectations at school, and she felt inordinate amounts of pressure to perform, especially when deadlines were involved. Even simple pressures like writing a letter to someone could put her into a spiral of anxiety, fearing that her writing was inadequate, and then “real” pressures would accumulate because of her procrastination. As time went on, efforts were made by the Adolescent Treatment Program team and also her OCD treaters to present Linda with defined and discrete tasks that would help her practice taking action and let go of her tendency to “over control” such processes.

Over time, Linda’s anxiety eased. She established reliable relationships in which she developed trust that her struggles could be understood, and she was able to use the support offered to her. Her OCD rituals diminished, and those that remained were minor and relatively inconsequential to her daily living. At discharge Linda remained vulnerable to assaults to her self-esteem (both from within herself and in the form of outside rejections or disappointments). However, she was not so despairing at such times and she believed that she could recover from such incidents.

Cognitive processing and school
The staff and teachers of the Menninger school program worked closely with the treatment team to establish reasonable and achievable goals for Linda. It was important that she participate in this process to help identify ways to manage her school anxiety and her difficulties with concentration. While Linda had some specific problems with modality learning and short-term memory, most of her difficulties were related to her overreactiveness to any pressure to produce. Linda’s school experiences were initially excruciatingly painful to her. Staff worked with her to reduce her reactions to deadlines by starting with short, easy-to-complete assignments, then working toward more complicated projects. This problem at school overlapped, of course, with Linda’s other anxieties about getting things done, including writing letters and cleaning her room. The unit treatment team and the school working together was crucial to Linda’s progress in both areas.

Family
Linda was devoted to and sometimes protective of her mother and father. However, sometimes she had intense and seemingly unpredictable conflict with them. As she became more trusting of her team, particularly her social worker, Linda complained about her parents’ various attributes and the ways the family often functioned. The parents were active in the treatment process and participated in family conference calls and on-site family therapy. Progress was made in helping the patient communicate more authentically with her parents. Still, the patient’s previous treaters, as well as the current treatment team, were of the mind that the home situation was not calm and predictable enough for Linda to return home immediately. All agreed that a placement in a therapeutic boarding school after discharge from the current program was appropriate.

Medications
The psychiatric team carefully reviewed the patient’s history of medication support. Linda had taken antidepressants, antipsychotics and stimulants for ADHD symptoms with questionable effects. Changes in dosage and new medications were started. The patient was encouraged to work closely with her physicians to evaluate the medications. As with the other aspects of her treatment, she initially had a great deal of trouble describing her feeling states and experiences. This improved across the board with help from her total treatment team.

Linda had consistently complained of difficulty concentrating, and a diagnosis of ADHD had been suggested prior to admission. A trial of Concerta was begun to treat her ADHD symptoms. However, it was immediately discontinued due to the development of dramatic EPS symptoms. Linda recovered from the EPS problems, and new medications were started to help her with her thinking and concentration. Ultimately, the medication regimen consisted of antipsychotic medication for her thinking problems, antianxiety medications and antidepressants. Linda seemed to do well on these medications, and all agreed it had been a considerable task to find appropriate medications for Linda that provided support and that she could tolerate.

Summary
Linda grew very attached to members of her treatment team, many of her fellow patients and developed a sense of confidence in the safety and predictability of her program. While she was anxious about leaving, she was also eager to move forward in hopes of not having to remain in institutional settings for too long. Toward the end of her course of treatment, Linda and her primary clinician identified a number of specific treatment issues needing continued attention. They included:
1. Linda’s tendency to get into “compulsive scenarios” in which she felt compelled to act on some negative behavior she had previously decided to do, even in the face of her own judgment indicating she should not act.
2. Her continuing struggles in completing assignments at school and other work for fear that it wasn’t good enough, or that she couldn’t make herself get started because the task seemed overwhelming.
3. Linda’s worries and sensitivity to anticipated or perceived social criticism–often related to problems of her self-esteem and body image.
4. Knowing how to recover from periods when she got very worked up emotionally.

Contacts were made with the receiving clinicians to describe our findings and experiences and get their input about what might work best in their setting.

Overall, in our view, this patient’s complicated clinical picture and the difficult treatment process that followed was facilitated mostly by the systematic collaboration within the treatment team itself and the inclusion of a close working relationship with other institutional specialists, the referring clinicians and those receiving the patient, regular communication with the patient and her family, all supporting shared responsibilities for outcome. Linda’s own ability to take more agency for her problems was enhanced by the continued hope expressed by her treaters in her ability to get better.