Twelve Patients: Life and Death at Bellevue Hospital by Eric Manheimer Page B

or decompensate when she was six years old. She was up all night, had tantrums, head banging, withdrawal into her room, and extreme irritability from minor provocations of everyday life. There were some family deaths, grandparents were killed in a freak car accident, that may have been triggers but nothing obvious. From what I can piece together, her first hospitalization was for depression and suicidality with a good response to SSRIs or anti-depressants. She had intermittent therapy for a few years and ended up in a pattern of a new therapist, a new diagnosis, and a new medication almost as an annual rite of spring. I am cataloging at least ten different switches over that many years.” She handed me a piece of graph paper. The time line had columns and lists in her precise handwriting with arrows to medications and assorted treatment regimens. After looking at it, I asked Ingrid for her interpretation.
    “Eric, kids in this developmental period have pretty non-specific symptoms. Their brains are growing and maturing like crazy. They don’t have symptoms like adults. Depression in kids does not look like it does in adults, with depressed mood, sleepiness, a lack of enjoyment in life, decreased libido. Irritability is the hallmark symptom in kids. The kids’ psychiatric illnesses are pretty undifferentiated, and sometimes hard to tease out. One kid will turn out to have major depression, another schizophrenia, still another a personality disorder, and the last will outgrow everything. The worst mistake is to assume these little humans are little adults. They’re not. Adult rules do not apply here.”
    “And trauma, Ingrid? A common denominator?”
    “For the kids we see usually it is. But not always. Take Emily, for example. Her doctors have looked high and low for trauma, parental abuse, or sexual abuse, but many times that’s not the case. There are other subtle issues like personality, coping skills, and environmental cues that we don’t know about. Remember your biology: Kids are what their grandmothers ate!” She smiled and got back to business.
    Through the window I saw a girl about ten years old accompanied by a young female psych tech approach the two teenagers at the table.She had been watching them from a seat outside her room where she had sat through a fifteen-minute “time-out” for a mini tantrum when she refused to get dressed for breakfast. The two girls looked at her as she spoke to them. They then made room around the table, and the tech pulled up another chair and brought some paper and crayons. In a few minutes she was hunched over her project. Tanisha lent her some pencils, and Emily started talking to her.
    The picture that emerged of Emily was a pre-pubertal girl with a pretty average upper-middle-class life, who developed fluctuating or exaggerated emotional highs and lows in first or second grade. Then over the years she was diagnosed with depression, anxiety, histrionic personality, schizo-affective disorder, eating disorders when she suffered from anorexia and bulimia, conduct disorder, borderline personality disorder, and manic depressive disorder plus a handful of other “disorders” from the
DSM
, or
Diagnostic and Statistical Manual
, psychiatry’s bible for the last thirty years. Equally impressive was the list of medications in another column with dates connected by arrows to the disorders, as well as a list of psychiatrists, psychologists, and psychiatric social workers she had seen in a decade of peripatetic therapy throughout the city of New York. The list of medications included all the SSRIs I was familiar with and a few I had seen on television ads but didn’t know anything about. Ritalin and long-acting stimulants, anti-psychotics from Abilify to Seroquel to clozapine, and a long list of anti-anxiety medications in a broad range of dosages from short to long acting. Emily was also taking a variety of other medications for allergies, mild asthma, abdominal pain, menstrual