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"Our problem child is back.” Ann whispered as I sat down at the nurses' station to chart.
"You mean Susan? I hope she's okay, I'm worried about that girl.” I said.
"Will you take her? I'm getting so sick and tired of dealing with these freshmen. I think most of the time they just miss home and want someone to talk to. I'm not in the mood to be mommy today.” I raised my eyebrows at Ann, thinking for the umpteenth time that she was really in the wrong business if she didn't want to talk to students, but nodded affirmation.
I reviewed Susan's chart. This was her fourth visit in one month. She was an out of state student, here on scholarship. She had first come in just a few weeks after the semester had begun. She stated she had fallen in the stairwell after a dizzy spell and hit her head on the railing. I had seen her then and assessed her for a concussion, but she was asymptomatic, with no loss of consciousness, just a large lump on her forehead and a headache. I educated her about the signs and symptoms of concussion and brain injury and then asked if she had anyone she could check-in with in case symptoms did arise later.
"Have you made a friend yet? Someone who checks up on you and vice versa?” She looked away and shook her head. I asked about her parents and she had expressed anxiety over being away from home for the first time. I asked her about the possibility of a visit home, or her parents visiting and she had looked sad and uncomfortable, saying,
"I love my mom, I really miss her, but my dad, well it's my stepdad actually, he and I just don't get along.”
Something about her pulled on my maternal heartstrings. She seemed so bedraggled and lost. She had shared that her father had died when she was quite young and her mother had remarried a few years ago. I encouraged her to call her mom, just for a chat and she had promised to think about it, though her parting words had worried me, "He wouldn't like it.” I wanted to follow up on that statement, but the clinic was busy, and the PA was motioning to me to hurry up for a procedure and I had to let it go. She was coming back in a week for a follow-up and I made a note in her chart "ask about the home situation.”
Unfortunately, when she returned the following week, I had been out sick, so I read through the chart and saw that she had stated "no problems" from the head injury. The nurse had charted a subjective note about a different problem - deja-vu. "It's so weird. I know it's silly, but I will be walking to class, or sitting and having lunch in the caf and I will just feel so strongly that I've been there before. It happens at least once a day.” A few weeks ago, she had returned complaining of a rapid heart rate and feelings of impending doom before taking a biology test, and that time it had been my day off. The PA had talked to her about test anxiety and referred her to a counselor. Ann documented education about meditation and calming techniques, but there was nothing about her home life. Her vital signs had all been within normal limits and there was nothing unusual about her health history. She was on no medications, no birth control, and had normal menstruation.
I approached Ann to clarify, "did you talk to Susan about her home life, her social situation? I'm worried about her. Something's off with this one.”
"No, both times I saw her, the clinic was slammed. Honestly, she strikes me as a lonely, scared little girl who is homesick. I think it's all in her head.” Ann had worked here a lot longer than me, and I wondered if I would become that jaded if I stayed.
"It's not just about physical health, Ann. I'd like to think we are here for mental health, spiritual health, all of those things.” I replied, deciding that advocating for Susan was a better choice than keeping the peace with Ann.
She signed and rolled her eyes, "That's what the school counseling center is for. I barely have time to chart vital signs, much less be a therapist.” She grabbed her laptop and hurried off to see her next patient.
I opened the door to call Susan back and saw her sitting in the waiting room, tapping on her smartphone. Her greasy hair was pulled back in a ponytail, and her shoulders were slumped. She looked exhausted. As she walked to the vital signs station I asked, "Susan, how are you feeling today?”
"I'm okay, I guess. I'm sorry I keep coming back so much. I'm kind of freaking out. I'm not sure what's going on.”
"Are you still having deja-vu?”
"Yes, that's still happening, and, I'm still having dizzy spells.”
"How about the anxiety? Have you had a chance to see the counselor?”
"Yeah, I've been to see the therapist, and she gave me some good ideas for calming myself before exams, but I'm still struggling with anxiety. It's happening at odd times, like not just before tests, but when I lie down to go to bed, or when I'm walking home from classes. And there's this new thing. It's so weird, I don't even know how to tell you about it.”
"It sounds like you've had a frustrating semester so far. I'm glad you've come here, that you're reaching out.” Susan looked at me gratefully, and I could see her body relax a little bit. I got her vital signs and motioned her into the exam room. Once she was seated I looked at her and said, "Tell me what's been going on.”
She said, "Okay, but I think you're going to think I'm crazy when you hear this. When I listen to my favorite album, I've been getting into Queen, listening to them a bunch since the movie came out.”
"Oh, that was such a good movie. I'm glad you younger kids are getting to hear some Queen!”
"Yeah, I've seen it like, 5 times.”
Susan looked down, and I noticed her hands twisting together. I decided to wait her out until she finally said, "So whenever I listen to Bohemian Rhapsody, I smell peppermint.” She blurted the last part out, looking up at me with wide eyes. There was a faint flush of embarrassment on her cheeks.
"It sounds like you're saying that when you listen to that song, you have the sensation that you are smelling peppermint. Does it happen at any other time? To any other songs?”
"No, just that song. It's so bizarre. It's so strong. It's like I'm sucking on a candy cane, or I've got some peppermint oil on me somewhere, but there's nothing there. It's just so...I don't know. I feel like I might be going crazy.”
"You sound scared.”
"Yeah, I'm alone here, you know? My parents aren't…” She trailed off and stared at the wall.
"Did you have a chance to call your mom?” I regretted asking as soon as the words came out because Susan instantly tensed up.
"I did call her, but…” she trailed off again.
I nodded encouragingly, "What happened Susan? Is there something going on at home that you want to talk about? Whenever you talk about your dad, you tense up.”
"Not my dad, my stepfather.” She said and I could hear anger in her voice. I waited, mustering up as much nursing presence as I could. Letting the silence spin out.
In a small voice, so low I could barely hear her, she said, "My stepfather...he um. Well, he hurts us.”
Now it was my turn to tense up. My internal alert level went to Defcon 5 and I felt like an alarm bell was going off in my brain. I had trained for this but had never had a patient tell me about abuse before. I wanted to get this right. Susan burst into tears. I put down my computer and asked, "Can I put my hand on your shoulder?” She nodded and I handed her a tissue as I did my best to comfort her with that small touch, sending out healing energy through my hand into her shaking back.
"Susan, I'm here for you and I'm listening.”
She clutched her stomach and said, "It's happening - the deja-vu, and I feel so dizzy. And my stomach hurts so bad.” She leaned over and then suddenly slumped forward in a full-on faint.
I assisted Susan safely to the ground, and then alerted Ann to the situation. She called 911, and we got a set of vital signs while we waited for the EMTs. Susan's BP and pulse were elevated, but respirations, temp. and pulse-ox were normal. I told Ann what Susan had said, and she went to get the NP as I tried to arouse Susan. I kept calling her name while protecting her head and neck. Her eyelids fluttered and she finally opened them, asking,
"Where am I? What happened?”
What's Going On Here?
After reviewing all of Susan's symptoms and assessment data, what do you think is happening? Is it related to the fall in the stairwell? Is it a brain tumor? What other information do you want? What's next for Susan?
In the hospital, Susan got the full workup – labs and a CT scan. The NP also recommended an EEG. What do you think they found?
If you enter the following symptoms into Google: dizziness, nausea, deja-vu, panic attacks and synesthesia, (the production of a sense impression relating to one sense or part of the body by stimulation of another sense or part of the body – as in when Susan heard the song but smelled peppermint) you get what you'd expect: brain tumors being number one, migraine is on the list and epilepsy, specifically temporal lobe epilepsy (TLE). Of course, all possibilities have to be explored for a differential diagnosis, but TLE fits with her symptoms:
Symptoms Of Temporal Lobe Epilepsy
What Causes Seizures?
There's a wide variety of etiology for seizures: traumatic brain injury (maybe Susan did have a concussion after all), infections like meningitis (common in freshmen), stroke, brain tumors, blood vessel malformations, genetic syndromes, and childhood trauma (AHA!).
The Body Keeps The Score
Research shows that childhood abuse has enduring negative effects on brain development. In a groundbreaking book, The Body Keeps the Score, author Bessel van der Kolk pulls together research and years of practice to make the case for the complex impact childhood trauma has on the mind, body and spirit.2 Physical, sexual and psychological trauma in childhood may lead to psychiatric difficulties that show up much later. Anger, shame and despair can also be directed inwards, resulting in depression, anxiety, impulsivity, delinquency and substance abuse.
Recent research into the impact of childhood trauma on the brain focuses on the limbic system. In the popular movie Inside Out, the audience gets to see cartoon characters acting out the various emotions of a pubescent girl. This film does a great job of showing what the limbic system does. The limbic system lies deep to the cerebrum and includes the hypothalamus, the hippocampus and the amygdala. It supports a variety of functions including emotion, behavior, motivation, long term memory, and olfaction. Recent research points to brain abnormalities associated with childhood abuse including limbic irritability, manifested by increased symptoms suggestive of temporal lobe epilepsy, and an increased incidence of clinically significant EEG abnormalities.1,2
TLE is difficult to diagnose because its symptoms mimic those of other psychiatric and non-psychiatric illnesses. Common psychiatric disorders associated with childhood trauma are a somatoform disorder (patients experience complaints with no discernible medical cause), panic disorder with agoraphobia (fear of open spaces), borderline personality disorder and dissociative identity disorder (formerly called multiple personality disorder). PTSD has also been linked to childhood trauma, in which people re-experience the traumatic event in waking life or in dreams.1
The characteristic electrical discharge of TLE is observed with an EEG during a seizure. The authors of a recent study have developed a Limbic System Checklist (LSC-33) which calibrates the frequency with which patients experience symptoms of TLE. I've included a presentation that shows the LSCL-33 and included the first page of the tool so you can see what it looks like.3 In patients who acknowledge both physical and sexual abuse, the average score on the LSC-33 is 113% greater than patients reporting no abuse.4
Susan's Case
In Susan's case, the EEG was positive for TLE. Her lab results were normal and there was no sign of brain trauma or tumor with CT or MRI. Upon further discussion with Susan, it was discovered that she had suffered several years of physical and sexual abuse by her stepfather.
The good news is that there is treatment available for TLE induced by childhood trauma. Though more severe forms of epilepsy can require medication and/or surgery, psychotherapy has been shown to alleviate TLE symptoms in those with childhood trauma.
I've written about treatments for childhood trauma in two other articles:
Keep What You Love, Return the Rest: Healing from Trauma with EMDR Part 1
EMDR: Another Tool for Your Mental Health Toolbox
PART 2
I hope you'll check back in on my blog and read part 2. I'm going to discuss the specific impact of childhood trauma on the amygdala and hippocampus as well as the Adverse Childhood Events (ACEs) Study. I will also cover some innovative new treatments like the use of psilocybin to treat PTSD.
Resources
1. Wounds That Time Won't Heal: The Neurobiology Of Childhood Abuse: http://www.dana.org/Cerebrum/2000/Wounds_That_Time_Won't_Heal__The_Neurobiology_of_Child_Abuse/
2. Van der Kolk, B. (2015). The body keeps the score: Brain, mind and body in the healing of trauma. New York, NY: Penguin Books.
3. Reference for attached image, which is only part of the LSCL-33 (You can view the entire LSCL-33 in this pdf starting on on page37):https://drteicher.files.wordpress.com/2011/06/nesttd_keynote_post-key1.pdf
4. Teicher, M. H., Gold, C. A., Surrey, J. & Swett, C. (1993). Early childhood abuse and limbic system ratings in adult pyschiatric outpatients. Journal of Neuropsychiatry and Clinical Neuroscience, 5(3), 301-6.
DISCLAIMER: These case studies are presented for learning purposes only and with full understanding that it is outside the scope of practice for a nurse to make a medical diagnosis. When participating, assume that a licensed healthcare provider is making the actual diagnosis, ordering all the tests and interpreting the results. You are looking at the case retrospectively to learn from the data presented – the idea is to increase your knowledge so you can sharpen your assessment and teaching skills.
About SafetyNurse1968, BSN, MSN, PhD
Dr. Kristi Miller, aka Safety Nurse is an Assistant Professor of nursing at USC-Upstate and a Certified Professional in Patient Safety. She is obsessed with patient safety. Please read her blog, Safety Rules! on allnurses.com. You can also get free Continuing Education at www.safetyfirstnursing.com.
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