Beaters and cutters: the underworld of the teenage girl

Issue: April 2007

Today, a year later, while she was in the office, I joked with her that she was one of my more memorable and favorite patients. As unpredictable as a seething cobra.

Undergarments

On a cold dreary February morning last year, the agitated 14-year-old girl presented with her three month history of headaches, presumptively migraine in origin. I have visited with her in the office since she was a newborn. She was well groomed, slightly overweight, and was wearing the typical youthful teen fashionable white “beater,” so common among her sex and age group. (A “beater” is the pervasive undergarment of teens, an Archie Bunker style half tee shirt/tank top.)

Stan L. Block

She had called the office numerous times in the last few months, asking for pain medications and some form of relief from her multitudinous migraine headaches, one of which was precipitated by an episode of streptococcal pharyngitis in December. The headaches were often associated with nausea and vomiting, photophobia and phonophobia. She obtained some relief with zolmitriptan (Zomig, AstraZeneca) 2.5 mg tablets. The thought of narcotic–seeking behavior had entered my mind.

But, I am still concerned about the possibility that her latest prescription for ortho evra patches for her dysmenorrhea and irregular menses may be exacerbating the problem. So last month, I tried to switch her to the etonogestrel/ethinyl estradiol vaginal ring (NuvaRing, Organon), which she must insert intravaginally. Normally, I would never suggest this formulation for such a young teenager, but this young lady is fairly mature and comfortable with this concept, as I had already fished around for her willingness to try it as an option.

Once again, she is in the office complaining of frequent headaches occurring once or twice weekly.

Cardinal rules for Superman

Cardinal rule one (pediatric neurology): Unexplained recurrent headaches always deserve a thorough funduscopic examination. Voila, spontaneous venous pulsations on the sharp optic nerve disc are visualized. The remainder of the cranial nerves is normal as is the remainder of her brief neurologic examination.

Cardinal rule two (Jimmy Simon, MD): Always perform a thorough physical examination. I finally cajole her to remove her sweatshirt for my complete examination.

“But why doctor Block? Can’t I just lift it up?”

As I explain to her: “I am a super-doctor, but not Superman! I do not possess X-ray vision!”

“So you will need to remove your sweatshirt and put on the gown, or you can just leave on your ‘beater.’” (Note that the beater has no psychological or sociologic meaning for these young girls, so do not try to read much into this fashion undergarment statement.)

Under the garments – cut to the quick

Underneath the garment sleeves, this hides: She had multiple small linear 4 cm to 6 cm old healing cuts on her left forearm-palmar aspect. (They are never on the right forearm, unless she is ambidextrous or left-handed.)

“And how did this happen?”

(The usual girl response is: The cat or dog scratched me, or I just scraped myself on the door, trampoline, pipe, etc.)

With this simple query, she promptly and unexpectedly popped up and stormed out of the room, hissing and fuming like a cat confronted by a barking dog.

Alone

So there I sat, alone with my chart. Decision time: sit alone, move on to the next patient or search for hormonally self-hijacked patient?

I will usually wait about a minute to see if the girl will return. Then I will peek out into the hallway to determine whether she has vacated the premises.

And yes, this type of patient vitriolic exodus may happen to me about once a year, usually whenever the topic becomes too uncomfortable for the teenager.

In this case, as is the usual sequence, she was standing just outside the doorway, and I merely re-invited her, in an affable tone, to come back in and visit with me.

Despite my reassurances and calming demeanor, during this visit again she became upset and stomped out of the room for a few seconds.

Finally, I cajoled her that I just needed to ask her a few simple questions. I was trying to help her.

She adamantly denied any sadness or depression, school or family problems.

Cardinal rule three: Never discuss “cutting” with the parent in the room — initially. These young ladies really appreciate the opportunity for confidentiality and to be treated as adults. Nothing alienates them more than when a physician “exposes” them in front of their parents. But they are eventually warned that their parents must be notified if the girl is a danger to herself or suicidal. All cutting events are considered major signs of depression or dangerous impulsivity.

I explained to her that I often see teenaged girls who try to cut themselves when they are in pain emotionally, depressed, upset with boyfriend or parent, or tormented by a previous rape or molestation.

She said she was not suffering from any of this.

But she did admit she was rarely happy lately. She denied any suicidal thoughts or attempts. Then I moved on to my next topic for the self-tormented.

Fortunately, although denying any alcohol use, I was able to get her to discuss her recent marijuana dabbling. Her brother, whom I also have taken care of, was a somewhat nefarious drug peddler in the area.

Cardinal rule four: Whenever a teenager admits to using marijuana, quantify the frequency of use.

For instance, a declaration of once a month often means weekly usage; once a week, most days use; and only on weekends, daily use. This is some kind of teenage exponential mathematical equation to rationalize that the real frequency is not as bad as they would have you think.

I then discussed the negative impact that marijuana was likely having on her mood and her grades. It was making her more depressed, sad and irritable. She was bickering constantly with her mother, who was once her best friend. And this very bright young lady, who was previously on the honor roll, was barely passing academically this year. Her short term memory was zapped.

The lack of a stable father figure was further exacerbating her cloudy judgment. I figure she was, in part, with the highs, trying to escape the pain of this hole in her life as well.

I further attempted to explain to her that her father’s absence was not her fault in any way…to buffer the egocentric magical thinking so common even in this age group.

Tempest in a teapot

I have dealt with way too many young teenagers during their tempestuous rages, both in the office and at home. So being a battle-worn veteran of many youthful estrogen eruptions, I always remain calm and, in Pollyanna fashion, anticipate the best will happen for my young patients if only I am patient too.

Nonetheless, in too much of a funk, I decided to cut my losses here and have her return in a few weeks under the guise to check on her headaches, and to consider possibly starting her on some beta blockers daily for her migraines and even a selective serotonin reuptake inhibitor if the mood was a persisting problem.

She seemed to comprehend much of what I explained earlier, and shockingly gave me a hug at the conclusion of the visit.

The headaches did not abate over the next few days, and I suggested we go ahead and start some atenolol (no history of asthma) daily to see if we could prevent the attacks.

Much to my pretentious shock, when she returned in the next month, her teenage sparkle and joviality were evident again.

Her headaches were much improved with the daily atenolol. She admitted that she had abandoned all her marijuana smoking. She was not having outbursts at home, and she actually said that her mother and she were getting along quite well. And proudly, her grades were rising to the A and B range since she had discontinued her illicit smoking habit. She even now laughed at dumb Dr. Block Wisecracks.

Denouement

I still see this young lady frequently in the office and even out in public, and she always goes out of her way to talk with me and is quite affable. Today in the office for her recurrent vomiting and abdominal pain, she continues to show an impressive maturity with her perceptions of her schoolwork and her special relationship with her single mother. She is a survivor. And she is one less victim of that “recreational” drug.

Now, as for that recurrent vomiting and lower abdominal pain precipitating today’s visit, I had to inform her that all indicators point toward her estrogen in her NuvaRing, in light of her negative mega-workup thus far. She may need to change to a no-estrogen contraceptive. But no fit was triggered today. Rather, she just said, “I hate you Dr. Block, for making my life miserable again,” and she giggled.

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Stan L. Block, MD, is a general pediatrician in private practice in Bardstown, Ky., and is on the editorial board of Infectious Diseases in Children.