An Adolescent with Suicidal Behavior After Liver Transplant

The patient was a 14-year-old sixth-grade girl who had been born in Sweden and now lived with her mother. The patient was taken to the Psychiatric Emergency Department because she was aggressive toward her mother, who reported that the patient had frequent periods of uncontrollable rage, during which the patient would scream and spit at her mother. The patient had undergone cadaveric left lateral segment orthotopic liver transplantation (OLT) for extrahepatic biliary atresia at 10 months of age and had developed hepatitis B from the donor. She had been treated with tacrolimus anhydrous (current dose 1mg q12h) since the transplant. She fi rst manifested anxiety symptoms and violent tantrums at age 6 years, following surgery for a bile duct stricture. She developed nonsuicidal self-injurious behavior at age 12 years, including hitting herself with belts and an attempt to cut herself a few months before presentation to the PED. The patient had experienced worsening depressive symptoms over the previous 6 months, including sadness, crying, poor sleep, poor concentration, poor appetite, excessive guilt about her aggressive behavior, transitory auditory hallucinations, and thoughts of suicide. She was evaluated in the emergency department of another institution 3 months ago, after she was prevented from jumping from a window to commit suicide. Since then, she had been treated with psychotherapy without psychiatric medication. She was hospitalized for PTC replacement for biliary obstruction with elevated liver enzymes and cirrhotic liver changes 3 weeks before presenting to our PED. During that hospitalization, psychiatric consultation was required to manage disruptive behavior. The patient was loud and agitated in the pediatric emergency department (PED), clinging tearfully to her mother. She spoke in a high-pitched voice and was not completely fl uent in English. She expressed resentment and anger about her medical condition and being in the PED. The patient demanded that her dog be permitted to stay with her in the hospital and threatened to pull out her percutaneous transhepatic catheter (PTC) when refused. She denied active suicidal ideation, current auditory hallucinations, and delusions; she was distractible with poor impulse control. At the behest of her mother, who felt the separation made her daughter’s symptoms worse, the patient was hospitalized but discharged after 2 days, with instructions to continue individual psychotherapy. The patient was born in Sweden and raised by both parents until they separated, when she was 3 years old. Her mother reported that the patient met all developmental milestones at the appropriate ages, but had longstanding academic diffi culties. She had received special education in Sweden, which was discontinued when she moved to New York; although for the past year, she had been tutored. The patient was close to her father and brother, who remained in Sweden; she found the separation painful. The patient had a stormy relationship with her mother and demanded attention frequently. Adjusting to New York City also had been diffi cult; she had no friends and did not participate in extracurricular activities. There was no history of physical or sexual abuse, or substance use. Family history of psychiatric disease was negative. All authors are with the Department of Psychiatry, Mount Sinai School of Medicine Elmhurst Hospital Center, Elmhurst, NY. Yu Yang, MD, PhD, is a PGY-III resident, Adult Psychiatry Residency program, Elmhurst Medical Center. David Schnur, MD, is Director of Adult Psychiatry Residency Training Program, Elmhurst Hospital Center, and Associate Professor of Psychiatry. Carrol Longshore, MD, is attending psychiatrist, and Assistant Professor of Psychiatry. Address correspondence to: Yu Yang, MD, PhD, Department of Psychiatry, Mount Sinai School of Medicine Elmhurst Hospital Center, 79-01 Broadway, Elmhurst, NY 11373; email: [email protected]. Drs. Yang, Schnur, and Longshore have disclosed no relevant fi nancial relationships. doi: 10.3928/00485713-20110921-03