CASE STUDY |
(The client's name has been changed to honor the family's request for confidentiality. All other details of the case are factual.)
Michael Noble
A 30 Year-Old Man
with Bi-Polar Disorder
At the beginning of February, 1995, a man in his early thirties was referred to us by his psychotherapist. He was in therapy for Bi-Polar Disorder (also known as manic-depressive disorder), for which he was also receiving medication therapy (Lithium). He presented with a moderate to severe attentional disorder and general learning disability, particularly in the areas of organization, handwriting and expressing himself in words. These conditions, including problems of anger management, had been prevalent throughout his life. As a youth, he had been treated for his attentional disorder (which included hyperactivity) with Ritalin.
Michael had been seeing the psychotherapist for a considerable time, mostly in an effort to deal with temper flare-ups and some intimacy issues. He was a building contractor by trade. He had chosen this trade to minimize the effect of his learning disability. The most difficult part of the work for him was the bookkeeping aspect. Sustaining visual focus was so taxing that he would put this part of the job off, frequently putting jobs in jeopardy. His attentional deficits required him to 'over focus' while doing the physical part of his job. This was reflected in his reported inability to continue working while engaged in conversation.
During the evaluation Michael showed several signs of vestibular weakness. The vestibular issues were shown in a variety of ways, by deficits in those functions supported by the vestibular system, rather than by severe ear infections, motion sickness or other concerns that might be directly linked to inner ear disturbances. His proprioception was weak, as evidenced by his planting himself in a sitting posture that provided him a broad and certain base, and also by reported irregularities in sleep patterns. His muscle tone was irregular, evidenced by excessive neck tension but low overall muscle tone that required him to prop himself up on the table in order to work on worksheets or converse with the evaluator. Visually he had an aversion to anything that appeared to go around. And he had marked difficulty tracking moving objects with his eyes, so much so that his breathing became impaired when he attempted this task for less than a half minute. Interesting to find these basic neurodevelopmental deficits in the system responsible for balance in a man who had his whole life been told he was out of balance--although the focus had been placed on mental balance, emotional balance.
Michael also demonstrated hypersensitivity to touch. This was evident through his need to distance himself from others, that is to protect his personal boundaries, as well as by an avoidance of contact between most surfaces and the palms of his hands. He was bothered by tags in his clothes, and other such signs of tactile hypersensitivity. He engaged in behaviors described neurodevelopmentally as tactile-defensiveness. Psychologically, these were read to indicate that he did want contact, that he struck out when others were trying to get close to him.
Michael reported a total inability to dance, which interfered with his socializing. How could he dance, when knowing where his own body was in space was problematic, and he had to worry about not only his body, but others moving in unpredictable patterns around him. Because he was tactile defensive the movements of others in his space also put him jeopardy. As well, watching things go around in front of his eyes was a problem.
Michael had numerous visual dysfunctions. Not only could he not track moving objects due to vestibular deficits, he could not focus his two eyes together. Instead they were rivalrous--that is fighting for control. He saw things momentarily through one eye and then the other, without knowing this trick was taking place. This gave him even more difficulty assessing where his body was in space, since his visual perception of the space he was in kept shifting, and rarely had three-dimensionality. Michael was also hypersensitive to light, not an uncommon finding among individuals with poor binocular teaming.
Michael also had a noted avoidance of what is called midline crossing. That is, he either turned his whole body to pick up or place an object with one hand from the opposite side of the table. Sometimes, he still transferred the object at midpoint from one hand to the other, just as an infant would. This and other signs, including the visual rivalry pointed to deficits in communication between his right cerebral hemisphere and his left (commonly referred to as right brain and left brain). Although Michael is right handed, when he needed to point to signify his answers on various tasks of visual discrimination and memory, he used his left hand consistently. The left hand is governed by the right cerebral hemisphere, the same one that is known for organizing our visual and spatial perceptions. The fact that Michael was able to access language (a left hemispheric function) through his right hand, and was not even tempted to engage his right hand to access right hemispheric functions, further supported our findings that there was insufficient integration between the two sides of his brain. Again, it was interesting to note that a man who was diagnosed with bi-polarity had great difficulty getting the two sides of his brain to engage and communicate readily one with the other--a trend we are noticing in most of our clients who come to us with the diagnosis of or suspicion of bipolar disorder.
Michael tended to organize himself with language whenever possible, talking his way through most tasks. He also relied on rhythm to help him remember and organize things. If he could watch someone else do a task a few times in immediate repetition, he was able to learn and internalize the function through mental rehearsal, although he could not have organized the task himself initially.
Michael listened with great interest to the neurodevelopmental explanation of his problems. He felt it explained the various problems he had throughout his life. And he was eager to begin taking action to resolve these issues. He was a willing participant in the presentation of his individualized activity program. The program included such activities as drinking through a crazy straw and blowing through a blow pipe or whistle--aimed primarily at developing binocular teaming and reducing light sensitivity. He began strengthening his vestibular system through HANDLE's basic three slow, controlled vestibular exercises (ball-back-roll, side-to-side rock, and quarter-turn-roll), all performed on the floor so there would be no fear of falling. He was guided through two intensive exercises for developing midline crossing and interhemispheric integration--both of them incorporating rhythm so one of his weakest senses would be supported by one of his strongest. And he had a few other activities aimed at reducing his hypersensitivity to touch and increasing his proprioceptive awareness.
Michael worked on his program, periodically calling in to report that he was feeling much more balanced. He felt the most dramatic shift during the first week of the program, making steady increments after that. Four months after his initial evaluation, Michael returned for a follow-up. He reported that his attentional disorder was almost non-existent--he could do his own bookkeeping, take a momentary break, and come right back to finish the job.
His general learning disability was barely felt at all, to the extent that he noticed that his memory had improved greatly. His eyes were servicing him better, and his light sensitivity was almost gone, resulting in his being able to use the computer and present professionally produced bids on jobs. He could read for a half an hour even at the end of the day when he was tired. His sleep problems were a thing of the past. He felt that he had intelligent control over his issues of boundaries and distances, and that this was no longer an issue. The degree of general tension in his body had diminished, although he still felt some when he was driving (probably a prudent thing to have remain!), and similarly his palms, which had been unusually sweaty most of the time from tension, only sweated when he was driving. He was no longer fearful about getting or doing new jobs. He had no more manic drives to do such things as clean up the whole house in one sweep, even if he was exhausted. He was developing a meaningful relationship. On reevaluation, many of his functions had improved notably, including his visual tracking, midline integration, etc.
Within just about a half year's time, Michael had what he wanted: A successful independent contractor's status, a meaningful relationship, and he was off medication, relying only on his own strengthened systems to support the every day demands on his systems and to keep him balanced.
Michael called us recently, just about eighteen months from our first meeting. He reported that just a few months prior, he had felt that he was slipping a little in his stability issues across the board. This time instead of running in panic for a quick medication fix and long-term psychotherapy, he calmly picked up the list of activities he had been given at the follow-up evaluation, and began to perform them again. In only a few weeks, he was back in balance, under control, and fearful no longer that he would lose control again. Not to be corny, he did state that he knows he has gotten a handle on his problems.
Michael, like many adults we treat, may need to give himself a tune-up periodically. Admittedly, it is more difficult to create permanent alterations in the nervous system of an adult than a child. But many of the changes do become permanent, and others respond to a few minutes of "tune-up" every few weeks.
