The story of Romeo and Juliet: ‘never was a story of more woe’

November 2005

The 16-year-old athletic young lady entered the office with her tearful mother.

Growing up in a small farm house with three younger, very boisterous siblings, Juliet sometimes became the surrogate mother for them, as her mother often worked long hours at the hospital.

As she matured, she appeared to be a sweet and most charming, quite docile, pleasant and toothsome young lady. Socially, Juliet was a star athlete, and she achieved mostly As in advanced classes in her high school. Her parents were happily married, both worked steadily in professional jobs, and they cared deeply for their children, by all indicators that I witnessed both in the office and what I saw of them in the community. And yet, her father rarely attended any of her athletic functions.

“O Romeo, Romeo, wherefore art thou Romeo?/Deny thy father and refuse thy name…”

She began to use illicit drugs by age 15, “hanging out with the wrong crowd,” my daughter, a contemporary of hers, told me later. Family arguments became the norm, escalating to slammed doors, screams of contempt and running away from home a couple of times.

“Is love a tender thing? It is too tough/Too rude, too boist’rous, and it pricks like thorn...”

When she turned 16, Romeo, the 19-year-old high school dropout, who also happened to be a convicted felon, impregnated our Juliet. He was somewhat domineering, always demanding to know her whereabouts, and they argued frequently. Her parents vociferously disapproved of this young man. Her pediatrician discussed her options regarding the pregnancy. Within four months of conception, she said that she miscarried spontaneously.

She returned to the office eight months later for a paronychia and uneventful ingrown toenail removal. Soccer season had created great pressure on her time and also on her great toe, so she needed to return as soon as possible for the team’s big game this week. “Tell me, how is everything?” I asked. Fine. “And your grades?” Doing real well. “Any problems?” No, she said, I’m doing fine.

“Is there no pity in the clouds/That sees into the bottom of my grief?”

Five months later, she was brought into the office after cavorting for an entire weekend night driving nearly 100 miles away from home with some of her new friends. The same evening after the nocturnal escapade and threats of suicide and quite hateful attitude, her mother drove her down to the local children’s hospital where Juliet was evaluated. She had a negative drug screening, and was deemed as being reactively depressed due to her circumstances, and not a high risk for suicide.

She was released home that night and they were instructed to follow-up with her local pediatrician the next morning.

The good news — she had been seeing a counselor for the last four months for her depression and family problems. The bad news — she was apparently not responding. Her mother said they never discussed her depressed mood nor her miscarriage.

During my interview, my mouth went agape, for I noticed she had nearly 50 fairly deep, acute and chronic slices/abrasions on her left forearm.

She was despondent, avoided eye contact, and claimed she did not want to live. Her mother said the daughter constantly yelled epithets at her, argued with every request and frequently screamed that she “hates her.”

“Alas that love, so gentle in his view/Should be so tyrannous and rough in proof.”

Upon further interrogation, she immediately denied to me that she had any lingering issues with the miscarriage, any recent drug or alcohol use or boyfriend issues. She still “loves him,” she said, as he only yelled at her a few times weekly and he rarely hit her anymore. Since Juliet was “grounded forever,” she could only talk with her “lover” on the phone, during which time they usually argued and cried.

As some consolation, she was still faithfully using her weekly contraceptive patch.

She also freely discussed her contempt for her mother. She said she was now failing several courses and had no desire to play sports.

Clinical exam

Her examination revealed a pulse of 92 and blood pressure of 110/80, a flat affect, frequent tears, and she appeared to be otherwise physically normal. Except for one detail, her eyeballs appeared somewhat prominent, and the pulse rate was actually quite elevated for a star athlete. Add these findings to the chronic mild tachycardia (for two years — I looked at our office chart) and some really erratic, tempestuous and out of character behavior, I think that I had at least a reason to check her thyroid function, urinalysis and complete blood count.

Her T4 and free thyroxine index were 17.6 and 5.8, respectively. Perhaps, her thyrotoxicosis and early Graves disease (slight exophthalmos) were exacerbating her alarming self-destructive behavior and depression. Perhaps?

Clinical treatment

I elected to initiate therapy with methimazole and fluoxetine, along with careful monitoring for worsening suicidality and mood disorder, and elimination of any weapons and risky medications in her household. I always cringe when starting many medications with out-of-control female adolescents for fear of teratogenicity, no matter how benign the medications allegedly are. Thus, my emphatic emphasizing continued contraception monitoring by the parent.

Within three days a frantic phone call for some mild abdominal pain, nausea and hot flashes or fever ensued. Hopefully, this was merely the gastrointestinal virus that was circulating in her high school, of which I had observed several cases that week. This mercifully passed uneventfully.

An utter transformation

During the follow-up visit the following week, I observed a happier, smiling, garrulous young Juliet — an utter transformation! She could even talk and interact with her mother in a peaceful tone. After a month of an increasing dose of methimazole and stable use of her fluoxetine, all suicidal behavior had resolved, her grades had skyrocketed back to As, and she once again appeared to be contentedly heavily involved with her sports.

She was living at home without problems, she reported.

I patted her on the back and congratulated her. Next, I patted myself on the back and sighed in relief.

“Thy Head is as full of quarrels as an egg is full of meat.”

A few days later, I found out that the thyroid functions had not budged. She had run away from home again.

Old Romeo, the boyfriend, entered the picture again a week later, and he broke her feeble heart again by “dumping her.”

A tirade to the family ensued, and she ran away from home for several days in an absolute tiff, only to wind up at her grandmother’s house as a safe haven. Playing “phone tag” with her mother, her counselor said she needed “more antidepressants.”

I finally caught up with the mother a few days later, spotting her car as she was leaving my parking lot in the morning while I was strolling into the office out of my Ford F-150.

Window down, we exchanged the latest news and plan of action and medication adjustment for her contentious daughter.

Without her chart staring at me, these specifics were retrieved in my ancient mental computer very slowly while standing in the bright sun.

“I may need medicine for my nerves more than she does,” she pleaded tearfully.

You and me both, I agreed. Will our Shakespearean “Juliet” survive? Next, will she and I both survive this Romeo and Juliet romance?

“Tis not hard, I think, for men so old as we to keep the peace.”

As we grow older, I also realize we may not be able to fully understand the impetuous vital self-importance and irrational exuberance of youthful love. (Much like Federal Reserve chairman Alan Greenspan said about tech-blinded traders in the stock market.) How can a talented and lovely young lady turn into a “star-crossed lover,” a victim of such a brutish Romeo, and a sheer menace to herself, and in such woeful proportions?

She showed up at school again, this week with an ecchymotic eyelid. Just wrestling with him allegedly? However, her thyroid functions had finally normalized the next week, and she had “allowed” her parents to live in “her” household again.

Let me tell you a secret.

My gut instinct may have been wrong about her tumultuous history, as I may have been seeing her world through my own rose-colored glasses.

Too many times I have witnessed the utter despair that follows an abortion. Could it be she was not actually a victim of uterine spontaneity? Perhaps it was an intentional “miscarriage?” In my lengthy experience, a few external tragedies in any Juliet’s life will certainly drive a young lady to this depth of despair, namely abortion, rape or sexual abuse, particularly in the community in which I reside.

I then realized that I am like Friar Laurence in Romeo and Juliet, as I repeated his mantra: “Care keeps his watch in every old man’s eyes.”

This old man will keep his post, monitor the thyroid and be caring and available to this tormented family and Juliet, for “Parting is such sweet sorrow...” Each quote in italic was excerpted from Shakespeare’s Romeo and Juliet.

For more information:

• Bradley M, Giedd JN. Yes, Your Teen is Crazy! : Loving Your Kid Without Losing Your Mind. New York, N.Y.: Harbor Press; 2003.
• Pipher MB. Reviving Ophelia: Saving the Selves of Adolescent Girls. New York, N.Y.: Putnam; 1994.

• Stan L. Block, MD, has a pediatric practice in Bardstown, Ky., and is a member of the Infectious Diseases in Children editorial board.