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The case of physician do not heal thyself
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Check My Assignment!PATIENT FILE 69 The Case: The case of physician do not heal thyself The Question: Does the patient have a complex mood disorder, a personality disorder or both? The Dilemma: How do you treat a complex and long-term unstable disorder of mood in a diffi cult patient? Pretest Self Assessment Question (answer at the end of the case) Frequent mood swings are more a sign or symptom of a mood disorder than they are of a personality disorder A. True B. False Patient Intake • 60-year-old man • Chief complaint is “being unstable” • Patient estimates that he has spent about two thirds of the time over the past year being in a mixed dysphoric state and about one third as depressed, but waxing and waning every few days, or even every few hours Psychiatric History: Childhood and Adolescence • As a young child, had symptoms of generalized anxiety and separation anxiety • Also, as a child, remembers “emotional trauma” from mother, herself with recurrent episodes of either unipolar or bipolar depression who was often physically unavailable because of hospitalizations, or emotionally distant when depressed at home • Has had a lifetime of multiple turbulent interpersonal relationships since childhood, with family members, with friends and especially with women • As an older child and adolescent, continued to have not only subsyndromal generalized anxiety but developed at least subsyndromal levels of OCD with ruminations, checking and rigidity • He was told these were good traits and would make him a good student, which he was, with good grades through high school and college, gaining admission to medical school Psychiatric History: Adulthood • Diagnosed as major depression for the fi rst time at age 23, early in medical school – Was his worst depression so far, as other depressions previously Downloaded from http://stahlonline.cambridge.org by IP 192.168.60.239 on Wed Jun 14 08:38:53 BST 2017 Stahl’s Essential Psychopharmacology Online © 2017 Cambridge University Press. All rights reserved. Not for commercial use or unauthorized distribution. PATIENT FILE 70 characterized as unhappiness and transient depressed moods of a few days duration and with more anxiety than depression, improving without treatment – Actively suicidal and overdosed on his medications at this time but recovered – In retrospect, patient believes that he has long experienced rejection sensititivity with up to 2 depressive episodes per year since age 16 up to the present • No clear history of any full syndromal manic or hypomanic episodes • Since age 23, however, has had many episodes lasting a week or more of irritability, infl ated self esteem, increased goal-directed work activity, decreased need for sleep, overtalkativeness, racing thoughts, psychomotor agitation and risky behavior; could also experience euphoria or expansiveness to a signifi cant degree but only for 2 or 3 days at most and usually shorter • He interpreted these as good traits, indicative of creative persons, and were the reason he was productive as well as creative • In getting his history, it is not clear whether he has had an irritable dysphoric temperament since childhood, a superimposed episodic subsyndromal dysphoric mixed hypomania, or both • First marriage ages 32–33 – Depressive episode and overdosed again when fi rst marriage broke up • Second marriage between 35 and 36 – Another depressive episode after breakup of this marriage • Third marriage ages 46 to 58 – Another depressive episode after breakup of this marriage Medication History • Starting with his fi rst diagnosed episode of depression in medical school, treated off and on with TCAs and benzodiazepines, starting and stopping them over many years in relationship to his symptoms • First received lithium at age 43, 17 years ago • Unclear whether this was an augmentation strategy for resistant depression or for bipolar spectrum symptoms • Was not that helpful according to the patient • States he has had many, many medication trials since then • Valproate (Depakote) not tolerated • Clonazapam (Klonopin) helped sleep • Oxcarbazapine (Trileptal) caused dysphoria and agitation • Verapamil caused/worsened depression • Risperidone (Risperdal) caused depression • Fluoxetine (Prozac) caused rapid fl eeting relief of depression, but also insomnia and headache Downloaded from http://stahlonline.cambridge.org by IP 192.168.60.239 on Wed Jun 14 08:38:53 BST 2017 Stahl’s Essential Psychopharmacology Online © 2017 Cambridge University Press. All rights reserved. Not for commercial use or unauthorized distribution. PATIENT FILE 71 • Other SSRIs caused activation and were not tolerated and discontinued after a few doses • Presents now only taking methylphenidate (Ritalin), which he prescribes for himself as he does not think his physicians know as much about his case, or what he needs, as he does and they will not prescribe it for him Social and Personal History • Married and divorced 3 times, currently single • No children • Non smoker • No drug abuse, rarely drinks • Physician and successful businessman Medical History • Crohn’s disease Family History • Father: sleep disorder • Mother: either bipolar or unipolar depression, unsure, but successfully treated with ECT • Maternal uncle: depression • Maternal aunt: depression • Maternal grandmother: hospitalized for “manic depressive disorder” Current Medications • Azothiaprine and Remicaid for Crohn’s • Methylphenidate Based on just what you have been told so far about this patient’s history what do you think is his diagnosis? • Recurrent major depression with an anxious/dysphoric temperament • Bipolar II depression • Bipolar II mixed episode • Bipolar NOS • Bipolar NOS superimposed upon a personality disorder (narcissistic, borderline, other) • Primarily a cluster B personality disorder (antisocial/histrionic/ narcissistic/borderline) Downloaded from http://stahlonline.cambridge.org by IP 192.168.60.239 on Wed Jun 14 08:38:53 BST 2017 Stahl’s Essential Psychopharmacology Online © 2017 Cambridge University Press. All rights reserved. Not for commercial use or unauthorized distribution. PATIENT FILE 72 Attending Physician’s Mental Notes: Initial Psychiatric Evaluation • Here is a case that could be a complex combination of a mood disorder plus a personality disorder in someone who has never experienced mania and probably has never reached the threshold of experiencing unequivocal hypomania as defi ned by DSM IV or ICD10 • It is very diffi cult to separate the mood disorder from the personality disorder in a one hour initial evaluation session, plus looking at the medical records • A complete diagnosis will have to await spending more time with the patient, and if possible, having access to the input of other observers as well • However, seems likely that there is more to this case than a mood disorder, and probably cluster B personality traits if not personality disorder is comorbid How would you treat him? • Continue his methylphenidate • Discontinue his methylphenidate • Start an antidepressant • Restart lithium • Start an anticonvulsant mood stabilizer • Start an atypical antipsychotic • Make sure he agrees to weekly insight oriented psychotherapy • Consider psychoanalysis Attending Physician’s Mental Notes: Initial Psychiatric Evaluation, Continued • Since the patient lives in another city, psychotherapy will have to be an option via another mental health professional, although some supervision of that plus advice on medications can be possible as a consultant • The patient is open to pursuing psychotherapy as long as he respects the therapist • Before recommending psychopharmacologic treatment, it would be good to review what we know from the available history about his response to medications already taken • As shown from the history of this case, it can be impossible to determine with great accuracy the effects of the medications by taking a history. One should be skeptical of the information as it can be unreliably reported in records and by a patient because it is complex and the medication effects can be subtle Downloaded from
