Case 2: Volume 1, Case #7: The case of physician do not heal thyself

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 hief complaint is ¥ing 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 s a young child, had symptoms of generalized anxiety and separation anxiety lso, as a child, remembers motional trauma&rom 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 as had a lifetime of multiple turbulent interpersonal relationships since childhood, with family members, with friends and especially with women s 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 e 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 iagnosed as major depression for the fi rst time at age 23, early in medical school as 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 ctively suicidal and overdosed on his medications at this time but recovered n 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 o clear history of any full syndromal manic or hypomanic episodes ince 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 e interpreted these as good traits, indicative of creative persons, and were the reason he was productive as well as creative n 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 irst marriage ages 32ó epressive episode and overdosed again when fi rst marriage broke up econd marriage between 35 and 36 nother depressive episode after breakup of this marriage hird marriage ages 46 to 58 nother depressive episode after breakup of this marriage Medication History tarting 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 irst received lithium at age 43, 17 years ago nclear whether this was an augmentation strategy for resistant depression or for bipolar spectrum symptoms as not that helpful according to the patient tates he has had many, many medication trials since then alproate (Depakote) not tolerated lonazapam (Klonopin) helped sleep xcarbazapine (Trileptal) caused dysphoria and agitation erapamil caused/worsened depression isperidone (Risperdal) caused depression luoxetine (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 ther SSRIs caused activation and were not tolerated and discontinued after a few doses resents 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
arried and divorced 3 times, currently single o children on smoker o drug abuse, rarely drinks hysician and successful businessman Medical History rohnàdisease Family History ather: sleep disorder
other: either bipolar or unipolar depression, unsure, but successfully treated with ECT
aternal uncle: depression
aternal aunt: depression
aternal grandmother: hospitalized for anic depressive disorder urrent Medications zothiaprine and Remicaid for Crohnà
ethylphenidate Based on just what you have been told so far about this patientàhistory what do you think is his diagnosis? ecurrent major depression with an anxious/dysphoric temperament ipolar II depression ipolar II mixed episode ipolar NOS ipolar NOS superimposed upon a personality disorder (narcissistic, borderline, other) rimarily 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 PhysicianàMental Notes: Initial Psychiatric Evaluation ere 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 t 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 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 owever, 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? ontinue his methylphenidate iscontinue his methylphenidate tart an antidepressant estart lithium tart an anticonvulsant mood stabilizer tart an atypical antipsychotic
ake sure he agrees to weekly insight oriented psychotherapy onsider psychoanalysis Attending PhysicianàMental Notes: Initial Psychiatric Evaluation, Continued ince 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 he patient is open to pursuing psychotherapy as long as he respects the therapist efore recommending psychopharmacologic treatment, it would be good to review what we know from the available history about his response to medications already taken s 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 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 73 ow many medications were taken long enough to have had a chance to work? id some medications provoke mood instability while others stabilized mood? f the person has a mood disorder with an underlying personality disorder, will medications treat only the mood disorder and expose the symptoms of the personality disorder, or ill treating the mood disorder with medications allow the patient to recompensate and thus have improvement not only in mood but in personality disorder symptoms? hese questions are better answered if you live the ups and down along with the patient and experience the signs and symptoms of such a patient in real time owever, the real question is what can you do to help such a patient and what are the realistic goals of treatment inally, is treatment defi ned as medications, insight oriented psychotherapy, or both? bout the only thing solid here is that antidepressants seem to be provocative at times in terms of causing activation and thus should be given cautiously and only concomitantly with mood stabilizing medication as taken numerous mood stabilizing medications that he reported cause depression, especially those that are used to treat mania e has a demanding job and is not willing to put up with much sedation and will not accept weight gain t is possible that he is a bipolar spectrum patient with more depression than mania and with more pure depressive states alternating with mixed states of dysphoria/irritability superimposed upon depression, but not full syndrome mixed bipolar disorder hus he has four needs Treat from ¥low(i.e., antidepressant) tabilize from ¥low: (i.e. prevent cycling into depression) reat from bove(in his case, not to treat euphoric mania, but to treat irritability) tabilize from bove(i.e. prevent cycling into mixed states of dysphoric/irritable depression) ighly unlikely that this will be possible with a single agent or now, decided to avoid an antidepressant and to stop the methylphenidate which may help depression but at the expense of destabilizing him and causing cycling into irritable mixed states or now, a low side effect mood stabilizing agent with antidepressant and maintenance potential (i.e., treating from below and stabilizing from below) such as lamotrigine seems to be a good bet 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 74 fter this is given, might consider adding lithium which he has tolerated in the past although unclear what therapeutic actions it had for him; however, might treat and stabilize him from above in synergy with lamotrigine for a total therapeutic picture Case Outcome: First Interim Followup, Week 12 atient fl ies back for a followup appointment 3 months later as stopped methylphenidate and his psychiatrist in his home city started lamotrigine by slow upward titration, but a bit faster and to a higher dose than recommended and now taking 400 mg/day
ood stabilized but at a level of low grade consistent depression with decreased libido and sexual dysfunction old to reduce lamotrigine to 200 mg and wait another month or two because it can take a while yet for lamotrigineàantidepressant effect to kick in and its mood stabilizing effects may have already started Case Outcome: Second Interim Followup, Week 16 hone consultation earned that the patient decided that lamotrigine was making him depressed and ruining his sex life, so discontinued it and completely relapsed in terms of depression atient agrees to restart lithium after blood and urine tests from his physician Case Outcome: Third, Fourth, and Fifth Interim Followup Visits, Weeks 20, 24 and 28 hone consultations atient has normal labs and starts lithium at week 20 only has a blood level of 0.4, so told to increase dose t week 24 calls and states that higher doses give him unacceptable diarrhea and exacerbates his Crohnàdisease symptoms, so he is back down to the low dose of lithium lso, restarted methylphenidate as needed for dysphoric mood and low energy old to increase his lithium again, more slowly and not to 1800 mg/ day which caused diarrhea but only to 1500 mg a day or 1500 mg alternating with 1800 mg/day on alternate days and to stop his methylphenidate lso told to restart lamotrigine titrating up to only half his previous dose, namely 200 mg/day with the strategy that both drugs together would allow him to take each in lower tolerable doses for him, yet working together to add their therapeutic effects 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 75 Case Outcome: Sixth and Seventh Interim Followup Visits, Weeks 32 and 36 rief phone consults with the patient and his psychiatrist on the phone together etting regular psychotherapy èatever Monitored by his local psychiatrist monthly face to face appointments ithium level 0.7, occasional tremor and diarrhea but mostly tolerable
ood is stable and overall ¥els much better ase Outcome: Eighth Interim Followup, Week 40 mergency phone call an get a hold of his psychiatrist where he lives atient calls from a football stadium where his alma mater is playing in a big football game I`in trouble Patient states he has been much troubled recently about always feeling somewhat dysphoric, not really worse recently, but just tired of never being åll Denies psychosocial stressors but feels desperate and suicidal ow at the football game, his thoughts are entirely about suicide, making his will, shooting others at the game, and killing himself ortunately, he states he neither has a gun with him nor does he own one as weird reaction to the football game, because when his team scores, he is not euphoric but bursts into tears help me hat would you do now? ell him to call his local psychiatrist ell him to go to the emergency room ell him to call the suicide hot line ell him to settle down and that you will either call in a prescription for an antipsychotic or coordinate it with his local psychiatrist ell the patient to fi nd another consultant 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 76 Case Outcome: Eighth Interim Followup, Week 40, Continued old the patient to settle down and you would call his psychiatrist to meet him at his local emergency room which he agrees to do after the game ends lso patient states he feels much better now that he has spoken on the phone, and also now that his team is now winning ocal psychiatrist sees him in the emergency room and starts him on aripiprazole 2.5 mg increasing if tolerated and not effective to 5.0 mg 1 to 3 days later, increasing to 7.5 mg if tolerated and not effective 1 to 3 days later Case Outcome: Ninth Interim Followup, Week 41 ne week later, phone consult with his psychiatrist on the line atient states he contacted his local psychiatrist the same day as his phone call from the football stadium, and saw him a week later (which was yesterday) ot the prescription for aripiprazole and the next day following the phone call from the football stadium, left on a business trip from California to New York n New York, the aripiprazole was not effective at 2.5 mg, so the next day he became desperate and took 20 mg (not an overdose attempt, just to hurry up the therapeutic response) lso increased his lamotrigine on his own to 400 mg/day owered his lithium dose lew back to California ad gait disturbance, tremor, word-fi nding problems, memory loss, yet still verbally provocative, desperate with recurring suicidal and homicidal ideation I want to hang myself hat would you do now? tart another antipsychotic einstate the original doses of lamotrigine and lithium ell the patient and his local psychiatrist to fi nd another consultant Case Outcome: Ninth Interim Followup, Week 41, Continued ctually, this time, felt as though the patient was manipulating and scolded him with his psychiatrist on the line old him that his psychiatrist is the treating physician, not the consultant, and the consultantàadvice is to see his psychiatrist and to have future contacts with the consultant either by phone with his psychiatrist on the line, or face to face with his psychiatrist on the line 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 77 old to decrease lamotrigine, increase lithium back to previous levels and to discontinuie aripiprazole lso advised starting ziprasidone 40 mg at night with food Case Outcome: Tenth Interim Followup, Week 42 hone call with local treating psychiatrist and the patient one week later atient was compliant with instructions ow states the ziprasidone 5rned a switch By this he means that suicidal ideation abated immediately, depression no longer dysphoric but only low grade at worst ome fatigue/inertia ome tongue chewing suggesting a mild ziprasidone induced EPS ramatically better and very pleased uggest to them that the consultant will now resign from the case id he live happily every after? Case Outcome: Eleventh Interim Followup, Week 54 bout 3 months later, that is, 1 year after the initial psychiatric evaluation, got phone call from a new psychiatrist in the patientàhome city where the patient had transferred his care tates that the patient decided to add fl uoxetine 10 mg, stopped lamotrigine, tried 160 mg of ziprasidone, now back to 40 mg he story goes on. . . . Case Debrief his intelligent and manipulative patient with a genuine mood disorder and a personality disorder is decidedly unstable, but able to function as a physician even though not able to maintain long-term interpersonal relationships s not very compliant, often making therapeutic decisions on his own about how to treat his own case, especially when things are not going well t is diffi cult to determine whether his periods of mood stability are related to drug treatment or to the lack of psychosocial stressors, but there is the sense that medications are somewhat helpful for the worst of his mood swings even though the medications are not helpful for his responses to psychosocial stressors 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 78 Take-Home Points iffi cult patients are diffi cult o paraphrase Tolstoy in Anna Karenina Happy families are all alike; every unhappy family is unhappy in its own way One could say in cases like this one, ôable patients are all alike; every unstable patient is unstable in his own way Temperament and personality are factors in bipolar disorder and might even be part of bipolar disorder and are certainly part of the barriers to treatment effectiveness and to treatment compliance/adherence realistic goal in a case like this may be less of a roller coaster, but not full stabilization or true remission, yet well enough to stay employed, have relationships and not be desperate, suicidal or homicidal atients tend to hate depressed states more than mixed states whereas those around patients tend to hate the patientàmixed irritable states more than their depressed states Performance in Practice: Confessions of a Psychopharmacologist hat could have been done better here? hould the consultant have stayed engaged after the intial consultation? he involvement of two psychiatrists allowed the patient the opportunity for splitting and chaos hould psychotherapy have played a more prominent role here? ossible action item for improvement in practice
ake a more concerted effort to defi ne the role of a consultant versus a primary psychiatrist, who is the quarterback of the team, allowing the consultant to play a secondary role, and perhaps in cases like this, try and ensure no direct contact with the consultant without the primary psychiatrist also being present et realistic goals for a patient like this and realize long term stability may not be attainable Tips and Pearls amotrigine, lithium and an atypical antipsychotic can be a useful triple combination for unstable cases of mood and personality disorder and combinations and doses can be found that are relatively tolerable timulants have no role in a case like this ntidepressants can be destabilizing in a case like this hysicians can be especially diffi cult to treat when they are patients as they tend to interfere with their own treatments 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 79 Table 2: Personality disorders vs mood disorders luster A disorders (paranoid, schizoid personality disorders or schizotypal personality disorder) end to overlap with psychotic mood disorders luster B disorders (antisocial, borderline, histrionic and narcissistic personality disorders) an be easily confused for a bipolar spectrum disorder specially if no overt manic episode or any unequivocal hypomanic episode evertheless, symptoms can empirically improve when treated with agents for bipolar disorder very confusing and chaotic condition can be the combination of a bipolar disorder with a cluster B personality disorder luster C disorders (avoidant, dependent and obsessive compulsive personality disorders) an be confused with anxiety disorders ften predate the emergence of a mood disorder and can reappear when mood disorder symptoms under control Table 1: General symptoms of a personality disorder overlap with general symptoms of a mood disorder, particularly a bipolar spectrum mood disorder requent mood swings nger outbusts tormy professional and personal relationships ocial isolation uspicion and mistrust of others iffi culty making friends eed for instant gratifi cation oor impulse control requent drug or alcohol abuse Two-Minute Tute: A brief lesson and psychopharmacology tutorial (tute) with relevant background material for this case istinguishing personality disorders from mood disorders 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 80 Posttest Self Assessment Question: Answer Frequent mood swings are more a sign or symptom of a mood disorder than they are of a personality disorder A. True B. False Answer: False Mood swings are prominent signs of both mood disorders and personality disorders; not all mood swings are mood disorders References 1. Stahl SM, Mood Disorders, in StahlàEssential Psychopharmacology, 3rd edition, Cambridge University Press, New York, 2008, pp 453q0 2. Stahl SM, Antidepressants, in StahlàEssential Psychopharmacology, 3rd edition, Cambridge University Press, New York, 2008, pp 511¶6 3. Stahl SM, Mood Stabilizers, in StahlàEssential Psychopharmacology, 3rd edition, Cambridge University Press, New York, 2008, pp 667ò0 4. Stahl SM, Lamotrigine in StahlàEssential Psychopharmacology The PrescriberàGuide, 3rd edition, Cambridge University Press, New York, 2009, pp 259¶ 5. Stahl SM, Lithium, in StahlàEssential Psychopharmacology The PrescriberàGuide, 3rd edition, Cambridge University Press, New York, 2009, pp 2772 6. Stahl SM, Ziprasidone, in StahlàEssential Psychopharmacology The PrescriberàGuide, 3rd edition, Cambridge University Press, New York, 2009, pp 589t 7. Stahl SM, Aripiprazole, in StahlàEssential Psychopharmacology The PrescriberàGuide, 3rd edition, Cambridge University Press, New York, 2009, pp 45p 8. Schwartz TL and Stahl,SM, Ziprasidone in the treatment of bipolar disorder, in Akiskal H and Tohen M, Bipolar Psychopharmacotherapy: Caring for the Patient, 2nd edition, Wiley Press 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

By Day 3

Post a response to the following:

• Provide the case number in the subject line of the Discussion thread.
• List three questions you might ask the patient if he or she were in your office. Provide a rationale for why you might ask these questions.
• Identify people in the patientàlife you would need to speak to or get feedback from to further assess the patientàsituation. Include specific questions you might ask these people and why.
• Explain what physical exams and diagnostic tests would be appropriate for the patient and how the results would be used.
• List three differential diagnoses for the patient. Identify the one that you think is most likely and explain why.
• List two pharmacologic agents and their dosing that would be appropriate for the patientàantidepressant therapy based on pharmacokinetics and pharmacodynamics. From a mechanism of action perspective, provide a rationale for why you might choose one agent over the other.
• For the drug therapy you select, identify any contraindications to use or alterations in dosing that may need to be considered based on the clientàethnicity. Discuss why the contraindication/alteration you identify exists. That is, what would be problematic with the use of this drug in individuals of other ethnicities?
• If your assigned case includes èeck points(i.e., follow-up data at week 4, 8, 12, etc.), indicate any therapeutic changes that you might make based on the data provided.
• Explain %ssons learned&rom this case study, including how you might apply this case to your own practice when providing care to patients with similar clinical presentations