Challenging patient

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ghost dog

ghost dog

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Challenging patient, who I have seen for fibromyalgia for a
number of years.

She presents with convincing symptoms of bipolar d/0,
yet completely refuses a psych consult ( due to a court
ordered assessment in the past - which I don't have access to).

She filled out a mood questionairre recently, and indicated
"no" on all questions , when some were clearly YES ( i.e
racing thoughts, pressured speech, irritability,etc.)

She also dresses in a flamboyant manner, fairly typical
of a mania. This person has also expressed chronic paranoid
delusions to me on many occasions.

She was negative on a urine drug screen.

Suggestions?
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sounds similar to an psych oral board vignette case :laugh:

I'd be thinking of schizoaffective d/o (if you think she is truely delusional, not just having paranoid ideation/thoughts). Otherwise, would consider a cluster A personality d/o in the differential

I have no useful suggestions
 
Whats your training and comfort with this and who can you call locally for consult?
 
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ghost dog said:
Challenging patient, who I have seen for fibromyalgia for a
number of years.

She presents with convincing symptoms of bipolar d/0,
yet completely refuses a psych consult ( due to a court
ordered assessment in the past - which I don't have access to).

She filled out a mood questionairre recently, and indicated
"no" on all questions , when some were clearly YES ( i.e
racing thoughts, pressured speech, irritability,etc.)

She also dresses in a flamboyant manner, fairly typical
of a mania. This person has also expressed chronic paranoid
delusions to me on many occasions.

She was negative on a urine drug screen.

Suggestions?
Click to expand...

Her right to refuse treatment is actually stronger than her right to demand a certain treatment. In cases like these, it gets complex because she is essentially demanding suboptimal care. If she's not hospitalizable, then probably the best thing to do in the present is to show respect for her autonomy by engaging her in dialogue about her need for more optimal care.

You could choose to continue providing suboptimal care at her request but clearly document your rationale. This documentation should include the details of your discussion with her; your recommendations for optimal care; her refusal of optimal care despite understanding the risks, benefits, and alternatives; your assessment of her decisional capacity to refuse optimal care; and your ongoing concerns regarding her choice of treatment.

If at any point you believe that her choices are directly harming her (i.e., as opposed to causing her to not benefit from better treatment, although granted the distinction is probably more apparent than real), then you should feel okay about looking into more creative options -- i.e., transfer of care, etc. A patient's preferences for suboptimal care do not necessarily universally overrule a clinician's integrity.
 
atsai3 said:
Her right to refuse treatment is actually stronger than her right to demand a certain treatment. In cases like these, it gets complex because she is essentially demanding suboptimal care. If she's not hospitalizable, then probably the best thing to do in the present is to show respect for her autonomy by engaging her in dialogue about her need for more optimal care.

You could choose to continue providing suboptimal care at her request but clearly document your rationale. This documentation should include the details of your discussion with her; your recommendations for optimal care; her refusal of optimal care despite understanding the risks, benefits, and alternatives; your assessment of her decisional capacity to refuse optimal care; and your ongoing concerns regarding her choice of treatment.

If at any point you believe that her choices are directly harming her (i.e., as opposed to causing her to not benefit from better treatment, although granted the distinction is probably more apparent than real), then you should feel okay about looking into more creative options -- i.e., transfer of care, etc. A patient's preferences for suboptimal care do not necessarily universally overrule a clinician's integrity.
Click to expand...

I have done this in regards to documentation.

I have seen this patient for a number of years now, and she is fairly stable, psychologically speaking (i.e not suicidal, not a threat to others , is managing OK in the community - but not great).

My primary plan here would be a trial of a mood stabilizer - however, this would DEFINITELY exceed my expertise, particularly considering the patient has no insight into her psych issues. But, she refuses to see Psych. Thus, around and around we go.

I will call a local Psych and pick their brain.

Cheers.
 
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You might want to recommend that some psychotropics reduce chronic pain such as Lamictal, though unfortunately the other ones are antidepressants that can ramp up her mania.

Several questionnaires are useless. Many of them have not been tested and are on the order of a Cosmopolitan "Does your boyfriend think you got a hot ass?" test.

If the person doesn't acknowledge she has symptoms, you also go by what you see. A guy whipping out the hot dog, screaming, not sleeping for 4 days straight, a tangential thought process, obvious irritability, and a negative UDS is very likely manic no matter what he says.

In general, I tell PCPs not to deal with mania or psychosis, and only deal with anxiety disorders or depression that are not severe if they can handle it. Anything more extreme, leave it to the psychiatrists.

You cannot force treatment on anyone unless they lack capacity or are an immediate danger to self or others even if it's a good idea. Even then you got to do it in a manner that may not be in the patient's best interest. You emergency medicate an agitated and manic patient, in most states, you can only give a one-time dosage. If they don't want anything after they've calmed down you can't do anything else. This is a dilemna that we psychiatrists deal with quite a bit because many psychotic and manic patients don't realize they are that.

Other than that need more info.
 
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whopper said:
You might want to recommend that some psychotropics reduce chronic pain such as Lamictal, though unfortunately the other ones are antidepressants that can ramp up her mania.

Several questionnaires are useless. Many of them have not been tested and are on the order of a Cosmopolitan "Does your boyfriend think you got a hot ass?" test.

If the person doesn't acknowledge she has symptoms, you also go by what you see. A guy whipping out the hot dog, screaming, not sleeping for 4 days straight, a tangential thought process, obvious irritability, and a negative UDS is very likely manic no matter what he says.

In general, I tell PCPs not to deal with mania or psychosis, and only deal with anxiety disorders or depression that are not severe if they can handle it. Anything more extreme, leave it to the psychiatrists.

You cannot force treatment on anyone unless they lack capacity or are an immediate danger to self or others even if it's a good idea. Even then you got to do it in a manner that may not be in the patient's best interest. You emergency medicate an agitated and manic patient, in most states, you can only give a one-time dosage. If they don't want anything after they've calmed down you can't do anything else. This is a dilemna that we psychiatrists deal with quite a bit because many psychotic and manic patients don't realize they are that.

Other than that need more info.
Click to expand...

Awesome feedback.

To complicate matters further, her well meaning family physician had previously titrated this patient up to a ridonculous amount of Fentanyl
200 mcg Q 3days. Of course, this physician has since gone into administrative medicine, and is thus no longer scripting her this ludicrous / idiotic dose of opioid ; the patient catastophizes her pain (she has a hx of FM, and a past Hx of cocaine and sexual abuse).

I have counseled her that I would POTENTIALLY consider scripting her Fentanyl , with the EXPRESS condition of slowly tapering her off of it, as she is not obtaining meaningful benefit ( pain is always 9 -10 / 10 ). She does not agree with this course of action, and I will therefore not be scripting her opioid medication.

The only treatments I provide to her at the present time is that of nerve blocks and basic supportive therapy. I have encouraged her to participate in chronic pain group therapy , however she has yet to do so.

She is one of my most challenging patients.
 
ghost dog said:
Awesome feedback.

To complicate matters further, her well meaning family physician had previously titrated this patient up to a ridonculous amount of Fentanyl
200 mcg Q 3days. Of course, this physician has since gone into administrative medicine, and is thus no longer scripting her this ludicrous / idiotic dose of opioid ; the patient catastophizes her pain (she has a hx of FM, and a past Hx of cocaine and sexual abuse).

I have counseled her that I would POTENTIALLY consider scripting her Fentanyl , with the EXPRESS condition of slowly tapering her off of it, as she is not obtaining meaningful benefit ( pain is always 9 -10 / 10 ). She does not agree with this course of action, and I will therefore not be scripting her opioid medication.

The only treatments I provide to her at the present time is that of nerve blocks and basic supportive therapy. I have encouraged her to participate in chronic pain group therapy , however she has yet to do so.

She is one of my most challenging patients.
Click to expand...

Consider contacting the Risk Mgt attorney at your agency/institution or through your malpractice insurance. (You pay the premiums, why not utilize the service?) It's possible that refusing the psych referral is sufficient reason to "fire" her. I'm not saying that's what you Should do, only that you need to know precisely what your options are and how to utilize them. If she's part of a managed care plan, she may not need to agree to the referral for you to initiate it. Such a move would also demonstrate in the record Your commitment to getting her the specialist help you believe she deserves. Again, you should know your options.

There's also the tactic of:
"Ms X, I've been reviewing your records and labs and prescriptions and I've come to believe that you may have a serious, rather rare, neurological disorder. And if by chance you DO have this disorder, there is a significantly increased risk of disability or even premature death. (you don't tell her at this point that you mean suicide, which has a suicide rate around 10%, if I remember correctly.) There's no way for me to be absolutely sure with the information I've got, but it's concerning enough that I want to discuss the diagnostic and treatment options.
However, FIRST I need you to decide if you're going to let me pursue this at all. If you're going to refuse to see a specialist, then there's just not much point in having me pursue it. And if you're not going to allow me to refer you to a specialist, then I think we need to have conversation about whether I can continue in good conscience to be your physician."
 
Another day, another case where I see significant reason that a licensed medical doctor put someone on opioids and/benzos chronically, with no good reason, and their doctor showed no evidence of concern for possible dependence and addiction.

her well meaning family physician had previously titrated this patient up to a ridonculous amount of Fentanyl
200 mcg Q 3days
Click to expand...

I think "well meaning" is a bit diplomatic.

Of course, this physician has since gone into administrative medicine
Click to expand...

Wow, an even more very believable thing I often see. A bad doctor getting promoted up the food chain. Dr. Phil (had his license removed) and Nidal Hasan (Ft. Hood sole suspected shooter who had several complaints of inappropriate behavior, but kept getting promoted) you got another guy in your club....

Sorry about the rant. In all honestly I don't really know much about the case to comment, but seeing this type of problem so much made me jump into a defense mechanism....
 
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You could maybe approach it from an angle of hoping to reduce her fibromyalgia pain. Negative emotions, among other things, are associated with increased pain, both in individuals with and without fibromyalgia. If introduced it in enough of a "it's not because you're crazy" approach, maybe she'd bite, and you could leave it up to the psych to eventually steer sessions to assessing/treating the possible bipolar. Even if that didn't happen, maybe still see some benefit with the fibromyalgia pain.

P.S. I'm not a clinician.
 
whopper said:
Another day, another case where I see significant reason that a licensed medical doctor put someone on opioids and/benzos chronically, with no good reason, and their doctor showed no evidence of concern for possible dependence and addiction.



I think "well meaning" is a bit diplomatic.



Wow, an even more very believable thing I often see. A bad doctor getting promoted up the food chain. Dr. Phil (had his license removed) and Nidal Hasan (Ft. Hood sole suspected shooter who had several complaints of inappropriate behavior, but kept getting promoted) you got another guy in your club....

Sorry about the rant. In all honestly I don't really know much about the case to comment, but seeing this type of problem so much made me jump into a defense mechanism....
Click to expand...


A few points here:

1. I don't why someone would want to be an administrator in the first place (no bashing intended here). If I had to do this, I think I would shoot myself.

2. This physician in question is now the director of a large Physician assistant program at a major urban centre. Yikes!

3. The more I see opioids used for managing chronic non-malignant pain, the less I like it.

I saw a patient in consult today : she tells me the Oxycontin 80 mg BID she's currently taking decreases her pain , " like 85 - 90% ". However, all of her functional indices are uniformly diminshed , across the board by almost 80%-90%. Huh? I'm calling BS on that one. Horse**** detector pinging loudly.

AND she was negative for Oxycodone on a urine drug screen (which she initially lied about).

Opioids ain't for the masses.

The kicker: "I really need something for breakthrough pain, doc".

What , like a kick in the ass ? :(
 
2. This physician in question is now the director of a large Physician assistant program at a major urban centre. Yikes!
Click to expand...

Yikes indeed!

What I find surprising is the large number of doctors who choose to treat chronic pain that show little hope of improvement with opioids when there are plenty of meds out there that reduce chronic pain that are not addictive and don't build up a tolerance.

I can see the logic in a doctor giving out an opioid to someone with chronic pain only on a special occasion such as a guy wanting to dance with daughter on her wedding day who suffers from chronic pain. I can also see giving it out to the terminally ill, among a few other extreme cases, but from what I'm seeing these days, I think there's just too many doctors giving it out like candy.

That's funny because I remember a few years ago the general recommendations were that pain was being left under-treated in many cases. With all these new pill-mills, I wonder if anyone has decided to publish any opinions going against the previous recommendation.
 
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whopper said:
Yikes indeed!

What I find surprising is the large number of doctors who choose to treat chronic pain that show little hope of improvement with opioids when there are plenty of meds out there that reduce chronic pain that are not addictive and don't build up a tolerance.

I can see the logic in a doctor giving out an opioid to someone with chronic pain only on a special occasion such as a guy wanting to dance with daughter on her wedding day who suffers from chronic pain. I can also see giving it out to the terminally ill, among a few other extreme cases, but from what I'm seeing these days, I think there's just too many doctors giving it out like candy.

That's funny because I remember a few years ago the general recommendations were that pain was being left under-treated in many cases. With all these new pill-mills, I wonder if anyone has decided to publish any opinions going against the previous recommendation.
Click to expand...

The primary problem with a lot of opioid related studies, as I see it, is they look at pain reduction (subjective). Functional improvement seems to take a back seat. Even when this IS done, opioids don't do a heck of a lot for function.

Recent guidelines still recommend opioids for chronic non-malignant pain. However, a significant number of pain docs aren't terribly keen on this modality. This isn't to say some patients don't derive benefit; it's just you have to pick them carefully. Which a lot of docs still don't do, as demonstrated by the above case.

The real question, which has yet to be answered in any real evidence based manner, is how much benefit does this class of meds actually provide?
 
I saw a patient yesterday for "emergency anxiety visit" while her regular doc was on vacation. Unfortunately for her I already knew he had refused her request for Xanax.

Sure enough, "I'll be totally honest with you. Xanax is the only thing that works."

"And I'll be totally honest with you. I'm not prescribing you any. How about some Seroquel?":)

It was like someone had stuck a pin in her and let the air out.
 
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"the patient catastophizes her pain (she has a hx of FM, and a past Hx of cocaine and sexual abuse).

She is one of my most challenging patients".

Have you considered Borderline PD?
 
Atilla said:
"the patient catastophizes her pain (she has a hx of FM, and a past Hx of cocaine and sexual abuse).

She is one of my most challenging patients".

Have you considered Borderline PD?
Click to expand...

She sure has some Axis II / borderline traits.

However, this patients also has a heck of lot of manic symptoms. She is practically a standardized patient !!:laugh:
 
zenman said:
I saw a patient yesterday for "emergency anxiety visit" while her regular doc was on vacation. Unfortunately for her I already knew he had refused her request for Xanax.

Sure enough, "I'll be totally honest with you. Xanax is the only thing that works."

"And I'll be totally honest with you. I'm not prescribing you any. How about some Seroquel?":)

It was like someone had stuck a pin in her and let the air out.
Click to expand...

:thumbup:
 
zenman said:
"And I'll be totally honest with you. I'm not prescribing you any. How about some Seroquel?":)

It was like someone had stuck a pin in her and let the air out.
Click to expand...

Seroquel should certainly re-inflate her :p
 
I have seen at least one patient who self-medicated her mania with opioids.
 
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