How would you handle this case?

[Psychobabbling]

Just deleting this, pt made a comment about doing a search online for his combo, didn't want this to pop up lol

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[nitemagi]

History of DTs = contraindication to wellbutrin in my book. Even if they acknowledge the sz risk.

The real question is not the med choices, but how to manage a difficult narcissistic manipulative patient. That would take a long post.

 

[Psychobabbling]

How would you navigate the case, at least initially? I wasn't comfortable with going back to Wellbutrin which is why I wanted to try something else to begin with. I'm a PGY3, so I'm seeing this patient with an attending. We discussed restarting it, not going past 300 as our limit. Risk reduction and all.

 

[nitemagi]

Depends on the level of rapport I had with him. I would try to maximize it first, then try out a "heart-to-heart," pointing out what you've observed in terms of drinking, risks, and that you're very very concerned. Couch everything in extreme empathy and using language that focuses on his safety and well-being. I might point out the shaking, and what I think it means, and include the biggest consequences/risks of going down this road, that of death. I would also use depersonalized language if direct "you" triggers defenses. "I've seen people with problems that become like X." If this kind of approach doesn't break through at all, figure out what your points of leverage are, and work that (can't get meds elsewhere, pressured by someone to be there, you offer something else, other ppl he does listen to who are on your side). Maybe you agree to prescribe WBT only if he's in a recovery program. Those would be my first approaches.

 

[Psychobabbling]

Thanks a lot for the advice nitemagi. I will definitely make use of that depersonalized language idea. He won't do AA (because of its roots, super long conversation), but maybe I could get him to switch to MICA or something, which is in the same building, would just come at a different day and time...I could try and coordinate that with them...

Good ideas! Thanks so much

 

[F0nzie]

I've tried talking about maximizing his Zoloft rather than the Wellbutrin. Then comes the guilt trip/you're trying to punish me/you don't care, etc.

"I understand stand it feels like I don't care even though I am doing what is best for you." DC Wellbutrin.

 

[F0nzie]

Once you point out the difference between his perception and reality and empathize with his feelings and he realizes you won't be following him down the rabbit hole he may be more open to talking about alternatives.

 

[F0nzie]

Keep a sticky note of this interaction as you further delve into therapy

 

[Psychobabbling]

I think I just need to set a better limit with him and what I'm willing to do/not do. We'll see how it goes. Wish me luck

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Edit: Maybe I got a little lucky today. Doing much better with the increase in Zoloft. I had a very open conversation with him. Told him that he's relapsed in the past, recently, and that he's my patient and I care about his well being, and I have to balance that with his safety. He really opened up after that, and was on board with maximizing his Zoloft. I set the ground for if he's doing better on a higher dose of Zoloft than he has been on before, maybe it was the Zoloft all along and not the Wellbutrin - and tapering off of that in time - and he was actually better with that.

Pretty cool stuff. Thanks for the comments