odd combo of meds

[Borderline123]

For those of you practicing psychiatrist, what do you when you are referred a patient who is on a bunch of meds that don't seem to make a lot of sense. I have one who is on 8mg of Trilafon, 2mg of Klonopin, 20mg Lexapro, 10 Adderall BID, 50mg Trazadone, (and a nicotine patch). My working diagnosis is borderline PD, ADHD (by history, no apparent sx). (I usually don't tack on MDD recurrent unless the mood sx seem to be in addition to the personality component). The patient has a trauma history - physical abuse growing up and an abusive ex. The current complaints are reactive mood, anxiety, interpersonal conflicts, insomnia, trust issues, misunderstood... Main concern is risk of TD on Trilafon with no hx of psychosis and very questionable "mood swings" - at least in the DSM sense. I'm also no fan of long term benzos and I question a stimulant and a tranquilizer at the same time. What do you all think?

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[strangeglove]

Sounds like the typical Borderline med regimen. Good thing that you actually think that she has BPD, as opposed to a combination of Bipolar Disorder, ADHD, PTSD (this combination, when reported by patients, is pathognomic for BPD in my mind). I imagine that each medication in this regimen was added by the previous psychiatrist every time he or she was made to feel helpless by this patient. If you are confident in your diagnosis, you might consider referring her (I presume her) to DBT, to learn how to regulate herself without needing to turn to the medications. Once that's in place, you may be in a better position to wean her off of all of these medications (good luck getting her off the stimulant!). At that point, a mood stabilizer and a touch of atypical antipsychotic may be all that she needs.

 

[billypilgrim37]

I think the bigger question here is: where's the Topamax?

 

[sonofthesouth]

good luck getting her off the stimulant!

i think you'll need even more luck to get her off the benzo. and i second the idea of getting her OFF nearly everything and ON a mood stabilizer

 

[OldPsychDoc]

I think the bigger question here is: where's the Topamax?

She's allergic. Gives her migraines. And seizures.

 

[whopper]

If this person had borderline PD, I hope you are recommending DBT and only continuing medications if it's justified.

Psychotropic medications don't show much benefit with borderline PD and are not considered first-line treatments for it.

Despite that, several psychiatrists continue the practice of treating borderline PD in a manner that goes against several treatment philosophies.

1) DBT is the treatment of choice yet several psychiatrists, not understanding DBT or having anyone they know who could provide it, do not point borderline PD patients in this direction.

2) Several psychiatrists diagnose borderline PD as having mood disorder NOS, psychosis NOS, etc even though the DSM clearly indicates that a diagnosis of borderline PD or the other disorders are due to symptoms not from another disorder. I've heard psychiatrists argue "This patient is so parasuicidal, it merits a mood disorder NOS diagnosis." Not according to the DSM.

3) We psychiatrists are supposed to avoid polypharmacy when available. When we prescribe psychotropics, we are supposed to do so in a manner where we use the least amount needed and only if the benefits outweigh the risks.

In the treatment of those with borderline PD, giving out medications--to the point where it becomes a stew goes against all the above.

That said, if someone does have borderline PD, don't close off your mind to the possibility that psychotropics may help. Borderline PD is often times comorbid with PTSD. Try to find out if the person has PTSD and treat that disorder. Psychotropics may also help acute breakthrough symptoms. (E.g. an antipsychotic if the person is experiencing a micro-psychotic episode, but strongly consider stopping the antipsychotic when the episode ends). The person may also have a true comorbid condition, though don't diagnose something such as psychosis NOS unless there are reasonable medical grounds to do so. A borderline showing impulsivity and dysregulation of anger is not somehow psychosis NOS despite what some of my teaching attendings told me in residency. It's simply borderline PD.

But do not throw more and more medications at someone with borderline PD and expect it to treat someone as if they had panic disorder and you're giving them an SSRI. It doesn't work that way.

Of the borderline PD patients I treat, if I get to the point where I don't think psychotropics will help, or they are doing as much help as they can, I simply tell the patient that I don't think it's worth it to continue to see medications as the answer and that psychotherapy, if it already hasn't started, has to be the end goal of getting them better.

I pretty much never give any borderline PD patient a substance of potential abuse unless they have a comorbid disorder that truly merits it's use. (e.g. Borderline PD and ADHD--and ouch, yes they are hard to differentiate in the same person). Even then I try medications to treat the ADHD that are not stimulants such as Wellbutrin or Strattera.

 

[kugel]

Here's my take:

1) Obtain consent to release info from every past provider (inpt and outpt) that is possible. Also call the last provider and try to ferret out the strategy involved, if it's not obvious in the records.

2) Ask the pt for a list of every medication and nutiritional/supplement used and what his/her memory is of whether it helped and any problems associated with it. If necessary, compile a list of all possible meds used for such pt's (every antidepressant, mood stabilizer (incl Neurontin), antipsychotic, anxiolytic, hypnotic) and let the pt complete the profile at home. Often, I go through the Pocket Pharmacopeia and get a Yes/No to each med, and then go from there.

3) compare the list from #1 and #2 above, clarify differences with the pt.

If the pt has been treated by many people over time, it's quite possible that the list is huge and basically useless. Nothing has really worked and the pt keeps trying to find the "right combination that will make me feel normal." That, of course, is the fantasy you are fighting against.

At that point, it may be useful to go over with the pt that all these meds and combos have been essentially useless and maybe, just maybe, meds should not be the focus of treatment. Perhaps, we should be focusing on helping you to train your brain to react a little differently to the world around you - rather than medicating you. If you were a tennis student, we would not be worrying about specific nutritional supplements (and certainly not anything as powerful and full of side-effects as steroids) until we were sure you had learned how to perform the skills involved in playing tennis. That's often the position we are in with personality disorders.

Learning the skills to play tennis is my analogy for DBT.