Dealing with nebulous, confusing patients

[jbomba]

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I have recently started seeing patients at a residential treatment facility. I am finding many of these patients (along with prominent personality traits) have vague, atypical, symptomatic presentations. They are often pan-positive, highly somatic, have tried 15+ psych meds and "nothing works for me". They'll claim PTSD, bipolar, etc etc but nothing fits. They are just generally discontent, often have trauma (sometimes quite severe), poor sleep, chronically passive SI.

I try not to write them all off as just personality disordered, but they are quite frustrating to assess and treat. Any thoughts on how to approach patients like this and/or how you actually attempt to medically treat, given the above? Because yes, there is pressure from insurance to add or change medications to validate their need for a residential program. I do believe they will most significantly benefit from the very good group of therapists we have, so staying around long enough for treatment would benefit them.

 

[comp1]

"Just personality disordered?" Personality disorders are MUCH (orders of magnitude) more common than bipolar disorder and they almost uniformly are comorbid with PTSD symptoms, if not frank disorder. Your description is not at all nebulous or confusing unless you are trying, desperately, to avoid diagnosing a personality disorder. I don't deal with private insurance (thank goodness), but purely from a clinical perspective, you need to resist, hard, the urge to constantly change medications to change medications. To me at least, that doesn't actually justify a need for residential treatment at all. You can adjust meds weekly perfectly well in an outpatient setting. Residential treatment is ALL about the talk therapy, group and individual. It's about developing coping skills in a supportive environment. You are a tiny, often insignificant part of the program. Med changes might occasionally occur, but they certainly aren't the reason someone should be in residential treatment. I think you need to clarify some stuff with insurance companies. Document why you AREN'T changing medications (eg it's harmful in personality disorders) and how they actually are benefitting from the program, even if you aren't the clinician providing that benefit. Personality disorders are very serious mental illnesses.

 

[jbomba]

"Just personality disordered?" Personality disorders are MUCH (orders of magnitude) more common than bipolar disorder and they almost uniformly are comorbid with PTSD symptoms, if not frank disorder. Your description is not at all nebulous or confusing unless you are trying, desperately, to avoid diagnosing a personality disorder. I don't deal with private insurance (thank goodness), but purely from a clinical perspective, you need to resist, hard, the urge to constantly change medications to change medications. To me at least, that doesn't actually justify a need for residential treatment at all. You can adjust meds weekly perfectly well in an outpatient setting. Residential treatment is ALL about the talk therapy, group and individual. It's about developing coping skills in a supportive environment. You are a tiny, often insignificant part of the program. Med changes might occasionally occur, but they certainly aren't the reason someone should be in residential treatment. I think you need to clarify some stuff with insurance companies. Document why you AREN'T changing medications (eg it's harmful in personality disorders) and how they actually are benefitting from the program, even if you aren't the clinician providing that benefit. Personality disorders are very serious mental illnesses.

I appreciate that take. I guess part of it is, I am hearing these variety of psychiatric complaints and I would generally like to help them with this....BUT, I also know those 1-2 day episodes of mania which occur 4-5x a month which your psych NP diagnosed as BAD1 isn't going to get better based on anything I am going to be prescribing you here. I just get a vomit of symptoms which have previously been diagnosed as cPTSD, BAD, MDD, SAD and I feel some internal pressure to help them with that. But I know what you're saying - the true treatment is going to be the therapy, and the groups, which we offer.

But then there's this small voice inside of me that says, "youre diagnosing everyone with a personality disorder, maybe you're just ****ty and this is your way to avoid having to pharmacologically help difficult patients".

 

[romanticscience]

Look into Otto Kernberg's ideas related to "identity diffusion," the structural interview, and borderline personality organization.

 

[aim-agm]

I have recently started seeing patients at a residential treatment facility. I am finding many of these patients (along with prominent personality traits) have vague, atypical, symptomatic presentations. They are often pan-positive, highly somatic, have tried 15+ psych meds and "nothing works for me". They'll claim PTSD, bipolar, etc etc but nothing fits. They are just generally discontent, often have trauma (sometimes quite severe), poor sleep, chronically passive SI.

I try not to write them all off as just personality disordered, but they are quite frustrating to assess and treat. Any thoughts on how to approach patients like this and/or how you actually attempt to medically treat, given the above? Because yes, there is pressure from insurance to add or change medications to validate their need for a residential program. I do believe they will most significantly benefit from the very good group of therapists we have, so staying around long enough for treatment would benefit them.

I am reminded of a joke:
Patient: "Doc, something is wrong with my body - it hurts when I poke my forehead, it hurts when I poke my legs, it hurts when I poke my stomach. It hurts when I poke anywhere!"
Doctor: "You have a broken finger."

When a patient is pan-positive (and isn't trying to be deceptive or malinger), it suggests that there is a problem with their perception or insight. So you have to go off your perception - what are the problems or symptoms you are observing they are having?

 

[shoomer]

They are often pan-positive, highly somatic, have tried 15+ psych meds and "nothing works for me". They'll claim PTSD, bipolar, etc etc but nothing fits. They are just generally discontent, often have trauma (sometimes quite severe), poor sleep, chronically passive SI.

If I asked someone to describe cluster B personality pathology informally, it would literally be this. This is all about psychotherapy here. If you want to help them, your job is to promote buy-in to the programming and decrease unnecessary psychotropic burden.

In the real (clinical) world, de-prescribing or not prescribing is an intervention in of itself.

 

[psydocc]

I have recently started seeing patients at a residential treatment facility. I am finding many of these patients (along with prominent personality traits) have vague, atypical, symptomatic presentations. They are often pan-positive, highly somatic, have tried 15+ psych meds and "nothing works for me". They'll claim PTSD, bipolar, etc etc but nothing fits. They are just generally discontent, often have trauma (sometimes quite severe), poor sleep, chronically passive SI.

I try not to write them all off as just personality disordered, but they are quite frustrating to assess and treat. Any thoughts on how to approach patients like this and/or how you actually attempt to medically treat, given the above? Because yes, there is pressure from insurance to add or change medications to validate their need for a residential program. I do believe they will most significantly benefit from the very good group of therapists we have, so staying around long enough for treatment would benefit them.

This sounds like run-of-the-mill BPD. They have such a classic clinical presentation that it's, frankly, diagnostically banal. I would argue that pretending these patients are MDD, BPAD, ADHD, etc is writing off their actual problem and leads to unnecessary use of psychotropics which do not work for them (these patients aren't lying when they say meds don't work for them) and then they start thinking they are some sort of medical mystery, treatment-resistant alphabet soup of conditions.

 

[splik]

This is good old fashioned hysteria of Briquet. While some of these patients have a borderline level of personality organization, not all of them do by any stretch.

Residential treatment has very little to do with meds and psychiatrists are often highly peripheral to residential programs (as you indicate you are) so don't believe any nonsense about having to make med changes to validate the need for residential. This is not inpatient where there is pressure to stabilize. For inpatient, hysterical patients would historically be loaded up with mellaril or stelazine as ego glue. In the residential setting, I would not be focusing on medications. The justification for residential treatment for these patients is either they decompensate with brief hospitalizations (which are often counter therapeutic) or they are unable to engage or benefit from a lower level of care because of the psychosocial complexity and chaos in which they exist.

while I find cPTSD is overdiagnosed these days or used as a euphemism for BPD, if the patients have complex developmental trauma, meet criteria for PTSD, and also have messy relationships, dissociation, somatization, high levels of healthcare utilization, then they can be conceptualized as having cPTSD (which is an hysterical diagnosis) and residential provides the holding environment that is the perfect opportunity for trauma focused therapy. The patients need a lot of structure, positive expectancy, and need to be stepped down to PHP and then IOP and then outpatient care with multiple times per week treatment.

If you want some pro tips for pharmacological management of these patients, they often do quite well with PRN promethazine. A long list of medication is often taken by the medication as a badge of honor for their treatment resistance and hopelessness of their case. Conversely, peeling away at medication confirms their unlovability and unworthiness and activates attachment anxiety unless done in a very careful gradual way. In the old days, MAOIs, and particularly Nardil, was thought to be helpful for hysteroid dysphoria. You have to have more reliable patients for this but the meds can help. How much of it is from the "this drug is so powerful, if you eat smelly cheese, you'll die", I couldn't tell you. Again, the drug can confer a sense the patient is special and worthy. Can be combined with a low dose of lithium.

When I was in training there was this really old psychiatrist who would refer these patients for a course of just 2 bilateral ECT sessions. I am sure it was a placebo but it worked for their acute decompensation. He seemed to know that these patients get worse with anymore than 2 ECT treatments.

 

[TexasPhysician]

Maybe consider a conference devoted to just personality disorders for more in-depth therapy training. I felt my training on personality disorder based therapy was lacking. Your original post almost perfectly described personality disorders as the culprit.

 

[jbomba]

Thank you all. Yes, in my head I saw these patients all as personality disordered. I just haven't worked in an environment like this before and was starting to question myself.

 

[Ceke2002]

I have recently started seeing patients at a residential treatment facility. I am finding many of these patients (along with prominent personality traits) have vague, atypical, symptomatic presentations. They are often pan-positive, highly somatic, have tried 15+ psych meds and "nothing works for me". They'll claim PTSD, bipolar, etc etc but nothing fits. They are just generally discontent, often have trauma (sometimes quite severe), poor sleep, chronically passive SI.

I try not to write them all off as just personality disordered, but they are quite frustrating to assess and treat. Any thoughts on how to approach patients like this and/or how you actually attempt to medically treat, given the above? Because yes, there is pressure from insurance to add or change medications to validate their need for a residential program. I do believe they will most significantly benefit from the very good group of therapists we have, so staying around long enough for treatment would benefit them.

I was one these patients. I mean not literally one of the patients you're seeing at a residential centre, but the general description fits. A long term course of psychotherapy and correct prescribing when needed has meant a near complete recovery and/or remission of all diagnoses/symptoms in my case.

More than happy to discuss what helped me personally in this sort of situation, if you would find that helpful.

 

[clausewitz2]

If you want some pro tips for pharmacological management of these patients, they often do quite well with PRN promethazine. A long list of medication is often taken by the medication as a badge of honor for their treatment resistance and hopelessness of their case. Conversely, peeling away at medication confirms their unlovability and unworthiness and activates attachment anxiety unless done in a very careful gradual way. In the old days, MAOIs, and particularly Nardil, was thought to be helpful for hysteroid dysphoria. You have to have more reliable patients for this but the meds can help. How much of it is from the "this drug is so powerful, if you eat smelly cheese, you'll die", I couldn't tell you. Again, the drug can confer a sense the patient is special and worthy. Can be combined with a low dose of lithium.

This was the approach of Donald Klein (RIP). I have done this occasionally with phenelzine, it definitely seems to have turned things around for one such patient who has gone from bouncing between IOPs, PHPs, and very unproductive hospitalizations for several years and wanting to meet extremely frequently to someone who is fine with being seen monthly for many months at this point. I do not think I am harnessing the placebo effect as powerfully as I could (my MAOI pitch emphasizes that the dietary restrictions are actually much less stringent than what they will find on the Internet) but can't discount the possibility that's a part of it.

I will have to try the promethazine PRN trick. I have become more partial to very small PRN doses of neuroleptics generally for these folks but I can see the potential appeal of promethazine in particular.

 

[Merovinge]

This was the approach of Donald Klein (RIP). I have done this occasionally with phenelzine, it definitely seems to have turned things around for one such patient who has gone from bouncing between IOPs, PHPs, and very unproductive hospitalizations for several years and wanting to meet extremely frequently to someone who is fine with being seen monthly for many months at this point. I do not think I am harnessing the placebo effect as powerfully as I could (my MAOI pitch emphasizes that the dietary restrictions are actually much less stringent than what they will find on the Internet) but can't discount the possibility that's a part of it.

I will have to try the promethazine PRN trick. I have become more partial to very small PRN doses of neuroleptics generally for these folks but I can see the potential appeal of promethazine in particular.

Can you or @splik explain the promethazine further? I have never seen/heard this used for psychiatric purposes. Is the point to be a hydroxyzine that also has some anti-nausea effects? Or asked another way how is this different/better than hydroxyzine PRN (which I use all the time as a CAP).

 

[Stagg737]

Can you or @splik explain the promethazine further? I have never seen/heard this used for psychiatric purposes. Is the point to be a hydroxyzine that also has some anti-nausea effects? Or asked another way how is this different/better than hydroxyzine PRN (which I use all the time as a CAP).

“This is a very try old but very powerful med. No one really uses it anymore but your situation is unique and warrants using every trick in the book.”

That and it’s a powerful H1 antagonist that’s dirty af as it also hits alpha-1, 5HT-2, is very anticholinergic and has a dash of dopaminergic activity. I used it once or twice in residency, but haven’t used it since.

 

[splik]

Can you or @splik explain the promethazine further? I have never seen/heard this used for psychiatric purposes. Is the point to be a hydroxyzine that also has some anti-nausea effects? Or asked another way how is this different/better than hydroxyzine PRN (which I use all the time as a CAP).

tolerance fast develops to hydroxyzine which you don't see with promethazine. promethazine was recommended in the NICE guidelines for BPD. For some reason, patients love it. It's not abusable in itself, but could be when combined with opioids a la purple drank. also unlike hydroxyzine it does block D2 receptors and is a phenothiazine but has like 1/10th of the potency of thorazine. I guess it's not used much in psych in the US, but it is popular in the UK and Germany. I've used it for years, it's one of my top 10 most prescribed drugs.

 

[jbomba]

tolerance fast develops to hydroxyzine which you don't see with promethazine. promethazine was recommended in the NICE guidelines for BPD. For some reason, patients love it. It's not abusable in itself, but could be when combined with opioids a la purple drank. also unlike hydroxyzine it does block D2 receptors and is a phenothiazine but has like 1/10th of the potency of thorazine. I guess it's not used much in psych in the US, but it is popular in the UK and Germany. I've used it for years, it's one of my top 10 most prescribed drugs.

How do you dose it in bpd? And is it a time limited medication?

 

[hebel]

These people need therapy. However, the quality variance of therapists in the community is massive, which can make it difficult to actually get them the right treatment (unless your clinic has quality in house therapists).

 

[comp1]

It's residential treatment and the OP works there, so hopefully the therapists are good or the OP should leave. That said, the fact the OP hasn't received all the above feedback at RTF staff meetings is concerning.

 

[Wilf]

Splik, what sort of dose range do you use? Something like 12.5 mg bid or tid prn? Do you use it long term or only short?

 

[splik]

For those asking re: dosing of promethazine - typically it's 25mg prn qid. For some patients 25mg might be too much and 12.5mg is fine in that case. It's pretty uncommon for pts to develop EPS with promethazine. acute dystonia has been reported but I've never seen it. It is best used during times of crisis rather than chronically.

But then there's this small voice inside of me that says, "youre diagnosing everyone with a personality disorder, maybe you're just ****ty and this is your way to avoid having to pharmacologically help difficult patients".

That is actually a good thought. unfortunately a lot of psychiatrists do dx unlikable or difficult patients with personality disorder, sometimes reasoning that countertransference reaction is prima facie evidence of PD. Yet there are clear cut criteria for personality disorders which is there is persistent, inflexible and pervasive pattern of inner experience and behavior that deviates from cultural norms affecting cognition, affect regulation, impulse control and interpersonal functioning. The RTC population is certainly enriched for personality disorders but the description of the patients is not in itself consistent with PD but Briquet's hysteria. BPD specifically has clear diagnostic criteria such as fear of abandonment, unstable sense of self, tendency to form intense and volatile relationships etc. Interestingly the WashU group found that Briquet's was more closely correlated with antisocial personality disorder, and there is some argument about whether histrionic PD is the female version of psychopathy. Shallow affect is a hallmark of both. Somewhere along the line we forgot that so-called "malignant" patients are often antisocial or psychopathic with sadistic impulses who gain gratification from tormenting their clinicians.

Kernberg's concept of borderline personality organization as characterized by "pananxiety, panphobia, and pansexuality" may be in keeping with your description of the patients you see (in part). However, Briquet's has more recently been seen as a "polysymptomatic, polysyndromatic" disorder where multiple diagnoses and physical and mental symptoms seem to co-exist, often transforming from one day to the next. Somatization is the sine qua non of Briquet's, it is not a defining feature of personality disorder and in fact most BPD patients are not highly somatic.

 

[calvnandhobbs68]

But then there's this small voice inside of me that says, "youre diagnosing everyone with a personality disorder, maybe you're just ****ty and this is your way to avoid having to pharmacologically help difficult patients".

Sure but you’re working in a setting that’s highly enriched for personality disorders in that a lot of your treatment responsive patients have already responded/already excluded from needing that level of care. General outpatient psych already has a prevalence of something like 10-20% for just BPD to begin with.

Residential is also unique from IOP/PHP/inpatient in that it’s often a “last resort” kind of level of care for most people (making it even more likely you’re seeing personality traits) and you get to see many of these people longitudinally very frequently. Good opportunity to diagnose a personality disorder and provide education about it for those people who don’t already have that diagnosis….might actually make it easier for their outpatient psychiatrist.

I’ll speak for myself here but in my experience I’ll tell you that the majority of adolescents were sending to RTFs have some level of budding personality pathology or they’re going for eating disorders.

 

[comp1]

It's my experience that formally diagnosing personality disorders due to countertransference is quite rare, at least in the outpatient setting, but diagnosing bipolar or schizoaffective disorder in order to justify primary medication management or, even more often, medication changes is epidemic. I always advise students to pay attention and be aware of their countertransference. Schizophrenia or a frank manic episode (even when aggressive) don't often elicit an extraordinarily negative countertransference.

 

[phonyreal98]

I am reminded of a joke:
Patient: "Doc, something is wrong with my body - it hurts when I poke my forehead, it hurts when I poke my legs, it hurts when I poke my stomach. It hurts when I poke anywhere!"
Doctor: "You have a broken finger."

When a patient is pan-positive (and isn't trying to be deceptive or malinger), it suggests that there is a problem with their perception or insight. So you have to go off your perception - what are the problems or symptoms you are observing they are having?

 

[Stagg737]

Sure but you’re working in a setting that’s highly enriched for personality disorders in that a lot of your treatment responsive patients have already responded/already excluded from needing that level of care. General outpatient psych already has a prevalence of something like 10-20% for just BPD to begin with.

Residential is also unique from IOP/PHP/inpatient in that it’s often a “last resort” kind of level of care for most people (making it even more likely you’re seeing personality traits) and you get to see many of these people longitudinally very frequently. Good opportunity to diagnose a personality disorder and provide education about it for those people who don’t already have that diagnosis….might actually make it easier for their outpatient psychiatrist.

I’ll speak for myself here but in my experience I’ll tell you that the majority of adolescents were sending to RTFs have some level of budding personality pathology or they’re going for eating disorders.

This. Certain settings are going to have higher incidence of certain diagnoses and OP is going to see far higher rates of pathological personality traits in residential than in other settings, mainly because those are the kinds of patients whose conditions don't respond as well in other settings. This is also arguably the best setting to diagnose PDs at's it's pretty much the one of the only settings where you can longitudinally observe a patient including how they interact with staff and other patients in as close to a socially "normal" situation without following them around in their daily lives. Even if they don't meet full PD criteria I'd be very surprised if the vast majority of patients don't at least have notably maladaptive personality traits.

@jbomba , I'd honestly be more concerned if you weren't seeing a lot of maladaptive personality traits. Keep in mind most people will have some level of maladaptive traits but this does not mean they rise to the level of a full personality disorder. Even so, those maladaptive traits are great subjects to address in therapy.