anxiety/spasicity in a patient with spastic quadriparesis

[annoyedpsychiatrist]

I dont get too many patients like this, but im getting a new patient with the above condition, 2/2 to spinal cord injury. Wheelchair bound. Significant spasticity from reading the notes, terrible anxiety, etc. Its very rare for me to keep someone on scheduled benzos, as i generally hate that for anxiety, but ive been wondering if low dose valium may be appropriate for this patient. Shes not on opiods and i didnt see anything about respiratory issues. Any thoughts?

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[SmallBird]

I dont get too many patients like this, but im getting a new patient with the above condition, 2/2 to spinal cord injury. Wheelchair bound. Significant spasticity from reading the notes, terrible anxiety, etc. It's very rare for me to keep someone on scheduled benzos, as i generally hate that for anxiety, but ive been wondering if low dose valium may be appropriate for this patient. Shes not on opiods and i didnt see anything about respiratory issues. Any thoughts?

Like with any patient it's about risks/benefits/alternatives. The best treatments for anxiety are exposures and that isn't any different with someone in a wheelchair. But at the same time benzodiazepines absolutely reduce anxiety, albeit with risk for dependence and escalating doses over time. Despite these realities I do have some patients on scheduled benzodiazepines because it's the best option that is feasible even with those risks.

 

[aim-agm]

Have you considered alpha-2 agonists? Good for anxiety, should help with spasticity, and main risk (orthostasis/falls) is moot in this case.

 

[mistafab]

For folks like this I would weigh more in considering anticholinergic burden/ delirium risk when thinking about benzos. Folks like this are often on chronic muscle relaxers, even bladder meds that are all anticholinergic. Additional consideration if they self cath TID, or other risks for UTI. Depending on the age, delirium might be higher risk given the above than other run of the mill anxiety folks.

Not saying benzo would be wrong, but just consider risk of delirium and pharmacodynamic interaction of these factors above. Discuss this with the patient and let them know delirium can happen in this setting.

 

[Celexa]

I agree with a pt like this my first thought would be the alpha-2 agonists, but I would be more likely to consider benzos than I might be for other pts. Would also strongly depend on type of anxiety and likelihood pt is going to be able to find and engage with therapy.

I would also try and speak with whoever is the primary physician for their spasticity complaints and get their thoughts so as to avoid messing with each others efforts--usually it'll be either neuro or pm&r.

 

[Sushirolls]

Therapy?
SSRI?
Why is this PMH warrant different approach?

Have people not seen the medical "ill" population whose acceptance of their new life circumstances opt to cope by being gorked out on Benzos and/or opioids and/or cannabis and/or alcohol?

Prevention is worth a pound of cure.

Let the spasticity be managed by PM&R.

 

[annoyedpsychiatrist]

Therapy?
SSRI?
Why is this PMH warrant different approach?

Have people not seen the medical "ill" population whose acceptance of their new life circumstances opt to cope by being gorked out on Benzos and/or opioids and/or cannabis and/or alcohol?

Prevention is worth a pound of cure.

Let the spasticity be managed by PM&R.

well i was mainly considering very low dose but ultimately i had same thoughts that ultimately spasticity should be managed by people who generally manage it. I suppose ill see what her cognitive status is too, im not sure what other deficits are there as a result of her injury.

Some of the above are good thoughts, i intially did not think of alpha agonists but that is definitely a consideration. I dont really have too much info yet till I see her so my question was very broad in that I dont like benzos but quality of life vs potential for adverse issue, is an interesting thing to weigh. Im not even sure what her the overall picture of her health so that will provide more insight.

Thanks for the input everyone

 

[Stagg737]

Agree with Sushi to treat the anxiety with EBT. SSRI/SNRI with therapy. For this patient, agree that alpha agonist would be a good though. You could also discuss with neuro/PM&R about gabapentin or pregabalin for anxiety and spasticity as there is some evidence for them for SCI-related spasticity as well as off-label use for anxiety (or on-label for pregabalin if you're European). I personally like gabapentin d/t the wide dosing range available, though the TID+ dosing for steady state is obnoxious.

 

[annoyedpsychiatrist]

Ironically this ended up being a really straightforward case. She was depressed and anxious because she desired relationships with other people and was basically home 24/7 for years.

 

[Celexa]

Ironically this ended up being a really straightforward case. She was depressed and anxious because she desired relationships with other people and was basically home 24/7 for years.

Aw. Sad but common.

One thing it can be worth thinking about for pts with significant functional limitations is if they've had adequate OT involvement. Sometimes they're restricted due to finances etc and there's nothing we can do, but sometimes they haven't been connected with the type of occupational therapy assistance that would help them engage more with the world.

 

[annoyedpsychiatrist]

Aw. Sad but common.

One thing it can be worth thinking about for pts with significant functional limitations is if they've had adequate OT involvement. Sometimes they're restricted due to finances etc and there's nothing we can do, but sometimes they haven't been connected with the type of occupational therapy assistance that would help them engage more with the world.

yep i see them back in a month and im going to see what I can add quality of life wise. I did a low dose of mirtazipine because the patient struggles with appetite, sleeping, and nausea so it made sense from a logical perspective. Patient was very reasonable and she understood that her situation was just part of her light but she hasnt had intimacy/social relationships since her 20s when the accident happened, and she was previously very extroverted.

But yeah, great ideas. In psychiatry I guess you never know how an encounter will go.