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.