Differential diagnosis/med recommendations

[LadyHalcyon]

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Patient is a 60 yo Black female diagnosis of Schizophrenia. Client had first psychotic episode at the age of 30 after her abusive husband left her. Due to not having childcare, she had to quit her job and lost her home, which caused her children to be removed from her care. At this point, she entered into a depressive episode and experienced psychosis (she thought she was pregnant despite doctors consistently telling her she was not). Fast forward 30 years, client is stable, has been on Risperdal 3mg for last 20 years. Client is overweight and has mild Tardive Dyskinesia. Client would like to switch to an antidepressant and wean off her antidepressant but her new psychiatrist, who she just met, refuses to change her meds. I am currently a doctoral intern and treating the client for therapy. My personal belief is a diagnosis of MDD with psychotic features would have been more appropriate, but I was curious as to what others' perspective would be.

 

[thoffen]

I wouldn't take a stable outpatient I just met off their meds either unless it was clear they were causing them immediate harm. There's no way from your clinical stem to say anything for certain, but it does sound as though MDD with psychotic features in prior episodes and BPAD should be on the differential. Sometimes antipsychotics do well for positive symptoms over a long stretch of time. I'd be more interested in possible negative symptoms as a measure for schizophrenia and other evidence of a thought disorder where psychologic testing might help elaborate. But I also wouldn't discount the ability for actively psychotic patients to keep their psychosis hidden, particularly if they are motivated to not be seen as schizophrenic. And this is of course assuming she neatly fits within DSM categories and doesn't have symptoms caused by substances or a medical condition. And it ignores things like personality disorders, developmental deficits, trauma, etc. as contributors to the clinical picture.

So who knows? We certainly couldn't tell you. It would probably be most prudent to contact the treating psychiatrist and discuss your concerns and possibly work out whether a slow taper of antipsychotic would be appropriate and what kind of surveillance she would have for symptom recurrence.

 

[LadyHalcyon]

I wouldn't take a stable outpatient I just met off their meds either unless it was clear they were causing them immediate harm. There's no way from your clinical stem to say anything for certain, but it does sound as though MDD with psychotic features in prior episodes and BPAD should be on the differential. Sometimes antipsychotics do well for positive symptoms over a long stretch of time. I'd be more interested in possible negative symptoms as a measure for schizophrenia and other evidence of a thought disorder where psychologic testing might help elaborate. But I also wouldn't discount the ability for actively psychotic patients to keep their psychosis hidden, particularly if they are motivated to not be seen as schizophrenic. And this is of course assuming she neatly fits within DSM categories and doesn't have symptoms caused by substances or a medical condition. And it ignores things like personality disorders, developmental deficits, trauma, etc. as contributors to the clinical picture.

So who knows? We certainly couldn't tell you. It would probably be most prudent to contact the treating psychiatrist and discuss your concerns and possibly work out whether a slow taper of antipsychotic would be appropriate and what kind of surveillance she would have for symptom recurrence.

Thanks! I do understand why he wouldn't take her off her meds, having never met her before and not really knowing her history. It's always a tricky situation because each psychiatrist differs in regards to how "open" they are to input from others on the treatment team. I would never make specific recommendations regarding drugs etc but considering I see clients weekly and they see clients for 15min every 3 months... Well let's just say I usually have more information about the course of their illness. Its a flawed system. Too many patients, not enough resources.

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[FlowRate]

Not enough history to contravene her diagnosis, but also not super consistent with typical schizophrenia. Stable? How long? Any hospitalizations? Stably employed? Full time? Negative symptoms? Med history? There's a reason our case presentations aren't just a brief paragraph.

 

[Attending1985]

Does sound like mdd with psychosis it’s unfortunate she was kept on antipsychotics and now has TD

 

[nitemagi]

That history is a little muddy. Psychosis followed by MDD with new psychotic symptoms?

And do you mean wean her off an antipsychotic and put her only on an antidepressant?

 

[smalltownpsych]

I recall some literature that minorities, especially African Americans, are more likely to be overdiagnosed with schizophrenia so it is always a good question to ask. From my perspective as a psychotherapist though, I am picking up quite a few subtle dynamics that could be playing out with this. It would be a great case to talk about in supervision. One aspect of this is I always think the patient should advocate for and understand their own care. If a patient has questions about their medications, I direct them to their psychiatrist and we process that. Do they have difficulty communicating with their psychiatrist? Great, we can work on that. It’s just more grist for the mill. Are they looking for me to rescues them? Do I see myself in the role of rescuer (that’s one I really have to watch out for myself)? Why does patient want to change now as opposed to anytime in the last twenty years? How does patient go through changes? Impulsively? Tentatively? Back and forth? Stubbornly? In other words, there is a lot to focus and work on other than the medication, diagnosis, and side effects and once those are worked through, then the patient can make the change.

 

[LadyHalcyon]

That history is a little muddy. Psychosis followed by MDD with new psychotic symptoms?

And do you mean wean her off an antipsychotic and put her only on an antidepressant?

So my conceptualization is mdd with psychosis. What I see now is major trust issues with people and low self esteem, but 30 years ago she did have at least a year where she thought she was pregnant and she wasn't. I have not seen any current psychosis or delusion thinking. But yes.. Eventually I would like to see how she does on just an antidepressant; maybe by introducing an ssri now and weaning off Risperdal over a few months. Is this something that many psychiatrists would simply be unwilling to do?

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[LadyHalcyon]

I recall some literature that minorities, especially African Americans, are more likely to be overdiagnosed with schizophrenia so it is always a good question to ask. From my perspective as a psychotherapist though, I am picking up quite a few subtle dynamics that could be playing out with this. It would be a great case to talk about in supervision. One aspect of this is I always think the patient should advocate for and understand their own care. If a patient has questions about their medications, I direct them to their psychiatrist and we process that. Do they have difficulty communicating with their psychiatrist? Great, we can work on that. It’s just more grist for the mill. Are they looking for me to rescues them? Do I see myself in the role of rescuer (that’s one I really have to watch out for myself)? Why does patient want to change now as opposed to anytime in the last twenty years? How does patient go through changes? Impulsively? Tentatively? Back and forth? Stubbornly? In other words, there is a lot to focus and work on other than the medication, diagnosis, and side effects and once those are worked through, then the patient can make the change.

She did bring it up to her psychiatrist who reduced her antipsychotic but would not even engage in a discussion about eventually going without them. The doctor apparently told her the meds were working and he wasn't willing to change them.

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[LadyHalcyon]

I'm also just generally curious regarding thoughts about late onset schizophrenia...

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[NickNaylor]

She did bring it up to her psychiatrist who reduced her antipsychotic but would not even engage in a discussion about eventually going without them. The doctor apparently told her the meds were working and he wasn't willing to change them.

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You didn’t provide enough information to say for sure whether that would be an appropriate strategy to attempt. The questions @FlowRate asked would be relevant to know the answers to as they would provide some insight into the patient’s functioning. I agree that the story doesn’t sound all that consistent with schizophrenia but who knows. I would throw a complex trauma presentation on the differential, particularly given the history of abuse you presented.

A psychosocial history would be helpful. A history suggestive of consistently high psychosocial functioning would weigh against though not completely rule-out schizophrenia and suggest an alternative diagnosis.

 

[LadyHalcyon]

You didn’t provide enough information to say for sure whether that would be an appropriate strategy to attempt. The questions @FlowRate asked would be relevant to know the answers to as they would provide some insight into the patient’s functioning. I agree that the story doesn’t sound all that consistent with schizophrenia but who knows. I would throw a complex trauma presentation on the differential, particularly given the history of abuse you presented.

A psychosocial history would be helpful. A history suggestive of consistently high psychosocial functioning would weigh against though not completely rule-out schizophrenia and suggest an alternative diagnosis.

Let's just say hypothetically that she does have schizophrenia. Is the belief that people need to be on antipsychotics forever? Or is tapering and monitoring an appropriate response if someone is stable. I honestly could argue either side

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[NickNaylor]

Let's just say hypothetically that she does have schizophrenia. Is the belief that people need to be on antipsychotics forever? Or is tapering and monitoring an appropriate response if someone is stable. I honestly could argue either side

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The conventional wisdom is that, yes, the appropriate treatment for schizophrenia is lifelong antipsychotic treatment.

That being said, there’s a large study I believe from one of the Nordic countries which showed that, in individuals with schizophrenia, a taper and discontinue vs. continuing treatment strategy resulted in similar symptom burden among the two groups but greater psychosocial functioning in the former. So there is perhaps some evidence that a trial of tapering and discontinuing is not completely off the wall, but good luck getting anyone to give it a go.

 

[LadyHalcyon]

The conventional wisdom is that, yes, the appropriate treatment for schizophrenia is lifelong antipsychotic treatment.

That being said, there’s a large study I believe from one of the Nordic countries which showed that, in individuals with schizophrenia, a taper and discontinue vs. continuing treatment strategy resulted in similar symptom burden among the two groups but greater psychosocial functioning in the former. So there is perhaps some evidence that a trial of tapering and discontinuing is not completely off the wall, but good luck getting anyone to give it a go.

Clinical outcome after antipsychotic treatment discontinuation in functionally recovered first-episode nonaffective psychosis individuals: a 3-year n... - PubMed - NCBI

Yeah I was looking at this article earlier

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[Attending1985]

This is a disregard for patient autonomy and very paternalistic. Patient is no longer psychotic and wants off a toxic medication for which she has suffered iatrogenic harm. Appears to have decision making capacity and she is told flat out no. That’s ridiculous. We are not here to make decisions for our patients. We are here to discuss risks and benefits and collaborate with them. And it’s already been stated that the evidence for long term antipsychotic treatment is poor. This is where psychiatry needs a major shift in the treatment paradigm.

 

[LadyHalcyon]

This is a disregard for patient autonomy and very paternalistic. Patient is no longer psychotic and wants off a toxic medication for which she has suffered iatrogenic harm. Appears to have decision making capacity and she is told flat out no. That’s ridiculous. We are not here to make decisions for our patients. We are here to discuss risks and benefits and collaborate with them. And it’s already been stated that the evidence for long term antipsychotic treatment is poor. This is where psychiatry needs a major shift in the treatment paradigm.

That was my Initial reaction. I do understand the prescribers concern but with case management and therapy etc she can have eyes on her weekly. Also, she is very much willing to go back on them if she decompensates

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[Attending1985]

That was my Initial reaction. I do understand the prescribers concern but with case management and therapy etc she can have eyes on her weekly. Also, she is very much willing to go back on them if she decompensates

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Unfortunately she is not receiving good care she should seek out another opinion

 

[LadyHalcyon]

Unfortunately she is not receiving good care she should seek out another opinion

I work at a fairly large CMHC. This patient is poor, female, Black, with some pretty serious health issues and minimal support systems. It will be a difficult to seek out another opinion, although not impossible.

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[hamstergang]

She did bring it up to her psychiatrist who reduced her antipsychotic but would not even engage in a discussion about eventually going without them. The doctor apparently told her the meds were working and he wasn't willing to change them.

Have you actually spoken to the psychiatrist and know this to be true? While it's certainly plausible, it's also plausible that the patient is misinterpreting her discussion with the psychiatrist. I've had a patient or 2 tell another doctor that I've said things I never came close to saying.

 

[splik]

Let's just say hypothetically that she does have schizophrenia. Is the belief that people need to be on antipsychotics forever? Or is tapering and monitoring an appropriate response if someone is stable. I honestly could argue either side

no it is not. the general recommendation is that patients with schizophrenia should continue for one year after experiencing remission and at that point, antipsychotics can be gradually tapered. unfortunately there is a lot of idiocy that is specific to north america when it comes to managing so-called schizophrenia, which is why the prognosis is worse in the US than anywhere else in the world

 

[LadyHalcyon]

no it is not. the general recommendation is that patients with schizophrenia should continue for one year after experiencing remission and at that point, antipsychotics can be gradually tapered. unfortunately there is a lot of idiocy that is specific to north america when it comes to managing so-called schizophrenia, which is why the prognosis is worse in the US than anywhere else in the world

Wow. That is very interesting considering where I work no one implements this into practice

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[NickNaylor]

no it is not. the general recommendation is that patients with schizophrenia should continue for one year after experiencing remission and at that point, antipsychotics can be gradually tapered. unfortunately there is a lot of idiocy that is specific to north america when it comes to managing so-called schizophrenia, which is why the prognosis is worse in the US than anywhere else in the world

Is there an organization or something that actually provides this as a formal treatment guideline? I’ve never heard it before and I would like to think of myself as lacking as much idiocy as possible...

 

[smalltownpsych]

I work at a fairly large CMHC. This patient is poor, female, Black, with some pretty serious health issues and minimal support systems. It will be a difficult to seek out another opinion, although not impossible.

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In my experiences pretty much everyone at a CMHC will fight against decreasing or dc’ing medications. Also, anytime patient has any sort of problem, the first accusation/assumption is that the patient stopped taking their meds and if they actually believe that the patient didn’t because they just happen to be a particularly compliant patient then they want an immediate appointment with the psychiatrist for a “med adjustment”. Oftentimes it seems that the only path to health in these systems is to fight against the system. Just make sure to use all of your psychological skills and knowledge to help do it wisely and with good guidance first so that you don’t get into trouble and second so that the patient might actually benefit.