Difficult Patient

[Dapplegrey]

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CC: Anxiety, ADHD, Depression

HPI: 25 y/o otherwise healthy MWF with a history of panic attacks, bipolar (type II) depression, generalized anxiety, and ADHD. She meets individual DSM criteria, at separate times, for all. However, currently suffering from all at the same time. No history of substance abuse. Currently on Klonopin (1mg TID) and Lamictal (400mg daily on estrogen based OCP's). Main problem is anxiety and ADHD symptoms. Klonopin exacerbates ADHD symptoms and psychostimulants have exacerbated anxiety and destabilized mood. Seroquel showed promise but caused significant weight gain. Adequate trial of Strattera of no benefit for ADHD and antidepressants of no benefit for anxiety, while on mood stabilizer. Patient reluctant of lithium. We are In the same situation as we were six months ago. Debilitating anxiety and panic attacks. Unable to function at work as an upper level school administrator d/t anxiety and ADHD symptoms. Depression minimal but fluctuates with anxiety and ADHD symptoms. No recent hypomanic episodes.

ROS otherwise unremarkable, no significant medical problems, and recent labs WNL

I understand the pathophysiology of each disorder and the mechanism of action of each drug, and how they can exacerbate each other.


What's your opinion?

 

[billypilgrim37]

CC: Anxiety, ADHD, Depression

HPI: 25 y/o otherwise healthy MWF with a history of panic attacks, bipolar (type II) depression, generalized anxiety, and ADHD. She meets individual DSM criteria, at separate times, for all. However, currently suffering from all at the same time. No history of substance abuse. Currently on Klonopin (1mg TID) and Lamictal (400mg daily on estrogen based OCP's). Main problem is anxiety and ADHD symptoms. Klonopin exacerbates ADHD symptoms and psychostimulants have exacerbated anxiety and destabilized mood. Seroquel showed promise but caused significant weight gain. Adequate trial of Strattera of no benefit for ADHD and antidepressants of no benefit for anxiety, while on mood stabilizer. Patient reluctant of lithium. We are In the same situation as we were six months ago. Debilitating anxiety and panic attacks. Unable to function at work as an upper level school administrator d/t anxiety and ADHD symptoms. Depression minimal but fluctuates with anxiety and ADHD symptoms. No recent hypomanic episodes.

ROS otherwise unremarkable, no significant medical problems, and recent labs WNL

I understand the pathophysiology of each disorder and the mechanism of action of each drug, and how they can exacerbate each other.

What's your opinion?

Neat case.

She might be a good TCA candidate (I assume you might not have meant a TCA when you said she's been on antidepressants) actually given the severity of the anxiety. Question I would have is how bad the anxiety/panic gets when she is not in an active mood episode (you say she's had them all separately, so I'd assume you're saying she's had anxiety/panic when euthymic). And the NE effects of the TCA might be helpful for the ADHD. Effexor might be another option (if she hasn't tried it), but I don't know if you'd get the same bang for the buck on the ADHD unless you really pushed the dose.

If you go back and ask and she only has significant anxiety when depressed, you could actually think about Wellbutrin, as there's pretty good evidence that it is HELPFUL not harmful for anxiety related to a mood disorder. And that might be better for her than Strattera than ADHD (maybe not). I know most folks would avoid bup in a patient like that, but I would think it would be worth a shot.

Alpha-blockers might be a shot in the dark but worth it kind of adjunct for the ADHD and anxiety?

My take about the klonopin is my own, but in folks that need that high of a dose (to me, 3mg/day is high, though I know for many folks it's fine), she might have so much tolerance that she's not getting much benefit out of it but it might still be giving her the cognitive side effects you describe which then, in turn, worsen her anxiety. Tapering might be a good idea, though I'm sure there's a good chance she won't like that one bit. And I'd certainly be open to the idea that I was dead wrong on that.

Geodon, Abilify, or Saphris might all be good ideas for mood stabilizers that would be weight neutral and maybe have some benefit for the anxiety. I would think a lower dose of Geodon might give her the tranquilizing effect w/ minimal akathisia risk relative to the others. If you just need to break the cycle of intense anxiety for a few weeks to get her stabilized a little, a few weeks of Zyprexa wouldn't be the most ridiculous thing either, though it's clearly not a good long-term solution.

Just thoughts, I by no means I think I have it figured out. I'm assuming you've already encouraged her to be in therapy and have checked her TSH.

 

[Dapplegrey]

All good points and I have considered most.

1. She's deathly afraid of trying another SGA, whether more weight neutral or not. Previous 10lb weight gain to a 120lb young woman, as you know, is not an option.

2. She's on a high dose of Klonopin, and she's obviously built a tolerance, but it's the only thing that's helped keep her functional till now, whether right or wrong. Started at 0.5 bid and have gone up since. I hate that part, but would terrify her by suggesting a taper right now.

3. Her anxiety has always precipitated mood disturbances. To my knowledge not the other way around.

4. In my experience Wellbutrin has worsened a patient's anxiety, which is the last thing she needs. Afraid to try.

5. Trial of Cymbalta ineffective, hesitant to try Effexor.

6. Cognitive effects of Klonopin are apparent to her and I, but the cognitive effects of her uncontrolled anxiety are worse at this point.

No trial of a TCA...interesting.

 

[Iwillheal]

As an upper level school admin, maybe she will have the discipline and resources/coverage to try some alternative medicine (whatever relaxation methods), CBT or some sort of talk therapy, and exercise in order to control her anxiety better...before a Klonopin taper. And then go from there.

 

[billypilgrim37]

Another thought: neurontin? Probably the only other aed she could really be on due to interaction w/ the whopping lamictal dose.

Sent from my DROID RAZR using SDN Mobile

 

[heyjack70]

I second psychotherapy. Are there any correlates between life stressors and anxiety fluctuation. Is ADHD truly present or is she having concentration symptoms from her mood or anxiety disorder? And I'm often skeptical of bipolar II...any personality disorder present?

 

[vistaril]

CC: Anxiety, ADHD, Depression

HPI: 25 y/o otherwise healthy MWF with a history of panic attacks, bipolar (type II) depression, generalized anxiety, and ADHD. She meets individual DSM criteria, at separate times, for all. However, currently suffering from all at the same time. No history of substance abuse. Currently on Klonopin (1mg TID) and Lamictal (400mg daily on estrogen based OCP's). Main problem is anxiety and ADHD symptoms. Klonopin exacerbates ADHD symptoms and psychostimulants have exacerbated anxiety and destabilized mood. Seroquel showed promise but caused significant weight gain. Adequate trial of Strattera of no benefit for ADHD and antidepressants of no benefit for anxiety, while on mood stabilizer. Patient reluctant of lithium. We are In the same situation as we were six months ago. Debilitating anxiety and panic attacks. Unable to function at work as an upper level school administrator d/t anxiety and ADHD symptoms. Depression minimal but fluctuates with anxiety and ADHD symptoms. No recent hypomanic episodes.

ROS otherwise unremarkable, no significant medical problems, and recent labs WNL

I understand the pathophysiology of each disorder and the mechanism of action of each drug, and how they can exacerbate each other.


What's your opinion?

first off, she is 25 and an "upper level" school administrator?

Most people graduate college at 22. Let's say she started teaching in the classroom at 22, and in just three years she has already been promoted to "upper level" school administrator? Something seems fishy there.....even if she started grad school right after getting her bachelors in education, it would take a couple of years(putting her at 24 at least) to finish while working full time.....

that said, if she did go from recent college graduate to teacher to administrator then to "upper level" administrator in just three years, I'd say that is probably close to record pace advancement and she is functioning at an extremely high level. Always keep in mind what the objective data shows when listening to what a pt describes as their symptoms. You see this all the time with adult adhd. For example, if a professional student comes to you and lists all the symptoms for ADHD but you get their transcript and they have a 3.9 gpa and are making all A's in their current classes......should raise a red flag. Same thing here.

This is a pt that you run the risk of converting from high functioning to much lower functioning with your interventions. Just remember that as you progress. She CERTAINLY doesn't have all of the dx you have listed so confidently, and I wouldnt be shocked if she doesnt have any. She is almost certainly part of the 'worried well', and she should be offered therapy. I'd give her a benzo prn for what she calls 'panic attacks'(but are most likely just self-cycling exaberations of her baseline anxiety).

the idea of adding SGAs in this pt is borderline malpractice imo.

I'd treat her with a therapy referral, an AD if she wants it(suspect her hypomania is not all that real), and prn only benzos if she wants them if she decompensates or experiences worsened point of time anxiety. As for the adhd, I'd have to know more about that to give advice there.....

 

[erg923]

first off, she is 25 and an "upper level" school administrator?

Most people graduate college at 22. Let's say she started teaching in the classroom at 22, and in just three years she has already been promoted to "upper level" school administrator? Something seems fishy there.....even if she started grad school right after getting her bachelors in education, it would take a couple of years(putting her at 24 at least) to finish while working full time.....

that said, if she did go from recent college graduate to teacher to administrator then to "upper level" administrator in just three years, I'd say that is probably close to record pace advancement and she is functioning at an extremely high level. Always keep in mind what the objective data shows when listening to what a pt describes as their symptoms. You see this all the time with adult adhd. For example, if a professional student comes to you and lists all the symptoms for ADHD but you get their transcript and they have a 3.9 gpa and are making all A's in their current classes......should raise a red flag. Same thing here.

This is a pt that you run the risk of converting from high functioning to much lower functioning with your interventions. Just remember that as you progress. She CERTAINLY doesn't have all of the dx you have listed so confidently, and I wouldnt be shocked if she doesnt have any. She is almost certainly part of the 'worried well', and she should be offered therapy. I'd give her a benzo prn for what she calls 'panic attacks'(but are most likely just self-cycling exaberations of her baseline anxiety).

the idea of adding SGAs in this pt is borderline malpractice imo.

I'd treat her with a therapy referral, an AD if she wants it(suspect her hypomania is not all that real), and prn only benzos if she wants them if she decompensates or experiences worsened point of time anxiety. As for the adhd, I'd have to know more about that to give advice there.....

I second the notion that it is not particularly helpful to conceptualize her) as having all these different disorders (nor is it likely to be true). Meeting criteria is NOT the same as actually having it. Use the "not better accounted for by" statment judiciously when diagnosing. It's there for a reason. For some reason, I don't think it gets used or stressed enough in the differential diagnostic process in psychiatry.

 

[Dapplegrey]

I appreciate all of your input and opinions.

A little more information...she's in a town with population of 15K and her being thrust into such a high level administration role at such a young age has exacerbated symptoms. Yes, she has moderate axis II pathology for which she is seeing a very competent therapist.

The FDA has stated that Seroquel XR has demonstrated great efficacy in treating GAD, but was not approved because of it's metabolic concerns. Neurontin has never shown efficacy for any psychiatric disorder and has thus been removed from all state formularies in Texas for such uses. Oral estrogen-containing contraceptives decrease lamotrigine concentrations by approximately 50%.

Diagnosis were mentioned for background and coding purposes only. At this point I have no idea which disorder I'm treating, only tackling most pressing symptoms at the time.

 

[nitemagi]

I'd prioritize one disorder at a time.
1. Mood stabalizer (lamictal is fine). Does she really have hypomanic episodes or are these extreme anxiety?
2. Go for a more pure serotonergic antidepressant, rather than an SNRI. I'd say prozac, for example. Go high (80+mg). Then buspar if needed.
3. Address the ADHD last, IMHO. While Whopper pushes that ADHD can look like anxiety, I see the opposite way way more often. Get the anxiety under control first and see how much attentional issues remain. Lastly, consider non-stimulant ADHD meds that may also help anxiety, like guanfacine. Using a stimulant is a last resort, IMO.

 

[fiatslug]

When pillz aren't working, it's time for skillz. 👍

CBT is so so so awesome for anxiety and panic (a good book for pts & providers is When Panic Attacks by David Burns MD. And regular morning exercise of at least moderate intensity (Spark: The Revolutionary New Science of Exercise and the Brain). Is there a CBT focused Partial Hospitalization program near you? That might be exactly the intervention she needs (says the CBT focused PH psychiatrist 😀).

When I feel like pts are stuck, and we keep searching for the psychopharmacologic magic bullet, I pull back and think: are we using every arrow in the quiver? What is the charaterologic comorbidity at play? Are they exercising? Would they benefit from a formal Mindfulness Based Stress Reduction (MBSR) class? Are they getting stuck in a neurovegetative cycle (if so: have them plan out every hr of their days)? Is she passively waiting for a pill to fix everything? What is she willing to change to get well?

 

[birchswing]

I didn't read any of the other responses so I could come at this with a fresh mind.

I'm assuming you're a psychiatrist and that she sees you. Do you only work with presenting medical symptoms or are you also trained in therapy? If not, does your patient she a therapist?

Either way, is there a clear reason outside of the realm of inherent psychiatric disease that is causing her anxiety and ADHD symptoms? (Examples could be: someone died, etc.)

What would she tell you is wrong?

The next thing I would say is that these diagnoses, while interesting descriptions, probably overwhelm the patient or at the least contribute to a distorted self-concept. It makes it sound as if there are four gremlins inside a person's head, one called Bipolar Type II, one called Panic Disorder, one called GAD, one called ADHD, etc. A friend of mine saw a psychiatrist who prescribed him an SSRI and SNRI for depression and he became extremely anxious and couldn't sleep. The psychiatrist told him that the SNRI and SSRi had unmasked the anxiety that previously "beneath" his depression. She prescribed him to take Xanax in the day and Ambien at night to deal with what were certainly side effects of the other meds.

I wouldn't focus on the balkanization or taxonomy. If we really understood the biology, it wouldn't match the taxonomies we've created anyway.

I would just focus on one thing: suffering. She's suffering. It's that simple. But once you've presupposed that when she suffers in this particular way, it's this disease, which takes this medication, and then you do the same thing for every other type of suffering, you've completely limited yourself and your patient.

Next, If I understand correctly you have her on about the equivalent dosage of 60 mg of Valium daily by taking Klonopin at 1 mg 3x daily.

That could be a lot of the problems right there. The side effects of taking benzodiazepines long term are great. The body can be in withdrawal even staying at the same dose. Klonopin in particular is not a pleasant benzo in my experience. Crossing over slowly to Valium could be helpful and then very, very slowly tapering a slight amount of Valium might be good.

I'm not saying she should do that right now. Benzodiazepine withdrawal should always be a personal choice because it is terrifying for the patient. But just knowing that some of these symptoms could be from the benzos might make the patient feel better. And knowing that people who have withdrawn or lowered their doses actually feel relief from their anxiety in the long-term could be a very positive message to share (look up that info on Wikipedia).

I don't know anything about Lamictal except that I've heard it's very good for Bipolar Type II. But what does the patient think of it?

I would also point out that being a 25-year-old "upper level school administrator" sounds like a stressful job. Is it what she wants to do? The body can have a way of rejecting things the mind wants to.

My final advice: if she's not seeing a therapist, ask her to see one.

Oh, also fish oil. I take 2,000 mg per day. Oh, and magnesium citrate! Helps a lot. Also for panic attacks, squeezing my stomach muscles really hard helps.

I should point out that my qualifications are that I have a high school diploma and have seen psychiatrists for 15 years. But I am always happy to help when it comes to mental suffering because I have been there myself.

Maybe it would help more (and I know I've already written too much) if I told you what finally stopped the horrible never-ending anxiety for me:

I realized I had too much of people telling me what was wrong with me and the ways I needed to get better. I realized that cycling through psychiatric drugs left me feeling always worse and always out of control. I finally told the psychiatrist: just put me on what worked the best (which to me was Paxil and Ativan—I was going to have be on one benzo or another—I couldn't go cold turkey off the one I had been on, but Ativan had made me feel better than Klonopin) and stop changing it. And let me figure things out. Stop changing my meds, and let me figure things out. I had to go into a foxhole I built for myself and find out what was going on and make the world safe again. It was the only thing that ever worked. When you have anxiety you feel everything is out of your control. Psychiatric drugs made me feel even more out of control. I couldn't even control how my mind would feel every time I had to try a new drug. So that's why I finally realized: I can't get off all these drugs, but I can at least stop changing them.

I trained my family to focus on my small successes instead of my huge failures. I had been going out into every day life every day and experiencing trauma everywhere due to my anxiety. I had to stop the bleeding and get success under my belt. That's what made the change. Every day in high school I was so panicked and felt like I couldn't tell if I was breathing in or out. I went off to college but every day was even worse there.

I had to drop out. I had to save my own life by taking care of myself. I still don't know why I was so sensitive that I was afflicted with anxiety the way I was. But I know I had to practice good self-care and gentleness toward myself. I saved myself. My parent saved me by changing. They used to believe they could wear the anxiety out of me by making me busier and busier so I'd be tired out. And they would yell at me when I had panic attacks or was anxious. I got them to see that the only way to get better was not to beat anxiety. You can't get angry at anxiety and beat it. You have to just let the part of you that is relaxed already come out. And I started creating meditations for myself that I would record and play back. Hearing about breathing on the tapes you can buy made me more anxious. So I made ones specially tailored for me.

It wasn't psychiatry that saved me. It was being allowed to stop the trauma. Allowing time to pass. And adding to my small successes. I firmly believe with anxiety you can't keep throwing yourself out there in the name of exposure. Exposure quickly turns to trauma, which becomes a new illness. You should do what you can successfully and build from there.

Best of luck to both of you!

 

[twright]

I don't know anything about Lamictal except that I've heard it's very good for Bipolar Type II. But what does the patient think of it?

The evidence supporting the use of lamotrigine in bipolar II (depending on the phase) is not that strong.
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2580079/