How would you help this type of patient?

[wolfvgang22]

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I have a patient who is in his early 60s who has chronic severe PTSD and I think likely either borderline traits or borderline personality disorder. This patient doesn't have any suicidal ideation. No mania or psychosis. No depressive episode. The patient refuses to take medication for PTSD, and mistakenly says another physician has told him SSRIs will harm his heart and wont' accept education to the contrary. He won't even listen to that same physician. He will only take clonazepam 1mg PO BID. He doesn't ask for more benzos. He refuses any psychotherapy in any setting. Refuses to leave his home most of the time due to PTSD hypervigilance. He has a lot of paranoia, and frustrated a past therapist who chastised him a bit. So now he refuses therapy to avoid any further negative reactions. He complains this type of reaction from others including family is common. The patient's wife left the country for several weeks in part to escape temporarily. The patient hasn't ever attempted suicide or had parasuicidal behaviors.

The problem: The patient sends pages of emails to the clinic saying that his various health care providers don't care, are tired or him (some probably are), and claims to administration that no one cares about him or wants to help him and alleges abandonment. This constant begging for attention and care and yet refusing care except on his very specific terms (emails and supportive listening whenever he wants it) is an issue. Partly because it eats up the time of clinic staff, and partly because the culture is that administration will likely investigate his care as he continues to complain, further eating up time and resources and not helping the patient at all.

How would you approach this situation?

 

[littlefred]

What most clinicians would do is meet them halfway and continue Clonazepam 1 mg PO BID.
It has some evidence for PTSD, albeit lower evidence than SRI's (paroxetine, sertraline) and other meds like Prazosin.

Quoting UpToDate:

"Benzodiazepines have not been tested in adequately powered randomized clinical trials in PTSD, yet they are frequently used to treat anxiety and hyperarousal. Benzodiazepines may impair the therapeutic effects of treatments such as exposure therapy that rely on extinction learning. All patients prescribed benzodiazepines for PTSD should be monitored for signs of misuse or abuse. Benzodiazepines should be avoided in patients with an active substance use disorder or a history of a benzodiazepine use disorder or alcohol use disorder. (See 'Benzodiazepines' above.)"

 

[erg923]

I have a patient who is in his early 60s who has chronic severe PTSD and I think likely either borderline traits or borderline personality disorder. This patient doesn't have any suicidal ideation. No mania or psychosis. No depressive episode. The patient refuses to take medication for PTSD, and mistakenly says another physician has told him SSRIs will harm his heart and wont' accept education to the contrary. He won't even listen to that same physician. He will only take clonazepam 1mg PO BID. He doesn't ask for more benzos. He refuses any psychotherapy in any setting. Refuses to leave his home most of the time due to PTSD hypervigilance. He has a lot of paranoia, and frustrated a past therapist who chastised him a bit. So now he refuses therapy to avoid any further negative reactions. He complains this type of reaction from others including family is common. The patient's wife left the country for several weeks in part to escape temporarily. The patient hasn't ever attempted suicide or had parasuicidal behaviors.

The problem: The patient sends pages of emails to the clinic saying that his various health care providers don't care, are tired or him (some probably are), and claims to administration that no one cares about him or wants to help him and alleges abandonment. This constant begging for attention and care and yet refusing care except on his very specific terms (emails and supportive listening whenever he wants it) is an issue. Partly because it eats up the time of clinic staff, and partly because the culture is that administration will likely investigate his care as he continues to complain, further eating up time and resources and not helping the patient at all.

How would you approach this situation?

Clarify what he DOES want. Does he want his life and functioning to be different? If not, then sucking up valuable physician and licensed therapist resources to gripe is not appropriate. Would then suggest support groups. VFW, veterans orgs, etc. You are in VA, right?

 

[sloop]

This might not be the best answer, but it is what I would actually do.

I would tell him that standing Klonopin is not an appropriate long-term treatment for PTSD and we will need to work on tapering it. No, that is not negotiable. There are other treatments for PTSD which include antidepressants, etc., as well as exposure therapy. I would tell him that I would like to help him if he will let me, but that part of this relationship has to involve him being invested in actually getting better. If he is unwilling to engage in therapy or take any medications other than Klonopin, I can’t actually help him and he would have to be discharged from the clinic with appropriate referrals.

 

[wolfvgang22]

What most clinicians would do is meet them halfway and continue Clonazepam 1 mg PO BID.
It has some evidence for PTSD, albeit lower evidence than SRI's (paroxetine, sertraline) and other meds like Prazosin.

Quoting UpToDate:

"Benzodiazepines have not been tested in adequately powered randomized clinical trials in PTSD, yet they are frequently used to treat anxiety and hyperarousal. Benzodiazepines may impair the therapeutic effects of treatments such as exposure therapy that rely on extinction learning. All patients prescribed benzodiazepines for PTSD should be monitored for signs of misuse or abuse. Benzodiazepines should be avoided in patients with an active substance use disorder or a history of a benzodiazepine use disorder or alcohol use disorder. (See 'Benzodiazepines' above.)"

Yes, I am not rushing to stop the clonazepam. Before the clonazepam this patient had a lot of insomnia and worse symptoms than he does now. Like I implied, I am try to get him to accept an SSRI like Sertraline. I don't mind continuing motivational interviewing toward this end.

The main problem is really the long emails begging for help. I'm trying to gently set limits and have encouraged the patient to walk in to clinic for support or even call but he refuses. From experience with past patients, this patient will start filing complaints soon with the hospital and that will result in lengthy meetings and investigation between administration and myself. I'd like to avoid all that or at least show I've done what I can.

 

[wolfvgang22]

Clarify what he DOES want. Does he want his life and functioning to be different? If not, then sucking up valuable physician and licensed therapist resources to gripe is not appropriate. Would then suggest support groups. VFW, veterans orgs, etc. You are in VA, right?

Yeah, I'm at the VA.
I've offered referrals to everything I can think of - therapy at various places, residential treatment, intensive case management, etc. He refuses it all claiming he is just too anxious and paranoid.

When ask him what he does want he says he wants to "have a normal life and be able to leave my house and get along with people." I spend an hour with this patient despite his med management appointment being only 30 minutes. He really needs more therapy, but refuses to speak to anyone else other than me and one nurse he likes. I've advised him in detail how medications could help him, but he refuses.

Since I'm at the VA I am not allowed to discharge him, or transfer him. This VA is very sensitive to any hint of patients claiming abandonment, real or imagined.

 

[littlefred]

Yes, I am not rushing to stop the clonazepam. Before the clonazepam this patient had a lot of insomnia and worse symptoms than he does now. Like I implied, I am try to get him to accept an SSRI like Sertraline. I don't mind continuing motivational interviewing toward this end.

The main problem is really the long emails begging for help. I'm trying to gently set limits and have encouraged the patient to walk in to clinic for support or even call but he refuses. From experience with past patients, this patient will start filing complaints soon with the hospital and that will result in lengthy meetings and investigation between administration and myself. I'd like to avoid all that or at least show I've done what I can.

I don't miss working at the VA, as above discharging is not a possibility and some patients will never do what's recommended (but then they call their congressman or go to the news to complain). Keep trying your best, looks like you're trying to help the patient with the limitations at hand.

Some patients require more time and use the system more often, maybe see if someone has more expertise with PTSD and takes challenging patients like him?

 

[sloop]

Yeah, I'm at the VA.
I've offered referrals to everything I can think of - therapy at various places, residential treatment, intensive case management, etc. He refuses it all claiming he is just too anxious and paranoid.

When ask him what he does want he says he wants to "have a normal life and be able to leave my house and get along with people." I spend an hour with this patient despite his med management appointment being only 30 minutes. He really needs more therapy, but refuses to speak to anyone else other than me and one nurse he likes. I've advised him in detail how medications could help him, but he refuses.

Since I'm at the VA I am not allowed to discharge him, or transfer him. This VA is very sensitive to any hint of patients claiming abandonment, real or imagined.

That is frustrating, but in that case I would still move forward with tapering Klonopin. I hear the responses from others that it can be helpful in PTSD, but I personally would not be comfortable prescribing long-term benzos for PTSD in a person who is rejecting therapy and first-line medications. To me, this all indicates a person at high risk for abuse and it seems poor form to continue prescribing Klonopin when you know this. The other thing is that he may be unwilling to consider better treatments as long as, in his mind, he’s on Klonopin and that’s fine by him. I think that if you do this, you’ll either find that he will eventually consider other treatment options, or he will never follow up with you again and start doctor shopping.

 

[erg923]

Yeah, I'm at the VA.
I've offered referrals to everything I can think of - therapy at various places, residential treatment, intensive case management, etc. He refuses it all claiming he is just too anxious and paranoid.

When ask him what he does want he says he wants to "have a normal life and be able to leave my house and get along with people." I spend an hour with this patient despite his med management appointment being only 30 minutes. He really needs more therapy, but refuses to speak to anyone else other than me and one nurse he likes. I've advised him in detail how medications could help him, but he refuses.

Since I'm at the VA I am not allowed to discharge him, or transfer him. This VA is very sensitive to any hint of patients claiming abandonment, real or imagined.

The VA has long tried to get away from the notion of long-term, supportive "therapy." It just cant be sustained in that system, and it takes up resources and time for people who actually want to work to get better. Nevertheless, there were always people floating around the MHC who has been there for years and years and not engaged in real evidence-based treatment. If your VA wants to let him linger with a therapist for years without any real treatment plan or goals, or a commitment to help himself.....That's on them. But its certainly not doing his health any favors, either. Its unfair to other patients as well.

We sure there isn't a service connection issue going on here? He sounds awfully invested in the sick/disabled role to me?

 

[deleted1100659]

Well, you don't have to fire him. But what you can do, is set firm boundaries. he doesn't like those boundaries? He can always choose not to come back, that is up to him. Sometimes you dont have to fire someone, you just stop giving them attention/their controlled and they feel less inclined to show up.

You are probably a saint for giving this guy so much of your time but sounds like hes going to burn people out. You gave multiple treatment recommendations he refused to follow and had capacity at the time to refuse those instructions. Document this, hold firm to your recommendations, if he decides to stop coming then thats on him.

Sometimes a little bluntness/tough love is what a patient needs.

 

[wolfvgang22]

The VA has long tried to get away from the notion of long-term supportive "therapy." It just cant be sustained in that system, and it takes up resources and time for people who actually want to work to get better. Nevertheless, there was always people floating around MHC who has been there for years and years and not engaged in real evidence-based treatment. If your VA wants to let him linger with a therapist for years without any real treatment plan or goals, or a commitment to help himself.....That's on them. But its certainly not doing his health any favors, either. Its unfair to other patients as well.

Yep, we even discuss this in meetings all the time. The problem is the double bind the VA creates by basically banning discharges to avoid bad press and complaints but at the same time requiring all patients participate in evidence based, time limited psychotherapy if they are going to do therapy. He is already service connected, never asks about it. Claims he wants to be independent.

I think I'm going to do as sloop and Dr. Amazing recommend.

Disclosure: I put the patient on the clonazepam myself several months ago. I typically do NOT prescribe benzos but this patient wouldn't even interact with me or anyone at the time. He'd always show up to appointments in crisis, with no grounds for involuntary hospitalization but refuse voluntary hospitalization. He couldn't process anything I told him. When he started the benzo the crises reduces to a point he did start participating in evaluation and sharing. He says the benzo helped him interact with his wife and adult son much better, so his wife didn't divorce him as threatened. So he made some minor progress initially, but that has stalled.

Perhaps the benzo was a mistake. I was probably too soft hearted this time. As I write this I feel really stupid. I really hoped to get him on an SSRI and therapy and then taper him off, which he had initially agreed to. It has worked before with others, but not this time. I think we will have to revisit that conversation and treatment plan. His memory is both selective and impaired by severe PTSD, so he will deny we had that documented plan and file a complaint when we start a slow benzo taper. And I will get to defend my care as patriotic again to the hospital administration.

 

[deleted1100659]

Yep, we even discuss this in meetings all the time. The problem is the double bind the VA creates by basically banning discharges to avoid bad press and complaints but at the same time requiring all patients participate in evidence based, time limited psychotherapy if they are going to do therapy. He is already service connected, never asks about it. Claims he wants to be independent.

I think I'm going to do as sloop and Dr. Amazing recommend.

Disclosure: I put the patient on the clonazepam myself several months ago. I typically do NOT prescribe benzos but this patient wouldn't even interact with me or anyone at the time. He'd always show up to appointments in crisis, with no grounds for involuntary hospitalization but refuse voluntary hospitalization. He couldn't process anything I told him. When he started the benzo the crises reduces to a point he did start participating in evaluation and sharing. He says the benzo helped him interact with his wife and adult son much better, so his wife didn't divorce him as threatened. So he made some minor progress initially, but that has stalled.

Perhaps the benzo was a mistake. I was probably too soft hearted this time. As I write this I feel really stupid. I really hoped to get him on an SSRI and therapy and then taper him off, which he had initially agreed to. It has worked before with others, but not this time. I think we will have to revisit that conversation and treatment plan. His memory is both selective and impaired by severe PTSD, so he will deny we had that documented plan and file a complaint when we start a slow benzo taper. And I will get to defend my care as patriotic again to the hospital administration.

No, you're not stupid; you have empathy for the patient. You did what was best for the patient at that point of time, based upon the information you had to work with. Now that you have more information, you are forced to revaluate his treatment.

I can promise you every psychiatrist, including myself, has trusted the patient and gotten burned at least once. Its been a long time since ive started someone on a benzo, because once you start them on it, it is extremely hard to get them off. Even saying its only for four weeks, honestly they are addicting to many patients.

I think you genuinely want to help everyone, and sometimes its hard to accept the harsh reality that some people you cant help because medicine is a team sport that requires involvement from the patient.

 

[comp1]

Boundaries! It already sounds like you're kind of taking this on all yourself. A lot of people above describe the negatives of the VA, but one of the positives is that you shouldn't ever be alone with your decision making. Whatever is being done should be a team decision. That said, IMHO, he needs a single point of contact for complaints. It shouldn't ever just "go to the clinic." It's important that your leadership is aware of his single point of contact (and probably their leadership) so that he understands that really, seriously, only that single point of contact will receive and respond (if appropriate) to care complaints. He likely gets slightly different responses from different people around the clinic and this re-enforces the behavior. That single point of contact should for one time relay team decisions about what care would benefit the patient and how it is his and only his decision to accept or reject it. That single point of contact should also make it clear that issues already addressed will not be repeatedly readdressed. Every communication will be read, but not every communication responded to, etc. However, if he decides to make different choices about treatment options, those are always available to him. I think the benzos aren't the major thing here. The help rejecting is. The ball needs to be in his court and sending complaints about care is not actually engaging in care.

 

[wolfvgang22]

Boundaries! It already sounds like you're kind of taking this on all yourself. A lot of people above describe the negatives of the VA, but one of the positives is that you shouldn't ever be alone with your decision making. Whatever is being done should be a team decision. That said, IMHO, he needs a single point of contact for complaints. It shouldn't ever just "go to the clinic." It's important that your leadership is aware of his single point of contact (and probably their leadership) so that he understands that really, seriously, only that single point of contact will receive and respond (if appropriate) to care complaints. He likely gets slightly different responses from different people around the clinic and this re-enforces the behavior. That single point of contact should for one time relay team decisions about what care would benefit the patient and how it is his and only his decision to accept or reject it. That single point of contact should also make it clear that issues already addressed will not be repeatedly readdressed. Every communication will be read, but not every communication responded to, etc. However, if he decides to make different choices about treatment options, those are always available to him. I think the benzos aren't the major thing here. The help rejecting is. The ball needs to be in his court and sending complaints about care is not actually engaging in care.

That point of contact has been me, lol. We already do this. My triage nurse forwards everything to me. I dont answer many of the emails and discussed why with him. I appreciate the reminder and encouragement though. We can always do it better. I've been trying to get him to accept engaging with a therapist, too, as obviously I can't handle this patient alone. So far he has refused the team based approach, sadly.

Seems like the consensus is to set limits, and revisit the treatment plan and put the ball back in his court.

 

[robellis]

Yep, we even discuss this in meetings all the time. The problem is the double bind the VA creates by basically banning discharges to avoid bad press and complaints but at the same time requiring all patients participate in evidence based, time limited psychotherapy if they are going to do therapy. He is already service connected, never asks about it. Claims he wants to be independent.

I think I'm going to do as sloop and Dr. Amazing recommend.

Disclosure: I put the patient on the clonazepam myself several months ago. I typically do NOT prescribe benzos but this patient wouldn't even interact with me or anyone at the time. He'd always show up to appointments in crisis, with no grounds for involuntary hospitalization but refuse voluntary hospitalization. He couldn't process anything I told him. When he started the benzo the crises reduces to a point he did start participating in evaluation and sharing. He says the benzo helped him interact with his wife and adult son much better, so his wife didn't divorce him as threatened. So he made some minor progress initially, but that has stalled.

Perhaps the benzo was a mistake. I was probably too soft hearted this time. As I write this I feel really stupid. I really hoped to get him on an SSRI and therapy and then taper him off, which he had initially agreed to. It has worked before with others, but not this time. I think we will have to revisit that conversation and treatment plan. His memory is both selective and impaired by severe PTSD, so he will deny we had that documented plan and file a complaint when we start a slow benzo taper. And I will get to defend my care as patriotic again to the hospital administration.

What you did is very standard and probably what half of psychiatrists would’ve done so I’m not sure why you think you’re stupid ..I don’t think you even need to taper the klonopin I probably wouldn’t to be honest..he’s seen benefit from it and that’s all that matters as long as he’s not having side effects and he understands the long term risks..the care sloop is talking about is “ideal” and theoretical and doesn’t always work in the real world..having the patient leave and never come back and then end up dead somewhere after not being seen for 2 years because you stopped his benzo so he fell back into a depression is not the outcome we’re looking for

 

[Merovinge]

That point of contact has been me, lol. We already do this. My triage nurse forwards everything to me. I dont answer many of the emails and discussed why with him. I appreciate the reminder and encouragement though. We can always do it better. I've been trying to get him to accept engaging with a therapist, too, as obviously I can't handle this patient alone. So far he has refused the team based approach, sadly.

Seems like the consensus is to set limits, and revisit the treatment plan and put the ball back in his court.

You should not be working harder than your patient towards their treatment.

 

[aim-agm]

Yes, I am not rushing to stop the clonazepam. Before the clonazepam this patient had a lot of insomnia and worse symptoms than he does now. Like I implied, I am try to get him to accept an SSRI like Sertraline. I don't mind continuing motivational interviewing toward this end.

The main problem is really the long emails begging for help. I'm trying to gently set limits and have encouraged the patient to walk in to clinic for support or even call but he refuses. From experience with past patients, this patient will start filing complaints soon with the hospital and that will result in lengthy meetings and investigation between administration and myself. I'd like to avoid all that or at least show I've done what I can.

If he is so dead set against SSRIs because of what that doctor told him, maybe you could offer something else serotenergic, like a TCA or even an MAOi?

 

[splik]

You are already helping this pt. He is not going to benefit from therapy in the rigid confines of the VA. An SSRI is not going to make a huge difference. It sounds like the clonazepam has helped. He will feel abandoned if you try to take it away from him. I would recognize that the goals with this patient are more modest and that you are already developing a relationship with him. Just remember there is no alliance. I would schedule longer sessions with this patient so you have more time. Doesn’t make sense to schedule 30min visits with him. You are basically his therapist even if you are not doing formal weekly therapy. I would suggest seeing pt at the beginning or end of the day and never on Fridays/whenever your week ends. Let him send his messages just tell him that you will review them in your own time line and won’t respond to them but are reading them. It will give you a window into his world and is harmless. Does not require lots of resources. I wouldn’t push the SSRI. The more he feels this is being pushed the more resistant he will be. Just tell him that is your recommendation but you respect his choices and it’s no skin off your nose whether he takes it or not.

 

[wolfvgang22]

You are already helping this pt. He is not going to benefit from therapy in the rigid confines of the VA. An SSRI is not going to make a huge difference. It sounds like the clonazepam has helped. He will feel abandoned if you try to take it away from him. I would recognize that the goals with this patient are more modest and that you are already developing a relationship with him. Just remember there is no alliance. I would schedule longer sessions with this patient so you have more time. Doesn’t make sense to schedule 30min visits with him. You are basically his therapist even if you are not doing formal weekly therapy. I would suggest seeing pt at the beginning or end of the day and never on Fridays/whenever your week ends. Let him send his messages just tell him that you will review them in your own time line and won’t respond to them but are reading them. It will give you a window into his world and is harmless. Does not require lots of resources. I wouldn’t push the SSRI. The more he feels this is being pushed the more resistant he will be. Just tell him that is your recommendation but you respect his choices and it’s no skin off your nose whether he takes it or not.

Good suggestions for sure, thank you. I figured out very quickly I am his putative therapist. After seeing this guy for a year or so I feel exhausted. I don't think he'll engage more than he is. I'm going to stop pushing this patient to take an SSRI, he knows what the recommendations are. I really do appreciate the different advice here, a lot of it echoes my own deliberations. I always wonder if I'm missing something.

Past similar patients have benefitted hugely from an SSRI plus a SGA for severe PTSD and paranoia, I had hoped the same for him. I just saw a patient who started this vastly improved because he had no resistance to trying meds.

My organizational role right now is basically to churn med management patients per the chief, as admin has been complaining about productivity post-COVID restrictions. So that doesn't help, lol

 

[sloop]

What you did is very standard and probably what half of psychiatrists would’ve done so I’m not sure why you think you’re stupid ..I don’t think you even need to taper the klonopin I probably wouldn’t to be honest..he’s seen benefit from it and that’s all that matters as long as he’s not having side effects and he understands the long term risks..the care sloop is talking about is “ideal” and theoretical and doesn’t always work in the real world..having the patient leave and never come back and then end up dead somewhere after not being seen for 2 years because you stopped his benzo so he fell back into a depression is not the outcome we’re looking for

You are already helping this pt. He is not going to benefit from therapy in the rigid confines of the VA. An SSRI is not going to make a huge difference. It sounds like the clonazepam has helped. He will feel abandoned if you try to take it away from him. I would recognize that the goals with this patient are more modest and that you are already developing a relationship with him. Just remember there is no alliance. I would schedule longer sessions with this patient so you have more time. Doesn’t make sense to schedule 30min visits with him. You are basically his therapist even if you are not doing formal weekly therapy. I would suggest seeing pt at the beginning or end of the day and never on Fridays/whenever your week ends. Let him send his messages just tell him that you will review them in your own time line and won’t respond to them but are reading them. It will give you a window into his world and is harmless. Does not require lots of resources. I wouldn’t push the SSRI. The more he feels this is being pushed the more resistant he will be. Just tell him that is your recommendation but you respect his choices and it’s no skin off your nose whether he takes it or not.

I think it matters how we got to this situation, though. It’s not like he tried a bunch of therapies and the only thing that worked was Klonopin, so you stopped everything else that wasn’t working. At the end of the day, this is a veteran with personality vulnerabilities who is refusing to try anything but benzos. He says they “helped,” but who knows if what this means is that he likes the feeling of being sort of sedated. You could be facilitating his avoidance, and helping him build a house of cards that will crumble down when he’s in a situation where he really can’t avoid stressful stimuli. There are all sorts of hypotheticals about how the Klonopin could actually be helping or hurting him. What we do know is that this person has several risk factors for substance abuse and is acting in a way that suggest he may be dependent on it.

This is how people wind up on unnecessary opiates, too. A patient comes in with some actual pain problem and gets put on some opiate pain medication. They tell every subsequent doctor they see that the opiate is the only thing that works, and they refuse to try other medications or CBT. They find some doctor who will just go along with it and prescribe them oxycodone for eternity.

At the end of the day, this person does not sound like they are such a hopeless victim of severe mental illness that they don’t have responsibility for their own choices. If they are acting like they call the shots and making choices that box you into practicing medicine that is not the standard of care, those choices are on them. If a depressed patient demanded ketamine and refused to try anything else, I wouldn’t just refer them for ketamine because I figure that, if I appease them, I might be able to actually help them in the long-term in some vague way. There are exceptions, such as when somebody is profoundly ill or psychotic, but I generally believe that people need to take some responsibility over their own recovery. As a psychiatrist, I can only be responsible for so much. A patient with capacity knowingly making self-sabotaging decisions and refusing an appropriate treatment plan that was adequately explained is on them, not me. They have the autonomy to reject my treatment recommendations, but that autonomy does not mean that they get to select a treatment plan that is inappropriate.

 

[Fan_of_Meehl]

Good suggestions for sure, thank you. I figured out very quickly I am his putative therapist. After seeing this guy for a year or so I feel exhausted. I don't think he'll engage more than he is. I'm going to stop pushing this patient to take an SSRI, he knows what the recommendations are. I really do appreciate the different advice here, a lot of it echoes my own deliberations. I always wonder if I'm missing something.

Past similar patients have benefitted hugely from an SSRI plus a SGA for severe PTSD and paranoia, I had hoped the same for him. I just saw a patient who started this vastly improved because he had no resistance to trying meds.

My organizational role right now is basically to churn med management patients per the chief, as admin has been complaining about productivity post-COVID restrictions. So that doesn't help, lol

I've found that it can be useful to routinely try to consequate increasing demands for my 'help' from such patients with increasing structure/intensity of actual psychotherapy (including worksheets, goal-setting. workbook chapter assignments, etc). Think of the metaphor of sticking your fingers down the throat of the dog who has just bitten your hand to force him to let go--crude, but perhaps apt. Oftentimes, it will be useful to do so (and document) regardless of their response or non-response. If he refuses the offered help, document that. Then cut the task in half and re-offer or ask him what he would be willing to do (and document his respose). Then offer him an option so ridiculously reasonable and low-effort that he almost can't refuse to do it (or it would be ridiculous). Whatever his response, document that. Follow up on assignments. Document his noncompliance and specific excuses. Offer him The PTSD Behavioral Activation Workbook. It's a non-trauma-focused but intermediate structure treatment approach with some evidence base for efficacy. Ask him to read the intro chapter to discuss next time. If he doesn't do it, explore why but redirect. And document. Negotiate what he can/can't and is/isn't willing to do. Document all your efforts. Have him read one sentence or bullet point or vignette at a time. Discuss/process.

Whatever you do, be aware of making sure you're not reinforcing (if you can help it) his rambling emails or histrionics with access to you. Build in a reasonable delay before you respond. Consequate complaints of symptom exacerbation with INCREASED therapeutic structure and work. Even if he's not borderline, Linehan has some excellent suggestions on maintaining boundaries with demanding patients.

Of course, motivational interviewing, psychoed about the patient role in psychotherapy and even judicious humor or occasional irreverence to break the tension and avoid being maneuvered by him into a corner can be used. And, of course, reminding yourself that you can only do your part of the process (not his). You sound like an awesome psychiatrist who cares.

 

[whopper]

I only read the first post as of this writing and will try to read some more to catch up, but my answer to the first post is this.
IF a patient clogs up your administrative staff, you tell them either to stop (with rules, e.g. politely tell them they can only give messages to your assistants that's relevant for office administration, otherwise it goes directly to you) and that anytime you spend billable time working on his case you will bill him.

So if a guy calls up and leaves a 25 minute message-1) "No you can't do this. It clogs up our lines and we could get an emergency call. 2) Write me a note or text your message to my texting system. 3) If you really are spending that much time that shows to me you need to see me more often. 4) "I'm trying to meet you where you are at. You cannot clog my office so please communicate relevant data so we can help you better."

I had a patient who did this and I told him he'd have to start seeing me more than weekly cause he was calling my assistant daily saying completely irrelevant information that didn't further anything office-wise or with his treatment. HE told me that we should, as part of our service, listen to him hours a day without billing him. We told him if that's case get a new doctor, one that listens to patients for hours a day without billing them.

If you spend, say 20 minutes, and call him well guess what? You've spent 20 minutes on a patient. So long as that call meets the criteria of a billable note submit it and bill him.

Clonazepam 1 mg PO Q BID is the upper limit of where I will still allow Clonazepam without harsh push to reduce the dosage. I still tell patients to get off of it but at this dosage I'm willing to do it very very slowly at a rate of about 10% every 3 months, but prefer it to go faster.

 

[clausewitz2]

While an SSRI may be the right call for PTSD, I tend to agree with @splik that Lexapro is not going to make a bit of difference here. The problematic behaviors you are describing are not a normal or typical consequence of PTSD. With hindsight benzos were probably a mistake but I can totally see how you got there and might have succumbed to the same temptation myself in the moment. We are pretty clearly in personality disorder territory here.

This guy sounds like he's really terrified of being rejected and finds the prospect of a positive attachment to anyone very threatening. Hence the 'how you like me now' approach guaranteeing nothing like this forms. He is daring you to do the same thing because if you don't he is in unfamiliar and scary territory.

If you do manage to build rapport and some kind of alliance with him you might try some MBT-flavored intervention. 'I am aware of feeling very frustrated during our appointments and I am wondering if other people in your life feel the same when they interact with you. What do you think?'

I think being extremely transparent with your emotional reactions will be critical. This guy is going to react poorly if he thinks you're dissembling or being 'fake.' He is well aware that a lot of people in your clinic and you in particular are experiencing some strong negative emotions about him, no point denying it. So own up to negative reactions (in a measured, professional way) but keep working with him anyway. This will start to undermine the world he's built for himself where people are either 100% accommodating or are indifferent/neglectful/hostile.

 

[hebel]

While an SSRI may be the right call for PTSD, I tend to agree with @splik that Lexapro is not going to make a bit of difference here. The problematic behaviors you are describing are not a normal or typical consequence of PTSD. With hindsight benzos were probably a mistake but I can totally see how you got there and might have succumbed to the same temptation myself in the moment. We are pretty clearly in personality disorder territory here.

This guy sounds like he's really terrified of being rejected and finds the prospect of a positive attachment to anyone very threatening. Hence the 'how you like me now' approach guaranteeing nothing like this forms. He is daring you to do the same thing because if you don't he is in unfamiliar and scary territory.

If you do manage to build rapport and some kind of alliance with him you might try some MBT-flavored intervention. 'I am aware of feeling very frustrated during our appointments and I am wondering if other people in your life feel the same when they interact with you. What do you think?'

I think being extremely transparent with your emotional reactions will be critical. This guy is going to react poorly if he thinks you're dissembling or being 'fake.' He is well aware that a lot of people in your clinic and you in particular are experiencing some strong negative emotions about him, no point denying it. So own up to negative reactions (in a measured, professional way) but keep working with him anyway. This will start to undermine the world he's built for himself where people are either 100% accommodating or are indifferent/neglectful/hostile.

I agree. Patients of this flavor bring up feelings in me of wanting to "give them a reality check" or to put them in their place. I find that acting on those impulses is usually an enactment.

Maintain your boundaries (such as communication frequency), but accept his anger/frustration when expressed in a non-hostile way even if it's totally not justified. There's other interventions for this patient type, but as a "prescriber," not enacting that dynamic is the key.

 

[wolfvgang22]

I think it matters how we got to this situation, though. It’s not like he tried a bunch of therapies and the only thing that worked was Klonopin, so you stopped everything else that wasn’t working. At the end of the day, this is a veteran with personality vulnerabilities who is refusing to try anything but benzos. He says they “helped,” but who knows if what this means is that he likes the feeling of being sort of sedated. You could be facilitating his avoidance, and helping him build a house of cards that will crumble down when he’s in a situation where he really can’t avoid stressful stimuli. There are all sorts of hypotheticals about how the Klonopin could actually be helping or hurting him. What we do know is that this person has several risk factors for substance abuse and is acting in a way that suggest he may be dependent on it.

This is how people wind up on unnecessary opiates, too. A patient comes in with some actual pain problem and gets put on some opiate pain medication. They tell every subsequent doctor they see that the opiate is the only thing that works, and they refuse to try other medications or CBT. They find some doctor who will just go along with it and prescribe them oxycodone for eternity.

At the end of the day, this person does not sound like they are such a hopeless victim of severe mental illness that they don’t have responsibility for their own choices. If they are acting like they call the shots and making choices that box you into practicing medicine that is not the standard of care, those choices are on them. If a depressed patient demanded ketamine and refused to try anything else, I wouldn’t just refer them for ketamine because I figure that, if I appease them, I might be able to actually help them in the long-term in some vague way. There are exceptions, such as when somebody is profoundly ill or psychotic, but I generally believe that people need to take some responsibility over their own recovery. As a psychiatrist, I can only be responsible for so much. A patient with capacity knowingly making self-sabotaging decisions and refusing an appropriate treatment plan that was adequately explained is on them, not me. They have the autonomy to reject my treatment recommendations, but that autonomy does not mean that they get to select a treatment plan that is inappropriate.

I am generally quite anti-benzo and anti-opiate in my practice and agree with you in principle. I have successfully weaned many, many patients off large doses of benzos (one guy was taking diazepam 100mg daily and alprazolam 1mg TID...yep, you read that right. He started it in 1968!)

This particular patient that we have been discussing I placed on clonazepam did have a 10 point improvement on the PCL-5 with the addition of clonazepam, and his wife and son noticed some improvement with a decrease in hypervigilance, irrititabilty, and anger as well. He doesn't freak out at distant ambulance sirens anymore. He stopped yelling at the neighbors kid for occasionally hitting his house siding with a nerf ball, too. He still complains, but he's not yelling at the neighbors anymore. He started fantasizing about traveling, though these are only fantasies before he withdraws. His PCL-5 still indicates severe PTSD. I do think he probably has borderline personality disorder.

 

[whopper]

Sorry.
Just read you're seeing through the VA. So telling him to simply find a new doctor is problematic there.
I'd tell him to work with his therapist on limiting excessive calls. You could also respond back, state the call was not needed and he needs to work on reducing unneeded communication while trying to formulate the basis of what he's doing it. E.g. dependent personality, histrionic, borderline PD etc.

About less than 1% of my patients are continued with benzos for long-term use other than people who use it about weekly or less for panic attacks. E.g. I have a patient where he tried over 10 meds including Trazodone and Prazosin for recurring severe nightmares. The only thing that reduced them was a benzo. Again this is less than 1% and we tried several alternatives. He's been taking them only as prescribed and the more his nightmares are under control, the less benzo he needs. E.g. he was on 2 mg PO Q HS, but after about 3-4 months of no nightmares he was then stable on 1.5 mg PO Q HS then eventually 1 mg PO Q HS. I still don't know WTF is going on physiologically in his case and even he wants off of Clonazepam.

Anyone I continue on benzos, all are at or less than 2 mg/day for most benzos (yes I know they're not all the same dosage for each one with efficacy), were tried on several other meds and were not found to be abusing them. Most use them less than daily or even weekly.

One alternative I don't see people utilizing much that I've found works well 60% of the time is Alpha-Stim. I've been able to lower benzos or get people off of benzos more quickly with use of an Alpha-Stim device.

 

[Celexa]

Don't beat yourself up about the klonopin. It did help him some as you said. Certainly wouldn't increase it but he did get back actual function, so there is benefit to go with the risk of chronic benzo use.

You mentioned you're already not responding to all his communications which is good. It seems he is able to directly email you. I would set up a filter so that his emails are dropped into a different folder and you choose when (probably right before his appts) you are actually going to look at them. This could keep him from preoccupying you so much outside of his appts. Of course there will need to be clear documentation that he understands these emails will not be read right away.

I agree with those who have said to scheudle him for longer appts--but would pair this with increasing the interval if possible. Maybe one hour every six weeks. Often enough to be clearly giving him attention but not so close together he regularly tanks your productivity.

And as you acknowledge, approach it as though you are his therapist. Med management is low down on the list at this point including tapering the benzo. See where you get with rapport building absent an acute agenda, as much as you want him in an evidenced based ptsd therapy.

 

[Candidate2017]

The problem: The patient sends pages of emails to the clinic saying that his various health care providers don't care, are tired or him (some probably are), and claims to administration that no one cares about him or wants to help him and alleges abandonment. This constant begging for attention and care and yet refusing care except on his very specific terms (emails and supportive listening whenever he wants it) is an issue. Partly because it eats up the time of clinic staff, and partly because the culture is that administration will likely investigate his care as he continues to complain, further eating up time and resources and not helping the patient at all.

How would you approach this situation?

1. I'd taper Klonopin to a lower dose. He will complain because it's the good stuff. No one ever complains if you stop their life-preserving insulin though.

2. You've likely documented recommendations and non/compliance. Nice. Same note and A&P every visit.

3. Some patients don't want to get better. That's ok. We don't fix anything. Our job is to render recommendations that reasonably fall within the standard of care and recognize safety issues. I remember the first time I told a patient behavioral changes were the solution to their particular issue because there are no meds for that issue, and I don't have anyting to offer if they aren't willing to change. It was gloriously freeing.

4. Continue to see him but without expectations, and don't work harder than him.

5. Number 4 will do wonders for one's mental health. Sometimes for the patient too. There is a zen-like psychodynamic quality to not having expectations. Everyone in his life likely nags him and leaves frustrated when he artfully deflects all rational suggestions. That is the role in which he is comfortable placing himself and you. Refuse to get drawn into that narrative by remaining passive. When you quiet your expectations, float above the chaos, and are less reactive, patients will begin to feel the discomfort of the echo of their thoughts/voice. See how he reacts and what defense mechanisms are elicited. Also, I find it boring when patients become a broken record and repeat the same old issues visit after visit. I find myself getting quieter, even drifting off and yawning if need be. Many patients remarkably get the hint. It would be worth it to explore other issues and relationships in his life. Then reward him when he willingly moves off his usual topic of himself and abandonment.

6. Admin gonna admin. They will always find something else to hound you about. Their job is to push stupid metrics and agendas made up to support their existence. But they're not going to fire you. When they flap their lips, they're really acting like your patient who whines without any desire for real improvement. So #3, 4, and 5 are equally applicable to admin.

 

[TexasPhysician]

If I couldn’t terminate/refer this patient, I would attempt strong measures to get counseling involved. It seems you aren’t in a setting to provide intensive counseling yourself. The current situation is leading to burnout. It’s time for drastic measures. Id consider stating that you are being advised to focus on medication management. It’s true. Tell him that frequent emails and calls is a sign that Clonazepam isn’t helpful by itself. We can either start weaning Clonazepam and try alternatives or initiate therapy. Continuing a medication that isn’t working can result in poor outcomes and meeting with a supervisor. We won’t make a decision today on a change, but I set up an appointment right now with my favorite counselor for you. I’ll walk you. For now, I’ll refill the Clonazepam. If you have continued medication issues, reach out to my staff, and we will try a serotonin based medication instead to see if we can work together for a better outcome. If you have non-medication concerns, contact your counselor to help address them.

 

[wolfvgang22]

I appreciate everyone's advice and observations. I'm going to think about my approach further with these suggestions in mind and then try to apply them in practice. I especially appreciate the support, sometimes it gets lonely out here and it's really nice knowing there are smart and compassionate psychiatrists like you all. 🙂😊

 

[PsyDr]

Unless he met his wife before the criterion A event, or she knocked on his door Mr. Belvidere style, the “used to be worse” statement is a strawman. He used to be better too. The timing in the change in functionality could easily be correlated to the start of his benzodiazepine prescription history.

Cite the VA classification of benzos as causing harm in PTSD. Offer the standard of care for PTSD. State that if the benzo is causing such increased symptoms and causing the patient to spend an inordinate amount of time obtaining benzodiazepines as reflected by the email behaviors, it meets two of the required criteria for substance use disorder, indicating you should stop the medication. Then Administrators can’t force you to prescribe a harmful medication.

Call it what it is.

 

[theduderino]

Are you in a cboc or a bigger VA center? If you're in the latter, I'd consider a CWT (vocational rehab) referral or referral to volunteer services. Encourage him to leave his house and do things. Frame medications as a minor part of the equation in helping him to do so. If he's part of the PTSD clinic, discuss him in whatever meeting you have. If he ever complains to admin, you can frame your treatment decisions as representing the collective.

 

[FlowRate]

I would schedule longer sessions with this patient so you have more time. Doesn’t make sense to schedule 30min visits with him.

I like this but obviously only if it's practical for OP to do so. The patient is making an ask that pushes OP's boundaries. OP can explicitly loosen but also reaffirm the new boundary to accommodate the patient (see for 50 minutes but not longer). If not able to accommodate, OP will need to do like most other people suggested and make the current acceptable boundary more clear and firm (20 minutes, med/brief supportive focused, get a consistent therapist) so that the patient isn't stuck in yet another relationship where he burns out the other person and ends up feeling/being rejected.

 

[singasongofjoy]

Did not read many of previous suggestions (yet) and I don't work at the VA, but wanted to take a few mins to chime in since client sounds similar in ways to a person in a support group I run who has basically burned through a hell of a lot of medical providers and systems in our area over the years for similar (and for filing complaints). My guy kinda cycles through but gets really "stuck" on a particular system, provider, perceived wrong, and then goes in deep, spirals and starts cc'ing everyone and their local and state representatives, and cannot stop until it turns into a huge mess. COVID / isolation has exacerbated this 100x- especially since he burned through all home health care and related services he was getting.

what seems to have helped most to establish and maintain boundaries and also give him other outlets and thus out of my email box (though this is an evolving issue/process) is

1) put certain things in concrete terms, closed (rather than open-ended) questions in writing/email: "This is what we can offer you: a, b, c, d, e... Which, if any, do you choose? Here are local resources I can connect you with: f, g, h, i. Which would you like? Here is what I am not able to do (and help for those things can be obtained via x, y, z; happy to help you connect). Here are online resources/chats/hotlines to have on had in case you need someone to talk to outside of our available/scheduled times" I repeated this like a broken record for a whiel and also passed along hte same script to others in my practice he was known to email

2) Explain that super long, detailed emails that involve significant PII/HMI or personal info / complaints regarding other people, cc other people not directly involved in our organization or that I don't have RoI for, or that include attachments (my guy sending photos, medical record snaps etc) will not be responded to via email - not secure to be sending all that over your email, and to protect yourself (email hacking, identity theft, and everyone else from liability / personal, you don't know who else might sending things on to someone else etc etc etc (in fact for my guy we're collaboratively coming up with a communication contract regarding emails and our center)

3) I also will not respond in any way to an email that does not have a specific request or question for me. (in the communication contract will include/discuss when, why, and how to include people in cc's (and v importantly when NOT to). Any correspondence needs to have the specific reason for the correspondence in the subject line or first couple of sentences. (I provided examples) Also set boundaries around what he is and is not to email my staff and supervisees about and participation in our services is contingent; violations result in various periods of "time out" & referral elsewhere since we are presumably not able to meet his needs, but sounds like you don't have that option and i havnet needed to bring that one up again more than the first reminder.

4) When I feel a response is required to some email that isn't a very quick and simple response, I hold that over phone- I want to minimize the amount of back and forth in email for many reasons- they always elicit a response and so drag things out that would otherwise be done once he was done venting, and who knows what he might send or forward elsewhere- and at the beginning of the phone call I state that it is limited to x number of minutes so we need to get to the point quickly; this often finds me circling back to point 1 / asking specifically what the goal of this specific conversation is and/or saying a few minutes before the end that if he needs to discuss in more depth we need to set up an appointment.

5) Summarize the bullet points of the interactions in EMR so there's an ongoing record and make srue all are doing the same so it's clear there's no abandonment and people don't' have to pester you for your emails or whatever to see that. document document document especially offers to connect with or provide services and how/why they were declined

6) finally, FINALLY got my guy to agree to a DBT group and to connect with a local interest group that meets online; also made a list of people in his life he could call, text, email, or write letter to when he needs to vent. Turns out I think that's what has had the most positive impact overall. He just needs someone to blow off steam to. Thought about considering encouraging him to start a blog or something but decided that had too much potential to backfire and be a headache down the road. Having people to vent to turns out to be all he needed and that's not my role nor do I want it. I also provided a super long list of relevant online chat rooms, etc for his diagnoses/complaints/interests so he can hopefully always find some anonymous person to vent to. I ultimately ended up offering him very explicitly limited sessions (6) to work with him in person to connect with some other resources

Good luck. I'd be interested to hear where this goes for you, what works/doesn't - I"ve sought a good bit of consultation from colleagues on it as my guy has a long history of this though it's only recently come to my plate and to a head in severity. I'm very interested to learn from others' similar experiences.