Huntington's OCD and psychosis

[Slingshot]

I saw a very sad case of a lady with moderate to later huntington's, on no medication and not willing to see any physicians until now do to her OCD getting extremely bothersome to the whole family and her. She is also "seeing bugs" sometimes on her skin and having other delusions. Her chorea is getting worse etc.

She is a tiny thing and already has balance issues. I was going to start with zyprexa 2.5mg to help with all of the above symptoms and since it has the least alpha blockade and lowest orthostasis I figured it was good since she is already a fall risk, as well as being tiny, and considering the high metabolic demands of these patients and need for high nutrition this might help. (she is already not eating much.)

I am cautious to start two meds at once and thing the psychosis and movements are so pressing that an antipsychotic is a must. Anyone would start an SSRI shortly after or see how effective zyprexa alone may be?

Any thoughts on potential doses to shoot for ( I was going to go based on symptom relief and tolerability)

Any thoughts on Namenda for OCD in the context of huntingtons?

This is the first huntingtons patient I have had and I am also starting psychotherapy weekly and am preparing a good approach as I have to be honest, huntingtons are one of the worst prognoses and it is hard even as a therapist to work with them, although I am privelaged to do so.

Thoughts?

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[splik]

there is some evidence for risperidone in OCD (due to effects on 5HT2a supposedly and risperidone is much more selective for 5HT2Athan 5HT1a if that actually means anything) - i wonder if risperidone alone might be helpful for both the OCD-like symptoms and psychosis in this patient? olanzapine monotherapy may also be helpful and you may not need the SSRI... have a look at this for a summary of huntington's mx.

 

[vistaril]

I saw a very sad case of a lady with moderate to later huntington's, on no medication and not willing to see any physicians until now do to her OCD getting extremely bothersome to the whole family and her. She is also "seeing bugs" sometimes on her skin and having other delusions. Her chorea is getting worse etc.

She is a tiny thing and already has balance issues. I was going to start with zyprexa 2.5mg to help with all of the above symptoms and since it has the least alpha blockade and lowest orthostasis I figured it was good since she is already a fall risk, as well as being tiny, and considering the high metabolic demands of these patients and need for high nutrition this might help. (she is already not eating much.)

I am cautious to start two meds at once and thing the psychosis and movements are so pressing that an antipsychotic is a must. Anyone would start an SSRI shortly after or see how effective zyprexa alone may be?

Any thoughts on potential doses to shoot for ( I was going to go based on symptom relief and tolerability)

Any thoughts on Namenda for OCD in the context of huntingtons?

This is the first huntingtons patient I have had and I am also starting psychotherapy weekly and am preparing a good approach as I have to be honest, huntingtons are one of the worst prognoses and it is hard even as a therapist to work with them, although I am privelaged to do so.

Thoughts?

I'd go with an antipsychotic and an AD......why are you hesitant to use an AD as well? She came to you for help, so even though there may be some reluctant to take meds she's obviously made the decision that she wants them now. And she has later stage Huntington's....she's almost certainly depressed even if she doesnt say so.

 

[dl2dp2]

she's almost certainly depressed even if she doesnt say so.

This is not good evidence based practice. You sound like a serious troll.

 

[vistaril]

This is not good evidence based practice. You sound like a serious troll.

and you sound like someone who is not in the real world.....when you screen patients for depression, do you have a nifty little check box as you go down each symptom? Patients are notoriously poor at reporting things like their energy level, concentration, even mood.......

when you're evaluating a person for depression, unless you are participating in a clinical trial, your first goal should be to just sit down with the pt and strike a bond with them, develop rapport, etc....then you can really get to know the pt. Time is limited, so what I see a lot of junior residents doing is trying to skip over the rapport building, bond bonding, etc and jump to symptom screening. pts hate this, and I'm far more likely to get a sense if a pt is depressed or not by just talking to them. Eventually during the interview, I'll ease into some questions that in a roundabout way to allow him to screen specifically(sort of) for some dsm specific symptoms, but even then it's not clear to the pt.

I'll often ask med students and junior residents- How do you know this person is clinically depressed? The *wrong* answer is- "well, because the pt endorsed poor sleep of late, decreased interest in doing things that were formerly pleasurable, difficulty concentring the last 2 weeks blah blah blah".......that doesn't tell me anything about the pt is *really* depressed or not.

For example, this Huntington's pt....I would try to find out more about why she came to a psychiatrist. It may be for these other symptoms, but Im not going to find out if she is depressed or not by just asking her what her mood has been lately, how much she's slept, what her energy is like, etc...that's less than useless. Im going to talk to her, and get her to tell me those things without me even asking.....

Perhaps "almost certainly" is too strong a word, but I'd guess that if I sat down with her and developed that rapport and bonded with her I'd be able to state she is depressed.....and if she is not, I would feel pretty confident that she is not depressed.

 

[dl2dp2]

Patients are notoriously poor at reporting things like their energy level, concentration, even mood.......

And clinicians are notoriously bad at reading minds. And racist.

I'll often ask med students and junior residents- How do you know this person is clinically depressed? The *wrong* answer is- "well, because the pt endorsed poor sleep of late, decreased interest in doing things that were formerly pleasurable, difficulty concentring the last 2 weeks blah blah blah".......that doesn't tell me anything about the pt is *really* depressed or not.

This is why we have Prozac nation. Impressionistic diagnosis, while commonly practiced, is really not evidence based. Just because you THINK someone's depressed doesn't mean that they need medications, and the fact that at clinical trials they checked boxes means EXACTLY that you should at least try to make your diagnosis reliable and internally and externally valid.

The DSM was developed because there is low inter-clinician reliability for common diagnosis like depression, and given there's no objective markers for these disorders, we need to be especially careful. And the fact that we need to build rapport does NOT mean that we could be lazy and discount what the patient report and form diagnosis without the precision that the current guidelines dictate. Maybe where you trained, not where I'm trained.

Just because someone has a terminal illness does NOT mean that they are automatically depressed or need an antidepressant. Subjective report and clinician assessments are both important components of the diagnostic process. While the risk vs. benefit ratio could tip the management towards treating symptoms rather than not in this case, giving out an antidepressant automatically is neither helpful nor risk free.

In a number of posts now you make remarks that are clearly contrary to the ways most good psychiatrists practice psychiatry, and make it sound like this is the standard of care. It is not. In a couple of posts you sound outright antagonistic to the current system of training without proffering a constructive solution. I am not really sure where you are going with this: I feel that either you are angry with the way things are done wherever you are, which is very problematic, or you are trying to get a reaction out of people here.

 

[Slingshot]

While I agree with the premise that she is depressed even if she did not state this, I question your conceptualization of the case in terms of (paraphrased) "why start 1 med when you could start 2"

Someone who has been reluctant to seek help or take medications will be very quick to stop treatment if the side-effects are at all bothersome. I got better at this through the years as I used to be much more aggressive because in residency we are forced to do this on the fast pace inpatient and ER world but even if someone was clearly depressed, you have to evaluate the overall picture.

Is it better that you start very slowly and maybe depression won't resolve as quickly but the chance of her taking the medicine consistently is much higher if she does not have side-effects and thus the end-goal of getting her and keeping her treated is met?

Or starting two medications, both of which have bothersome side-effects commonly, especially at first, for a mariginal benefits in speed to resolution of depression in turn for her potentially stopping treatment and no longer buying into the utility of medications?

Also consider "depressed" does not mean use anti-depression. Consider you having worsening chorea, being unable to get a fork to your mouth, have to be fed, are feeling cognitively confused and delusional at times. If you can ameliorate these symptoms don't you think the depression may drastically improve via improved quality of life?

Maybe it will not and then adding a second medication is then prudent.

I was (and often am) still too aggressive with wanting to get the ball rolling but as you begin life outside of residency, and start seeing more patients who are medication naive, you start to learn that people do not tolerate medications that well much of the time, especially compared to patients we see in residency who have been on psychotropics for decades and can handle much higher doses and faster titrations.

Anyway, good points but the approach you mention in my humble opinion may be too aggressive in this case.

Starting two medications at once is just never a great idea unless acutely manic. It is so hard to tell which side-effect is from which medicine and the more side-effects the more patients get turned off taking them, poor compliance and you actually lose the absolutely best effect of many of our medicines which is the placebo effect.

The more someone buys into taking it rather than feeling "forced" or having to "put up with it" the better chance a significant placebo effect will have added value to the physiological/pharmacological benefit.

Bottom line is conceptualize the whole picture both short and long term goals and make a decision.

At the end of the day starting both medications is totally prudent and by no means "wrong" just giving my .02 and since I asked for opinions that is exactly the thoughts I wanted so don't get me wrong. More ideas the better and more idea sharing the better for us to learn (mostly me) and to benefit all of our patients who may benefit from all of us collaborating

 

[vistaril]

And clinicians are notoriously bad at reading minds. And racist.

This is why we have Prozac nation. Impressionistic diagnosis, while commonly practiced, is really not evidence based. Just because you THINK someone's depressed doesn't mean that they need medications, and the fact that at clinical trials they checked boxes means EXACTLY that you should at least try to make your diagnosis reliable and internally and externally valid.

The DSM was developed because there is low inter-clinician reliability for common diagnosis like depression, and given there's no objective markers for these disorders, we need to be especially careful. And the fact that we need to build rapport does NOT mean that we could be lazy and discount what the patient report and form diagnosis without the precision that the current guidelines dictate. Maybe where you trained, not where I'm trained.

Just because someone has a terminal illness does NOT mean that they are automatically depressed or need an antidepressant. Subjective report and clinician assessments are both important components of the diagnostic process. While the risk vs. benefit ratio could tip the management towards treating symptoms rather than not in this case, giving out an antidepressant automatically is neither helpful nor risk free.

In a number of posts now you make remarks that are clearly contrary to the ways most good psychiatrists practice psychiatry, and make it sound like this is the standard of care. It is not. In a couple of posts you sound outright antagonistic to the current system of training without proffering a constructive solution. I am not really sure where you are going with this: I feel that either you are angry with the way things are done wherever you are, which is very problematic, or you are trying to get a reaction out of people here.

1) Prozac nation, imo, came about much more due to mindless depression screenings than actual clinical judgment and interpretation of less subjective depressive symptoms when possible.

2) The purpose of the dsm is not to serve as a management or practice guide. It's especially useful in research, studies, trials, etc because it gives us a common language.

3) It's more than a terminal illness in this case. They have a terminal illness that is specifically LINKED WITH DEPRESSION(apart from the terminal aspect of it). We also have a pt who has been bothered by something who presents to a psychiatrist. I'd be willing to bet this pt is depressed. Again, I would try to develop that rapport and talk with them to really explore it a bit more. Here is the key, and something I would encourage you to learn since you clearly don't get it now- me asking a pt whether they have poor concentration and them saying "yeah" is about 50x less meaningful than me engaging the pt in conversation in such a way that HE TELLS ME unprompted that he hasn't been reading the sunday paper anymore and that he used to the last 20 years.....

 

[nitemagi]

2) The purpose of the dsm is not to serve as a management or practice guide. It's especially useful in research, studies, trials, etc because it gives us a common language.

Man, just straw man argument after straw man with your posts, vistaril. Sluox never said it was for a management practice guide.

DSM was developed because there is low inter-clinician reliability for common diagnosis like depression, and given there's no objective markers for these disorders, we need to be especially careful.

Interrater reliability refers to Diagnosis, not management.

 

[vistaril]

Man, just straw man argument after straw man with your posts, vistaril. Sluox never said it was for a management practice guide.


Interrater reliability refers to Diagnosis, not management.

and diagnosis in many cases leads to/affects management......

 

[nitemagi]

and diagnosis in many cases leads to/affects management......

But is different. One may lead to another, but is not the same and should not be conflated.

 

[surftheiop]

I read these forums a lot and try not to post too much seeing as I'm only a medstudent. But vistaril since you have started posting the whole mood/demeanor of the forum has changed for the worse. While I'm sure everyone appreciates getting alternative viewpoints, you seem to present them in ways that intentionally breed a sense of abrasion/conflict/condescension. I know this is the norm for most online forums, but I always enjoyed reading this one because it doesn't become a "competitive sport" between posters.