"I'm so sensitive to medications!"

[nancysinatra]

So last summer I moved across the country and now I'm in a small town somewhere, doing a mix of inpatient and outpatient. I have pretty much become convinced over the last several months that this entire town suffers from panic disorder with a special form of agoraphobia that involves being afraid to go to Walmart. Day in and day out I get these patients who complain of mild but astonishingly intractable anxiety and depression (and panic attacks, of course, which always happen in Walmart) and they insist that "the medications always make it worse." Ok, I can understand not responding to medications, but the medications making it worse??? And most of them have no interest in therapy so I'm stuck trying to figure out what to do with medications when they've "tried everything" and had "tons of side effects."

The most common things I hear are these really extreme or paradoxical complaints. For example I hear things like, "the neurontin made my legs weak so I stopped taking it." (Can neurontin really cause this?) Or "the zoloft made my depression so much worse." I understand that medications have side effects and I want to be acknowledging of that, but what do you do with patients who say this about every medication?? Do you tend to believe them? Or chalk it up to some part of their pathology? Upon further inquiry I almost always find that the time frame for the "side effect" did not really correspond to when the medication was started. So why do the patients blame the medication???

Yes I know that there are slow metabolizers, but a whole town full of them? I also know that if you look at the possible side effects of most medications, you will see everything listed. What the patients are telling me is probably theoretically possible. But why I am seeing so much of these complaints, which should be rare?

I also have noticed that no one ever has side effects to benzos or stimulants.

---

Members don't see this ad.

 

[vistaril]

So last summer I moved across the country and now I'm in a small town somewhere, doing a mix of inpatient and outpatient. I have pretty much become convinced over the last several months that this entire town suffers from panic disorder with a special form of agoraphobia that involves being afraid to go to Walmart. Day in and day out I get these patients who complain of mild but astonishingly intractable anxiety and depression (and panic attacks, of course, which always happen in Walmart) and they insist that "the medications always make it worse." Ok, I can understand not responding to medications, but the medications making it worse??? And most of them have no interest in therapy so I'm stuck trying to figure out what to do with medications when they've "tried everything" and had "tons of side effects."

The most common things I hear are these really extreme or paradoxical complaints. For example I hear things like, "the neurontin made my legs weak so I stopped taking it." (Can neurontin really cause this?) Or "the zoloft made my depression so much worse." I understand that medications have side effects and I want to be acknowledging of that, but what do you do with patients who say this about every medication?? Do you tend to believe them? Or chalk it up to some part of their pathology? Upon further inquiry I almost always find that the time frame for the "side effect" did not really correspond to when the medication was started. So why do the patients blame the medication???

Yes I know that there are slow metabolizers, but a whole town full of them? I also know that if you look at the possible side effects of most medications, you will see everything listed. What the patients are telling me is probably theoretically possible. But why I am seeing so much of these complaints, which should be rare?

I also have noticed that no one ever has side effects to benzos or stimulants.

I think you are probably overthinking it, and you sorta know this already......these seem like patients who aren't invested in really getting better(not that a high dose ssri or whatever will 'cure' them either) and medicating unpleasant feelings with benzos. Simple as that. Whether to give them the benzos or not is your decision, but sorta irrelevant in the big picture imo....

if there is someone who really knows how to do exposure therapy or something similar to it in the area(doubtful), then that would probably help. But as you said the patients don't seem interested in that anyways. I certainly am not skilled in this, and very few psychiatrists I come into contact with are. Very few masters level therapists are as well. A larger % of clinical psychologists(but certainly not all) seem to know what they are doing here, but trying to get them to actually implement these skills on large volumes of patients is an uphill battle.

but I wouldn't sweat it....it's extremely unlikely that your intervention(whatever it is) for patients like this is going to help a lot. And barring you doing something crazy which I know you wouldn't do, it's extremely unlikely your intervention is going to hurt either. If it were me and they weren't interested in really working, I'd probably just titrate their ssri as tolerated and give them a small dose of some klonopin or whatever- doesn't really matter whether you schedule the klonopin or make it prn since they are going to take it however they want it anyways.

 

[Shikima]

I feel your pain. Instant gratification with no interest in wellness. I've been experiencing the same - when I've pushed the issue and told them that talk therapy is necessary for continuing in my clinic, they tend to do better and remain compliant with treatment. Or they can move on - I don't have an interest in enabling behaviors.

 

[strangeglove]

I also have noticed that no one ever has side effects to benzos or stimulants.

This is the key piece of information. What you are describing is typical for sedative/hypnotic use disorder. They are smart enough not to ask for it directly, but what you will arrive at collaboratively, after an exhaustive medication history is "Nothing works except Xanax." Unfortunately, this is a massive problem among the Walmart set. Check the utox and the state prescription drug database, if there is one in your state.


Sent from my iPhone using Tapatalk

 

[erg923]

you seeing alot a vets? Sounds like the VA. Walmart is often like cryptonite to folks here. I totally get why, but it does get a little tiring after a while I have to admit. And yes, anything that deadens the anxiety to the provoking stimulus will prevent habituation, thus preventing the actual "curing" of anything.

If people were as well informed about the science of behaviorism/behavioral theory, as much as they are about the science of Xanax, life would be alot easier for both parties.

 

[Shikima]

you seeing alot a vets? Sounds like the VA.

It happens in the VA, but also at large in the community. I see it primarily in the late 40's to mid-70s age range.

 

[PsyDr]

Lemme guess: You work in a military town and you are seeing people who are on disability.

Remember, the base rate for malingering in compensation seeking populations is 40%.

 

[erg923]

It happens in the VA, but also at large in the community. I see it primarily in the late 40's to mid-70s age range.

Well theres certainly nothing about aging that explains that. Although I think it's important to differentiate between not liking to go to Walmart and thus avoiding it if possible/given the choice vs avoiding it at all costs do to specific fears or specific symptoms of anxiety. I think the former is much more common as one gets older. I am only in my early 30s and already hate gong to my local suburban mall. 😉

 

[F0nzie]

I see this everyday in my community outpatient practice and private practice.

1. Consider revising your diagnosis: Is this bipolar d/o, personality disorder, a substance use disorder? I have a good handful of bipolar patients that articulate their symptoms as "anxiety + panic" but it's really hypomania/mania that responds to mood stabilizers and antipsychotics. Get collateral information, look through the records, get drug testing-- if they refuse assume they are using, check your state drug monitoring program to see if they are doctor shopping.
2. Psychodynamic pharmacotherapy: Work through their reactions, emotions in the moment and any meaning they may be attaching to the medications. For example, I had a patient that would get side effects from every pill. I asked him the time frame of the side effects and he said "several seconds after swallowing them". From there we processed what that meant to him. He shared a story about how his mother would medicate him for every cold and bring him to doctors and hospitals for minor reasons. To him, she was emotionally invalidating-- and taking pills brought back some unresolved anger and sadness from childhood. He's better with medications now.
3. CBT and exposure therapy: work on the heirarchy of fears. See how their anxiety levels respond to just the thought of going to Walmart. I have found that the best way is to just offer the therapy yourself. They are in your office and that's one less anxious fear to overcome and get them better faster. For the skeptical patient, attach them to a blood pressure cuff while they are doing the exercise so they can see the physiologic response it is having on them. Follow up by having them do a relaxation exercise then recheck their bp. I have done this numerous times and often demonstrated a 10-20 drop in systolic bp.
4. Gene testing: Genesight if offering genetic testing for 0-$200 depending on income. Currently on the list are SSRI's and antipsychotics. They are working on adding mood stabilizers and benzodiazepines. You will get a breakdown for "high, medium, and low risk" depending on their metabolic profile. Go over the report with your patient and address further concerns regarding their sensitivity to medications.

 

[hamstergang]

4. Gene testing: Genesight if offering genetic testing for 0-$200 depending on income. Currently on the list are SSRI's and antipsychotics. They are working on adding mood stabilizers and benzodiazepines. You will get a breakdown for "high, medium, and low risk" depending on their metabolic profile. Go over the report with your patient and address further concerns regarding their sensitivity to medications.

One of my attending said that you can rather cheaply test the metabolic rates of various CYP isoenzymes by giving the patient some amount of some easily detectable substrate (apparently labs actually do this). Sounds cheaper and more accurate than genetic testing. And yet, I don't see anyone promoting that.

 

[Shikima]

One of my attending said that you can rather cheaply test the metabolic rates of various CYP isoenzymes by giving the patient some amount of some easily detectable substrate (apparently labs actually do this). Sounds cheaper and more accurate than genetic testing. And yet, I don't see anyone promoting that.

Can you find out more and share with us?

 

[xlithiumx]

Yes. For instance you can use nortriptyline to assay 2D6 activity, which is the most relevant CYP for most drugs.

 

[hamstergang]

Can you find out more and share with us?

For various reasons, it's too hard to find out more from this attending. So the only additional info I would find would come from Google.

More interesting, to me, is to discuss why these tests tend not to be ordered. Is the information just not clinically relevant? How well are positive and adverse effects correlated with serum levels? How much is the enzyme activity influenced by other factors?

 

[vistaril]

For various reasons, it's too hard to find out more from this attending. So the only additional info I would find would come from Google.

More interesting, to me, is to discuss why these tests tend not to be ordered.

because this isn't an antibiotic we are ordering here. There is a very good chance that, plasma levels and metabolism aside, that the drug isn't going to do anything to help simply because the drug isn't going to do anything to help. So the problem with going down this path is what do you do if you prescribe psychotropic A to a pt with crying spells, irritability, labile emotions/mood and they don't respond and you find out that she may be a fast metabolizer or whatever and may not have much in their system at that dose? Have you really accomplished anything? You still have no clue if the drug is going to help the patient in the first place, and have to be aware that there is a good chance it won't. And all the testing was irrelevant in the first place.

 

[notdeadyet]

Remember, the base rate for malingering in compensation seeking populations is 40%.

I just want to mention that this stat (if it's from the source I'm thinking of) applies to the compensation SEEKING population. This should not be inferred to read that 40% of compensated patients are malingering.

 

[nancysinatra]

Thanks for all these great responses!

Here's a little more info about my patient population. It's not a VA. It's a small midwestern community. It has its socioeconomic problems and plenty of substance abuse, but nothing like what I saw in residency. I do get med seekers, and people on disability, but I also see a fair number of semi-employed people . For some odd reason, they all seem to work as nursing assistants or personal care assistants. It's rare that someone doesn't at least have a GED. It's even rarer that someone completed more than 3 semesters of college and vanishingly rare that the 3 semesters weren't at the community college. Ok so that's the demographic.

I swear to god, in addition to this Walmart thing, and in addition to half the town being home health care providers, a huge percentage of people here have fibromyalgia in their chart. They don't just want me to cure their panic attacks, they also want their pain to go away. It's pretty rare in my clinic that someone asks for a narcotic. They mainly seem to just complain a lot and want me to "fix" them. I get a lot of referrals by primary care, and unlike in my residency, the primary care is good and these people are pretty well attended to. I do feel though that when patients are given the diagnosis of "fibromyalgia" that it elevates their sense of suffering. And so at that point, all bets are off. Every medication causes them to suffer from intolerable side effects!

I do get the drift that some people just want me to give them benzos and stimulants. There's also a ton of bizarre polypharmacy, often thanks to some rogue local nurse practitioners. It's hard to take on these patients because they have come to expect certain things, I guess.

I do think psychotherapy is the way to go with a lot of these people. Honestly you could cut out all the medications and focus on some "life" issues and I think that would make a way bigger difference. But everyone just seems to want a magic pill that will erase the problems in their lives!

 

[Shikima]

Using MI and providing psychoeducation will be your ally. Document it too in your notes. Get the hospital/clinic to recruit more people to provide CBT. I feel your pain as I see the same in my private clinic - almost the same exact process.

 

[nancysinatra]

Using MI and providing psychoeducation will be your ally. Document it too in your notes. Get the hospital/clinic to recruit more people to provide CBT. I feel your pain as I see the same in my private clinic - almost the same exact process.

Thanks - I like the idea about MI. I am just getting so jaded about people I guess. I would say that 3/4 of the patients I've seen between my first day of residency and now don't have what I would call medication-ammendable brain-based problems. I am starting to think there is some unidentified psychosomatic syndrome running like crazy through our society which is leading all these people to me with their high hopes of a pill that will fix it. The "standard of care" seems to be to throw a barrage of medications at everything. Maybe with more MI I can turn a person or two around...

As far as Walmart, no kidding it causes panic attacks. I'd rather be trapped in North Korea than set foot in there.

 

[F0nzie]

As far as Walmart, no kidding it causes panic attacks. I'd rather be trapped in North Korea than set foot in there.

Always low prices though... 😛

 

[erg923]

Maybe with more MI I can turn a person or two around.

Being a skilled MI operator is also about rolling with the resistance and having to accept "nope, i dont want to change" from your patient too. The good thing is that each stage a person does move within the stages of change model increases liklehood of actual behavior change down the road. So, even moving a person from pre-contemlation to contemplation IS actually a big victory...statistically/probability speaking.

 

[Ceke2002]

I've had some pretty freaky rare side effects from the ADs I've tried (at least one requiring emergency hospitalisation), plus I got pulled off of Seroquel when it started making my heart go a tad wonky. I'm fine with other Atypical's, but my experiences with ADs have left me with a very deep seated fear of taking them. It's pretty much taken my Psychiatrist 3 years of gentle persuasion to even get me to the point where I'm now willing to try another AD, and that's only under the proviso that I come into the clinic and be monitored for my first dosage. Anyway, my point, after all that, is that just because I haven't jumped to taking a certain type of medication doesn't mean I've been sitting there for the past few years twiddling my thumbs and whistling dixie. I engage in Psychotherapy, I do Yoga, Mindfulness, Spiritual Awareness, I'm currently trying to gradually build up my fitness level through dance, there's a lot of stuff I'm trying to do to help reduce my symptoms. I don't understand people who just go to a Psychiatrist and sit there saying 'Cure Me, but don't expect me to do any work'. Unless there version of 'Cure Me' is 'please prescribe be Xanax for my irretractable anxiety, and whilst you're at it could you throw in some MS Contin for my Fibromyalgia.

Sorry, reading this stuff just makes me want to bang my head against the nearest wall, because it took me 20 odd years to find a decent, ethical Psychiatrist I could really work with, and I would have metaphorically killed to have had that a lot sooner. And then there's these buffoons just sitting there wasting opportunities.

 

[shan564]

Word has gotten around in town regarding what you need to say to get benzos. Tell the doctor you had a panic attack at Walmart, and he'll give you some Xanax. Read the black box warning about suicidality and tell the doctor that Zoloft made your depression worse.

 

[whopper]

I think you are probably overthinking it, and you sorta know this already......these seem like patients who aren't invested in really getting better(not that a high dose ssri or whatever will 'cure' them either) and medicating unpleasant feelings with benzos. Simple as that. Whether to give them the benzos or not is your decision, but sorta irrelevant in the big picture imo

Disagree-kind of.

I've mentioned this before on the forum and I've never seen this problem ever before until after I graduated form residency. In outpatient, I've encountered very few patients that could not tolerate what were often normal dosages for most people, but they could take benzos. I've never tried stimulants.

Now of course there's the typical malingerer that will say they can't tolerate anything except for Xanax, yada yada yada. That's not what I'm talking about. Further, Nancy's been on the board for years and based on what's she's posted, she's not an idiot and would already have known what you mentioned Vistaril.

Here's what I'm talking about. In several of these patients, if I told them I didn't want to give them a benzo and why (because they're addictive) they agreed with my recommendation not to take them. So that pretty much eliminated them from my malingering suspicions. Further, all of them at one point had a problem with some rheumatological or autoimmune phenomenon. E.g. several of them had Epstein Barr Virus, one of them had Guillian Barre. Epstein Barr typically isn't considered autoimmune but there is data suggesting that post infection, it could cause chronic fatigue syndrome and one of the theorized mechanisms is that it's an autoimmune issue, similar to MS or type 1 diabetes, that was set-off by a virus.

Now bear in mind these were about 1 in 50-100 patients. This is rare from my experience.

I started hypothesizing that some of these people may have had some type of autoimmune issue not yet clearly defined that was making medication tolerance difficult. Further, there's plenty of patient message boards with people mentioning similar complaints. I've done plenty of lit-searches but I can't find anything solid on this other than several patients mentioning they got this problem.

Later on, a very attractive lady entered my D&D group (yeah I know, how many attractive ladies are role-playing gamers), and she too had EBV as a child and now has chronic fatigue syndrome and fibromyalgia. She too cannot tolerate meds at dosages that work for most people. SHE IS NOT A MALINGERER. She never sought my medical help, she has a deadbeat husband she's divorcing and is a single parent working her tail off despite her fibromyalgia. I found out incidentally her medical issues, I asked did she had EBV and she said yes. Then I asked if she had a problem tolerating meds at usual dosages and her explanations were almost identical to the cases I mentioned above.

Now is this what's going on with your patients Nancy? I got no idea.

I would strongly consider what's been mentioned above. Consider possible drug-seeking or malingering, but if you don't think that's going on, ask them did they ever had EBV or any autoimmune issues as a child.

A problem is that even if these people are similar to the patients I've had, I've found no easy solution for them other than to give them the meds at low dosages, and this did not help much. Only after I stopped seeing these patients (because I let them to work for the university) did it cross my mind to try SAM-E on them because most of them had depression and couldn't tolerate SSRIs.

 

[nancysinatra]

Thanks Whopper - that's an interesting idea. It's worth thinking about and trying to learn more.

I have to admit I have a certain countertransference towards certain kinds of patients. I am not a fan of dealing with chronic disease whether it's psychiatric or rheumatological or whatever. Even worse, so-called medication allergies (i.e. "zoloft made me cross-eyed" or "codeine makes me vomit") are the bane of my existence. I will sit there wasting minutes in my intake interviews clarifying if they HAD hives, yes or no? and if they HAD anaphylaxis, yes or no? and when the answer is invariably "no, but my leg hurt when I took the depakote" I just move on. Anyway things like that set me up to be skeptical of the patient. Fibromyalgia is the worst.

But if I meet someone in a social setting who claimed to have FM, I don't think I'd be as skeptical. I honestly wouldn't care other than wishing them well. I don't know why these vague illnesses bother me at work, except that I get frustrated being faced with trying to help people who seem like they're in a holding pattern, often a mental one.

And for what it's worth, I wasn't offended by Vistaril. Vistaril and I get along pretty well I think because I like his sardonic attitude.

 

[F0nzie]

But if I meet someone in a social setting who claimed to have FM, I don't think I'd be as skeptical. I honestly wouldn't care other than wishing them well. I don't know why these vague illnesses bother me at work, except that I get frustrated being faced with trying to help people who seem like they're in a holding pattern, often a mental one.

I feel your frustration.

I did 6 months of weekly therapy with one of my depressed fibromyalgia patients before she finally went into the pool. After that it was the first real smile I had ever seen from her.

Change is possible but it takes time and some motivation on the patient's part. As frustrating as it is for me to feel futile, it's feats like these that give me a great sense of reward in our profession.

 

[PikminOC]

Good to see you again Nancy sinatra! Among the nursing/nurse aassistant/caregiver population I used to see I have noticed them selling their own medications and the medication of the people they are taking care of. Fast cash.

 

[Ceke2002]

Disagree-kind of.
Later on, a very attractive lady entered my D&D group (yeah I know, how many attractive ladies are role-playing gamers),

Sorry OT for a moment. You play D&D? That is sooo freakin' awesome. I used to table top D&D back in the early 90s with a group of friends, before switching to an online VtM (Vampire the Masquerade) group. As for lady role players, I'm wondering what stereotype a tall, slender tattooed goth with bits of metal strategically stuck in her face would fufil. 😛

Okay, back on topic now.

 

[TexasPhysician]

Wait, it's abnormal to feel uncomfortable in Walmart?

If you leave Walmart wishing you could spend more time there, you more likely have a DSM5 diagnosis because it isn't normal. Walmart is a madhouse.

 

[whopper]

I used to table top D&D back in the early 90s with a group of friends, before switching to an online VtM (Vampire the Masquerade) group

Yeah well this lady is freaking hot (better not mention her too much cause my wife occasionally reads my posts. She's not a psychiatrist but has an interest in my posts because she's a mental health professional). In my group we got two doctoral level psychotherapists, 1 published forensic psychiatrist/former boss, a doctoral level political scientist, an IT tech guy that is literally one of the top gamers in the country (he knows the Gygaxes and has gamed with them, and does some very impressive work with miniatures), and I'm thinking of wooing a top psychiatric researcher into our group.

(The problem now is that my wife is being considered for a faculty position in St. Louis and that will force me away from my awesome group!)

As for the patients I've mentioned, I brought this on the forum because if anyone saw any similar patients I was thinking of doing an article on this. I really believe I'm onto something here and it's something that patients on message forums have mentioned is going with them. Some of you may be aware of this but some disorders have only become known because people with similar problems brought them about on message forums and they were so rare that primary care docs that were never taught about them couldn't get enough patients to see a pattern. When people have diseases that are literally less than 1/100,000 they often are not taught or even formally cataloged, but message forums brought these people together enough for researchers to see something as a possible new disorder.

(E.g. Body Integrity Identity Disorder
http://en.wikipedia.org/wiki/Body_integrity_identity_disorder)

I see a pattern, but I got no idea what in the heck could've caused the problem and all I got is a grasping for straws theory.

 

[F0nzie]

(E.g. Body Integrity Identity Disorder
http://en.wikipedia.org/wiki/Body_integrity_identity_disorder)

I see a pattern, but I got no idea what in the heck could've caused the problem and all I got is a grasping for straws theory.

Makes me think of the fragmented self externalized with a semi psychotic sort of feel...

 

[Ceke2002]

Yeah well this lady is freaking hot (better not mention her too much cause my wife occasionally reads my posts. She's not a psychiatrist but has an interest in my posts because she's a mental health professional). In my group we got two doctoral level psychotherapists, 1 published forensic psychiatrist/former boss, a doctoral level political scientist, an IT tech guy that is literally one of the top gamers in the country (he knows the Gygaxes and has gamed with them, and does some very impressive work with miniatures), and I'm thinking of wooing a top psychiatric researcher into our group.

(The problem now is that my wife is being considered for a faculty position in St. Louis and that will force me away from my awesome group!)

As for the patients I've mentioned, I brought this on the forum because if anyone saw any similar patients I was thinking of doing an article on this. I really believe I'm onto something here and it's something that patients on message forums have mentioned is going with them. Some of you may be aware of this but some disorders have only become known because people with similar problems brought them about on message forums and they were so rare that primary care docs that were never taught about them couldn't get enough patients to see a pattern. When people have diseases that are literally less than 1/100,000 they often are not taught or even formally cataloged, but message forums brought these people together enough for researchers to see something as a possible new disorder.

(E.g. Body Integrity Identity Disorder
http://en.wikipedia.org/wiki/Body_integrity_identity_disorder)

I see a pattern, but I got no idea what in the heck could've caused the problem and all I got is a grasping for straws theory.

Okay, now I'm jealous of your awesome gamer's group. I should get back into it myself, but the groups that tend to still be open are either constantly on the verge of having a huge flounce off over some ridiculously pedantic reading of the rules, or they turn into impromptu group therapy sessions because everyone has mental health issues. *hmmph*

So, ah, any pictures of this ridiculously hot gamer girl who has suddenly became the woman of dreams Hey, when I took my wedding my vows I didn't promise to love, honour, and spork my eyeballs out, I can still look if I want. 😏

*ahem* Getting back on track.

Interesting you spoke about EBV and med sensitivity. I had pretty severe EBV (confirmed by blood tests, laid me out for over a year) when I was a teenager and I'm pretty sensitive to a lot of medications. Like if anyone's going to get the freaky rare side effects, it'll probably be me. If you end up writing a paper you're welcome to ask me whatever you need to know and use me as a research subject if it helps. The offer's there at least.

 

[strangeglove]

It may not be so much that EBV or some other virus triggers an immune response that renders the patient sensitive to medication side effects, but rather that patients who are highly somatically focused to begin with (for no particularly interesting physiological reason, but primarily for dynamic reasons related to trauma, etc.) are going to fixate on their bodies after a prolonged illness, or when they start a medication. This has everything to so with taking on a sick role. There is often an unconscious secondary gain of being taken care of and regressing to a childlike dependent state, along with projective identification of feelings of anger and hopelessness that the patient cannot tolerate, so they are projected into the doctor, who them feels like Sun Lioness.


Sent from my iPhone using Tapatalk

 

[Shikima]

But it begs the question - does an autoimmune or viral process cause intolerance to medications? I would submit that many out there have these problems and/or exposures and are able to tolerate SSRI/SNRI just fine.

** EDIT: I just saw the response by strangeglove and I believe my question mirrors his statement.

 

[hamstergang]

Aren't nearly all adults exposed to EBV (ie developed antibodies against)?

 

[Shikima]

Exactly.

 

[Zenman1]

Thanks - I like the idea about MI. I am just getting so jaded about people I guess. I would say that 3/4 of the patients I've seen between my first day of residency and now don't have what I would call medication-ammendable brain-based problems. I am starting to think there is some unidentified psychosomatic syndrome running like crazy through our society which is leading all these people to me with their high hopes of a pill that will fix it. The "standard of care" seems to be to throw a barrage of medications at everything. Maybe with more MI I can turn a person or two around...

As far as Walmart, no kidding it causes panic attacks. I'd rather be trapped in North Korea than set foot in there.

I work with active duty Soldiers. When they can walk in and out of Walmart during a busy time, they are cured, lol! If you're near a military base check out the soldiers sitting in their cars in the parking lot. Good bet the spouse is inside shopping alone.

 

[Ceke2002]

It may not be so much that EBV or some other virus triggers an immune response that renders the patient sensitive to medication side effects, but rather that patients who are highly somatically focused to begin with (for no particularly interesting physiological reason, but primarily for dynamic reasons related to trauma, etc.) are going to fixate on their bodies after a prolonged illness, or when they start a medication. This has everything to so with taking on a sick role. There is often an unconscious secondary gain of being taken care of and regressing to a childlike dependent state, along with projective identification of feelings of anger and hopelessness that the patient cannot tolerate, so they are projected into the doctor, who them feels like Sun Lioness.


Sent from my iPhone using Tapatalk

*takes notes* Fascinating, something I'd never considered before. I don't actually know that much about somatic illness, now I feel like I should. Just making myself a mental reminder to discuss this with my Psych. We often pick topics to talk about if we have time, one of our last sessions was Transference, Mann's vs Freudian theory and Neuroplasticity as it applies to Psychotherapy. But anyway, cheers for this. 🙂

 

[nancysinatra]

It may not be so much that EBV or some other virus triggers an immune response that renders the patient sensitive to medication side effects, but rather that patients who are highly somatically focused to begin with (for no particularly interesting physiological reason, but primarily for dynamic reasons related to trauma, etc.) are going to fixate on their bodies after a prolonged illness, or when they start a medication. This has everything to so with taking on a sick role. There is often an unconscious secondary gain of being taken care of and regressing to a childlike dependent state, along with projective identification of feelings of anger and hopelessness that the patient cannot tolerate, so they are projected into the doctor, who them feels like Sun Lioness.


Sent from my iPhone using Tapatalk

This is kind of how I have been understanding the phenomenon. I am curious about the dynamic processes that could lead to this. It seems there are so many people who take on the sick role not just with regards to medications not working, but often even with their chief complaints. It's like the modern day form of conversion disorder. But I feel like I'm "required" to try medication after medication. I bet I would probably like psychiatry more than I do if, instead of throwing medications at every symptom people have, we had the luxury of actually working with patients to figure out why they have these symptoms in the first place.

 

[erg923]

It is quite amazing to see how rapid the paradigm of psychiatry and the practice of the modal American psychiatrist has changed in just 50 years! Working through all those dynamics ain't all its cracked up to be though, nancy. At least not in my view/experience as a psychologist. I do primary care psychology ("primary care mental health integration" to be official) in the VA so all my sessions are 30 minutes and very symptom focused. Lots of homework and lots behavioral activations and psychoeducation. Its perfect for me, as I dont (can't) see anyone for more than 8 sessions. Thus, alot of my job is mental health triage to other services within our VA too.

I agree that there is an amazing amount of shunning of personal responsibility and shuning of internal locus of control in many mental health patients these days. It may even be the highest in vets, many of whom are on disability from the VA. Much of this may be the unintended consequences of pushing the "disease model" of mental health. Its no longer "I have difficluty controling my temper/with anger," its I CAN'T control my anger. I agree it can be hard not to become patentalistic with patients when this happens.

 

[whopper]

It may not be so much that EBV or some other virus triggers an immune response that renders the patient sensitive to medication side effects, but rather that patients who are highly somatically focused to begin with (for no particularly interesting physiological reason, but primarily for dynamic reasons related to trauma, etc.) are going to fixate on their bodies after a prolonged illness, or when they start a medication. This has everything to so with taking on a sick role. There is often an unconscious secondary gain of being taken care of and regressing to a childlike dependent state, along with projective identification of feelings of anger and hopelessness that the patient cannot tolerate, so they are projected into the doctor, who them feels like Sun Lioness.

Possible.

I can tell you that the lady I mentioned doesn't have the sick role problem, nor one of my other patients that fit this profile was a teacher for over two decades but developed PTSD after he was brutally beaten by a student (16 years old but over 300 lbs and a gang-member), and he couldn't tolerate meds unless they were about 10-20% of their typical dosage that most people could tolerate.'

I don't know or wouldn't even be confident that this phenomenon I mentioned is real in the sense that there is a physiological mechanism causing it. It could just be a freak coincidence.

I will say, however, that often times in medicine, several doctors develop a sophomoric viewpoint that because they're a doctor they know what's going on and since it's not something that easily fits with known disorders, it's got to be not real. In Body Integrity Disorder, the people who have it were told by their doctors that this was all somatic and/or something to the effect of BS because those doctors never heard of this issue before. The phenomenon was so rare those same doctors never had a patient with the same presentation. When a body of patients were found, (thanks to the Internet where forums developed for people that shared this problem) there were corresponding possible neurological issues associated with that phenomenon. Is it real? Maybe, maybe not.

I do not mean that anyone here thinking that such a phenomenon is sophomoric and egocentric. A somatic disorder is something that should be on the differential.

There are other disorders, such as POEMS that do exist, but it's so rare it's not taught in medschool or residency, and a patient could have it and a doctor, because they've never seen anything like it, simply blows it off as something all in the head of the patient simply because it's outside their limited knowledge, and then tell a patient (IMHO quite egocentrically) that whatever's going on is not real in a medical sense.

The entire foundation of several medical disorders are patients showing a body of correlated similar signs and symptoms. Often times the mechanism isn't even found for decades if ever. Schizophrenia along with several other psychiatric disorders have been in that state for decades.

I'm not convinced that this phenomenon I mentioned is a real thing. Personally, I'd want to find more patients with a similar problem and then start doing some in depth research on it with other investigators in other fields of study, but this is the foundation of how these things start. You mention it to colleagues--"Have you seen anything like this, because I've seen a few." IMHO, the freak coincidence of continued problems all after a specific disease occurred-either EBV or Guillan-Barre, all with similar symptoms that do not correspond with other somatic disorders, and a group of at least dozens of people who've never met each other having similar presentations is worth at least an intellectual investigation.