Negligence accusation story.

[nexus73]

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Inspired by a recent ED forum post, I thought I would share my experience of negligence accusation. It never progressed to a lawsuit thankfully but took a lot of time and emotional toll. This occurred shortly after I finished residency.

Working inpatient psych, our team was consulted to see a woman in her early 50s who appeared frankly psychotic/manic. History from her husband notable for depression, and unclear history of possible hypomanic episodes on a few occasions over their 30-year marriage, like periods of 2-3 days not sleeping and more talkative and energized. Certainly not clear cut bipolar especially because he wasn't all the confident about the symptoms either.

The backstory was she had presented to the hospital following a seizure 1-2 weeks prior and was put on Keppra by the on call neurologist. Epileptiform activity was verified with EEG. Within a week she started hallucinating, developing paranoia, not sleeping. So another neurologist in the clinic was gracious enough to get her in over his lunch hour and raised concern about Keppra induced psychosis. He switched her over to Depakote. About 3 days later and she's not doing better so husband brings her to the ED.

In the ED, her valproic acid level was not therapeutic, so she was given an IV loading dose and admitted to medicine for further workup. Neuro consulted. Extensive workup was completely unremarkable, and repeat EEG was normal. Yet she persisted in manic/psychotic state. Psych was consulted with recommendations to treat with Seroquel as she was psychotic/manic and not sleeping and continue Depakote. Mixed diagnostic opinions from consulting psychiatrists, initial eval diagnosed bipolar mania, subsequent doctor (me) said unspecified psychosis because the history, age of severe symptoms was not clearly bipolar. There was also a recent death in the family and possibility of psychotic/mixed depression or brief psychotic episode.

During her time on medicine her husband expressed concern the Depakote was making her psychotic, which the neurologist thought was unlikely especially because her psychosis started before the Depakote. But after a few days of him pleading, Depakote was stopped in exchange for zonisamide. A few more days go by and she's doing a little better but still hallucinating and paranoid, not sleeping well, and becoming a problem on medicine because she gets up at night and wants to walk around. So I suggest, at this point, moving to the psych unit would be a better option, because it's a safe place, locked, she can get up and walk the halls all night if she needs to, and we have nurses who are better at managing behavioral patients. Medicine and neuro will follow on psych.

She transfers to psych, her meds are further titrated, and she slowly stabilizes over another 10 days in the hospital to be discharged home. End of story you would think.

But 5 months later started receiving letters from her husband, handwritten in sharpie, all capital letters about how horrendous her care was in the hospital. All the doctors received letters like this (husband was retired I think and must have had plenty of time), something like 9 total doctors including ED, multiple hospitalists, neurologists, and psychiatrists.

Every 3-4 months we're getting letters. He claims no one was listening to him. Clearly the depakote was making her psychotic. Then when that was stopped, it must have been the Seroquel that made her psychotic, and she wasn't really stable when she discharged but only after her took her off Seroquel following discharge did she stabilize. She has PTSD from being admitted to the psych unit and was injured being labelled as a psych patient, when in reality it was medication induced and all the doctor's fault. And can I please call him and "figure out some way to make it right."

A handful of meetings with malpractice attorney as more letters keep coming in. The husband also doesn't have a lawyer. Our lawyer said this basically made it impossible to stop him from sending these all-cap sharpie letters, whereas if he had a lawyer we could pursue a hearing to get his attorney into the process to make it stop.

The other interesting piece was nowhere in all of this did we get anything from his wife, the actual patient. Our lawyer explained that the wife as the allegedly injured party would have to file the lawsuit, not the husband. And her husband couldn't be her lawyer, she would have to bring the case herself if she couldn't find a lawyer to take the case (and seems like they never did have a lawyer).

Letters continue every few months until about 3 weeks before the statute of limitations for malpractice lawsuits runs out. Then he sends all the doctors certified letters he is going to file a lawsuit against all of us, but first it will require review from the medical board (state law here requires a hearing by the medical board before filing suit), which will push out the final date on the malpractice filing requirement.

The letter requesting the medical board hearing was written by the husband but signed by the patient, oddly. The medical board hearing requires all doctors to attend and was stressful getting prepared for that. And he and his wife don't even show up! OK, now it's really starting to feel like he just wants to make this as painful as possible for everyone involved, really felt like we were being extorted. Like pay me something or I'm going to pursue every avenue I have available to hassle you.

Following the medial board hearing which found nothing wrong with care provided, the filing date for the lawsuit came and went. Our attorney sent us letters the case was now time-barred, and that was the end of it.

But not really. About 2 years later, he files board complaints against all the doctors. The board didn't accept his first complaint because it was basically pages of rambling accusations that didn't have a cohesive issue. So then he collects himself and puts together something more organized, and the medical board wants all our responses. Interestingly they sent us his initial complaint to review as well. So I typed up a response and reviewed it with the lawyer. 6 months later (COVID delays), medical board meets and dismisses the complaint.

It took about 5 years in total from the patient being admitted to the hospital to the board complaint dismissal.

Looking back, clearly nothing was done wrong on the doctor's part. Diagnostically, what was the etiology of her manic/psychotic episode? We'll probably never truly know. Does she really have bipolar? Keppra induced that took weeks to clear? Post-ictal psychosis? Does it really matter if there are no damages? She was treated and stabilized, should be the end of the story.

This experience made me feel the current system puts way too much power in the hands of an individual person. Can you imagine if instead of 1 person like this over several years in practice, you had 6 or 8 or 10? One person can create a significant amount of chaos for a doctor, even without a lawyer. It makes me feel very exposed.

 

[clausewitz2]

First off, this sounds like a horrible situation and it doesn't sound like any of the medical staff involved did anything at all wrong.

I would bet money husband has some history of run-ins with the mental health system that left him extremely reactive to implications of anyone or anything he cares about being a 'psych patient'. I doubt he was looking for money so much as just looking to punish someone.

Out of curiosity, do you have any idea what she eventually stabilized in and went home with? Also, was the EEG while on non-therapeutic Depakote suggestive of seizure activity? If not, forced normalization could describe this whole unfortunate episode.

 

[nexus73]

EEG on Depakote showed generalized slowing only, not suggestive of epilepsy. This is the first I've heard of forced normalization.

 

[Jules A]

Sounds horrendous and uncalled for.

 

[Bartelby]

...forced normalization could describe this whole unfortunate episode.

Thanks for sharing that! I had not heard of this term, looking it up it seems like a pretty good fit for this case.

 

[wolfvgang22]

I'm so sorry you went through all that. Has that experience changed how you view your career or how long you plan to practice?

I used to think I would try to practice until I could no longer work into my 80s or so, but now I plan to retire the second my financial goals are met which will be decades sooner.

 

[comp1]

The medical board likely wanted to stop receiving his letters, too. I'm impressed he's stopped since. I've seen this go on for even longer, although fortunately they didn't try to involve the medical board or if they did, it was dismissed before any sort of response was requested.

 

[Celexa]

This is a terrible story and I'm sorry you went through it. I also appreciate being willing to post about experiences like this--it's important in terms of demystifying situations in which the unknown is as scary as the known.

Clinically, clearly you were all doing the right things. It certainly sounds like her psychiatric symptoms were directly related to the seizure SOMEHOW--although exactly how is impossible to say. Which also makes it unsurprising that she got better with time (if there were no subsequent seizures) and probably eventually didn't need the antipsychotic chronically. But admitting her to the psychiatric unit for stabilization was entirely appropriate regardless of the etiology of those symptoms, once it was confirmed she wasn't actively seizing.

I do think this is interesting in that to the lawyers, this probably was a very low risk case. (I wish we had a resident malpractice lawyer on this forum, although I know we have some people who work in forensics). There seems to have been no clear cut lasting harm to the pt. No one clear medical error or misdiagnosis. The husbands letters would not have inspired particular faith in his rationality given the description. I would doubt there was ever a time the hospital legal or medical board seriously thought there would need to be practice implications for the physicians involved... But thats from the view of the retroscope.

 

[heartsink]

Can these people be sued? Or even threatened with lawsuits for unnecessarily disrupting 9 doctors ability to practice medicine?

I don't think the husband actually deserves to be sued, but maybe if initially a return letter by the hospital attorney back to the husband had a warning to the effect of "frivolous lawsuits risk countersuit for libel / emotional stress / damages / some other legal threat" then maybe it would have been enough to curb his later efforts (but I know nothing of law).

I do agree that right now there is too much power on the side of the accusers and very little if any recourse by physicians to prevent its abuse, which is troubling.

 

[SmallBird]

Wow, thank you for sharing that story. I think this type of thing is likely to continue as long as there is no consequence for the person making the complaint, and if anything people are encouraged to advocate against systems not realizing there are people on the other side.

One thing that I thought when reading this is whether you have an Office of Patient Experience - for better or worse, we have one at my hospital system and they would have met with a family member like this to try and figure something out at the point in time that letters were being written. I'm not saying it would have solved it but in all the complaints that I've had to deal with they were basically doing the heavy lifting.

 

[nexus73]

We do have a patient advocate, risk management type office with several employees that handle initial complaints from patients, but I think the first contact we received was I'm going to sue all of you. And once they hear that, conversations stop.

I was told multiple times by lawyer and hospital risk management they weren't worried about the care or potential lawsuit. Almost to the point of, well what if we could just pay this guy $20K to go away? That would make things easier for everyone right now. But if word gets out the hospital will settle any nuisance claim for $10-20K, they'd expect to get inundated with claims as lawyers know they can write a letter, or have their paralegal draft a letter in 20 minutes, that could payoff $5K for lawyer's fee for less than an hour's work. So strategically they can't just pay off these small claims because it makes everything much worse long term.

I did read up on counter suing as heartsink suggested. Suing for emotional distress etc etc. Everything you read makes it sound basically pointless. First, the plaintiff has no professional standards and owes no duty to the target of their lawsuit, so a pro se plaintiff is pretty safe from actually losing a lawsuit (you may be able to threaten a countersuit, which may do something but you'd probably never actually win). You can sue the attorney if they bring the case maliciously, but super hard to prove, and there are some egregious examples where you think the attorney should have lost a countersuit but didn't.

The best advice is try and get through the process and away from these people as fast you can. They're not healthy individuals and probably wish in some perverse way that you do countersue them. It probably feeds into a distorted ego, makes them feel more important..."now the doctor is counter suing me, my meaningless life isn't so meaningless now."

There was a book I found tangentially helpful which is a good read for any psychiatrist I think. It's called The Gift of Fear, written by a former FBI or CIA agent. One of the pieces of advice regarding stalkers (like ex boyfriends or refused romantic partners, etc who won't stop harassing women typically). The advice was just completely cut all ties, don't answer their calls, don't agree to meet up hoping you can explain you don't want to hear from them. To the point you shouldn't even call police or file restraining orders, because it just feeds into their ego and makes them more likely to keep coming. So through a process like a lawsuit, the lawyer will tell you this anyway, not to contact them. I viewed this person in part as an unstable stalker which helped me mentally deal with it, and the advice from the book would argue against any sort of countersuit which would just prolong this person's time in your life.

 

[nexus73]

I think if anything would change for me clinically, maybe not be so helpful offering transfer to psych. Holding a stricter formulation, that this is organic, meds or seizures or something else we've not identified, but someone in their 50s shouldn't be having first break psychosis. But then again we don't know, because a woman post-menopausal in her 50s could have onset of psychotic disorder free of any underlying organic process, right?

But could have had her to stay on medicine. I don't know if that would have stopped anything. The husband could have sued because we forced his wife to stay on medicine instead of transferring to psych, if she ended getting restrained or IM for agitation or something. Or just mad about her getting antipsychotics. Who knows.

 

[Celexa]

I think if anything would change for me clinically, maybe not be so helpful offering transfer to psych. Holding a stricter formulation, that this is organic, meds or seizures or something else we've not identified, but someone in their 50s shouldn't be having first break psychosis. But then again we don't know, because a woman post-menopausal in her 50s could have onset of psychotic disorder free of any underlying organic process, right?

But could have had her to stay on medicine. I don't know if that would have stopped anything. The husband could have sued because we forced his wife to stay on medicine instead of transferring to psych, if she ended getting restrained or IM for agitation or something. Or just mad about her getting antipsychotics. Who knows.

It's still appropriate for someone whose primary issue is management of psychiatric symptoms to be on a psych unit, if the medical issue is appropriately treated and stable. The timeline for seizure-related psychotic symptoms is extremely variable, and as you noted less safely managed on medicine than in a psych unit. Neurology appears to have done their job by controlling the seizure activity and it was confirmed by EEG. You'd want this patient in a psych unit where the physicians understand the difference between psychosis secondary to a medical condition and a primary psych disorder, but the appropriate place for her was still the psych unit. Agree its a false hope to think that if you had kept her on the medical unit her husband would not have been a crazy person. What if she got hurt on the medical unit while psychotic and he latched on to her not being in a psych unit which knows how to deal with psychotic patients instead? Externalizing people like this will find fault regardless.

Good clincial care remains good clinical care.

 

[Sushirolls]

These types of encounters will only increase in frequency. Our country has changed in demographics. I've already witnessed this first hand moving from a blue metro, where google reviews negatively accost you for counseling against cannabis, or slew of other things. People making financial comments about their bills - that are dictated by their insurance - that you are XYZ. All originating from their socialist political view point. Now, I'm in rural red hamlet and the cultural underpinnings are a breath of fresh air. People are nicer, accepting of the foundations of capitalism and paying their bills, communicating before hand if/when they can't, and not hostile to recommendations you make.

Things will get worse as our country's demographics continue to change from red/conservative/rural to blue/urban/liberal. This will also be further hastened as the baby boomer generation, one of the harbingers of the original entitled mentality, barrels into retirement. Their displeasure of being older/sicker/more frail, on medicare, and having ample time on their hands will be a marked bane on the health care workforce. Essentially they aren't going to transition into their aged demographic with grace, and their frustrations are going to bubble over.

Medical board fees will continue to rise to fund these rising complaints to do the investigations. As ARNPs and PAs continue to take over greater percentages, the disposable nature of clinicians will seep into all fields - including physicians - and dealing out board actions will only become more commonplace. Similar to current (and historic?) Russian war tactics, another body will step up onto the trench shooting board to use your rifle stethoscope.

I hope I'm wrong. I really do. And that my observations and conclusions are simply born of the statistical variance you see in data sets; but y'all's observations/conclusions are more uniform.

 

[allantois]

It sounds to me like her psychosis was caused by her husband

 

[Jules A]

Things will get worse as our country's demographics continue to change from red/conservative/rural to blue/urban/liberal. This will also be further hastened as the baby boomer generation, one of the harbingers of the original entitled mentality, barrels into retirement. Their displeasure of being older/sicker/more frail, on medicare, and having ample time on their hands will be a marked bane on the health care workforce. Essentially they aren't going to transition into their aged demographic with grace, and their frustrations are going to bubble over.

Yup. I already see many in their 70s-80s who have been fortunate to have had long, healthy, prosperous lives present as shocked and distraught that their health has taken a turn for the worse.

 

[Candidate2017]

I had a similar case in residency, minus complaints from the spouse as far as I knew. I'm sorry for your experience, which every doctor will experience multiple times during their career, in addition to lawsuits. This is something I've learned to make peace with. This is The Life we have chosen. I listen, provide professional care, do what is defensibly appropriate, and leave the rest to my malpractice carrier.

One thing is the husband's insistence on stopping meds. It's common for family to insist some weird side effect is due to meds. Everyone likes to blame the meds. But upon family request to DC a med, I generally honor it and switch after I give them my opinion, risks/benefits/alternatives, etc. Even if a side effect is rare, we have lots of encounters and prescribe lots of meds, so statistically we should see rare side effects multiple times each year.

But there's a subset of people who like to blame doctors/meds/hospitals/science for everything (i.e., social media comments to the effect of, "It's the COVID shot!" that gets tons of likes whenever a public figure dies). Physicians deal with large swaths of the public and unless you have a boutique practice, and the sad reality is we run into a lot of stupidity.

Likely, the husband has met with malpractice lawyers who have probably declined to take his case, or even tossed him out their office. The concern I would have is the potential for violence.

The best advice is try and get through the process and away from these people as fast you can. They're not healthy individuals and probably wish in some perverse way that you do countersue them.

There was a book I found tangentially helpful which is a good read for any psychiatrist I think. It's called The Gift of Fear, written by a former FBI or CIA agent. One of the pieces of advice regarding stalkers (like ex boyfriends or refused romantic partners, etc who won't stop harassing women typically). The advice was just completely cut all ties, don't answer their calls, don't agree to meet up hoping you can explain you don't want to hear from them.

Agreed. There is an economist who wrote 4-5 laws about stupidity, including how people underestimate how dangerous it is to engage with stupid people and how stupid people are the most harmful people in the world. We willingly invite enough bad juju into our lives as psychiatrists, there's no need to further engage with a former inpatient's husband.

As they say, you don't have to accept every invitation to fight/argue, and you win every fight/argument you decline.

 

[Bartelby]

There was a book I found tangentially helpful which is a good read for any psychiatrist I think. It's called The Gift of Fear, written by a former FBI or CIA agent. One of the pieces of advice regarding stalkers (like ex boyfriends or refused romantic partners, etc who won't stop harassing women typically). The advice was just completely cut all ties, don't answer their calls, don't agree to meet up hoping you can explain you don't want to hear from them. To the point you shouldn't even call police or file restraining orders, because it just feeds into their ego and makes them more likely to keep coming. So through a process like a lawsuit, the lawyer will tell you this anyway, not to contact them. I viewed this person in part as an unstable stalker which helped me mentally deal with it, and the advice from the book would argue against any sort of countersuit which would just prolong this person's time in your life.

I was thinking the same. "Engage and enrage." Once someone has shown that they will harass you and have no interest in seeing reason, cutting all contact can eventually result in their moving on. Also, when legitimate alternatives (such as the patient advocate office, the Medical Board, or a lawsuit) are exhausted is when you have to worry more about violent escalation. As unpleasant as it is for someone to focus on these legitimate avenues of attack, at least they are focused on those instead of violent threats.

But of course that's all cold comfort to someone going through this. I'm sorry to hear OP that you had to deal with this. It can create years of absolutely unnecessary stress, and can be pretty unsatisfying that the best you can hope for is the unstable stalker-type gets bored and moves on (with no consequences).

 

[nexus73]

Likely, the husband has met with malpractice lawyers who have probably declined to take his case, or even tossed him out their office. The concern I would have is the potential for violence.

I'm glad I started this thread

 

[J ROD]

Dealing with this crap is one reason I changed from inpatient to outpatient. In general having a relationship with patients and less severity cuts down on board complaints and even lawsuits. Biggest issues I deal with now is refusing to give ADHD diagnosis to every patient who wants it and stimulants. Also, I want my benzo patients. Xanax 2mg tid. Yeah I plan to retire or cut back to an easier outpatient clinic like VA as soon as I can. Hopefully, 5-7 years.

 

[wolfvgang22]

Dealing with this crap is one reason I changed from inpatient to outpatient. In general having a relationship with patients and less severity cuts down on board complaints and even lawsuits. Biggest issues I deal with now is refusing to give ADHD diagnosis to every patient who wants it and stimulants. Also, I want my benzo patients. Xanax 2mg tid. Yeah I plan to retire or cut back to an easier outpatient clinic like VA as soon as I can. Hopefully, 5-7 years.

I've got some bad news for you if you think the VA has less patients seeking benzos or stimulants. Yes, it's hard to get sued directly, but they make up for it with the endless checklists and required extra EMR notes and bureaucracy, lol. It's probably not so bad if you work 3 days a week and don't care what admin thinks because you have one foot out the door.

 

[annoyedpsychiatrist]

it is an absolute joke that it was allowed to even get that far. Wow what a great system where someone can cause someone endless emotional torment for years and get away with it. I wish we could somehow share stories like these and push for reform.

We give patients way too much power and the average person is clueless and has no idea how the system actually works resulting in cases like this. "The patient is always right" mentality was the reason we had an opiod epidemic, yet we still keep trying to shift back to that mentality.

 

[clausewitz2]

Can these people be sued? Or even threatened with lawsuits for unnecessarily disrupting 9 doctors ability to practice medicine?

I don't think the husband actually deserves to be sued, but maybe if initially a return letter by the hospital attorney back to the husband had a warning to the effect of "frivolous lawsuits risk countersuit for libel / emotional stress / damages / some other legal threat" then maybe it would have been enough to curb his later efforts (but I know nothing of law).

I do agree that right now there is too much power on the side of the accusers and very little if any recourse by physicians to prevent its abuse, which is troubling.

I don't think you would want the system to work like this. Say goodbye to the ability of anyone to sue a corporation, large organization, or even very rich person for damages. The moment you file, boom, you are obliterated by a team of in-house lawyers who countersue you into oblivion.

The system as it stands has some horrible downsides, but it is easy to go too far in the other direction.

 

[annoyedpsychiatrist]

I don't think you would want the system to work like this. Say goodbye to the ability of anyone to sue a corporation, large organization, or even very rich person for damages. The moment you file, boom, you are obliterated by a team of in-house lawyers who countersue you into oblivion.

The system as it stands has some horrible downsides, but it is easy to go too far in the other direction

my counter though to this, was that OPs scenario was quite extreme. The person didnt simply file a suit/complaint; they harrassed OP into oblivion. I think when it gets to the level of harassments, such as sending someone letters of disdain frequently and threats, then I believe retribution/countermeasures isnt unreasonable. I would say what the person did to the OP was harrassment inflicting emotional distress, which one could easily see was the clear intent of the letters/threats.

 

[clausewitz2]

my counter though to this, was that OPs scenario was quite extreme. The person didnt simply file a suit/complaint; they harrassed OP into oblivion. I think when it gets to the level of harassments, such as sending someone letters of disdain frequently and threats, then I believe retribution/countermeasures isnt unreasonable. I would say what the person did to the OP was harrassment inflicting emotional distress, which one could easily see was the clear intent of the letters/threats.

You really don't want the standard for a tort for someone exercising otherwise legal means of registering complaints to be emotional distress. This leads to the standards in public life to be set by the most easily offended people; if the prospect of being sued for their crappy exploding battery causing a house fire keeps Apple's CEO up at night, do you want Apple to be able to counter-sue for emotional distress?

My sympathy is 100% with OP and it sounds like a really awful situation that was horrific to be in. But suppose the person writing these letters felt genuinely aggrieved and thought they were actually acting to defend themselves/their spouse/other patients, even if we can all agree that factually they are wrong. It is going to be very hard to prove a specific intent, and without that intent, the line between "strong if justified utilization of legitimate means for resolving grievances" and "illegitimate harassment" is going to entirely depend on the balance of power between parties involved.

Mutatis mutandis, the same holds for why we don't try to ban "fake news". We generally recognize how easily this becomes good old fashioned censorship.

 

[annoyedpsychiatrist]

You really don't want the standard for a tort for someone exercising otherwise legal means of registering complaints to be emotional distress. This leads to the standards in public life to be set by the most easily offended people; if the prospect of being sued for their crappy exploding battery causing a house fire keeps Apple's CEO up at night, do you want Apple to be able to counter-sue for emotional distress?

My sympathy is 100% with OP and it sounds like a really awful situation that was horrific to be in. But suppose the person writing these letters felt genuinely aggrieved and thought they were actually acting to defend themselves/their spouse/other patients, even if we can all agree that factually they are wrong. It is going to be very hard to prove a specific intent, and without that intent, the line between "strong if justified utilization of legitimate means for resolving grievances" and "illegitimate harassment" is going to entirely depend on the balance of power between parties involved.

Mutatis mutandis, the same holds for why we don't try to ban "fake news". We generally recognize how easily this becomes good old fashioned censorship.

Im just playing a little devils advocate here, but if someone continuously attacks someone, whether its verbally or physically, then can you say it was done as a defensive measure? Im more focused on the aspect of harrassment in itself and how one could argue that it was a form of harrassment and not simply just emotional distress. What other purpose would repeated letters serve to someone? The OP wasnt conducting experiments on the patient, and the letters dont do anything to shield/defend his wife from a situation. They're a retroactive measure done on a repeated basis, attempting to use fear as a form of retaliation. The patient wasnt in a vulnerable position anymore in the sense that, him sending letters did not do anything for the benefit of the patient. They were done in a way meant to be offensive, rather than defensive, as the OP was not writing hateful letters to the patient/husband. The letters are an unwanted, repeated measure with the goal to inflict distress- its hard to objectively point out any other other goal, as there is no other purpose they could serve as they don't rescue the patient or act to improve her situation.

I get what youre saying though (and agree), that we have to be careful with cancel culture, lawsuit happy, etc, I just feel that one person can make another persons life hell if they choose to and that if someone harrasses another person continuously then perhaps they should be held accountable. Heck, I think specifically patients should be held accountable for their actions, and not just providers.

 

[Merovinge]

Out of curiosity, do you have any idea what she eventually stabilized in and went home with? Also, was the EEG while on non-therapeutic Depakote suggestive of seizure activity? If not, forced normalization could describe this whole unfortunate episode.

How is this managed clinically event if it's recognized? Do they just taper off the AEDs (what if the person has more seizures)? I had never heard of forced normalization before and my initial reading is not helping me understand management much better.

 

[clausewitz2]

How is this managed clinically event if it's recognized? Do they just taper off the AEDs (what if the person has more seizures)? I had never heard of forced normalization before and my initial reading is not helping me understand management much better.

There's a lot of controversy about what you do about this, but to the extent there is a clear difference in approach it probably comes down to figuring out balance between seizure control and psychiatric symptoms. Usually the goal of treatment for the epileptologists is always 100% seizure freedom, but that may not be ideal for a patient who becomes acutely psychotic when their seizure control is pristine. At least you get to consider a trade-off if seizure control is the result of AEDs; the do seem to be a fair number of cases of forced normalization after epilepsy surgery, in which case you're kind of hosed.

 

[splik]

There's a lot of controversy about what you do about this, but to the extent there is a clear difference in approach it probably comes down to figuring out balance between seizure control and psychiatric symptoms. Usually the goal of treatment for the epileptologists is always 100% seizure freedom, but that may not be ideal for a patient who becomes acutely psychotic when their seizure control is pristine. At least you get to consider a trade-off if seizure control is the result of AEDs; the do seem to be a fair number of cases of forced normalization after epilepsy surgery, in which case you're kind of hosed.

I'm certain I've seen more epilepsy pts than 99% of psychiatrists including lots of pts with psychosis, and I have never seen a case of forced normalization psychosis. If Landolt phenomena is a real thing, it is rare. It is much more common for patients to experience improvement in psychiatric symptoms following epilepsy surgery than to develop psychosis (and often the latter can be neuroanatomically explained when it does occur). Many of the cases reported nowadays have been associated with Keppra which is known to cause neuropsychiatric symptoms (and there are several other ASMs associated with neuropsychiatric symptoms), and there is a very broad differential diagnosis for seizures and psychosis (e.g. autoimmune encephalopathies, viral encephalities, TBI, Alzheimer's Disease, CADASIL, cerebral amyloid angiopathy, mitochondrial disease) as well as other psychoses of epilepsy. At one point there was believed to be a biological antagonism between epilepsy and psychosis (which was one of the reasons for the use of convulsive therapies, first cardiazol, and later ECT) though this has long been discredited since the prevalence of psychosis in patients with epilepsy is at least 7 times greater than the general population.

Another problem with the concept is that many supposed cases do not involve psychosis. Neurologists tend to lump in non-psychotic affective states, or dissociative states in with true psychosis as well as frank delirium. Then there are the major issues of many neurologists not being able to read an EEG. So you have people who are told they have epileptiform activity on their EEG which mysteriously disappears when they are seen by someone competent.

I still mention FN when I teach the psychiatry residents and epilepsy fellows about the psychoses of epilepsy but remain uncertain about it.

 

[clausewitz2]

I'm certain I've seen more epilepsy pts than 99% of psychiatrists including lots of pts with psychosis, and I have never seen a case of forced normalization psychosis. If Landolt phenomena is a real thing, it is rare. It is much more common for patients to experience improvement in psychiatric symptoms following epilepsy surgery than to develop psychosis (and often the latter can be neuroanatomically explained when it does occur). Many of the cases reported nowadays have been associated with Keppra which is known to cause neuropsychiatric symptoms (and there are several other ASMs associated with neuropsychiatric symptoms), and there is a very broad differential diagnosis for seizures and psychosis (e.g. autoimmune encephalopathies, viral encephalities, TBI, Alzheimer's Disease, CADASIL, cerebral amyloid angiopathy, mitochondrial disease) as well as other psychoses of epilepsy. At one point there was believed to be a biological antagonism between epilepsy and psychosis (which was one of the reasons for the use of convulsive therapies, first cardiazol, and later ECT) though this has long been discredited since the prevalence of psychosis in patients with epilepsy is at least 7 times greater than the general population.

Another problem with the concept is that many supposed cases do not involve psychosis. Neurologists tend to lump in non-psychotic affective states, or dissociative states in with true psychosis as well as frank delirium. Then there are the major issues of many neurologists not being able to read an EEG. So you have people who are told they have epileptiform activity on their EEG which mysteriously disappears when they are seen by someone competent.

I still mention FN when I teach the psychiatry residents and epilepsy fellows about the psychoses of epilepsy but remain uncertain about it.

Oh, for sure, it is absolutely the stuff of case series at best rather than something at all common. I am sure you have seen more epilepsy patients than I have overall, but I have seen one (possibly two) cases of Landolt phenomena. The one in particular was persuasive and absolutely like clockwork over the course of a year with more than one subsequent hospitalization, largely independent of the particular AED used. Definitely got a cadillac workup.

Agree with your about "psychosis" being very loosely defined in much of the literature on this. This guy was being seen by psychiatrists concomitantly and also by epileptologists at a major academic center; I can't guarantee for sure they read the EEG correctly but seems more likely than not.

At the end of the day I agree with you and it's a super fringe-y thing. There are also many other psychoses of epilepsy (I in fact have a copy of Trimble's the Psychoses of Epilepsy sitting on my bookshelf in my office) and totally could have been the real explanation for OP's situation.

 

[J ROD]

I've got some bad news for you if you think the VA has less patients seeking benzos or stimulants. Yes, it's hard to get sued directly, but they make up for it with the endless checklists and required extra EMR notes and bureaucracy, lol. It's probably not so bad if you work 3 days a week and don't care what admin thinks because you have one foot out the door.

I have worked at a VA for several years prior. I can dominate some CPRS. I mean from the sue happy culture and I related well to veterans and at least felt like I was helping a population overall that deserves it.

 

[FlowRate]

What a stressful ordeal!

More minor than what you went through, but the default position of medical boards as requiring a point-by-point written response to anything a patient sends them is pretty frustrating. Very long story short, a patient I was treating didn't like my take on something and submitted a board complaint where he lied and said that numerous things happened during the appointment that didn't. Took about 5 hours of my time between meeting with counsel, chart review, and a few rounds of drafts of the reply letter for it to then be dismissed by the board. But a very stressful several months preparing and waiting for the decision. I'm happy that it seems most disgruntled patients don't realize that a board complaint is an option available to them, as it would create serious hell if more patients used it as a tool for expressing their displeasure.

 

[whopper]

Some patients are what I call toxic or radioactive. If they're not their family members could be. They don't train you on dealing with toxic family members that keep calling your office over and over and over.

I've had patients I terminated because I could tell they were going to create a very toxic situation or were already creating it. If you're doing inpatient, at least you have the legal protection of the institution (their lawyers) working for you. When you discharge the patient the treatment relationship is terminated. In private practice you're on your own.

I have safeguards to prevent some future problematic patients from joining. E.g. they have to schedule the appointment themselves. Why does that matter? Toxic spouse could schedule it and the patient never wanted the appointment.

You will get a complaint during your career. It will happen sooner or later barring exceptional circumstances like your career was 1 year. If you did nothing wrong, have good documentation don't freak out. See it as part of the job. It's still frustrating.

 

[whopper]

Adding more: The type of personality I see as potentially toxic in a treatment relationship is often times one where someone in the relationship has too much free time on their hands, add to that they have a tendency to want to get revenge, and often times misperceives somehow being wronged.

I've noticed two financial types fall into this category. The unemployed and the wealthy to the degree where they don't have to work.

It doesn't have to be the patient. It could be the patient's spouse or parent. E.g. There's no HIPAA clearance but the spouse calls you repeatedly and takes the time and effort to make your life hell. What do you do? If it's the patient's fault the solution is simple to come up with but could be hard to execute --> terminate the doctor/patient relationship. What if it's not the patient? Terminate the patient when it's not the patient's fault? That's not fair to the patient. You'll have to work that out on a case-by-case basis, and I don't got a simple formula. Some I've had were...

a) Patient refused to sign HIPAA clearance. So I tell the patient the other person keeps calling me and is disrupting my office. It got to the point where I had to consider getting a lawyer and filing a restraining order against the person's father. In the most extreme case I had a lawyer ready to get to work but at the last moment the patient (thank GOD!) terminated me as their doctor. (I sent out a termination letter to make it official cause I didn't want that case again). Thankfully the lawyer was a friend of mine so getting the prep work done he didn't charge me, and we discussed the preliminary stuff during a hangout, but had this my lawyer-friend been someone I didn't know beforehand I would've had to have paid several hundred dollars at the point where the problem was solved.

b) Patient signs HIPAA, so then I invite the patient and the other person to my office. I tell both people that person cannot continue to continually call my office because they're disrupting my practice. I also tell them that if they have questions they really ought to talk to the patient and not me because I'm not their physician.

It's just not our field. I've seen other people be in similar situations. I have a patient (a financial advisor) who had a ex-client that felt wronged by him and she made it her pet-project to ruin his life for the next few years. The ex-client was wealthy and she had a team of lawyers only work on doing things to screw that guy up.

 

[whopper]

During her time on medicine her husband expressed concern the Depakote was making her psychotic, which the neurologist thought was unlikely especially because her psychosis started before the Depakote. But after a few days of him pleading, Depakote was stopped in exchange for zonisamide.

Was going to add, was this husband playing doctor? What were his grounds to start telling doctors how to do their jobs? There is such a thing as the patient or their family having an outside-the-norm physiology that has to be pointed out such as an allergy to penicillin, previous bad reaction to Depakote, but if it's not this, or some other reason that's solid, it suggests the husband was inappropriately trying to control the physicians.

Anyone in the field for a few years will see odd cases, such as prior case of Guillian Barre-if that happens you have to be very wary of further vaccines, so if a patient brings up something like this, it's very important. Did something like that happen here or was this guy inappropriately playing doctor?