Real Neuro Patients

[drboris]

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Hi Guys,

I am an M2 and have recently become very interested in Neuro. We had neuro as our first class this year, and I really enjoyed it and did well. To me. neuro seems logical, almost from in engineering like way. Once you learn the circuits, the pathology falls in place. Also, I find the CNS fascinating and really like neuro/CNS pharm.

From reading various posts on this forum, people say that many neuro patients are really psyc patients. I don't understand how a PD, MS, migraine, epilepsy patient is anything but a neuro patient?

Also, can people start posting cases and other neuro stories? I really want to know what its like in the field. My neuro rotation is 4th year, so I want to learn as much as I can now. Also, I think other people on this forum who are interested in neuro would really appreciate this info.

Finally, how common is it to treat headache/migraine with botox?

Thanks,
Boris

 

[DrDre']

I just spent two weeks on in-patient HA and szr. All the szr pts were in trying to prove they had seizures which were all pseudoseizures at best, and factitious at worst.

The HAs were all psych. Maybe psych issues lead to chronic HAs by somatization or conversion OR HAs cause u to go crazy?

The ones not faking it are MS, movement d/os(some fake 'em), strokes, MG


I respect the hell out of neuros fund of knowledge but u better like psych.

 

[NR117]

I just spent two weeks on in-patient HA and szr. All the szr pts were in trying to prove they had seizures which were all pseudoseizures at best, and factitious at worst.

The HAs were all psych. Maybe psych issues lead to chronic HAs by somatization or conversion OR HAs cause u to go crazy?

The ones not faking it are MS, movement d/os(some fake 'em), strokes, MG


I respect the hell out of neuros fund of knowledge but u better like psych.

Whoa, all the headaches are psych??? Based on your vast *2-week* experience? Clearly you've never had a migraine H/A yourself or seen a patient with one...
Some patients with chronic medical conditions may go on to develop psych issues but that doesn't make those medical conditions primarily psych problems, does it?

 

[skb21]

I've been rotating with a neurologist for our second year clinical involvement. I have to say that by far, I've seen more headache presentations than anything else, but they weren't psych people. Now, I've seen a couple of patients that I would tend to believe have some psychological and/or mental issues, but there aren't many of them.

I did get to see a follow up on a patient that had been treated for trigeminal neuralgia. I wish I could have seen the initial presentation of that one.

 

[NoSz]

I hope you realize, that most (>>50%) of "real" epileptic patients do have pseudoseizures.
I hope you also realize that most of "real" epileptic patients going in for 24hr-Video-EEG experience a "honeymoon" period with a reduced seizure occurence rate.
I hope you realize that you can have "real" (mostly simple partial) seizures without any EEG changes (rare, but certainly possible).
I hope you realize that you can help the patient and their family with "pseudoseizures" a tremendous lot by explaining the causes (for example psychological stress) and proper treatment (you do not need to rush to the ER, you might not need AEDs).
I hope that you realize, that any epileptologist with years of experience has been fooled more than once into disbelieving a "real" seizure and strongly believing in a pseudoseizure.

It is true, though, epilepsy is a major part of neurology.
Best wishes,
NoSz!

 

[neurologist]

Hi Guys,

I am an M2 and have recently become very interested in Neuro. We had neuro as our first class this year, and I really enjoyed it and did well. To me. neuro seems logical, almost from in engineering like way. Once you learn the circuits, the pathology falls in place. Also, I find the CNS fascinating and really like neuro/CNS pharm.

From reading various posts on this forum, people say that many neuro patients are really psyc patients. I don't understand how a PD, MS, migraine, epilepsy patient is anything but a neuro patient?

Also, can people start posting cases and other neuro stories? I really want to know what its like in the field. My neuro rotation is 4th year, so I want to learn as much as I can now. Also, I think other people on this forum who are interested in neuro would really appreciate this info.

Finally, how common is it to treat headache/migraine with botox?

Thanks,
Boris

Neurologic disease = brain disease (well, yeah, you can have peripheral nerve or spinal disease too, but stick with me while I make this point)

Psychiatric disease = . . . .BRAIN DISEASE!!!!! (remember, it's been a long time since anyone has postulated that the seat of the personality was is the heart or the liver or anywhere other than the brain . . . )

It is exhaustively documented that patients with "organic" neurologic problems (epilepsy, MS, Parkinson's, Alzheimer's, migraine, you name it) also have high rates of comorbidity for depression, anxiety, ADHD, bipolar disorder, OCD, etc. This is no mere coincidence; the brain is the organ of both motor and cognitive/emotional behavior. Therefore, it is not unreasonable to postulate that if there is something wrong "organically" with the brain, there is very likely to be something wrong with it "nonorganically" as well.

Can a patient have a purely psychiatric condition with "pseudoneurologic" presenting symptoms? Of course, the classic example being "pseudoseizures" (the preferred terminology for which, by the way, is "nonepileptic seizures.") All the dilantin in the world won't help these people. Can an honest to gosh epileptic be depressed or anxious? You bet. At least half of them are. Can anxiety or depression worsen or complicate chronic pain conditions like migraine or complex regional pain syndrome? It can and does. And few of these patients seem to have much insight into or willingness to accept the interplay of the two.

So, the moral is: the neurologist cannot divorce the "organic" from the "inorganic." They both stem from the brain, like it or not, and if you only focus on one aspect, you are only treating half the patient.

Remember: Freud started out as a neurologist!

Of course, I will also grant you that as a neurologist you get a fair number of referrals for patients with all sorts of bizarre symptoms that make no sense at all from any medical perspective, neurologic or otherwise. These people are, of course, just plain nuts, and should be sent back to the referring physician with a polite note stating "this patient's symptoms cannot be explained on the basis of a neurologic illness" or something like that.

As for Botox for headache, it is becoming more and more common. Works pretty well in my experience, although if you really look at the literature it is somewhat inconclusive, most likely due to the dozens of different protocols that have been used in various studies. It's easy to do, safe, and a money-maker for the provider.

 

[neglect]

6 months ago. Had a 45 yo with migraines her entire life. Unresponsive to all medications, which included all NSAIDS, bi-weekly morphine and demerol in the ER, and fioricet.

Told her she had migraines, not a tumor. Told her no more fioricet. Put her on VPA and Imitrex for breakthroughs. At follow up she hugged me (I do not invite hugs) and told me I'd saved her life.

Too bad neurologists can't help anyone.

 

[neurologist]

6 months ago. Had a 45 yo with migraines her entire life. Unresponsive to all medications, which included all NSAIDS, bi-weekly morphine and demerol in the ER, and fioricet.

Told her she had migraines, not a tumor. Told her no more fioricet. Put her on VPA and Imitrex for breakthroughs. At follow up she hugged me (I do not invite hugs) and told me I'd saved her life.

Too bad neurologists can't help anyone.

She'll be back to kick your a$$ in a couple months after she notices that 30 pound VPA-induced weight gain . . . .

Actually, glad to see it worked . . . biweekly morphine and demerol in the ER is usually a bad prognostic sign in my practice . . .

 

[drboris]

Thanks Guys!

Please keep responding. I really want to hear more about what neuro is like in the real world in private practice. Please keep posting patient presentations, it is really informative.

Thanks

 

[bustbones26]

There certainly are a lot of overlying psychosocial issues sometimes which makes patients embellish their symptoms, but not always the case. Usually, you can defuse these people by coming down to their level and 3explaining what is going on.

In regards to botox, give if a person complains of more than 15 headahce episodes per month. Does not completely rid the patient of headaches, but does certainly reduce the frequency down to a tolerable rate. Not to mention that patients get a nice wrinkle free face too. But my recent botox patients are very happy.

Yes the words fiorcet, demorol, morphine, and fibromyalgia make a neurologist cringe. As far as neurology being a specialty that helps people, I think we all do a good job of fixing people up who come to us with a medication list that includes a narcotic, benzodiazepine, and several anti-depressants with on overlying history of hitting the ER for toradol, demorol, morphine you name it. How do they get all of those medications and get so f__ked up?