Strange Case

[MySpirit]

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My supervising physician has a new patient who is an unemployed woman (X) in her 30s. X often rides the city bus because she wants to meet and find a boyfriend that is a bus driver. So, X will constantly talk to male drivers while they are driving. X has gotten many drivers into trouble because of this. Out of 900 drivers, X knows the names of 450 of them. She can tell you who graduated in what class.

In one situation, she kept getting on to a particular driver's bus to talk to him. Eventually, the driver told X that she should find a husband and that she shouldn't be talking to drivers so much. X got angry with this driver and wrote him a long and nasty letter.

I may be asked to do medication management with X. Has anyone ever had a case like this?

 

[birchswing]

Is the medication to make her better at landing a bus driver or a better letter-writer?

 

[benlinus]

Sounds like either:

1.Cluster B (borderline or histrionic)
2.Cluster C(dependent)
3.Intellectual Disability of some degree
4.Bus Driver Fetish

Mostly likely will benefit from some sort of psychotherapy referral

 

[Ceke2002]

Is the medication to make her better at landing a bus driver or a better letter-writer?

I legit snorted coffee out my nose at that. 😆

 

[smalltownpsych]

Presenting complaint? Eccentric or odd behavior or interests is not necessarily a mental disorder. I would hate getting a psychotherapy referral for this case as patient likely has no insight into need for therapy and when asked what brought her into see me today would probably say something along the lines of "I don't know, the doctor told me to come here."

 

[nitemagi]

Like any behavior, if approached through meds, look for underlying symptoms/problems driving the behavior. Anxiety, loneliness, obsessiveness. Meds will likely just add some flexibility and not solve the problem, but I'd aim to explore going in that way if I had to use meds, in combo with therapy.

 

[hamstergang]

Presenting complaint?

This is key, I think. Why is she actually coming to the office?

 

[Shikima]

Someone sent her over for 'acting weird' and want the psychiatrist to fix that.

 

[MySpirit]

She has been told to get help for several reasons: One, it is a safety issue to be talking to drivers while they are driving. Thus, her behavior is interfering with the lives of many people. Two, it is inappropriate to be constantly getting on a particular driver's bus just to talk to him. Three, she also lies to everyone by telling them that she is a substitute teacher. Drivers know that this isn't true because she spends the day riding the bus.

 

[smalltownpsych]

She has been told to get help for several reasons: One, it is a safety issue to be talking to drivers while they are driving. Thus, her behavior is interfering with the lives of many people. Two, it is inappropriate to be constantly getting on a particular driver's bus just to talk to him. Three, she also lies to everyone by telling them that she is a substitute teacher. Drivers know that this isn't true because she spends the day riding the bus.

It sounds like the behavior is not a problem for her but for others. We don't do so well at fixing behaviors that people don't want to change. If the patient says that they do want to stop but can't and they have emotional distress, then you would have a patient you could help. If not, be honest with them about this and don't give them a medication that is not indicated for "bus-driver paraphilia" because it probably won't work.

 

[deleted343839]

Depending on her level of insight I might focus on what other roles, life goals, relationships, values, etc. are meaningful to her, in an effort to elicit any motivation for change that she might have. Though admittedly that would be a lofty goal if she has never had a sustained period of better functioning.

 

[Shikima]

I wish I had a magic pill to fix this.....

 

[heyjack70]

She has been told to get help for several reasons: One, it is a safety issue to be talking to drivers while they are driving. Thus, her behavior is interfering with the lives of many people. Two, it is inappropriate to be constantly getting on a particular driver's bus just to talk to him. Three, she also lies to everyone by telling them that she is a substitute teacher. Drivers know that this isn't true because she spends the day riding the bus.

Who told her to get help and why is she actually listening to what they say? She doesn't listen when they say stop harassing bus drivers. It sounds like the bus company should just get a restraining order if she refuses to stop talking to the drivers, especially if they think it is truly dangerous to be distracting them.

 

[erg923]

My supervising physician has a new patient who is an unemployed woman (X) in her 30s. X often rides the city bus because she wants to meet and find a boyfriend that is a bus driver. So, X will constantly talk to male drivers while they are driving. X has gotten many drivers into trouble because of this. Out of 900 drivers, X knows the names of 450 of them. She can tell you who graduated in what class.

In one situation, she kept getting on to a particular driver's bus to talk to him. Eventually, the driver told X that she should find a husband and that she shouldn't be talking to drivers so much. X got angry with this driver and wrote him a long and nasty letter.

I may be asked to do medication management with X. Has anyone ever had a case like this?

"Medication management?" Are you serious?

I once asked out every girl at the DG sorority house. I didn't remember all the names though....

 

[TexasPhysician]

"Medication management?" Are you serious?

I once asked out every girl at the DG sorority house. I didn't remember all the names though....

Subtherapeutic Adderall levels? [emoji3]

 

[MySpirit]

"Medication management?" Are you serious?

I once asked out every girl at the DG sorority house. I didn't remember all the names though....

But, asking out every girl at the DG sorority house is not interfering with the lives and careers of other people. Big difference.

 

[hamstergang]

But, asking out every girl at the DG sorority house is not interfering with the lives and careers of other people. Big difference.

There are still 2 things you're missing:

1. Diagnosis. This woman may be weird, but if you can't figure out a diagnosis then coming up with a treatment plan isn't likely to be very successful.

2. Why is the woman there? Like, why did she bring herself to the office, sit in the waiting room, and then go into the room with the psychiatrist? If you don't know her motivation for being there, you will have quite some trouble engaging her in treatment.

 

[deleted314290]

Clearly one of the 900 needs to take one for the team...

 

[erg923]

But, asking out every girl at the DG sorority house is not interfering with the lives and careers of other people. Big difference.

K. And you think medication is going to fix this behavior?

What do you think the function of the behavior is?

 

[thoffen]

Why are most discounting that there might be a diagnosable and treatable mental illness here? Even one responsive to medications. How about a delusional disorder? Or FTD? It certainly sounds worthy of evaluation. Seems like this behavior, if pathologic, is interfering with functioning. Of course, building an alliance with this patient toward changing it (if indicated) may be challenging.

 

[erg923]

Why are most discounting that there might be a diagnosable and treatable mental illness here? Even one responsive to medications. How about a delusional disorder? Or FTD? It certainly sounds worthy of evaluation. Seems like this behavior, if pathologic, is interfering with functioning. Of course, building an alliance with this patient toward changing it (if indicated) may be challenging.

Because there was no history presented with the case that would hint at such. Most weird behavior is not actually mental illness....

And yes, worthy of evaluation (ie., much more information about the person and the behavior needed). Treatment decisions and planning comes after that. The OP essentially hinted that they were being called upon to medicate this behavior, which seems like pretty piss poor psychiatry to me.

 

[whopper]

Could also be an erotomanic delusion.

But I agree with Erg923. We shouldn't be in the business of simply diagnosing anything that seems odd. IMHO abnormal psychology should be a required course for psychiatrists but it's not. As a result we see too much medication and diagnosis over BS.

I'm one of the few psychiatrists I know of that often times tells patients that maybe they shouldn't use medication to a degree I don't hear of other psychiatrists. I'm also one of the only psychiatrists I know of that's taken an abnormal psychology class.

 

[smalltownpsych]

But, asking out every girl at the DG sorority house is not interfering with the lives and careers of other people. Big difference.

This is the trap we fall into all too often. Many in society want us to fix other people who cause problems for others. That is not our job as much as it is the job of law enforcement and the legal system. It starts with the bus driver being able to tell someone to leave the bus and if she won't then call the cops.

 

[smalltownpsych]

Then again, pretty sexy!

 

[sunlioness]

I can ride the bus for free with my faculty ID. Maybe I am missing out on romance by not doing so.

 

[Doctor Bagel]

Because there was no history presented with the case that would hint at such. Most weird behavior is not actually mental illness....

And yes, worthy of evaluation (ie., much more information about the person and the behavior needed). Treatment decisions and planning comes after that. The OP essentially hinted that they were being called upon to medicate this behavior, which seems like pretty piss poor psychiatry to me.

This sounds pretty typical for the work we do. We get a consult or referral that sounds grossly inappropriate. Then we do an evaluation and find out something entirely different is happening and often that there is something worth treating in some manner, not necessarily with medications. I agree with the sentiment that we can't be recommending treatments yet just based on the history presented.

 

[erg923]

This sounds pretty typical for the work we do. We get a consult or referral that sounds grossly inappropriate. Then we do an evaluation and find out something entirely different is happening and often that there is something worth treating in some manner, not necessarily with medications. I agree with the sentiment that we can't be recommending treatments yet just based on the history presented.

Yes, but I was also taking into account the ego dystonic nature of the disturbance. Medication management for a problem that doesn't exist in the patients mind seems futile unless there is reason to pursue forced treatment. I would imagine an EPO or restraining order would be the first line, rather than forced psych treatment.

I agree we shouldn't be falling victim to the Uncle Georges Pancakes fallacy, but we shouldn't be doing the opposite either. This could just be a lonely savant for all we know.

 

[MySpirit]

This is the trap we fall into all too often. Many in society want us to fix other people who cause problems for others. That is not our job as much as it is the job of law enforcement and the legal system. It starts with the bus driver being able to tell someone to leave the bus and if she won't then call the cops.

I agree that it is up to the drivers to enforce boundaries. From what I understand, some drivers continue to talk to her without telling her anything. Then, when the drivers got into trouble, everyone (including spouses of the drivers) blamed her.

In the case about a particular driver, she kept getting on and off his bus. He finally told her that she should find a husband elsewhere. She shouldn't be talking to drivers so much. So, she got angry and wrote the driver a long and nasty letter.

So, this is why she came to our office for help: she is very upset with the driver and she wants help in dealing with what he told her. This is why she showed up in our office. No one referred her.

I may not agree to take this case. I am able to do that at the clinic.

 

[Doctor Bagel]

I agree that it is up to the drivers to enforce boundaries. From what I understand, some drivers continue to talk to her without telling her anything. Then, when the drivers got into trouble, everyone (including spouses of the drivers) blamed her.

In the case about a particular driver, she kept getting on and off his bus. He finally told her that she should find a husband elsewhere. She shouldn't be talking to drivers so much. So, she got angry and wrote the driver a long and nasty letter.

So, this is why she came to our office for help: she is very upset with the driver and she wants help in dealing with what he told her. This is why she showed up in our office. No one referred her.

I may not agree to take this case. I am able to do that at the clinic.

It could be an interesting yet very hard case. That's what you're in training for, so maybe pick it up, assuming you've got good supervision and support. So she wants help with dealing with her negative emotions around being rejected by the bus drivers? I think it's too soon for us to provide any detailed help -- instead you just need to do the evaluation and see what's happening. Remember that doing an assessment doesn't mean you need to start a treatment, though.

 

[whopper]

I had a bisexual patient whose wife told him he had a problem because on occasion (I'm talking not that often) watched gay porn. His previous psychiatrist dx'd him with OCD despite that he did not meet the criteria of it and every time he continued to watch or want to watch gay porn his doctor just added more and more meds.

Was the porn pathological? I don't think so. He didn't have a problem with it. He didn't watch it much (on the order of every few months) and it was really his ultra-strict Catholic wife having the problem and getting mad about it. I don't remember his medication regimen perfectly but he was on two SSRIs, an antipsychotic, and Depakote if I remember correctly.

I asked him why he was dx'd with OCD and he told me cause his urge to watch porn (again it wasn't often) was the basis of his dx. His previous psychiatrist retired and that's why he stopped seeing her and started seeing me.

I got him off all his meds and told him it was up to him and a Catholic priest (he too was a Catholic) to reach some type of peace with this. He did not have OCD or any other diagnosable mental illness or disorder. This issue with his wife shouldn't be addressed through medical practice and to leave it up to the Church that did offer counseling and psychotherapy. I also offered to talk to his wife with him to show her why I didn't think he met a diagnostic criteria of a disorder. She refused every single time.

 

[heyjack70]

I had a bisexual patient whose wife told him he had a problem because on occasion (I'm talking not that often) watched gay porn. His previous psychiatrist dx'd him with OCD despite that he did not meet the criteria of it and every time he continued to watch or want to watch gay porn his doctor just added more and more meds.

Was the porn pathological? I don't think so. He didn't have a problem with it. He didn't watch it much (on the order of every few months) and it was really his ultra-strict Catholic wife having the problem and getting mad about it. I don't remember his medication regimen perfectly but he was on two SSRIs, an antipsychotic, and Depakote if I remember correctly.

I asked him why he was dx'd with OCD and he told me cause his urge to watch porn (again it wasn't often) was the basis of his dx. His previous psychiatrist retired and that's why he stopped seeing her and started seeing me.

I got him off all his meds and told him it was up to him and a Catholic priest (he too was a Catholic) to reach some type of peace with this. He did not have OCD or any other diagnosable mental illness or disorder. This issue with his wife shouldn't be addressed through medical practice and to leave it up to the Church that did offer counseling and psychotherapy. I also offered to talk to his wife with him to show her why I didn't think he met a diagnostic criteria of a disorder. She refused every single time.

So you're saying his wife needed meds. /s

 

[nitemagi]

Basically this person has a behavior that's causing problems for others, and we don't know more than that. She may or may not know it's a problem. She may or may not have a SMI. Everything else is speculative.

 

[smalltownpsych]

I agree that it is up to the drivers to enforce boundaries. From what I understand, some drivers continue to talk to her without telling her anything. Then, when the drivers got into trouble, everyone (including spouses of the drivers) blamed her.

In the case about a particular driver, she kept getting on and off his bus. He finally told her that she should find a husband elsewhere. She shouldn't be talking to drivers so much. So, she got angry and wrote the driver a long and nasty letter.

So, this is why she came to our office for help: she is very upset with the driver and she wants help in dealing with what he told her. This is why she showed up in our office. No one referred her.

I may not agree to take this case. I am able to do that at the clinic.

It does sound like an excellent training case which is how one of my clinical supervisors would always refer to the most difficult cases we would encounter. Diagnosis and case conceptualization are like meat and potatoes for me and this is the kind of case that one can really sink their teeth into to mix a few metaphors. I might even go a little Freudian with this one. It definitely is not going to fall into the everyday blah-blah realm of evidence based treatment for depressive disorders. The fact that she brought herself in for treatment would mean that there is something to work with. Of course, since you aren't a bus driver, it might be difficult to develop the necessary rapport to find out what is really going on, and although that might sound silly, I'm actually being serious.

 

[Ceke2002]

So you're saying his wife needed meds. /s

Well that was a considerably politer response than I was planning on giving. 😉

 

[Ceke2002]

It does sound like an excellent training case which is how one of my clinical supervisors would always refer to the most difficult cases we would encounter. Diagnosis and case conceptualization are like meat and potatoes for me and this is the kind of case that one can really sink their teeth into to mix a few metaphors. I might even go a little Freudian with this one. It definitely is not going to fall into the everyday blah-blah realm of evidence based treatment for depressive disorders. The fact that she brought herself in for treatment would mean that there is something to work with. Of course, since you aren't a bus driver, it might be difficult to develop the necessary rapport to find out what is really going on, and although that might sound silly, I'm actually being serious.

Ooh, but what if you found out the bus route of her favourite driver, hopped on a few times for some field observation, noted a few of his mannerisms and then subtly blended them with your own to give her a more comforting and familiar frame of reference.

edited to add: That was actually a serious train of thought, by the way.

 

[whopper]

I brought up the case with the Catholic guy to clarify that not every undesirable behavior is a pathology we need to medicate and treat like a disease. I don't know what was going on with the guy's wife other than that she was like very strict with her beliefs but I never talked to her so I could only go on what the patient told me.

The case brought up by the original author above does have some red flags that could be signs of a pathology but again not enough is known. Mentioned this before in other threads. Some psychiatrist try to have the loosest of interpretations when diagnosing. This IMHO is not a good idea. While the DSM IV and V upfront say they are not the end-all-be-all guide almost every case I've seen does follow it at least very much so if not all the way so. Of course there were exceptions but in those cases you should document the signs and sx you are seeing that make you think it's a pathology and not try to fish.

Just as an example and here's two cases I actually had...
1-Guy had an urge to kill people he thought was incompetent. He did not have antisocial PD, nor psychosis, nor mania. He was in his 50s. He told me when he gets angry he's had the urge to kill someone and when he explained why he was angry it actually made sense to me (though of course he shouldn't kill anyone). He worked construction and one of his bosses wasn't following all the safety protocols and it was putting people in harm's way that was completely avoidable. The guy even reported it and I forgot why but it got brushed under a rug. At one time his anger at his boss was so much and his effort to not harm him so much he actually fainted from the anger and self-restraint. His wife came in for collateral and she corroborated that this guy is a good father, husband, worker, has a sense of right or wrong, no prior mania, psychosis, no drug use.

The only thing I could think of was he told me of an incident where he was in a car accident and suffered a TBI but he had no other sx that could be pointed at that were psychiatric or neurological. The TBI might not have even been significant. His head hit a windshield and there was no detectable damage on an MRI and no personality change either. The event occurred in the guy's late 20s.

Now was this simply Intermittent Explosive Disorder? Maybe. The problem here was the guy never actually assaulted anyone or damaged property so I don't think he met the criteria of aggressive. (Also at the time the DSM-V was not yet out so I was using a IV definition).

2-Patient had fetal alcohol syndrome and severe ADHD to the degree where he could not sleep for days straight, had a tangential thought process, pressured speech, anger/irritability to an extreme degree (was arrested several times while in this state). I knew it wasn't bipolar disorder because guess what? Clonidine stabilized him. He went through a battery of all of the meds one would consider for bipolar disorder and none of them worked except Seroquel had some slight improvement with sleep. I tried the Clonidine out of desperation because I kept thinking to myself that if a major dose of lithium and an antipsychotic did nothing then maybe this was something looking like bipolar disorder but wasn't. Also the more the D2-blockage the worse he got (e.g. Haldol and Risperdal made him tremendously worse).

But like I said these cases were extreme outliers.

 

[Ceke2002]

I brought up the case with the Catholic guy to clarify that not every undesirable behavior is a pathology we need to medicate and treat like a disease. I don't know what was going on with the guy's wife other than that she was like very strict with her beliefs but I never talked to her so I could only go on what the patient told me.

The case brought up by the original author above does have some red flags that could be signs of a pathology but again not enough is known. Mentioned this before in other threads. Some psychiatrist try to have the loosest of interpretations when diagnosing. This IMHO is not a good idea. While the DSM IV and V upfront say they are not the end-all-be-all guide almost every case I've seen does follow it at least very much so if not all the way so. Of course there were exceptions but in those cases you should document the signs and sx you are seeing that make you think it's a pathology and not try to fish.

Just as an example and here's two cases I actually had...
1-Guy had an urge to kill people he thought was incompetent. He did not have antisocial PD, nor psychosis, nor mania. He was in his 50s. He told me when he gets angry he's had the urge to kill someone and when he explained why he was angry it actually made sense to me (though of course he shouldn't kill anyone). He worked construction and one of his bosses wasn't following all the safety protocols and it was putting people in harm's way that was completely avoidable. The guy even reported it and I forgot why but it got brushed under a rug. At one time his anger at his boss was so much and his effort to not harm him so much he actually fainted from the anger and self-restraint. His wife came in for collateral and she corroborated that this guy is a good father, husband, worker, has a sense of right or wrong, no prior mania, psychosis, no drug use.

The only thing I could think of was he told me of an incident where he was in a car accident and suffered a TBI but he had no other sx that could be pointed at that were psychiatric or neurological. The TBI might not have even been significant. His head hit a windshield and there was no detectable damage on an MRI and no personality change either. The event occurred in the guy's late 20s.

Now was this simply Intermittent Explosive Disorder? Maybe. The problem here was the guy never actually assaulted anyone or damaged property so I don't think he met the criteria of aggressive. (Also at the time the DSM-V was not yet out so I was using a IV definition).

2-Patient had fetal alcohol syndrome and severe ADHD to the degree where he could not sleep for days straight, had a tangential thought process, pressured speech, anger/irritability to an extreme degree (was arrested several times while in this state). I knew it wasn't bipolar disorder because guess what? Clonidine stabilized him. He went through a battery of all of the meds one would consider for bipolar disorder and none of them worked except Seroquel had some slight improvement with sleep. I tried the Clonidine out of desperation because I kept thinking to myself that if a major dose of lithium and an antipsychotic did nothing then maybe this was something looking like bipolar disorder but wasn't. Also the more the D2-blockage the worse he got (e.g. Haldol and Risperdal made him tremendously worse).

But like I said these cases were extreme outliers.

So I suppose being a good diagnostician in Psychiatry is a bit like being an accomplished cook. Sure you could follow a recipe to the letter, weigh all the ingredients to their exact measurements, never deviate an inch from what is written out in front you you - but then you might end up with something edible, but it will lack a certain substance. On the other hand you could just throw the recipe book out the window completely and just experiment - but then you run the risk of it turning into a complete mess and having to start all over. A good cook can use and follow the recipe, but still have enough creativity to work in their own flair and inspirations as well. 🙂

 

[Ceke2002]

a serious train of thought about bus routes? i see what you did there 😏

I don't know what you're talking about 😏

(it was still a serious thought though 🙂)

 

[hamstergang]

So, this is why she came to our office for help: she is very upset with the driver and she wants help in dealing with what he told her. This is why she showed up in our office. No one referred her.

I find it interesting that she saw this as a problem that a psychiatrist could help with. I'd be interested in exploring her expectations for you.

 

[birchswing]

I agree that it is up to the drivers to enforce boundaries. From what I understand, some drivers continue to talk to her without telling her anything. Then, when the drivers got into trouble, everyone (including spouses of the drivers) blamed her.

In the case about a particular driver, she kept getting on and off his bus. He finally told her that she should find a husband elsewhere. She shouldn't be talking to drivers so much. So, she got angry and wrote the driver a long and nasty letter.

So, this is why she came to our office for help: she is very upset with the driver and she wants help in dealing with what he told her. This is why she showed up in our office. No one referred her.

I may not agree to take this case. I am able to do that at the clinic.

I think the fact that it upset her is probably a good sign. It may mean she's embarrassed, which would be a healthy sign (I think). Although, anger can be a cover for embarrassment. But if she were just completely delusional, I doubt she would have sought help.

I'm not a doctor.

 

[splik]

I think the fact that it upset her is probably a good sign. It may mean she's embarrassed, which would be a healthy sign (I think). Although, anger can be a cover for embarrassment. But if she were just completely delusional, I doubt she would have sought help.

if she were that embarrassed she probably wouldn't have sought help - embarrassment is usually why people DON'T seek help not why they do. it is rather more likely narcissistic rage that has led to her letter writing and help seeking

delusional people would seek help for the depression caused by their paranoid disorder not the paranoid illness itself. not saying she is delusional

 

[splik]

I may be asked to do medication management with X. Has anyone ever had a case like this?

tsk tsk people aren't being very helpful in thinking about this case as psychopharmacologists. We need to use the full therapeutic armamentarium to help our patients find new routes to wellness through the advances in biological psychiatry.

If I were a radical psychopharmacologist I would probably prescribe this patient 300mg clomipramine to modulate aberrant orbitofrontal cortex activity leading to her obsessional fixation on bus drivers, 0.25mg tid (titrated liberally as needed) of alprazolam for her anxiety that leads to the compulsion neurosis discharging her anxiety in this way, 50mg naltrexone qam to block the endogenous opioids necessarily released when talking to bus drivers which reinforce this behavior, 16mg prazosin qhs will suppress alpha-1 adrenergic receptors and increse R sleep helping with the nightmares she is undoubtedly experiencing from the trauma of the incident with the bus driver, 1mg of risperidone to suppress cortioco-thalamic-striatal activation and rumination from the narcissistic injury, and 90mg of Adderall because she too deserves to find new chemical living and optimal functioning through psychopharmacology. Increasing the alprazolam as needed to curtail any anxiety from the adderall is advisable.

One might also consider pramipexole 0.75mg qhs for a possible severe restless leg syndrome that leads her to fervently hop the bus routes, a combination of 10mg donepezil and 10mg bid of memantine to treat possible wandering behavior in vascular dementia, 20mg vortioxetine to establish a therapeutic alliance, IV depakote 45mg/kg for a possible non-convulsive status epilepticus leading to repetitive behaviors, heroic doses of lorazepam starting at 2mg tid for possible excited catatonia manifest by riding the buses, po depakote or lithium for a possible chronic mania, 10mg daily of pimozide for a possible forme fruste of De Clerembault syndrome. If the patient slips into a more serious melancholic state, one might consider deep transcranial magnetic stimulation with ketamine augmentation. The sunovion rep told me that latuda is a good bet for these tricky situations regardless of the diagnosis especially as diagnosis is so passe and we've advanced to the point of thinking of functional neuronal connectivity, and targetting the negative and positive valence systems and modulating arousal/regulatory systems

 

[birchswing]

tsk tsk people aren't being very helpful in thinking about this case as psychopharmacologists. We need to use the full therapeutic armamentarium to help our patients find new routes to wellness through the advances in biological psychiatry.

If I were a radical psychopharmacologist I would probably prescribe this patient 300mg clomipramine to modulate aberrant orbitofrontal cortex activity leading to her obsessional fixation on bus drivers, 0.25mg tid (titrated liberally as needed) of alprazolam for her anxiety that leads to the compulsion neurosis discharging her anxiety in this way, 50mg naltrexone qam to block the endogenous opioids necessarily released when talking to bus drivers which reinforce this behavior, 16mg prazosin qhs will suppress alpha-1 adrenergic receptors and increse R sleep helping with the nightmares she is undoubtedly experiencing from the trauma of the incident with the bus driver, 1mg of risperidone to suppress cortioco-thalamic-striatal activation and rumination from the narcissistic injury, and 90mg of Adderall because she too deserves to find new chemical living and optimal functioning through psychopharmacology. Increasing the alprazolam as needed to curtail any anxiety from the adderall is advisable.

One might also consider pramipexole 0.75mg qhs for a possible severe restless leg syndrome that leads her to fervently hop the bus routes, a combination of 10mg donepezil and 10mg bid of memantine to treat possible wandering behavior in vascular dementia, 20mg vortioxetine to establish a therapeutic alliance, IV depakote 45mg/kg for a possible non-convulsive status epilepticus leading to repetitive behaviors, heroic doses of lorazepam starting at 2mg tid for possible excited catatonia manifest by riding the buses, po depakote or lithium for a possible chronic mania, 10mg daily of pimozide for a possible forme fruste of De Clerembault syndrome. If the patient slips into a more serious melancholic state, one might consider deep transcranial magnetic stimulation with ketamine augmentation. The sunovion rep told me that latuda is a good bet for these tricky situations regardless of the diagnosis especially as diagnosis is so passe and we've advanced to the point of thinking of functional neuronal connectivity, and targetting the negative and positive valence systems and modulating arousal/regulatory systems

Quite an interesting risk scenario. The more drugs you suggest the greater number of practitioners who will recognize your sarcasm, but the more drugs you suggest the more drugs that will be prescribed by the smaller number of practitioners not recognizing the sarcasm. 1o patients on a moderate regimen for bus-driver seeking behavior vs. 1 on a walking-pharmacy regimen for bus-driver seeking behavior.

 

[Ceke2002]

tsk tsk people aren't being very helpful in thinking about this case as psychopharmacologists. We need to use the full therapeutic armamentarium to help our patients find new routes to wellness through the advances in biological psychiatry.

If I were a radical psychopharmacologist I would probably prescribe this patient 300mg clomipramine to modulate aberrant orbitofrontal cortex activity leading to her obsessional fixation on bus drivers, 0.25mg tid (titrated liberally as needed) of alprazolam for her anxiety that leads to the compulsion neurosis discharging her anxiety in this way, 50mg naltrexone qam to block the endogenous opioids necessarily released when talking to bus drivers which reinforce this behavior, 16mg prazosin qhs will suppress alpha-1 adrenergic receptors and increse R sleep helping with the nightmares she is undoubtedly experiencing from the trauma of the incident with the bus driver, 1mg of risperidone to suppress cortioco-thalamic-striatal activation and rumination from the narcissistic injury, and 90mg of Adderall because she too deserves to find new chemical living and optimal functioning through psychopharmacology. Increasing the alprazolam as needed to curtail any anxiety from the adderall is advisable.

One might also consider pramipexole 0.75mg qhs for a possible severe restless leg syndrome that leads her to fervently hop the bus routes, a combination of 10mg donepezil and 10mg bid of memantine to treat possible wandering behavior in vascular dementia, 20mg vortioxetine to establish a therapeutic alliance, IV depakote 45mg/kg for a possible non-convulsive status epilepticus leading to repetitive behaviors, heroic doses of lorazepam starting at 2mg tid for possible excited catatonia manifest by riding the buses, po depakote or lithium for a possible chronic mania, 10mg daily of pimozide for a possible forme fruste of De Clerembault syndrome. If the patient slips into a more serious melancholic state, one might consider deep transcranial magnetic stimulation with ketamine augmentation. The sunovion rep told me that latuda is a good bet for these tricky situations regardless of the diagnosis especially as diagnosis is so passe and we've advanced to the point of thinking of functional neuronal connectivity, and targetting the negative and positive valence systems and modulating arousal/regulatory systems

ROTFLMFAO! 😆😆😆

 

[Shikima]

tsk tsk people aren't being very helpful in thinking about this case as psychopharmacologists. We need to use the full therapeutic armamentarium to help our patients find new routes to wellness through the advances in biological psychiatry.

If I were a radical psychopharmacologist I would probably prescribe this patient 300mg clomipramine to modulate aberrant orbitofrontal cortex activity leading to her obsessional fixation on bus drivers, 0.25mg tid (titrated liberally as needed) of alprazolam for her anxiety that leads to the compulsion neurosis discharging her anxiety in this way, 50mg naltrexone qam to block the endogenous opioids necessarily released when talking to bus drivers which reinforce this behavior, 16mg prazosin qhs will suppress alpha-1 adrenergic receptors and increse R sleep helping with the nightmares she is undoubtedly experiencing from the trauma of the incident with the bus driver, 1mg of risperidone to suppress cortioco-thalamic-striatal activation and rumination from the narcissistic injury, and 90mg of Adderall because she too deserves to find new chemical living and optimal functioning through psychopharmacology. Increasing the alprazolam as needed to curtail any anxiety from the adderall is advisable.

One might also consider pramipexole 0.75mg qhs for a possible severe restless leg syndrome that leads her to fervently hop the bus routes, a combination of 10mg donepezil and 10mg bid of memantine to treat possible wandering behavior in vascular dementia, 20mg vortioxetine to establish a therapeutic alliance, IV depakote 45mg/kg for a possible non-convulsive status epilepticus leading to repetitive behaviors, heroic doses of lorazepam starting at 2mg tid for possible excited catatonia manifest by riding the buses, po depakote or lithium for a possible chronic mania, 10mg daily of pimozide for a possible forme fruste of De Clerembault syndrome. If the patient slips into a more serious melancholic state, one might consider deep transcranial magnetic stimulation with ketamine augmentation. The sunovion rep told me that latuda is a good bet for these tricky situations regardless of the diagnosis especially as diagnosis is so passe and we've advanced to the point of thinking of functional neuronal connectivity, and targetting the negative and positive valence systems and modulating arousal/regulatory systems

Or you could just give Zoloft 50mg and instruct them to see a therapist. 😛

 

[Extralong]

My supervising physician has a new patient who is an unemployed woman (X) in her 30s. X often rides the city bus because she wants to meet and find a boyfriend that is a bus driver. So, X will constantly talk to male drivers while they are driving. X has gotten many drivers into trouble because of this. Out of 900 drivers, X knows the names of 450 of them. She can tell you who graduated in what class.

In one situation, she kept getting on to a particular driver's bus to talk to him. Eventually, the driver told X that she should find a husband and that she shouldn't be talking to drivers so much. X got angry with this driver and wrote him a long and nasty letter.

I may be asked to do medication management with X. Has anyone ever had a case like this?

This calls for a case of polypharamcy including but not limited to Xanax with 6 month refills and absolutely no psychotherapy. 😀

 

[MySpirit]

Well, my SP came up with an Asperger diagnosis. I must say that I agree with it. She shows:

1. Restricted repetitive & stereotyped patterns of behavior, interests and activities. She is interested in the details of bus operator's schedules.
2. A lack of spontaneous seeking to share enjoyment, interest or achievements with other people, (e.g., by a lack of showing, bringing, or pointing out objects of interest to other people.

Will write more later. She has been referred to a psychologist, and no medication will be given.

 

[smalltownpsych]

Well, my SP came up with an Asperger diagnosis. I must say that I agree with it. She shows:

1. Restricted repetitive & stereotyped patterns of behavior, interests and activities. She is interested in the details of bus operator's schedules.
2. A lack of spontaneous seeking to share enjoyment, interest or achievements with other people, (e.g., by a lack of showing, bringing, or pointing out objects of interest to other people.

Will write more later. She has been referred to a psychologist, and no medication will be given.

So she was more interested in the details of the schedule than the relationships with the bus drivers. Looking back at the OP I am disappointed that I didn't come up with that differential. 😳 I have a relative on the spectrum that is very similar with planes and baseball. Looks like Erg was closest with this statement:

This could just be a lonely savant for all we know.