Time for A Case

[Zenman1]

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I’m going to try to present this case further down the road when she (hopefully) improves. Let me know your impression. Only seen her once.

31 year old married Caucasian female. “I’ve been off meds for 3 months.”

Patient has been off Effexor for 3 months and complains of an increase in mood swings, irritability, anger, isolation, decreased motivation, decreased energy, “crying all the time,” decreased concentration, frustration, decreased libido, hyper vigilance, “pretty much anxious and depressed all the time.” She feels “pretty ****ty” about herself as well as “worthless and broken.” She is very upset about not being able to do things with her 7 yr old daughter as she has difficulty getting out of her house due to anxiety. She trained as a cosmetologist but is unable to work. She rarely eats during the day and binges at night. She goes to a fitness center between the hours of 0745-0900 and if familiar staff are not there she will leave. She washes her hands between “200-300 times a day” and collects mini-hand sanitizers. She takes 4-5 showers a day about 20 “ in length each and when she takes a bath it is 2 hrs in length and she “scrubs and scrubs.” She was physically, emotionally, and sexually abuse by her stepfather from the ages of 9-23. Her mother, whom she had informed about the sexual abuse, physically and emotionally abused her. She has night terrors since the age of 9 where she is difficult to wake and tries to push away the person trying to comfort her. She remembers none of this and might also run to a closet or hide under the bed. She has had panic attacks since age 9. She has a “mini one” every other day and a full blown one 2-3 times a month. During a panic attack she has SOB, blurred vision, cries, sweats, has a feeling of doom, increased heart rate, and usually passes out. She has had numerous trips to the ED. She tried to overdose at the age of 13 and was slapped around by her mother when she told her what she had done. She was not hospitalized and this was the only self-harm attempt. At age 13 she started outpatient counseling but quit due to therapists reportedly “pushing me to say I was suicidal.” She didn’t do well with telepsych as the provider “broke down and cried.” She was sexually assaulted age 25 by around 50 yr old male and again last year by a familiar male. She has been married x 4 and currently has a supportive spouse. Previously she has been in abusive relationships. She denies hypomania, mania, or psychosis.

Rarely drinks a glass of wine, 1-2 cups coffee a day.

Family hx of depression in her mom who had “anger issues like no other.”

Current meds are all being prescribed by primary care. They are: Lisinopril 40 mg daily for HTN, Restoril 15 mg qhs prn insomnia, Xanax 0.5 mg tid prn anxiety, Klonopin 1 mg qhs for anxiety/insomnia, Metformin ER 500 mg twice a day, Fioricet EQ 50/32 1-2tabs q4hrs for pain, Lantus Solostar prefilled pen SQ per sliding scale q evening, Novolog flexipen 5x3 ml SQ 100 units per sliding scale before each meal.

Effexor caused N&V, decreased energy, and weight gain. Effexor was tried x 2 with the longest period being 2 months. Zoloft resulted in “couldn’t sleep for weeks,” and “was about to jump out of a 5 story window before I caught myself.” She was on Zoloft for 1 year. Wellbutrin worked for 1 year the first time and was tried again for 6 months at max dose and didn’t work. Prozac also didn’t work. Abilify had “a metallic taste and didn’t work.” She was on it for 2 years. Pristiq, along with Abilify, didn’t work. Paxil put her into a zombie-like state and she gained 40 pounds over a 4 month period. Currently on Klonopin which is not very effective. Xanax is effective for “really big panic attacks but I feel crappy and more depressed afterwards for 4-5 hours.” Restoril is not currently working for sleep. She has tried Trazodone in the past which was calming but didn’t help her sleep. She has not had a sleep study.

ROS: Morbid obesity, HTN, Lap band 2008 with removal 2013, Chapped hands, Headaches, Diabetic Retinopathy both eyes, Diabetes Type 2 dx at age 13, back pain due to MVA 2012 which also resulted in right fractured rib, right clavicle and right hemopneumothorax.

I stopped the Restoril and started Prazosin 1 mg, Celexa 20 ½ tab x 7 days, then 1 tab daily, Lamictal 25 mg chew tab. Kept all other meds.

 

[shan564]

Borderline + benzo/barbiturate dependence causing cognitive suppression leading to inability to respond to psychotherapy adequately, as well as anxiety when the benzo starts wearing off. She's on 4 different CNS depressants. I'll bet the SSRIs will work better when she gets off the benzos/fioricet. That also explains why restoril isn't helping her sleep and why she feels worse for several hours after taking a xanax. In most of these cases, it's also complicated by poorly controlled hyperglycemia, since they rarely take their insulin as scheduled. At my institution, we usually switch the benzos to klonopin and then taper it as quickly as the patient will tolerate. I like the choice of prazosin and lamictal.

Looks like the PCP had the patient on a lazy regimen. Problems include the following :
1. 3 different benzos AND a barbiturate. Why not simplify?
2. Metformin AND high dose of insulin. If she requires that much insulin, she has no pancreas and metformin is pointless.
3. The PCP is probably uptitrating the insulin because the a1c is high, so the insulin goes up. I find it hard to believe that a patient that young actually requires that much insulin. 90% of the time, patients with that high of an insulin dose are actually only requiring it because they don't actually take the insulin, so sugar goes up, so PCP goes up on the in insulin. That's how I know that her cognitive status is being compromised by her hyperglycemia. I'd be willing to bet that her a1c is at least 10.

 

[vistaril]

Borderline + benzo/barbiturate dependence causing cognitive suppression leading to inability to respond to psychotherapy adequately, as well as anxiety when the benzo starts wearing off.

huh? Unless I skipped over something, there is nothing to suggest this patient has benzo dependence. What do you base that on? Yes, she was being prescribed 3 benzos, but two are prn. Restoril prn qhs on top of Xanax prn may not be the strategy I would take as her psych, but the regimen you have described in no way makes it likely she is addicted. Based on her relatively low dose of klonopin(1mg total), if she doesn't typically take anything during the day(even if she does take a Xanax at 0.5 during the day most days), the fact is she doesn't have a whole heck of a lot of benzo in her system at any given time.

Maybe there are parts of the story that zenman didn't report, such as doctor shopping, filling prescriptions early, not really taking the Xanax prn but taking all 90 by day 12 of the month, etc.....which would open up the possibility of benzo dependence and if that's the case it may want to be explored further.

But throwing out a dx of sedative/anxiolytic dependence based on what we know about the pt from the vignette(again maybe this is more) is irresponsible.

Apart from that, looking at the case clinically.......has she been on a max dose(or even above the max) of an ssri, especially Zoloft? If not, I would try to get to 250 of Zoloft or 40 or so of Lexapro. The compulsions are pretty impressive to me from the vignette. If she has done that before without success(and I suspect she has), I'd probably try Clomipramine and look to push it up. Then if that fails, would try MAOIS. That would be my treatment approach.

Doubt prazosin and lamictal will hurt, but skeptical over whether they will help any here as well.

 

[Zenman1]

I don't get a feel for doctor shopping especially since she's so anxious about getting out of the house. I could have spent more than an hr with her but had a patient behind her so looking forward to her next visit in 2 weeks. She has a PA for primary care so I'll follow up with them on the labs. I was also thinking Lexapro but wanted to see if she could even handle the Celexa. You think Clomipramine over Luvox?

 

[vistaril]

I don't get a feel for doctor shopping especially since she's so anxious about getting out of the house. I could have spent more than an hr with her but had a patient behind her so looking forward to her next visit in 2 weeks. She has a PA for primary care so I'll follow up with them on the labs. I was also thinking Lexapro but wanted to see if she could even handle the Celexa. You think Clomipramine over Luvox?

sure....sounds like she has already been on about a billion ssris already. Time to go to the next step.

 

[notdeadyet]

sure....sounds like she has already been on about a billion ssris already. Time to go to the next step.

Clomipramine is the USMLE answer for OCD but I don't think more recent data holds out that it's much more effective than anything else. I wouldn't jump to it.

How well documented are the past medication trials? Is this all from the patient? Have you talked about her with her previous psychiatrists?

And what is her psychotherapy history? CBT is going to do her a LOT more good than any of these meds, especially for OCD and anxiety.

Lastly, this is the kind of patient that needs an MD as a PCP, not a PA or NP. Nothing against those folks, but with the things she's dealing with, I'd want her with someone with higher training.

 

[vistaril]

Clomipramine is the USMLE answer for OCD but I don't think more recent data holds out that it's much more effective than anything else. I wouldn't jump to it..

well given that she has already been on Zoloft(x 1 year), Prozac, and Paxil(not to mention wellbutrin and two snris) I'd say it's time try something else and it wouldn't be 'jumping' to anything. If she's never been on a tricyclic before and she's been on all these other medications without any success, going to a tricyclic is the correct treatment. Maybe it works some, maybe it doesn't(my guess is it doesnt), but just doing the same thing over again from a psychopharm standpoint isn't good management in my opinion. As I said it would be worthwhile to make sure her trials haven't consisted of low doses on Prozac and Zoloft, but Im guessing if she were on Zoloft for a year the dose was pushed up over time. And honestly if a patient sees no benefit on 100mg on Zoloft, that's different than seeing some benefit(but still symptomatic) on 100mg. In the first case, even in an anxiety d/o case, I would be thinking change agents because pt hasn't been helped at all. If patients has been helped some at 100, I'd keep pushing the dose higher and higher to see if we could maximize therapeutic benefit.

 

[softballtennis]

If this was my patient I would recommend TMS therapy first since it has little to none side effects. If that didn't work then I would start her on a tricylic or a MAIOs. For me those meds are just too risky to start without trying other options.

 

[vistaril]

If this was my patient I would recommend TMS therapy first since it has little to none side effects. If that didn't work then I would start her on a tricylic or a MAIOs. For me those meds are just too risky to start without trying other options.

they are most certainly not 'too risky'....especially tricyclics.

 

[Salpingo]

Maybe there are parts of the story that zenman didn't report, such as doctor shopping, filling prescriptions early, not really taking the Xanax prn but taking all 90 by day 12 of the month, etc.....which would open up the possibility of benzo dependence and if that's the case it may want to be explored further.

But throwing out a dx of sedative/anxiolytic dependence based on what we know about the pt from the vignette(again maybe this is more) is irresponsible.

Making any diagnosis on a patient you didn't meet is irresponsible. I'm assuming this was done for an educational purpose, and a chance to throw around ideas. I'm also assuming the benzo dependence was a reference to the old DSM-IV diagnosis of substance dependence, and looking at her reaction to alprazolam suggests at least rebound depression/anxiety, and likely some tachyphylaxis. Only need three criteria, and one of them doesn't have to be "stereotypical antisocial drug-seeking jerk".

I generally agreed with Shan's post. The diagnoses of dysthymia/MDD, OCD and PTSD (just missing ADHD) are skirting around the main issues, which seems to be the patient's affective instability and inability to engage in serious psychotherapy. She'd benefit from DBT or at least something structured to gain some coping skills and ways of dealing with her anger other than externalizing. You can make the argument that this is an atypical depression requiring MAO-I, but the slim chance it would work (10-20%) doesn't offset the risk that she can impulsively grab anything from a large pizza to a bottle of her old SSRIs and do some serious harm; judging by the experience with the lap band, I'd be nervous about compliance.

Not sure about the points re: insulin. It has a different mechanism from metformin, and is actually synergistic. Reading the post, it looks like everything is sliding scale (I'm assuming she's not taking 100units before every meal). Regardless, I think her retinopathy and MVA warrants a higher level of care than midlevel provider.

 

[vistaril]

Making any diagnosis on a patient you didn't meet is irresponsible. I'm assuming this was done for an educational purpose, and a chance to throw around ideas. I'm also assuming the benzo dependence was a reference to the old DSM-IV diagnosis of substance dependence, and looking at her reaction to alprazolam suggests at least rebound depression/anxiety, and likely some tachyphylaxis. Only need three criteria, and one of them doesn't have to be "stereotypical antisocial drug-seeking jerk"..

there is absolutely no evidence to suggest this person has benzodiazepine dependence. Throwing out benzo dep. based exclusively on the following statement is absurd: Xanax is effective for “really big panic attacks but I feel crappy and more depressed afterwards for 4-5 hours".

Who knows what to make of that....trying to extrapolate a dx of substance dependence on the basis of that statement is absurd.

I'm not saying she doesn't have benzo dep. I have no idea. My guess is no based on the history. But there is certainly nothing in the original history to put it on the differential. Similarly, I don't know if his patient likes to wear red sweaters or not. But I didn't see anything in the vignette to make me think she does love red sweaters.

 

[shan564]

I think it's a given that we can't make a diagnosis without seeing a patient. Obviously the history is incomplete. I figured that the purpose of putting a case on the Internet was to throw out ideas. I think it's self-evident that this is just a thought rather than a diagnosis, and to think otherwise is silly. That's why we don't give medical advice on these boards.

The reason I'm guessing that the patient might be benzo dependent is not just because of the xanax thing, but also because she thinks that klonopin and restoril don't really help her sleep. If she takes fioricet for pain, then that'll potentiate benzo dependence... again, I don't know how often she's taking it, but given that she has chronic back pain, I'm guessing that she takes it often enough to manage the pain. If she's been taking klonopin daily for years, I'd be surprised if she doesn't have some GABA downregulation, especially considering these "small panic attacks" that she has every other day. Klonopin has a half-life of 18-50 hours, so I'm not sure why you think that she'd have

I think you're assuming that by saying "dependence" I mean "stereotypical antisocial drug-seeking jerk", as Salpingo mentioned earlier. All I mean is that her GABA receptors are downregulated, and she needs the fioricet and the klonopin to fix that. Klonopin 1mg may not be a huge dose, but if her cognitive reserve is low, then a CNS depressant will make it very difficult for her to respond well to psychotherapy and also develop normal neuroplasticity in response to everyday life situations, thereby worsening her depression.

With regard to insulin - Lantus shouldn't be done on a sliding scale, and it's mentioned above that she takes 100 units. Metformin and insulin are synergistic to the point that the patient's pancreas is still working. Once the pancreas has failed (i.e. the patient is requiring doses as high as 100 units), the patient has essentially become an insulin-resistant type 1. The evidence is unclear because of patient compliance issues, but most endocrinologists at my institution recommend stopping the metformin at this point due to higher risk of hypoglycemia (metformin doesn't cause hypoglycemia alone, but it can if it's combined with insulin). http://www.bmj.com/content/344/bmj.e1771

The reason why I think that she's probably noncompliant with insulin regimen is because of the high insulin doses and retinopathy at such a young age. It's hard to follow specific recs for insulin, and if I had advanced DM2, I'm sure that I'd probably be poorly compliant too. I see this all the time - A1c is high, so PCP goes up on the insulin, then A1c is still high, then PCP goes up on the insulin again. Then when the patient comes into the hospital, you put them on less than half as much insulin, and they get hypoglycemic. Maybe it's because I'm at an academic hospital surrounded by some of the most impoverished areas in the country (therefore, poor access to primary care), but when we get patients admitted at my hospital with this sort of picture, we NEVER start them on their home insulin regimen for this reason. And a good chunk of the time, they come into the hospital with evidence of chronic hyperosmolar hyperglycemic state. When they get admitted to psych, you fix their hyperglycemia and their mood gets better in 2 days. We get a lot of exposure to this because my hospital tends to be pretty lax with the "medical clearance" for psych admissions, so we take patients with hyperosmolar states all the time. I get a patient with this picture at least once every 2-3 weeks.

 

[Zenman1]

She's only taking the Fioricet 1-2 times a month for 1-2 days at a time. Last A1C was 8.0 back last May. Incidentally, she has had a couple endocrinology consults.

 

[shan564]

Ah, well, that answers that.

 

[vistaril]

I think you're assuming that by saying "dependence" I mean "stereotypical antisocial drug-seeking jerk", as Salpingo mentioned earlier.

What I thought you meant by substance dependence was....substance dependence. Not that she was an antisocial jerk; not sure why you went there. And certainly not something about neuroplasticity. The term substance dependence(regardless of dsm changes) does still mean things in mental health and society as a whole.

 

[MLT2MT2DO]

huh? Unless I skipped over something, there is nothing to suggest this patient has benzo dependence. What do you base that on? Yes, she was being prescribed 3 benzos, but two are prn. Restoril prn qhs on top of Xanax prn may not be the strategy I would take as her psych, but the regimen you have described in no way makes it likely she is addicted. Based on her relatively low dose of klonopin(1mg total), if she doesn't typically take anything during the day(even if she does take a Xanax at 0.5 during the day most days), the fact is she doesn't have a whole heck of a lot of benzo in her system at any given time.

Maybe there are parts of the story that zenman didn't report, such as doctor shopping, filling prescriptions early, not really taking the Xanax prn but taking all 90 by day 12 of the month, etc.....which would open up the possibility of benzo dependence and if that's the case it may want to be explored further.

But throwing out a dx of sedative/anxiolytic dependence based on what we know about the pt from the vignette(again maybe this is more) is irresponsible.
.

Isn't this more along the lines of addiction vs dependence? Additionally the op had 1-2 fiorcet q4h vs what we found out to be 1-2 a month. With klonopin/restoril no longer having an affect I don't see how dependence was such a stretch.
Lastly calling someone's answer to a case study irresponsible just seems silly.

Sent from my KFTT using Tapatalk HD

 

[vistaril]

Isn't this more along the lines of addiction vs dependence? Additionally the op had 1-2 fiorcet q4h vs what we found out to be 1-2 a month. With klonopin/restoril no longer having an affect I don't see how dependence was such a stretch.
Lastly calling someone's answer to a case study irresponsible just seems silly.

Sent from my KFTT using Tapatalk HD

I don't feel like getting into a semantic dispute here, because we all know the dsm-5 contains changes to substance related disorder stuff.

but like I said, the term substance dependence(especially when it's the first thing thrown out there following a long clinical vignette) has meaning. If you're talking to a colleague and they run a case by you and you mention drug dependence as the pathology, that is a lot different than guessing the patient may just have some mild tolerance to a drug or a theory that a low total dose of Klonopin is interfering with her ability to progress in therapy(which quite frankly a total of 1mg per day I don't see as likely but thats not the point). If that's what your thoughts are on the matter, then say them(wouldnt take but a sentence). Saying benzo/sedative-anxiolytic dependence tells a different story.

 

[OldPsychDoc]

Agreeing with vistaril today.

This is where I find the word "habituation" useful in discussing a patient's physiological response to the agent(s).

 

[moonshined]

.

 

[OldPsychDoc]

Hope the world doesn't end today!

Nope--but it might have killed the thread!

 

[shan564]

Yeah, I think "habituation" was probably a more appropriate term. I used "dependence" to mean that a patient likely has physiological changes associated with chronic substance use, since "dependence" is no longer a DSM diagnosis, but I should probably be careful about using the term because it does have particular implications. Anyway, I should have said "habituation" or described my impression in a couple of sentences, but I didn't do that because I was typing on my phone instead of on a computer.

As far as the dose of klonopin - I'm still not sure how much restoril and xanax the patient was using, but in my very limited experience, I've seen patients get a lot better when benzos get stopped. Also, benzos are fat-soluble, so if she's been taking them regularly for a long time and she's morbidly obese, she probably has a fair bit of benzo in her system at all times. In patients with very high body fat, klonopin alone can have a half-life of 2 days, thereby essentially doubling the amount that is in her system at any given time. Plus the xanax and restoril.

Overall, I think the most important things in the patient's management are probably the SSRI, the prazosin for her PTSD, and the lamictal for her mood swings. But in addition to that, I think that chronic cognitive suppression exacerbates most psychiatric illnesses, and there's good evidence to say that any amount of chronic benzo use impairs neuroplasticity (especially in a person who already has a low cognitive reserve). SSRIs may work initially by increasing serotonin in the synaptic cleft, but there's mounting evidence to say that long-term Hebbian neuroplastic changes allowed by the increased serotonin are the best way to allow long-term recovery, and benzos interfere with that process.