Walkabout

[Zenman1]

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I picked up a 24 yr old black female soldier recently after her psychiatrist moved away. She was dx with Adjustment disorder with depressed mood and Insomnia. She was on Restoril, Abilify 2 mg, and Lexapro 10 mg. At this point she had failed Ambien, Melatonin, Trazodone, Prozac, Zoloft, Lexapro, and Wellbutrin due to side effects or ineffectiveness. She was irritable and depressed with passive SI. At her first visit I stopped the Restoril and started Doxepin 10 mg and increased the Abilify to 5 mg as she noticed positive effects with it.

2nd visit. She continues to be irritable and depressed with no improvement in symptoms. Doxepin not helping for sleep. Zoloft 25 mg added for adjunt to Abilify.

3rd visit. Less SI an dfeels like therapy is helping. Still depressed with some mood swings and poor sleep. Scored 15 on Bipolar Spectrum Diagnostic Scale. She is unaware of any genetic loading. Abilify increased to 10 mg and Zoloft to 50 mg. Changed dx to Bipolar disorder, NOS. R/O MDD

4th visit. She comes in with detailed notes detailing improved mood but with one day period where she felt really happy and took off walking and singing from her home to a neighboring town 18 miles away. Part of the trip was along an interstate. She then turned around and walked back home. After she arrived she was up all night playing games and then fell asleep the next morning. Lunesta 3 mg started for sleep as well as Lamictal 25 mg for 2 weeks then 50 mg. Zoloft 50 mg continued.

5th visit. She had another exact repeat episode of a walkabout. She ran out of Lunesta and Lamictal a week ago without notifying anyone. A couple days prior to running out of Lamictal she started having conversations with a shadow-like human figure with the only command halucinations being to go AWOL. She started drinking up to 8 beers or 2 mixed drinks to help with irritability and sleep. I stopped the Abilify and Zoloft and started Geodon 40 mg bid along with Klonopin 0.5 mg 1/2 - 1 tab twice daily. She has psych testing scheduled early next month. She will be followed daily.

I've never seen a 1 day manic episode like this but with her irritability I'm thinking Bipolar disorder is a pretty safe bet but I'm not entirely ruling out substance/medication induced Bipolar disorder or MDD with psychotic features. What do you think?

 

[st2205]

Any personality pathology?

 

[OldPsychDoc]

Trauma history? Because I'm thinking dissociation as opposed to psychosis...

Also, if this were a resident supervising a case with me, I'd have to tell them that I'm really uncomfortable with changing up the meds every time. You really haven't established adequate trials of anything here.

 

[hamstergang]

I think she's on entirely too many medications at one time throughout this story without a clear idea of what we're treating. At this point, we're up to 14 meds total and the diagnosis hasn't been settled on yet.

From the start, what was the adjustment disorder due to? Did it really require 4 antidepressant trials? Also at that point, she had been on 4 medications for sleep. What do you mean by them failing? I wonder about compliance issues, how success or failure is being defined by the patient and the provider, and if the insomnia really needs to be treated independently of the mood issue.

I'm not sure I agree with the bipolar diagnosis on the 3rd visit, but if you're thinking it was truly bipolar, why not use a real mood stabilizer?

Going along with the others, I'd want to get a clearer life history of this patient as it all seems rather strange.

 

[vistaril]

lol.....so much going on with this patient, and yet this patient is also much more typical in the real world than the cases you read about in clinical vignettes and encounter in dsm conference discussions(Im sure....I've never been haha): vague symptoms which appear to be a cluster**** and likely don't mean anything, a PD flavor, and a bunch of failed polypharmacy.

Look, she's probably not Bipolar. Or Bipolar spectrum d/o or whatever you want to call it. I agree with a lot of what others have said, but I do disagree with chasing down a more extensive history- that is very likely to be a useless endeavor(sp?). Psychiatrists who think they can usually correctly diagnose bipolar accurately by history greatly overrate the use of these histories in most cases- they simply usually aren't very accurate. There is so much lost in translation(as well as interviewer bias and lots of other problems) that it's just not worth it.

I'd stop most of this garbage you are giving her now. I'd probably put her on Remeron monotherapy(why not?) for awhile and call it a day......either that or go back to ssri montherapy and titrate to a higher dose.

 

[vistaril]

Look, she's probably not Bipolar. Or Bipolar spectrum d/o or whatever you want to call it. I agree with a lot of what others have said, but I do disagree with chasing down a more extensive history- that is very likely to be a useless endeavor(sp?). Psychiatrists who think they can usually correctly diagnose bipolar accurately by history greatly overrate the use of these histories in most cases- they simply usually aren't very accurate. .

I should point out that there are exceptions.....we've all seen cases where someone calls the mom or dad or ex husband and they describe a classic and picture perfect example of a Bipolar patient. But far more likely is a confusing mess.....

I've know some really hard working detail-oriented psychs who spend a bunch of time collecting DETAILED collateral histories to try to r/o or r/I Bipolar spectrum d/o, and unless it's one of those extremely rare cases where the collateral information describes classic bipolar d/o, you're likely to do more harm than good imo.

 

[Shikima]

Start with sleep diaries for 4 weeks and no changes to medications.

 

[F0nzie]

I have a ton of questions for this lady. Assuming she is not very insightful/impaired, we have no collateral, and no other relevant information to rule anything in or out, my first priority would be to treat the command hallucinations and mood instability (that may be contributing to her erratic behaviors) with a potent second generation antipsychotic like Olanzapine or Risperidone. For Olanzapine I would start 5mg HS and titrate in 5mg increments to effect or Risperidone 2mg HS and titrate in 1mg increments to effect. Start with monotherapy before adding anything else. Also no benzos for alcohol drinkers-- she is at an increased risk for dependency, respiratory depression, death. Consider meeting with her 1-2 times a week to stabilize her quickly, get a better idea with what is going on and clarify the dx. If it turns out she just has PTSD and substance use disorder consider the appropriate pharmacotherapy and referrals and then wean off the antipsychotics and see how she does.

 

[wolfvgang22]

This sounds like the type of thing I routinely see in patients I've inherited here at the VA. I agree with most everybody here, good advice.
Too much polypharmacy, likely trials of inadequate length of time, probably lots of underlying social issues.
Is this lady overweight? Does she have sleep apnea? I see that a lot in veterans with insomnia. Alcohol makes it worse. What is she abusing with the alcohol, anything?

 

[vistaril]

another common theme I've noticed throughout this patient's treatment: attributing changes in a patient's symptoms(likely transient) to short term changes in meds.

"and increased the Abilify to 5 mg as she noticed positive effects with it"

"A couple days prior to running out of Lamictal she started having conversations with a shadow-like human figure"

"Less SI an dfeels like therapy is helping"

One of the biggest questions in outpatient psychiatry is the following: Do we emphasize to the patients just how crappy our meds are in general, and that in many cases the data indicates(for their condition) they are likely to receive little benefit from pharmacotherapy. There are two sides to this of course.....one is that telling them the truth reduces/eliminates placebo effect. OTOH, the pro argument is that telling them the truth might push them to engage in other activities(eating healthy, exercising, forcing themselves to engage in meaningful life activities and goals) which actually will help them.

Because of the second, I tend to lean towards de-emphasizing the importance of meds to my patients(except in certain cases....for example high functioning real bipolar pt who works and does great on Lithium)

 

[hamstergang]

but I do disagree with chasing down a more extensive history- that is very likely to be a useless endeavor(sp?). Psychiatrists who think they can usually correctly diagnose bipolar accurately by history greatly overrate the use of these histories in most cases- they simply usually aren't very accurate.

I don't think anyone was suggesting to get more history to support the bipolar diagnosis. It's because we don't believe that diagnosis that we want more history to support a different diagnosis.

I'd probably put her on Remeron monotherapy(why not?) for awhile and call it a day

Why, what are you treating? Why not is not a reason to start a medication.

I've know some really hard working detail-oriented psychs who spend a bunch of time collecting DETAILED collateral histories to try to r/o or r/I Bipolar spectrum d/o, and unless it's one of those extremely rare cases where the collateral information describes classic bipolar d/o, you're likely to do more harm than good imo.

What harm would be done?

my first priority would be to treat the command hallucinations and mood instability (that may be contributing to her erratic behaviors) with a potent second generation antipsychotic like Olanzapine or Risperidone.

Why not a first generation antipsychotic?

 

[F0nzie]

Why not a first generation antipsychotic?

Safer, less side effects.

 

[vistaril]

I don't think anyone was suggesting to get more history to support the bipolar diagnosis. It's because we don't believe that diagnosis that we want more history to support a different diagnosis.


Why, what are you treating? Why not is not a reason to start a medication.


What harm would be done?

I'm not very good at quoting obviously🙂

I think the diagnosis is a depressive d/o. or adjustment d/o with depressed mood. I don't know what sort of wild goose chase I would go down from there. I think the most important thing is what she starts to look like going forward once you see her.

What are we treating? Well we would be treating her insomnia first and then depression I suppose.....Remeron monotherapy is most certainly conservative. Why not is a good reason to start remeron, especially for the insomnia indication if she isn't a large girl.(and she is in the military so I doubt she is)

Finally, the harm done in trying to get very detailed histories on mood symptoms that may have occurred in the distant past(especially from family members) is that unless the symptoms just jump off the page at you, they aren't of any value because the reliability(when you consider all the factors involved....time that's passed, what's lost in translation, the fact that it's not from the patient themselves, the way the source perceives the question and then the way we incorporate their answer) is just so low. IOW, if you work really hard to obtain a lot of information that is very likely not accurate, you're more likely to incorporate that in your dx and treatment plan......that does more harm than good.

 

[nitemagi]

I agree with most of above, esp OPD. Get a more thorough history, including service history. PTSD supported? More data is showing there are PTSD subtypes, which I lump as hyper vigilant and dissociative. The dissociative really opens up a whole other can of worms, including pseudohallucinations. Like everyone says above, I wouldn't chase every sx with a med change. Many of these are transient sx's. Think about the whole picture, rather than the symptom focused treatment we often fall into.

 

[Shikima]

Don't chase the insomnia... correct the underlying mood and/or anxiety disorder (?psychosis) first.

 

[wolfvgang22]

especially for the insomnia indication if she isn't a large girl.(and she is in the military so I doubt she is)

You'd be surprised. Sometimes I get obese veterans that just left active duty a month or two ago.
All the same, I agree with you for the most part. But I also think we ought to treat mood first, insomnia second unless there is obvious reason to do otherwise. Adjustment disorder is common in patients like this. Mirtazapine is often very useful.

 

[shan564]

I would have said the same things as OPD and Fonzie if they hadn't said them first.

If it is bipolar disorder, I don't think you can call it a "1-day manic episode" because there are meds and substances involved. Anything can be shorter or milder when they're being partially treated.

Most importantly, there is a lot of diagnostically relevant information that could affect how I'd approach that case beyond what is mentioned in the original post - of course, it'd probably be impractical to type all of that information here. Normally, from the information there, I'd suspect that substances, personality, or dissociation are more likely than mania. There's a reason why "hypomania" and "mania" are defined with specific minimum durations - sudden brief changes in mood aren't necessarily pathological. I agree that this presentation is probably pathological, but there's not enough information here to say exactly what that pathology is.

Also, I'm not sure if running out of the lamictal is relevant. I'm not convinced that 50mg is a therapeutic dose. I understand why she was on that dose, and I assume that you were planning to uptitrate, but I think that the Lunesta is more relevant.

Also, Lunesta can make people do weird things. Also, an extended period of insomnia (which I'd suspect was present if she'd run out of Lunesta, since she's probably habituated, especially if she's replacing it with alcohol) can make people do weird things.

 

[thepoopologist]

Need more info in general but,
-Stop chasing symptoms
-Decide what you're treating.
-Then decide how serious it is.
-Then decide what else could be contributing
-Simplify your regimen. Change one thing at a time so you can track side effects better. Have her followup more frequently before piling on more.

General thoughts
If it's Bipolar Disorder
-And she's running around, staying up all night then Lamictal was not the one to choose due to the slow titration.
-Then keep in mind that Zoloft is also dopaminergic, particularly at higher doses. Most likely not at 50 mg but something to think about
-Yes she had that 1 day period of craziness. But also consider that she was in general very irritable.
-It's not bipolar disorder if it's substance induced, in which case the treatment would be to get her off the offending agents. On the other hand if its an underlying bipolar disorder and she's smoking crack, that won't help either.
-Benzos and alcohol don't work well together. Mechanistically similar, and you worry about additive effects
-Sleep is important, but keep in mind that there are other meds with sedation as a side effect. Antipsychotics would be one, plus they're great for Bipolar Disorder
-As stated before, personality pathology and trauma are things to consider

 

[Zenman1]

I came in this weekend to do a chart review. Instead of quoting all over the place I’ll just address comments.

At her 1st visit in late 2012, psychiatrist thought she was underreporting ETOH use and continued to make note of that for many notes without any followup. He made the Adjustment Disorder with Depression dx due to occupational and marital problems. Depression and “angry a lot” was noted. Zoloft was started, up to 50 mg, and made her sedated but had no positive effects and was switched to HS and Ambien (ineffective) stopped. Her therapist reported less depression, increased irritability, hypersomnia on weekends. No history of trauma.

Along the way her spouse gets his 2nd DUI. Wonder if they are partaking together? Five months into treatment she falls and hits her head on a rock after drinking 5 beers and earns herself a concussion. Admits to drinking couple shots every other weekend and occasionally an extra 3 beers.

Forgot to take her Zoloft to Africa deployment and was started on Prozac 20 mg while there.

Early 2014 she reports “happy to mad” and shorter fuse than usual. Started on Trazodone for sleep. Still on Prozac 20 mg. Denies drinking.

Trazodone not working at 100 mg. Therapist notes anger with no triggers. Ambien CR 12.5 mg seems to work well. Started on Wellbutrin SR 100 mg bid since she also wanted to stop smoking. Results were “significantly positive mood” followed shortly by note of mild improvement.

She admitted to taking Wellbutrin only once a day instead of bid (reason not noted). More mood swings and short fuse noted.

Seen in ED with SI and increased depression.

Psychiatrist stopped Wellbutrin as he thought it might be responsible for increased irritability. Still depressed. Lexapro 10 mg started. Ambien CR 12.5 still working.

SI increasing. Sonata 5 mg started for some unknown reason. Abilify 2 mg started. Mood got better and SI decreased.

Sonata 5 mg not working (no idea why it wasn’t increased) and Restoril 15-30 mg started. Lexapro 10 mg stopped…no idea why it wasn’t increased.

I picked her up here. Restoril not working so Doxepin 10 -20 mg started. Abilify increased to 5 mg. Zoloft restarted at 25 mg and then increased to 50 mg.

Doxepin 20 mg worked well but noticed weight gain. Switched to Lunesta 3 mg. No improvement with increase in Abilify so increased to 10 mg.

In Dec 2014 had first walkabout. Lamictal added and made it up to 50 mg before she ran out while in the field. She also ran out of Lunesta.

In Jan she had another walkabout which was identical to the first. Started hallucinating. Also started drinking to help with irritability and sleep (she has less SI with good sleep). Therapist constructed timeline which showed mood changes with increases in Abilify and Zoloft. This might have been unrelated but due to increased irritability and her fear of hurting someone, I stopped Zoloft and Abilify and started Geodon as well as a few days worth of Klonopin to chill her out over the weekend. I have her on hi risk status and will follow every few days.

I like the idea of Remeron but have to be careful of weight gain while in the military.

With all this is mind, I’m more inclined to consider depression, PD, and substance abuse…and sleep problems.

 

[st2205]

As a gestalt this really just strikes me as personality flying under the radar, especially considering her primary symptoms, the irritability, mood swings, failed med trials (and the fact that she continues to go back and get more) and the pseudopsychosis.

 

[nitemagi]

Include TBI in the Ddx.

 

[shan564]

As a gestalt this really just strikes me as personality flying under the radar, especially considering her primary symptoms, the irritability, mood swings, failed med trials (and the fact that she continues to go back and get more) and the pseudopsychosis.

Also the fact that she seems to respond to small (nearly subtherapeutic) doses of some drugs, while tolerating/requiring moderate-large doses of other drugs (especially the addictive ones).

 

[vistaril]

Also the fact that she seems to respond to small (nearly subtherapeutic) doses of some drugs, while tolerating/requiring moderate-large doses of other drugs (especially the addictive ones).

I'd hardly call a total daily dose of 0.5-1mg klonopin 'moderate-large'.......

 

[vistaril]

As a gestalt this really just strikes me as personality flying under the radar, especially considering her primary symptoms, the irritability, mood swings, failed med trials (and the fact that she continues to go back and get more) and the pseudopsychosis.

agreed....she needs to be put in with a therapist who knows what they are doing to do the real work here and stop this med switcheroo every visit.

 

[shan564]

I'd hardly call a total daily dose of 0.5-1mg klonopin 'moderate-large'.......

I was referring to Restoril and Lunesta, but yeah... more "moderate" than "large."

 

[EMDO2018]

wait... so she walked 18 miles while singing, turned around and walked another 18 miles, then stayed up all night playing board games? That's awesome.

 

[vistaril]

I was referring to Restoril and Lunesta, but yeah... more "moderate" than "large."

well...the dose of restoril wasn't listed. I will agree that the dose of Lunesta was moderate I guess. 1/3 is good if you're a mlb hitter I suppose....

 

[shan564]

well...the dose of restoril wasn't listed. I will agree that the dose of Lunesta was moderate I guess. 1/3 is good if you're a mlb hitter I suppose....

The dose of restoril was listed as 15-30mg in the second post that the OP posted. Also Ambien CR 12.5mg. I'm not sure why you'd say "1/3" - I never said anything about "3," just referred nonspecifically because I didn't feel like going back through both posts and counting which drugs were at moderate doses and which ones were at small doses. I'm not sure why this is even relevant.

 

[vistaril]

The dose of restoril was listed as 15-30mg in the second post that the OP posted. Also Ambien CR 12.5mg. I'm not sure why you'd say "1/3" - I never said anything about "3," just referred nonspecifically because I didn't feel like going back through both posts and counting which drugs were at moderate doses and which ones were at small doses. I'm not sure why this is even relevant.

Sorry my mistake I looked at the first post and not the followup. I think it's important not to always jump to a substance use disorder or substance induced d/o or habituation or whatever as the cause of problems like this however.

 

[shan564]

Sorry my mistake I looked at the first post and not the followup. I think it's important not to always jump to a substance use disorder or substance induced d/o or habituation or whatever as the cause of problems like this however.

Yeah, I agree... I wasn't trying to suggest that the problem is substance-related or medication-related, just that that's one of the things on the differential. Just as important as not jumping to that conclusion is the idea of not ignoring medication side effects and adding more medications when we should be subtracting medications. For an unusual presentation, you have to have a wide differential.