Weird case. Treatment Resistant Depression but after a snake bite

[whopper]

Got a patient that was already seen by a great clinician and she couldn't get this patient better. Was tried on all the conventional meds. A few SSRIs, SNRIs, Lamotrigine, Lithium, atypical antipsychotics (and yes the better ones for depression such as Aripiprazole, Cariprazine) , Bupropion, augmentation agents such as Buspirone, Auvelity, Esketamine, TMS (not ECT...yet).

After several meetings she finally said something that hit me like a ton of bricks. She told me she never had mental health problems until she was bitten by a snake years ago.

So given that she never had depression until the snake bite and from there on several health problems including depression and syncope, I did a lit search. Unfortunately almost all of the snake bite data is only focused on acute treatment. There are very few articles on long-term outcomes of snake bites and adding to the problem the long-term issues seem to vary depending on the type of venom depending on the snake that bit the person.

The only thing I've been able to see as a pattern is some patients post-snake bit suffer from hypopituitarism. The problem here is I seem to know more about it than her PCP who hasn't done any lit searches so I'm going to contact the PCP and recommend an endo-follow up but other than this I don't know what to do.

MY theory is the snake venom did something permanent to the patient and not simply just PTSD. She's not c/o PTSD sx. She has severe depression with extreme insomnia but no PTSD nightmares, flashbacks, triggers. I'm theorizing the venom did some type of neurotoxic effect on her that caused long-term depression. The problem here is the lack of data to back it up other than the circumstantial evidence, and the lack of evidenced-based data.

Anyone have any experience with long-term effects of snake bites?

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[Stagg737]

I mean, it’s clearly a case of chronic super-lyme disease and she needs heavy doses of antibiotics…/sarcasm.

Speaking seriously, you mention “extreme” insomnia. Has that ever been successfully treated? Maybe if she starts getting restorative sleep the depression will improve. Seen it plenty of times with OSA or even just primary insomnias where mood symptoms seem to magically disappear with adequately addressing sleep.

 

[whopper]

The restorative sleep-I agree. Problem is we're having problems finding anything to help her sleep. The only meds that helped so far was Olanzapine, but it gave her nightmares, adding to the problem even 2 mg would knock her out for 14+ hours. Lithium also, even at small dosages such as 25 mg made her excessively sleep.

So right now the strategy is to microdose the lithium. I told her to take literally 5 mg (by dissolving the pill in distilled water, then taking a syringe to measure a very small amount). I told her if we can get her sleeping maybe all of this will get better. IF lithium at a small dosage makes her over-sleep maybe the right dosage is an even smaller amount will hit the sweet spot.

I doubt it's OSA. She's not close to overweight.

 

[Celexa]

I suggest consulting an Australian sleep specialist.

I'm joking but only partly. If this is a known phenomenon, go to the experts where it must happen most often... Which probably would be Austrailia, no?

 

[clausewitz2]

So what do her sleep diaries look like? I am curious to know what extreme insomnia means for someone who sleeps 14 hours after a whiff of olanzapine.

I have worked with underweight teenage girls who had OSA, being overweight is a risk factor but not a diagnostic requirement. What on earth does she have to lose from a home sleep study?

Any collateral on what her sleep is like? Any bedpartners you could talk to or anyone she loves with?

 

[PsyDr]

It would be important to differentiate if the patient was bitten by a venomous vs non-venomous snake, if it was a dry bite or wet bite, followed by differentiating if the venom was cytotoxic or neurotoxic.

If it’s not neurotoxic, potential for weird infections supporting a consult to infectious disease.

Potentially unrelated coincidence.

 

[annoyedpsychiatrist]

what kind of snake is it?

 

[Ceke2002]

Got a patient that was already seen by a great clinician and she couldn't get this patient better. Was tried on all the conventional meds. A few SSRIs, SNRIs, Lamotrigine, Lithium, atypical antipsychotics (and yes the better ones for depression such as Aripiprazole, Cariprazine) , Bupropion, augmentation agents such as Buspirone, Auvelity, Esketamine, TMS (not ECT...yet).

After several meetings she finally said something that hit me like a ton of bricks. She told me she never had mental health problems until she was bitten by a snake years ago.

So given that she never had depression until the snake bite and from there on several health problems including depression and syncope, I did a lit search. Unfortunately almost all of the snake bite data is only focused on acute treatment. There are very few articles on long-term outcomes of snake bites and adding to the problem the long-term issues seem to vary depending on the type of venom depending on the snake that bit the person.

The only thing I've been able to see as a pattern is some patients post-snake bit suffer from hypopituitarism. The problem here is I seem to know more about it than her PCP who hasn't done any lit searches so I'm going to contact the PCP and recommend an endo-follow up but other than this I don't know what to do.

MY theory is the snake venom did something permanent to the patient and not simply just PTSD. She's not c/o PTSD sx. She has severe depression with extreme insomnia but no PTSD nightmares, flashbacks, triggers. I'm theorizing the venom did some type of neurotoxic effect on her that caused long-term depression. The problem here is the lack of data to back it up other than the circumstantial evidence, and the lack of evidenced-based data.

Anyone have any experience with long-term effects of snake bites?

Some of these studies might help.

Australian & Asian combined studies

Mental health conditions after snakebite: a scoping review

Mental health conditions after snakebite: a scoping review

Snakebite is a neglected tropical disease. Snakebite causes at least 120 000 death each year and it is estimated that there are three times as many amputations. Snakebite survivors are known to suffer from long-term physical and psychological ...

www.ncbi.nlm.nih.gov

Long Term Effects of Snake Envenoming

Long-term Effects of Snake Envenoming

Long-term effects of envenoming compromise the quality of life of the survivors of snakebite. We searched MEDLINE (from 1946) and EMBASE (from 1947) until October 2018 for clinical literature on the long-term effects of snake envenoming using different ...

www.ncbi.nlm.nih.gov

Delayed Psychological Morbidity Associated with Snakebite Envenoming

Delayed Psychological Morbidity Associated with Snakebite Envenoming

The psychological impact of snakebite on its victims, especially possible late effects, has not been systematically studied.To assess delayed somatic symptoms, depressive disorder, post-traumatic stress disorder (PTSD), and impairment in functioning, ...

www.ncbi.nlm.nih.gov

Central American Study

Long-term sequelae secondary to snakebite envenoming: a single centre retrospective study in a Costa Rican paediatric hospital

Long-term sequelae secondary to snakebite envenoming: a single centre retrospective study in a Costa Rican paediatric hospital | BMJ Paediatrics Open

US Study Texas Specific

Long term complications of rattle snake bites

https://www.wemjournal.org/article/S1080-6032(13)00347-5/pdf

 

[whopper]

Copperhead snake.

 

[futureapppsy2]

I have worked with underweight teenage girls who had OSA, being overweight is a risk factor but not a diagnostic requirement. What on earth does she have to lose from a home sleep study?

Yep. Some people have structural issues in their palate/throat that cause OSA at any weight.

 

[Ceke2002]

Copperhead snake.

Australian or American? I'm assuming American but just double checking. If Australian they are in the same sub species as Cobras and tend to inject neurotoxic venom in a more sizeable amount. If American they are same sub species (not sure if correct terminology) as pit vipers and have Haemotoxic venom with a higher incidence of dry bites.

 

[Stagg737]

Copperhead snake.

So hemotoxic and actually pretty likely to be a dry bite. Could be related, but could be completely unrelated and coincidental. If you're chasing zebras, PsyDr's point wasn't a bad one. Snakes can transmit infections, but she probably would have had some kind of generalized symptoms after the bite which would be pretty atypical for a low-potency hemolytic envenomation common in copperheads.

Also agree with Clause. "Extreme insomnia" in someone who gets snowed by 2mg of Olanzapine and sub-therapeutic lithium is weird. Probably worth a consult to a good sleep medicine doc if they're available.

 

[whopper]

The problem with a sleep consult is most sleep docs I see suck.

Once they discover it's not OSA they just tell the patient there's nothing they can do. I've talked to sleep doctors about this. Some told me the money is with OSA and getting them a machine so it's really just bad sleep doctors. The problem is over 80% of the sleep docs I've referred to are these bad doctors, and the few good ones aren't taking patients or have a waiting list of several months.

 

[aim-agm]

The problem with a sleep consult is most sleep docs I see suck.

Once they discover it's not OSA they just tell the patient there's nothing they can do. I've talked to sleep doctors about this. Some told me the money is with OSA and getting them a machine so it's really just bad sleep doctors. The problem is over 80% of the sleep docs I've referred to are these bad doctors, and the few good ones aren't taking patients or have a waiting list of several months.

Maybe a general or stroke neurologist? If the venom is hemotoxic then the mechanism of brain injury would be like a stroke, or it would be autoimmune.

 

[FlowRate]

The problem with a sleep consult is most sleep docs I see suck.

Once they discover it's not OSA they just tell the patient there's nothing they can do. I've talked to sleep doctors about this. Some told me the money is with OSA and getting them a machine so it's really just bad sleep doctors. The problem is over 80% of the sleep docs I've referred to are these bad doctors, and the few good ones aren't taking patients or have a waiting list of several months.

Might as well get her on the wait list for the ones you trust. Has she tried eszopiclone yet?

Also, was she sleeping 14+ hours for multiple days or she quit taking it after one experience? If she's chronically sleep deprived, it'll take weeks to see a new steady state once she's sleeping adequately.

 

[comp1]

I mean how does the person know or even relate it to the snake bite other than that it was an unusually traumatic and memorable event? Why wasn't it an apple they ate around the same time? Roughly same amount of literature...

 

[ObsequiousAplomb]

I'm also curious about some quantifiable data like a sleep study of some type.
In addition to helpful diagnostics, the study can be helpful even if it is non-diagnostic.
It might show that the patient is actually getting that much sleep but doesn't recall it and thinks they were up all night (always a fun result on sleep studies). It could show any number of things that may or may not align with the patient's reported symptoms, and this might be important.

An endo workup is possibly warranted at this point, regardless of whether or not the snake bite caused neurotoxicity (which if it really is a Copperhead in the US, sounds like it wasn't. Speaking of, how certain are they it was a copperhead? Was it trapped and identified by someone trained in that, the patient used a field book, the patient knows snakes really well, etc?) They've been depressed an awfully long time, and depending on other symptoms, maybe it is warranted? I'm also curious about whether they have other symptoms that would indicate a rheum referral.

There's also the elephant in the room of mentioning TRD, listing a ton of great psychopharmacology approaches tried, mentioning ECT hasn't been tried, and now trying very bespoke psychopharm treatments (like 5 mg of lithium). I'm glad that you're trying to come up with a plan that fits her needs. You've got me really curious about low dose lithium for insomnia now, so I'll have to read up on that. I wonder though, is trying all of this serving to delay an adequate ECT trial? Based on the number of agents tried, it sounds like it's been quite a number of years of persistent depression. I'd be curious about exploring resistances to ECT for someone who's already tried that many drugs.

 

[whopper]

She wasn't on multiple meds. We're trying to keep this to 1 med at a time for obvious reasons.
Also it turns out all meds create bad side effects even and very small dosages. E.g. Escitlalopram 5 mg caused bad side effects. Only exception so far was Lamotrigine at 400 mg daily-no problem but not benefit either.

 

[aim-agm]

She wasn't on multiple meds. We're trying to keep this to 1 med at a time for obvious reasons.
Also it turns out all meds create bad side effects even and very small dosages. E.g. Escitlalopram 5 mg caused bad side effects. Only exception so far was Lamotrigine at 400 mg daily-no problem but not benefit either.

Perhaps trial SRIs (e.g. citalopram, sertraline) with liquid formulations with the same approach of using dilution to start with very tiny doses and work your way up. In a similar vein, you can try olanzapine again with the ODT formulation and dissolving in water and taking a fraction.

 

[Mad Jack]

Has the patient ever had any imaging done? I doubt it will yield anything, but kind of curious.

The other thing I think about when someone has a high side effect burden at a low dose of antidepressant is MTHFR gene mutations- had one patient that had really treatment resistant depression and would have bad side effects at anything over half of the usual minimum dose of SSRIs. She actually had previously received genetic testing before seeing me, which showed her homozygous for MTHFR gene mutation, and was started on folate by the NP she had been seeing, which obviously didn't work. I started her on L-methylfolate in addition to 5 mg of escitalopram (which she had previously been on before but couldn't tolerate due to side effects) and her symptoms drastically improved over the following months for the first time in over a decade. Zero side effects as well. My theory is she had so little serotonin to work with that inhibiting its reuptake resulted in her having such significant side effects due to there being very little serotonin to release since it was all hanging out in her synaptic clefts and not being recycled. This etiology seems unlikely in your patient, as they had been fine most of their life until that event. Still figured I would throw it out there on the off chance this is recall bias on the part of the patient, a la vaccines and autism claims.

 

[Merovinge]

Perhaps trial SRIs (e.g. citalopram, sertraline) with liquid formulations with the same approach of using dilution to start with very tiny doses and work your way up. In a similar vein, you can try olanzapine again with the ODT formulation and dissolving in water and taking a fraction.

You see, you start the dilution, then add in 100 parts water, then take one part of that and add it to one hundred parts water...

 

[whopper]

no imaging done and if I ordered it I don't know if insurance would pay for it, nor what I could do even if it did show an abnormality. I told this to the patient as others have stated, this might be too rare a zebra for a psychiatrist to pursue.

 

[calvnandhobbs68]

no imaging done and if I ordered it I don't know if insurance would pay for it, nor what I could do even if it did show an abnormality. I told this to the patient as others have stated, this might be too rare a zebra for a psychiatrist to pursue.

Or just really also consider that this is a red herring and it's recall bias because the patient remembers this event as being particularly eventful around the same time she got depressed. Or from a more existential psychotherapy perspective, maybe an event like this really provoked a "death anxiety" in patient who thought she was going to die from a snakebite and really brought her own mortality into focus which has persisted now over time. What's her psychotherapy contact been looking like?

If you wanted to go down the "neuroinflammation" route or something (which is what I assume you might be thinking in terms of such a remote history causing such significant current symptoms), fluvoxamine has the sigma 1 agonist effect which theoretically may help with inflammation. Could also go down the more wild route of adding statins, COX-2 inhibitors, omega 3s as augmenting options.

No TCAs? Also she hasn't really "tried" lithium if she can't even tolerate 25mg...what's her serum level at 25mg? If she can't even tolerate low doses of a lot of meds, I'd hardly call those trials rather than failures due to medication intolerance.

 

[Stagg737]

You see, you start the dilution, then add in 100 parts water, then take one part of that and add it to one hundred parts water...

And make sure to use the blue crystals and not the purple ones. Those purple ones will just completely snow her!

 

[Stagg737]

In all seriousness though, and not to question a thorough work-up, but repeated severe side effects to sub-therapeutic doses of multiple medications should also be a huge red flag for a certain cluster type of disorder. I'm pretty good at sniffing out personality traits, but I've had a few cases where I was convinced it wasn't really part of the formulation until a specific appointment or event when the floodgates opened and hit like a ton of bricks.

 

[whopper]

I don't see the patient showing any of the typical personality disorders. She's polite, cooperative, and follows medication instructions well. She also thoroughly reads up on all of the meds.

 

[whopper]

She actually had previously received genetic testing before seeing me, which showed her homozygous for MTHFR gene mutation, and was started on folate by the NP she had been seeing, which obviously didn't work. I started her on L-methylfolate in addition to 5 mg of escitalopram (which she had previously been on before but couldn't tolerate due to side effects) and her symptoms drastically improved over the following months for the first time in over a decade.

Often times when I see someone with a double MTHFR mutation, L-Methylfolate not just works well, it's a game changer with quick benefits within days. Many of these patients did better on 30 mg daily vs lower dosages, but I never saw anyone do better than higher dosages of 30 mg/day. I've asked several researchers why do all of the studies usually rely on 15 mg/day? Why not 10, or 20 mg or 30 mg? No one's been able to answer it.

Then, and not surprisingly, when I ask this person if they have several family members with depression the answer is a yes, and when those family members take L-Methylfolate on their own after the patient (not I) told them they have the mutation and felt much better, those same people improve.

With a single mutation I still see improvement but not as much as the homozygous patients. Further there's data showing if the person is homozygous MTHFR mutated they must take L-Methylfolate or suffer an increased risk of MI or stroke because LMF gets rid of homocysteine which is significantly elevated in such people.

The other issue I've seen in such patients is their other physicians tell them to just take more folate. Wrong-the problem is usually not a lack of folate, it's that the body cannot convert it into L-Methylfolate which is the version of folate that crosses the BBB.

 

[docksan]

Is there an MRI?

 

[clozareal]

This is a case that would warrant more thorough medical evaluation.

Sleep evaluation would be #1. They may recommend a overnight sleep study, but not always. They might recommend actigraphy instead or even a trial on a medication before a sleep study. You can order an at home sleep study yourself with a WatchPAT while you wait for an intake appointment with sleep medicine. Try going to a non-pulmonologist and those who have training to look for more than just OSAHS.

I would get an MRI Brain with/without contrast, pituitary protocol.

I would consider getting labs for hypopituitarism myself. PCP won't have time/knowledge to look into this. AM cortisol, TSH+FT4, serum estradiol, serum IGF-1. Throw in ferritin, B12, RBC folate, homocysteine/methylmalonic acid, celiac panel, CRP/ESR, ANA, HIV, RPR, possibly quantiferon depending on their exposure risk, maybe PT/INR and aPTT. This is in addition to the basic labs CBC + CMP.

Infection labs? No clue about snake bites. Might be worthwhile to consult with a toxicologist or microbiologist.

Sensitivity to side effects of medications would preclude using TCAs, MAO-Is, pramipexole, amantadine which is what I would probably try next if ECT isn't an option. Minocycline and celecoxib are unusual options to consider but can if the ESR/CRP is high, or maybe even D-cycloserine.

 

[Ceke2002]

I don't see the patient showing any of the typical personality disorders. She's polite, cooperative, and follows medication instructions well. She also thoroughly reads up on all of the meds.

I'm sure you've already considered this, but is it possible that someone that co-operative is perhaps showing signs of being a pathological people pleaser? And subsequently might not be following medication directions but is having trouble being honest about it? The only reason I mention it is your description reminds me of someone I worked with when I was doing voluntary peer support work a while back. Has she has blood tests done to test medication levels?

 

[Ceke2002]

I suggest consulting an Australian sleep specialist.

I'm joking but only partly. If this is a known phenomenon, go to the experts where it must happen most often... Which probably would be Austrailia, no?

Interesting you mentioned this. I found some stats on snakebite occurrence comparisons between Australian and the US. Depending on the year (different factors, like weather and food supplies tend to dictate if snakes here interact more with the population) the bite rate averages out to between 3 and 18 per 100, 000 people (2010's were a bad decade with 26 deaths, not counting bite victims who survived). In contrast the US seems to be reasonably steady with an average of 4 bites per 100,000 people. Australia does have a higher incidence of snakebite deaths as well, when compared to the US, but considering we have some of the world's most venomous snakes that's not surprising.

 

[Merovinge]

In all seriousness though, and not to question a thorough work-up, but repeated severe side effects to sub-therapeutic doses of multiple medications should also be a huge red flag for a certain cluster type of disorder. I'm pretty good at sniffing out personality traits, but I've had a few cases where I was convinced it wasn't really part of the formulation until a specific appointment or event when the floodgates opened and hit like a ton of bricks.

Are you trying to suggest the patient is NOT allergic to 17 different medications, latex, gluten, and compounds in perfume/cologne?!

Teddy bear sign and Polyallergy sign are like intern psych 101, definitely worth a mention here.

 

[clausewitz2]

Are you trying to suggest the patient is NOT allergic to 17 different medications, latex, gluten, and compounds in perfume/cologne?!

Teddy bear sign and Polyallergy sign are like intern psych 101, definitely worth a mention here.

Bonus points for allergic to prednisone.

 

[Stagg737]

Bonus points for allergic to prednisone. CD

Funny you mention that because my dad actually is allergic to at least 2 corticosteroids. Had to go to the ER for anaphylaxis more than once because docs kept not believing him and saying it was probably a dye or other substance. Another doc recently tried to prescribe it and wouldn’t do a procedure that required post-procedural steroids until I called to talk to the doc.

I’ve heard docs say they don’t believe people can be allergic to steroids, but after seeing it first hand in a parent I can assure all that it does happen.

 

[Merovinge]

Funny you mention that because my dad actually is allergic to at least 2mcorticosteroids. Had to go to the ER for anaphylaxis more than once because docs kept not believing him and saying it was probably a dye or other substance. Another doc recently tried to prescribe it and wouldn’t do a procedure that required post-procedural steroids until I called to talk to the doc.

I’ve heard docs say they don’t believe people can be allergic to steroids, but after seeing it first hand in a parent I can assure all that it does happen.

There are also cases of allergy to Benadryl but they are very rare. The odds of being allergic to steroid or Benadryl AND several other agents with totally different structures is just infinitesimally low.

 

[Candidate2017]

I'd refer to rheum, allergy, ID, neuro, and ECT. Because getting other specialists to curse at me is good medicine.

No mention of therapy? I'd start CBT/ERP. Initially, it will be entertaining to throw garter snakes at her, but I'd be bored after a few sessions. If she comes back, it means she can somewhat tolerate my countertransference, but at the same time, introjection has begun. So, we'll transition to psychodynamic therapy. Because I need to know if a snake is ever just a snake? It may take years, but we will find out together. Or maybe we'll forget why she started seeing me.

 

[whopper]

I don't think this person is faking the symptoms whether malingering or factitious disorder. Trust me. I've kicked out plenty of people out of the ER and dealt with my fair share of cluster B patients.

 

[Celexa]

I don't think this person is faking the symptoms whether malingering or factitious disorder. Trust me. I've kicked out plenty of people out of the ER and dealt with my fair share of cluster B patients.

Perhaps try contacting an academic neuroimmunologist who sees more than MS and likes a puzzle?

 

[SmallBird]

You sure have a colorful practice

 

[TexasPhysician]

I don't see the patient showing any of the typical personality disorders. She's polite, cooperative, and follows medication instructions well. She also thoroughly reads up on all of the meds.

I’d say she has shown symptoms of a personality disorder just based off of your comments that small doses cause big side effects, extreme sleep changes, snake bite causes, and thoroughly reading up on all meds.

1. In almost every patient that I’ve had with similar med responses, they will have a personality disorder or OCD. They work themselves up so much with medication that something happens. I’ve diluted Prozac to 0.5mg and still extreme side effects.

2. If many sleep meds aren’t working, but lithium/olanzapine cause sedation for 13+ hours, the patient is misrepresenting their sleep until proven otherwise. Many psych meds are hitting similar receptors for sleep.

3. “Thoroughly reads up on all meds”. Why? This sounds detrimental. If I was starting a new med and was otherwise very somatic, I’d feel something that day and try to relate it to the med. Despite being in medicine and enjoying what I do, I don’t read up on all meds given to me/family. If Derm gives me a new cream, I’m not reading MOA or side effect data. I trust it was given for a reason and I try it. If the patient is paranoid about side effects and lacks trust, placebo would cause side effects.

4. I’m a snake enthusiast and haven’t heard of this. I know medical snake experts and can ask, but I wouldn’t expect copperhead venom to cause depression.

Sounds like a patient that I’ve moved toward counseling and IV ketamine with significant improvement.

 

[Cath Up]

Has the patient ever had any imaging done? I doubt it will yield anything, but kind of curious.

The other thing I think about when someone has a high side effect burden at a low dose of antidepressant is MTHFR gene mutations- had one patient that had really treatment resistant depression and would have bad side effects at anything over half of the usual minimum dose of SSRIs. She actually had previously received genetic testing before seeing me, which showed her homozygous for MTHFR gene mutation, and was started on folate by the NP she had been seeing, which obviously didn't work. I started her on L-methylfolate in addition to 5 mg of escitalopram (which she had previously been on before but couldn't tolerate due to side effects) and her symptoms drastically improved over the following months for the first time in over a decade. Zero side effects as well. My theory is she had so little serotonin to work with that inhibiting its reuptake resulted in her having such significant side effects due to there being very little serotonin to release since it was all hanging out in her synaptic clefts and not being recycled. This etiology seems unlikely in your patient, as they had been fine most of their life until that event. Still figured I would throw it out there on the off chance this is recall bias on the part of the patient, a la vaccines and autism claims.

That is an interesting case, thank you for sharing. Your theory is that due to methylfolate deficiency she couldn't make enough SERT to reduce synaptic serotonin (thus leading to side effects)? I just want to make sure I understand the logic/not lose all my biochemistry to time.

 

[Mad Jack]

That is an interesting case, thank you for sharing. Your theory is that due to methylfolate deficiency she couldn't make enough SERT to reduce synaptic serotonin (thus leading to side effects)? I just want to make sure I understand the logic/not lose all my biochemistry to time.

So let's simplify it a bit. Let's say your neuron is transmitting as it does in order to, you know, function. It releases one arbitrary unit of serotonin to transmit signals, and let's say a normal person has like, 30 units. Without a SSRI, you might be able to reach a steady state of release to reuptake and synthesis in which you've always got, let's say 25 units in reserve, while 5 might be in the synapse. A reuptake inhibitor results in this balance shifting, so you might have 15 in reserve and 15 in the synapse due to slower reuptake. But you still have that reserve to signal with serotonin when needed. Now let's say someone has MTFHR deficiency and can only make 40% of the serotonin a typical person can. They've got 12 arbitrary units total, and if steady state with a SSRI will inhibit about 15 units from reuptake, you end up with a situation where all of your units of serotonin are in the synapse and you can't effectively signal using serotonin since there just isn't any in reserve. If you increase the serotonin supply by skipping the broken part of their metabolic pathway, you increase the amount in reserve to something closer to what is typical, and things should work as expected in a person with more typical metabolism.

Since serotonin is used pretty broadly in the body, this deficit in transmission could manifest as side effects in any of the expected places, from the gastrointestinal system to sexual function and anywhere in between

 

[Stagg737]

I don't think this person is faking the symptoms whether malingering or factitious disorder. Trust me. I've kicked out plenty of people out of the ER and dealt with my fair share of cluster B patients.

To be clear, I'm not suggesting she has a full blown PD. But because of my research I often dig into specific personality traits/domains more. For this patient I'd be looking into the Negative Affect domain more, specifically traits in anxiousness, perseveration, and submissiveness (d/t apparent somatic responses to meds). As pointed out, people who read in depth about side effects of commonly prescribed meds and have extreme responses to low doses of meds often have some psychological component going on.

Also, what are the actual symptoms of "depression". Low mood? Anhedonia? Lack of motivation? Low self-worth or hopelessness? She's "depressed" but what does that mean? All you really gave us was the sleep concern, what else?

 

[birchswing]

I’d say she has shown symptoms of a personality disorder just based off of your comments ... snake bite causes

<Not a doctor or medical student>

Is it clear which person in the room is interested in the snake bite theory?

I read it as an off-hand comment by the patient and a high degree of novelty-seeking by the doctor. But I could be wrong.

 

[TexasPhysician]

Went ahead and brought this up with a buddy that is a snake bite expert in the USA. He treats mostly bites with native Texas snakes, but the snake pet hobby has ramped up with exotics. He also treats mambas, cobras, etc that were pets. He reports only seeing depression secondary to long-term physical damage that some bites cause.

 

[clement]

In all seriousness though, and not to question a thorough work-up, but repeated severe side effects to sub-therapeutic doses of multiple medications should also be a huge red flag for a certain cluster type of disorder. I'm pretty good at sniffing out personality traits, but I've had a few cases where I was convinced it wasn't really part of the formulation until a specific appointment or event when the floodgates opened and hit like a ton of bricks.

I like to discredit myself as an ER cynic…As soon as I started reading, “…couldn’t get this patient better…,” “Not ECT…Yet…,””…never had depression until the…” ….seminal event of a snake bite…(and well before seeing severe side effects to sub-therapeutic doses)… A little voice started whispering… “borderline and indulgence in the sick role…” However, such a line of thinking would also discredit all the zebras that make academic CL so enchanting.

 

[Stagg737]

I like to discredit myself as an ER cynic…As soon as I started reading, “…couldn’t get this patient better…,” “Not ECT…Yet…,””…never had depression until the…” ….seminal event of a snake bite…(and well before seeing severe side effects to sub-therapeutic doses)… A little voice started whispering… “borderline and indulgence in the sick role…” However, such a line of thinking would also discredit all the zebras that make academic CL so enchanting.

I'm academic C/L, but I do think an important part of our job is discerning when we should be looking for zebras vs when there is something we can actually identify and treat. I like to think I'm pretty decent at sniffing out PDs with patients and I catch quite a few cluster C patients that others have missed for years, so I'm not so worried about mistaking a zebra for BPD most of the time on the C/L services. However, I do think this can be harder to do on an outpatient basis for those patients who repeatedly deny PD symptoms but just don't seem to get better. Imo, this is where the brief outpatient notes are useless, because it's piecing things together from repeated indirect reporting of symptoms that lead to the right PD diagnosis in these patients.

 

[Celexa]

I'm academic C/L, but I do think an important part of our job is discerning when we should be looking for zebras vs when there is something we can actually identify and treat. I like to think I'm pretty decent at sniffing out PDs with patients and I catch quite a few cluster C patients that others have missed for years, so I'm not so worried about mistaking a zebra for BPD most of the time on the C/L services. However, I do think this can be harder to do on an outpatient basis for those patients who repeatedly deny PD symptoms but just don't seem to get better. Imo, this is where the brief outpatient notes are useless, because it's piecing things together from repeated indirect reporting of symptoms that lead to the right PD diagnosis in these patients.

Oh cluster C. The deeply underappreciated cluster. Lost in the shadows of the drama of cluster B, yet actually just as much if not more problematic.

The most L heavy CL cases are almost always SEVERE cluster C. Sometimes there's some B wound in there, but it's C that really causes the problems.

 

[clement]

From years of er experience, not all that is borderline is loud and dramatic. Sometimes it’s a subtle chronic quiet meek yet serious appearing need for attention co morbid with depression. Conceptually the CL world may find it akin to the subtle chronic delirium of dementia.

 

[clausewitz2]

From years of er experience, not all that is borderline is loud and dramatic. Sometimes it’s a subtle chronic quiet meek yet serious appearing need for attention. Conceptually the CL world may find it akin to the subtle chronic delirium of dementia.

One of my outpatient mentors liked to hold forth on "the overcontrolled borderline" whenever he didn't have a specific educational topic in the can. Look for people who are extremely put together whenever they talk to you but have significant parts of their life actively on fire.