Weird case. Treatment Resistant Depression but after a snake bite

[whopper]

IMHO the biggest failure of this patient's case is she has a weird case and mediocre doctors. While I consider myself somewhere to above average to better (I've run organizations, worked with top doctors in the field and was asked to remain on their teams, worked as the psychiatric clerkship director, asked to take over a fellowship as the PD), I know this patient has other doctors that are the types to only spend a few minutes on the case and then pretty much tell the patient "it's all in your head" after they did perfunctory or worse evaluations.

To date I've been able to correctly figure out cases such as black mold poisoning, a prior stroke, cancer, parasitic infections (verified with labs), anti-NMDA encephalitis, antiphospholipid antibody syndrome presenting as psychosis that the patient's PCP missed and the PCP told the patient it was "all in your head." One of those patients is a top level physician who is a retired university professor eminent in her field. I couldn't believe some idiot community hospital doctor treated her as if her neurological condition, verified by 3 separate university neurologists was psychosomatic.

But anyway getting to the point I made 5 attempts to call the patient's PCP and each time no answer from a phone call, and no response to 3 faxes. This is what this poor patient is dealing with, and I'm already confident this is not something her psychiatrist is going to figure out.

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[Ludwig2000]

IMHO the damsel in distress is really working on your hero complex. The snake may as well have been a dragon.

 

[whopper]

IMHO the damsel in distress is really working on your hero complex. The snake may as well have been a dragon.

Reading too much into it. I've seen her several times. I haven't detected any reason to believe there's a personality problem on her end.

 

[calvnandhobbs68]

IMHO the biggest failure of this patient's case is she has a weird case and mediocre doctors. While I consider myself somewhere to above average to better (I've run organizations, worked with top doctors in the field and was asked to remain on their teams, worked as the psychiatric clerkship director, asked to take over a fellowship as the PD), I know this patient has other doctors that are the types to only spend a few minutes on the case and then pretty much tell the patient "it's all in your head" after they did perfunctory or worse evaluations.

To date I've been able to correctly figure out cases such as black mold poisoning, a prior stroke, cancer, parasitic infections (verified with labs), anti-NMDA encephalitis, antiphospholipid antibody syndrome presenting as psychosis that the patient's PCP missed and the PCP told the patient it was "all in your head." One of those patients is a top level physician who is a retired university professor eminent in her field. I couldn't believe some idiot community hospital doctor treated her as if her neurological condition, verified by 3 separate university neurologists was psychosomatic.

But anyway getting to the point I made 5 attempts to call the patient's PCP and each time no answer from a phone call, and no response to 3 faxes. This is what this poor patient is dealing with, and I'm already confident this is not something her psychiatrist is going to figure out.

Why are you trying so hard to convince us all that you're really smart? I mean, sounds like you've convinced yourself about this "weird" case and the "mediocre doctors" she's worked with so far (besides the "great clinician" you previously mentioned in your OP). This post itself is a psychodynamic goldmine...

 

[whopper]

I've said this before. Most doctors don't even do the minimum. E.g. several doctors prescribe benzos, don't warn of addiction risks or to not mix with alcohol. When dealing with evaluating cases where patients aren't getting better, that is a layer that has to be examined and ruled-out. E.g. patient's put on Escitalopram 5 mg daily, and has been on it for 6 months, and doesn't know why they're not getting better. "Why didn't the treating doctor raise the dose?" Am I going to think the treating doctor isn't any good if that's what they did to treat depression? If a psychiatrist-yes. If a non-psychiatrist I'll give the benefit of the doubt that this is not their field.

The amount of times I encounter the above phenomenon (and I'm sure it's the same for many here) is not every few months, or weeks, but on the order of usually every few days. E.g. BP >180/110 and their PCP tells them their BP is fine, not once but multiple times over the course of months and it's even in their records, doctor writes 120/80 as BP, but the patient told me they saw the BP themselves and it's presenting consistently as it is in my office which is a very different number.

Getting to some of the above posts, of course issues like factitious disorder, cluster B, malingering should be examined. Just that I've found no significant reason to believe this is what's going on in this patient's case.

 

[Ludwig2000]

Would you mind indulging us in an aside about the black mold poisoning case, whopper? Do you know what happened to that patient after the diagnosis?

 

[whopper]

Patient had several neuro symptoms. Their PCP referred them to psychiatry because all usual blood tests were within normal range such as CBC, TSH, BMP, etc.

Despite several med trials for mood problems no benefits. I always ask patients what's been bugging them, if anything, since the last visit. A common theme was the patient worked in a restaurant and despite several demands from employers to do things to fix the work environment including cleanliness, they wouldn't listen to the employees.

So I asked her about possible workplace exposure issues, e.g. food poisoning, other employees possibly having the same problems etc. She asked other employees if they had any similar symptoms to what she had. Other employees had similar symptoms so I was then starting to foment an idea it could be a workplace exposure thing. I told her that given that her labs were normal it could be something weird, and pretty much told her to get out of her workplace and even report the restaurant cause they were obviously not following the local laws with maintaining minimum standards. For whatever reason she and her coworkers, despite the employers' bad treatment of them, felt some odd desire to protect the restaurant. My only theory there is she was young (in her early 20s) and had a fall on your own sword for your boss personality trait that I sometimes see in other people. (I used to have that same problem myself). Another possible reason was the restaurant had a local rep of being a hip and sexy place, and the people working there liked the social advantages it provided them.

By this time this had been over 6 months of seeing this patient. The first several visits I kept it within the usual psychiatric arena of trying a few meds, but nothing was significantly helping.

She took a vacation from work, felt tremendously better, but then going back to work within 2-3 days all of her problems reappeared. At that time the theory went from "maybe" in my head to "I think it's some kind of workplace exposure thing," with a solid gut-feeling. I told her she should drop any idea of trying to protect her employer and think of the risks going on to customers and coworkers at the restaurant.

Someone called the health inspector, and turned out the place was filled with black mold. Restaurant was shut down. Within several days, all the coworkers who were feeling sick were feeling better. One of them got a mold exposure test (something not covered by regular insurance and it wasn't my patient), and levels of mycotoxins were extremely high.

 

[docksan]

Do you have a write up of that case? I've been intrigued about the neuropsychiatric manifestations of black mold since M4.

 

[whopper]

Problem with the above it the case occurred a few years ago, and the patient, after the restaurant was shut down felt completely fine and stopped seeing me. So while her case is in my records, I don't remember her name, but I remember the case. Mistafab is in the same area as I, and this same restaurant was shut down likely just before he got to the St. Louis area, but it was a popular hangout for young people. I can imagine the propinquity benefits for staff who used to work at that place. It was in the Creve Couer area and served only mostly deserts and high-end drinks.

 

[clozareal]

To date I've been able to correctly figure out cases such as black mold poisoning, a prior stroke, cancer, parasitic infections (verified with labs), anti-NMDA encephalitis, antiphospholipid antibody syndrome presenting as psychosis that the patient's PCP missed and the PCP told the patient it was "all in your head." One of those patients is a top level physician who is a retired university professor eminent in her field. I couldn't believe some idiot community hospital doctor treated her as if her neurological condition, verified by 3 separate university neurologists was psychosomatic.

Can you say more about this? I have no idea about this despite getting new patient requests sometimes with patients having "toxic mold syndrome" (along with Lyme, EDS, POTS, and many other diseases at the same time so it's hard to tease out).

 

[Ceke2002]

I've said this before. Most doctors don't even do the minimum. E.g. several doctors prescribe benzos, don't warn of addiction risks or to not mix with alcohol. When dealing with evaluating cases where patients aren't getting better, that is a layer that has to be examined and ruled-out. E.g. patient's put on Escitalopram 5 mg daily, and has been on it for 6 months, and doesn't know why they're not getting better. "Why didn't the treating doctor raise the dose?" Am I going to think the treating doctor isn't any good if that's what they did to treat depression? If a psychiatrist-yes. If a non-psychiatrist I'll give the benefit of the doubt that this is not their field.

The amount of times I encounter the above phenomenon (and I'm sure it's the same for many here) is not every few months, or weeks, but on the order of usually every few days. E.g. BP >180/110 and their PCP tells them their BP is fine, not once but multiple times over the course of months and it's even in their records, doctor writes 120/80 as BP, but the patient told me they saw the BP themselves and it's presenting consistently as it is in my office which is a very different number.

Getting to some of the above posts, of course issues like factitious disorder, cluster B, malingering should be examined. Just that I've found no significant reason to believe this is what's going on in this patient's case.

Sadly this is true, especially when there's already a diagnosis or suspicion of mental illness. My auntie had a severe presentation of Anorexia Nervosa, so when she started exhibiting other physical and neurological symptoms the attitude of her treating Doctors was, "You have a BMI of 11, you refuse to maintain proper nutrition, and 12 months ago you were lucky to survive a cardiac arrest after prolonged abuse of laxatives, so oh um gee you tell us why you're not feeling well, duh!" They more or less ran some perfunctory tests just to amuse her, sent her back to outpatient psych treatment, and by the time the metastasized cancer was actually diagnosed she had 2 weeks to left to live.

If that's the case for something relatively common, like cancer, I can fully see other, less common, disease processes being completely missed because someone didn't think it was necessary to go the extra mile and run a few extra tests.

 

[birchswing]

Sadly this is true, especially when there's already a diagnosis or suspicion of mental illness. My auntie had a severe presentation of Anorexia Nervosa, so when she started exhibiting other physical and neurological symptoms the attitude of her treating Doctors was, "You have a BMI of 11, you refuse to maintain proper nutrition, and 12 months ago you were lucky to survive a cardiac arrest after prolonged abuse of laxatives, so oh um gee you tell us why you're not feeling well, duh!" They more or less ran some perfunctory tests just to amuse her, sent her back to outpatient psych treatment, and by the time the metastasized cancer was actually diagnosed she had 2 weeks to left to live.

If that's the case for something relatively common, like cancer, I can fully see other, less common, disease processes being completely missed because someone didn't think it was necessary to go the extra mile and run a few extra tests.

I'm sorry for her and you and your family.

I only recently heard an official term for this: diagnostic overshadowing.