What Defines "Hopeless" Cases?

[Ceke2002]

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In terms of chronic and/or 'treatment resistant' mental illness/disorders, what actually defines a so called "hopeless" case? Is there any sort of algorithm to define the concept of "hopeless" or is this more something along the lines of certain chronic conditions being placed in the too hard basket because of lack of effective treatment, risk of countertransference with certain patient populations, work with chronic patients feeling thankless at times (whatever else I've missed)?

A discussion came up in one of my support groups regarding the difficulty that those with so called 'Severe and/or enduring (or chronic) eating disorders' face trying to find treatment providers who are willing to fully engage with them in a treatment setting (even when the patient themselves appears motivated). It made me wonder about other conditions in a mental health setting that might be considered 'chronic' as well, and how they are handled, or thought of in terms of when, how, and if a patient is ever labeled as 'hopeless'.

I'm actually considering looking at some of the data that might already be out there on this as a jumping off point for my Psychology Stats assignment, in the meantime I was interested in getting folks in here's take on the issue.

(I never thought I'd see the day where I was actually looking forward to an assignment involving stats as well )

 

[Shikima]

I don't think any case is hopeless. There's usually a reason and it's typically resistance to treatment.

Of course, I should point out, I'm not talking about terrible biological disorders - these are naturally excluded.

 

[MacDonaldTriad]

There isn't any research definition of "hopeless" so it remains one of those undefined "but I know it when I see it" things. We don't want to define this because it is our job to instill hope. We are taught not to give false hope, but unless you are dealing with dementia or Huntington's dx, there is always some hope. Other than life itself, these are the only two that are defined as progressive and downhill that come to my mind. Maybe we are all hopeless because no one makes it out of this world alive. (My favorite existential crisis from Take the Money and Run).

 

[singasongofjoy]

I concur with Shikima - I don't think anyone in mental health would use the term "hopeless." Treatment-resistant, sure. It can take a long time to find the right combination of things that will help some people. Additionally, you have to consider - is it successful treatment if someone who has severe, persistent treatment-resistant depression is finally feeling 50% better and able to get out of bed and shower, maybe engage in some daily activities outside of the house? Maybe they are not feeling like a typical person, per se, but it's so much better than baseline that it feels like a success. Or someone who is treated for schizophrenia and no longer has hallucinations and delusions. Maybe they still have some of the negative symptoms, like flattened affect, but are able to engage in normative activities. My point being that in the area of mental health, "successful treatment" comes in a matter of degrees, and even for someone who has chronic, persistent SMI I don't think anyone would ever call someone "hopeless" - there is always the possibility that some combination of evidence based treatment and environmental factors will align to bring some meaningful degree of relief for a significant period of time, even if the likelihood of eventual relapse is high for that given person's diagnosis and history.

Edited to add: of course, exceptions exist when mental health symptoms are caused by some biological factor like Huntingtons; we can do the best we can to support and help manage symptoms but in cases like that, everyone knows things are going to get more difficult over time even under the best circumstances; or long-term effects of Korsakoff-Wernicke syndrome- prob not getting better. But if you can help prevent symptoms from getting worse (in that case, preventing additional alcohol use) does that count as a success? it should, I think.

 

[Bartelby]

I agree that hopeless is not the right term. Hoping for what? There are certainly people who cannot be cured (not uncommon, especially for psychotic disorders), people who do not respond well to available treatments, people who will need to be institutionalized long-term, etc. Even in these cases, I would hope treaters would take an approach that tries to make life as good as possible for the person, decreasing symptoms, encouraging good functioning, and helping the person adapt to the hand life has dealt them.

For a mental health provider to tell someone they are "hopeless" in a global sense would be sad and, honestly, harmful to the patient.

 

[Stagg737]

Only a 3rd year, so grain of salt with my post, but the only "hopeless" case I've seen so far in the psych realm was a woman with chronic severe anxiety and depression. She'd literally been on every anti-depressant and anxiety med imaginable, years of therapy, multiple rounds of ECT, and was still on a pretty ridiculously strong regimen of meds and therapy and nothing was touching her symptoms. Anxiety 10/10, depression 9-10/10, constant SI (very few attempts), no family or friends left alive, homeless, and she'd burned through all of her Medicaid/medicare days. Obviously, we still don't give up on her and keep trying to help, but when she's been evaluated multiple times to rule out misdiagnoses, has tried every med, and still feels constantly anxious and is having SI, there really wasn't a lot more we could do given the situation. I'll honestly be amazed if she's alive a year or two from now, but then again I was amazed she was alive when I talked to her so who knows...

There isn't any research definition of "hopeless" so it remains one of those undefined "but I know it when I see it" things. We don't want to define this because it is our job to instill hope. We are taught not to give false hope, but unless you are dealing with dementia or Huntington's dx, there is always some hope. Other than life itself, these are the only two that are defined as progressive and downhill that come to my mind. Maybe we are all hopeless because no one makes it out of this world alive. (My favorite existential crisis from Take the Money and Run).

I'd probably throw some more neuro-degenerative disorders in there. ALS, some of the muscular dystrophies, and some of the metabolic diseases (tay-sachs, sandhoff, etc). Unless there's new, promising research I haven't heard of I'd say having to tell a parent their child won't live past 3-4 and will live in pain is a pretty hopeless situation...

 

[singasongofjoy]

A discussion came up in one of my support groups regarding the difficulty that those with so called 'Severe and/or enduring (or chronic) eating disorders' face trying to find treatment providers who are willing to fully engage with them in a treatment setting (even when the patient themselves appears motivated). It made me wonder about other conditions in a mental health setting that might be considered 'chronic' as well, and how they are handled, or thought of in terms of when, how, and if a patient is ever labeled as 'hopeless'.

I responded above to the more general idea but in the case of this very specific conversation you reference, sounds like you were talking with patients/clients, right? I think we've established that no mental health care provider is going to label someone as "hopeless" and would certainly never tell a patient/client that.

Maybe what you are referring to is that some clients may view THEMSELVES as hopeless, or the task of finding an available provider in their area as daunting/hopeless, but that's a different barrel of monkeys. In the case of the conversation you were having, it sounds like the people you were talking to were having trouble finding providers. That I can believe, especially f you're in an area where there are not many people trained specifically in eating disorders. There are some disorders that have a higher risk for negative outcome (e.g., death). You can't just go up to any outpatient clinic or private practice where the general practice is to see folks once a week or e/o week for an hour, and expect the next available clinician to feel competent to treat someone who likely requires more specialized expertise than they have (and probably more frequent and intense treatment than they are able to offer). I'm not sure what you mean by "fully engage," but for example, an evidence based treatment plan for some folks might include frequent followup and some additional availability throughout the week that just isn't a part of how many places/therapists operate. I am definitely not available by phone to patients after I leave the office. I also don't work with people who are all that likely to have a crisis. If someone with a severe eating disorder came to me and wanted therapy, they'd be at the wrong place. Run of the mill depression or anxiety? Ok. But eating disorder like bulimia or anorexia? Nope, definitely not, that would be well outside my competency and frankly unethical given my training and experience background (if it was a kid with rumination disorder, however, different story.) But I would do my best to find appropriate places to refer them, which fortunately in my geographical area is pretty easy with an eating disorders clinic down the road.

That is a long way of saying you might be asking the wrong question, or you might be asking the wrong crowd of people. Or maybe you need to separate out "chronic" from "hopeless," because you can have one without the other. Might want to clarify these things for yourself before starting your paper if you choose to pursue this topic.

 

[Ceke2002]

I responded above to the more general idea but in the case of this very specific conversation you reference, sounds like you were talking with patients/clients, right? I think we've established that no mental health care provider is going to label someone as "hopeless" and would certainly never tell a patient/client that.

Maybe what you are referring to is that some clients may view THEMSELVES as hopeless, or the task of finding an available provider in their area as daunting/hopeless, but that's a different barrel of monkeys. In the case of the conversation you were having, it sounds like the people you were talking to were having trouble finding providers. That I can believe, especially f you're in an area where there are not many people trained specifically in eating disorders. There are some disorders that have a higher risk for negative outcome (e.g., death). You can't just go up to any outpatient clinic or private practice where the general practice is to see folks once a week or e/o week for an hour, and expect the next available clinician to feel competent to treat someone who likely requires more specialized expertise than they have (and probably more frequent and intense treatment than they are able to offer). I'm not sure what you mean by "fully engage," but for example, an evidence based treatment plan for some folks might include frequent followup and some additional availability throughout the week that just isn't a part of how many places/therapists operate. I am definitely not available by phone to patients after I leave the office. I also don't work with people who are all that likely to have a crisis. If someone with a severe eating disorder came to me and wanted therapy, they'd be at the wrong place. Run of the mill depression or anxiety? Ok. But eating disorder like bulimia or anorexia? Nope, definitely not, that would be well outside my competency and frankly unethical given my training and experience background (if it was a kid with rumination disorder, however, different story.) But I would do my best to find appropriate places to refer them, which fortunately in my geographical area is pretty easy with an eating disorders clinic down the road.

That is a long way of saying you might be asking the wrong question, or you might be asking the wrong crowd of people. Or maybe you need to separate out "chronic" from "hopeless," because you can have one without the other. Might want to clarify these things for yourself before starting your paper if you choose to pursue this topic.

I did purposefully put the word 'hopeless' in quotation marks, because I was referring more to how patients (of which I am one, and have just started pre-req subjects for an undergrad in psychology) tend to think of themselves when they receive the label of chronic, or severe and/or enduring, or whatever the current correct term is.

Apologies, it's 7.20 am here, and I'm in the middle of getting breakfast whilst fending off an overly demanding cat who has suddenly decided she wants all the affection, all of it, right now!
Anyway, I really do appreciate your, and other's responses to this topic, so I will expand a bit more on what I mean when I don't have a cat attempting to twist itself around me while I try and balance a bowl of porridge in one hand.

Thank you again.

 

[tr]

I did purposefully put the word 'hopeless' in quotation marks, because I was referring more to how patients (of which I am one, and have just started pre-req subjects for an undergrad in psychology) tend to think of themselves when they receive the label of chronic, or severe and/or enduring.

Right. 'I'm a hopeless case' is exactly the sort of black-and-white, labeling type of thinking that you see in someone with active depression.
It's not in any sense an accurate or meaningful term, or one that a clinician would use.

 

[Ceke2002]

Right. 'I'm a hopeless case' is exactly the sort of black-and-white, labeling type of thinking that you see in someone with active depression.
It's not in any sense an accurate or meaningful term, or one that a clinician would use.

Of course not, hence the quotation marks around 'hopeless'. I don't believe there are such things as 'hopeless' cases, except of course in the cases of issues such as dementia, and so on, that have already been mentioned, and even then, as was also said there are still things that can be done in terms of symptom relief and comfort care. However the terms 'chronic' or 'severe/enduring' do tend to evoke that sort of 'well I'm a hopeless case then' reactions from many patients (myself not included in that particular list, because I refuse(d) to accept that as a self determined label). The conversation that sparked my starting this discussion had come from a group of patients in a support group setting, so again the reference to 'hopeless' when the clinician term would have been something much different. That being said though part of the statistical analysis I am looking at doing may possibly include a section on attitudes towards chronic cases of mental illness, and whether or not, in some cases at least, the therapist/treatment provider themselves may also be associating the clinical terms of 'chronic et al' with "hopelessness", or at least a sense of.

From the responses so far it seems as if I may be looking more at clinician's personal biases and attitudes as to what sort of personal judgement, emotions, opinions, etc, they may attach to a patient who is deemed to be 'chronically mentally ill', and how that might then affect their interactions with, treatment of, or refusal/reluctance to treat certain patient populations (and whether some sort of statistical analysis can be made of that based on any previously existing research).

This is obviously an area I'm interested in working in when I'm eventually licensed (a fair way down the track, obviously, but I figured it can't hurt to start somewhere).

 

[singasongofjoy]

Of course not, hence the quotation marks around 'hopeless'. I don't believe there are such things as 'hopeless' cases, except of course in the cases of issues such as dementia, and so on, that have already been mentioned, and even then, as was also said there are still things that can be done in terms of symptom relief and comfort care. However the terms 'chronic' or 'severe/enduring' do tend to evoke that sort of 'well I'm a hopeless case then' reactions from many patients (myself not included in that particular list, because I refuse(d) to accept that as a self determined label). The conversation that sparked my starting this discussion had come from a group of patients in a support group setting, so again the reference to 'hopeless' when the clinician term would have been something much different. That being said though part of the statistical analysis I am looking at doing may possibly include a section on attitudes towards chronic cases of mental illness, and whether or not, in some cases at least, the therapist/treatment provider themselves may also be associating the clinical terms of 'chronic et al' with "hopelessness", or at least a sense of.

From the responses so far it seems as if I may be looking more at clinician's personal biases and attitudes as to what sort of personal judgement, emotions, opinions, etc, they may attach to a patient who is deemed to be 'chronically mentally ill', and how that might then affect their interactions with, treatment of, or refusal/reluctance to treat certain patient populations (and whether some sort of statistical analysis can be made of that based on any previously existing research).

This is obviously an area I'm interested in working in when I'm eventually licensed (a fair way down the track, obviously, but I figured it can't hurt to start somewhere).

It's cool that you're interested in this topic of how biases can affect peoples' work/actions. Best of luck with your educational path- onward and upward! Also, best of luck trying to eat around an attention-loving cat- I have 3 of my own and can definitely relate, haha!

 

[Ceke2002]

It's cool that you're interested in this topic of how biases can affect peoples' work/actions. Best of luck with your educational path- onward and upward! Also, best of luck trying to eat around an attention-loving cat- I have 3 of my own and can definitely relate, haha!

Thanks. 🙂 I've always pretty open on here that I am in long term therapy as a patient, but my goal has also been to work towards returning to study as a non trad student. Originally I was hoping to do a post grad in Medicine, but after looking further into my chances of realistically being accepted into a program I decided last year to switch over to Psychology instead. Right now I'm doing my pre-req subjects for admission into a BA, and that includes a pre-req in statistics. Maths and me don't tend to be a good combination, so I've been looking for different ways to actually make studying a maths subject a bit more interesting and engaging -- hence looking at different topics I'm interested in and whether or not I can use them in a statistical analysis format.

In Australia, at least from my own experiences, as well as the experiences of others I've known over the years as well, trying to find treatment when you're considered to have an eating disorder with a chronic course is difficult at best. What you described before, with some practitioners not wishing to, or feeling uncomfortable taking on certain patients, because they don't have the experience with certain populations is understandable. I completely agree, and have no problem with a treatment provider saying 'I'm sorry, I don't have the training or experience to treat this person properly, therefore it is in their best interests for me not to take them on as a patient'. The thing is though, here at least, that's not typically what patients seeking treatment are told. I would not have had any issue, whatsoever, with approaching someone for treatment and having them say, "I'm sorry, this isn't a field I have much experience or expertise in, so I don't feel I am able provide you with the treatment that you need", but that's not what a lot of patients here are being told. When I first started to seek treatment, just over a decade ago, I was pretty much guaranteed one of two responses, either a straight out, "I'm sorry, but you're too chronic a case" -- note pad closed, no referrals or suggestions as to who might be able to take me on, end of session (you could practically feel the wind rushing past your head as they mentally bolted out of the room) -- or *deep breath, momentary pause, attempt at something akin to a sympathetic smile, followed by*, "Look, you have to understand that at this stage, because of the length of time you've been ill, there's really not that much chance of you ever achieving the level of recovery you're looking for; now I can help you to learn to live with your illness, but beyond that (blah blah statistically speaking, blah blah more talk of being 'too chronic a case', etc etc). As I said to tr in my comment above, I've never applied the idea of 'hopelessness', or being a 'hopeless case' to myself, but I can understand how other patients end up doing so, it's kind of hard not to when you're sitting in front of the umpteenth mental health care practitioner you've reached out to help for, and you're hearing the same thing over and over again. And 10+ years later I'm still hearing the same reports from others trying to find help when they've been labelled as 'chronic' as well.

The difficulty in finding help when you're considered to have a chronic eating disorder does become more understandable when you find out that, for example as far as I know I am the only one of my psychiatrist's patient with a chronic relapsing/remitting course of A.N who has actually remained in treatment with him (although it's not the only thing I'm being treated for) -- the others I don't think have lasted much beyond 6-12 months at the most. So from that point of view I can understand the reluctance to take on certain patient populations if you've seen those same patients come in all determined to get better one minute, and then dropping out of treatment the next. But it also makes me wonder, besides negative experiences, what else might drive certain attitudes towards particular patient groups. Because as much as its not a clinical term, and as much as it is something a patient is more likely to take on themselves, there does seem to be this underlying notion of 'hopelessness' with clinicians in certain cases. My question, and what I'm trying to form some sort of statistical analysis of, is 'why?'. 🙂

 

[smalltownpsych]

No such thing as a hopeless case. I don't mean that in a naively optimistic way either. What I mean is that I have seen that we are unable to predict who will get better vs who won't. Severity is not a predictor, although many confuse it as such. Initial motivation is not a predictor. In fact, we can't really predict who will get better and who won't so I just assume that the individual in front of me will be the one who gets better. The alternative perspective is not helpful at all although lately I have been drifting a bit too much in that direction. When we are looking at low recovery rates, it is hard to keep in mind that this individual patient might be the exception rather than the rule.

 

[Ceke2002]

No such thing as a hopeless case. I don't mean that in a naively optimistic way either. What I mean is that I have seen that we are unable to predict who will get better vs who won't. Severity is not a predictor, although many confuse it as such. Initial motivation is not a predictor. In fact, we can't really predict who will get better and who won't so I just assume that the individual in front of me will be the one who gets better. The alternative perspective is not helpful at all although lately I have been drifting a bit too much in that direction. When we are looking at low recovery rates, it is hard to keep in mind that this individual patient might be the exception rather than the rule.

I can imagine it must be difficult sometimes, to maintain a balance between optimism and realistic expectations when you're faced with a patient where the recovery rates aren't that great, and the retention rates of actually keeping them in treatment are probably even lower. The official guidelines for the treatment of eating disorders set out by RANZCP specifically cautions against taking on SE-ED patients, unless the practitioner is confident of their abilities/experience, due to the high level of countertransference they can engender.

 

[birchswing]

Only a 3rd year, so grain of salt with my post, but the only "hopeless" case I've seen so far in the psych realm was a woman with chronic severe anxiety and depression. She'd literally been on every anti-depressant and anxiety med imaginable, years of therapy, multiple rounds of ECT, and was still on a pretty ridiculously strong regimen of meds and therapy and nothing was touching her symptoms. Anxiety 10/10, depression 9-10/10, constant SI (very few attempts), no family or friends left alive, homeless, and she'd burned through all of her Medicaid/medicare days. Obviously, we still don't give up on her and keep trying to help, but when she's been evaluated multiple times to rule out misdiagnoses, has tried every med, and still feels constantly anxious and is having SI, there really wasn't a lot more we could do given the situation. I'll honestly be amazed if she's alive a year or two from now, but then again I was amazed she was alive when I talked to her so who knows...

Depression while having anxiety over the unending state of the anxiety, or are these two different states?

Is the anxiety more thought-driven or like a hyper-adrenergic state?

 

[Stagg737]

Depression while having anxiety over the unending state of the anxiety, or are these two different states?

Is the anxiety more thought-driven or like a hyper-adrenergic state?

From what I understood it was a constant state of treatment resistant anxiety which she was so sick of that she was getting SI and constant hopelessness. I know the anxiety was the major underlying issue. Not sure if it was thought driven or physiologic, but I believe it was probably a combination of both. I know my attending said she had about a dozen inpatient stays in the past couple years and had extensive out-patient treatment. He said he'd seen her in-patient quite a few times and that nothing they'd done seemed to even bring her anxiety below a 7 or 8 out of 10.

 

[birchswing]

From what I understood it was a constant state of treatment resistant anxiety which she was so sick of that she was getting SI and constant hopelessness. I know the anxiety was the major underlying issue. Not sure if it was thought driven or physiologic, but I believe it was probably a combination of both. I know my attending said she had about a dozen inpatient stays in the past couple years and had extensive out-patient treatment. He said he'd seen her in-patient quite a few times and that nothing they'd done seemed to even bring her anxiety below a 7 or 8 out of 10.

Not that long-term benzos are a good idea, but do they not work in the short-term?

Have they ever tried a beta blocker?

Was there previous medicine/drug use she was withdrawing from?

Or possibly anxiety/agitation from a combination of meds (serotonin syndrome)?

 

[Stagg737]

@birchswing

Not that long-term benzos are a good idea, but do they not work in the short-term?

They barely touched her. Brought her anxiety from a 9/10 to a 7. Even after being taken off of them for a week then restarted they barely did anything.

Have they ever tried a beta blocker?

Yep, no effect at all.

Was there previous medicine/drug use she was withdrawing from?

Possibly in the past, but when we saw her she wasn't withdrawing from anything. Tox screen was negative.

Or possibly anxiety/agitation from a combination of meds (serotonin syndrome)?

Definitely wasn't serotonin syndrome, but I guess it's possible she could have had some other medication involvement in the past.

When I was there we took her off all her meds, cleared her system, and restarted anxiolytics and nothing was working. She was there about 2 weeks. After a second week of claiming she wasn't having SI she ended leaving AMA because we wouldn't give her as high a dose of benzos as she wanted. She was very obviously still extremely anxious, but my attending had seen her inpatient several times before and said that was about as calm as she ever got.

 

[birchswing]

@birchswing

Not that long-term benzos are a good idea, but do they not work in the short-term?

They barely touched her. Brought her anxiety from a 9/10 to a 7. Even after being taken off of them for a week then restarted they barely did anything.

Have they ever tried a beta blocker?

Yep, no effect at all.

Was there previous medicine/drug use she was withdrawing from?

Possibly in the past, but when we saw her she wasn't withdrawing from anything. Tox screen was negative.

Or possibly anxiety/agitation from a combination of meds (serotonin syndrome)?

Definitely wasn't serotonin syndrome, but I guess it's possible she could have had some other medication involvement in the past.

When I was there we took her off all her meds, cleared her system, and restarted anxiolytics and nothing was working. She was there about 2 weeks. After a second week of claiming she wasn't having SI she ended leaving AMA because we wouldn't give her as high a dose of benzos as she wanted. She was very obviously still extremely anxious, but my attending had seen her inpatient several times before and said that was about as calm as she ever got.

Huh. Very interesting. And very sad for her.

I know with severe cases of OCD, they sometimes do psychosurgery. I wonder if that has any effect in a case like this, or if there's even any history of it being tried.

 

[Liquid8]

While I don’t believe any patient is “hopeless,” the issue of therapeutic nihilism is something that can set in, and it’s important for clinicians to be aware of this.

The patients I would often get nihilistic about were the rotating door ones who frequently have psychotic relapses due to never taking their medication consistently or being unable to abstain from using illicit drugs for long periods. Typically they lack sufficient insight, may fail to attend followup appointments, which results in community treatment orders and frequent involuntary admissions to hospitals usually with the assistance of the police and get discharged on depot medications. Soon after they get their day in court – in Australia we have mental health boards or tribunal. Some aspiring young legal aid lawyer convinces the board that the patient should be on the least restrictive treatment option. The depot injection gets changed to oral, they stop taking them, relapse, end up in hospital again etc. and the cycle continues.

It isn’t much in the way of quality of life and obviously frustrating for patients too. Even when relatively stable, these patients are managed in the public system which has a high turnover of staff. Their allocated doctor will usually rotate through and change every 3-6 months, which limits rapport and relationship building especially for chronic patients who have repeated their story to numerous clinicians.

Some of the reluctance of clinicians to engage with patients with eating disorders may stem from training experiences such as when rotating through Child Psych terms. Young patients with eating disorders can be especially frustrating: patients with anorexia nervosa often experience their symptoms as being ego-syntonic – i.e. their disordered behaviours are experienced as being congruent with their personality and they take pride in their ability to diet and lose weight which often makes for treatment resistance and little motivation to change their behaviours. These patients and their families require a lot of hard work if you use the Maudsley family therapy approach, and for solo clinicians this may not always be viable.

 

[Ceke2002]

While I don’t believe any patient is “hopeless,” the issue of therapeutic nihilism is something that can set in, and it’s important for clinicians to be aware of this.

The patients I would often get nihilistic about were the rotating door ones who frequently have psychotic relapses due to never taking their medication consistently or being unable to abstain from using illicit drugs for long periods. Typically they lack sufficient insight, may fail to attend followup appointments, which results in community treatment orders and frequent involuntary admissions to hospitals usually with the assistance of the police and get discharged on depot medications. Soon after they get their day in court – in Australia we have mental health boards or tribunal. Some aspiring young legal aid lawyer convinces the board that the patient should be on the least restrictive treatment option. The depot injection gets changed to oral, they stop taking them, relapse, end up in hospital again etc. and the cycle continues.

It isn’t much in the way of quality of life and obviously frustrating for patients too. Even when relatively stable, these patients are managed in the public system which has a high turnover of staff. Their allocated doctor will usually rotate through and change every 3-6 months, which limits rapport and relationship building especially for chronic patients who have repeated their story to numerous clinicians.

Some of the reluctance of clinicians to engage with patients with eating disorders may stem from training experiences such as when rotating through Child Psych terms. Young patients with eating disorders can be especially frustrating: patients with anorexia nervosa often experience their symptoms as being ego-syntonic – i.e. their disordered behaviours are experienced as being congruent with their personality and they take pride in their ability to diet and lose weight which often makes for treatment resistance and little motivation to change their behaviours. These patients and their families require a lot of hard work if you use the Maudsley family therapy approach, and for solo clinicians this may not always be viable.

I'm in South Australia, seen the revolving door system of which you speak with some friends I've known over the years. I remember one guy who used to hang out with a group of us up at the Adelaide Uni bar back in the 90s, cool bloke but very unstable without the right dose of meds. They finally did get him on the right dose of meds, he was placed under a treatment order for a year or so, was doing really well considering the severity of his symptoms, and then he decided he didn't need the meds anymore and got a lawyer to challenge his guardianship. He won the case, and two weeks later, while on a crystal meth binge, he suffered a relapse and committed suicide by train. But hey, score one for the big, bad guardianship board not being able to tell him what to do anymore. 🙄

The reluctance to engage with eating disorder patients, at any stage of the illness, is understandable. I certainly wouldn't expect, or want, a clinician to feel semi-forced to work in the field of treating eating disorders, especially if they don't feel they have the requisite training or experience. A situation like that is less than ideal both for provider and patient. One of the first counsellors I tried to engage with, albeit reluctantly, through CAMHS (many, many, many years ago now) was so clearly out of both her depth and comfort zone that to say the session didn't exactly go well would be an understatement. I could probably write a paper on eating disorder treatment options back then - 'The Treatment of Eating Disorders in South Australia in the 1980s: Wow What a Clusterf**k'

 

[feargift]

Huh. Very interesting. And very sad for her.

I know with severe cases of OCD, they sometimes do psychosurgery. I wonder if that has any effect in a case like this, or if there's even any history of it being tried.

Psychosurgery is not a treatment for OCD. The most effective treatments are a type of CBT called Exposure and Response Prevention, which has the strongest evidence supporting its use in the treatment of OCD, and/or a class of medications called serotonin reuptake inhibitors, or SRIs.

 

[birchswing]

Psychosurgery is not a treatment for OCD. The most effective treatments are a type of CBT called Exposure and Response Prevention, which has the strongest evidence supporting its use in the treatment of OCD, and/or a class of medications called serotonin reuptake inhibitors, or SRIs.

Are you saying it isn't a good treatment? I can't speak to that. But it definitely is a treatment. And there are other medications besides SRIs, Anafranil in particular, that are used for OCD.

Here are the first few Google results for OCD and psychosurgery—again, not saying it's a good or bad option, just posting this because I wanted to show that psychosurgery for OCD exists:

Treatment of obsessive-compulsive disorder by psychosurgery. - PubMed - NCBI

Brain Surgery Is an Option for Patients with Severe OCD

Treating Obsessive-Compulsive Disorder – OCD Treatment Options

PSYCHOSURGERY - Neurosurgical Service - Massachusetts General Hospital

 

[Ceke2002]

@birchswing

Not that long-term benzos are a good idea, but do they not work in the short-term?

They barely touched her. Brought her anxiety from a 9/10 to a 7. Even after being taken off of them for a week then restarted they barely did anything.

Have they ever tried a beta blocker?

Yep, no effect at all.

Was there previous medicine/drug use she was withdrawing from?

Possibly in the past, but when we saw her she wasn't withdrawing from anything. Tox screen was negative.

Or possibly anxiety/agitation from a combination of meds (serotonin syndrome)?

Definitely wasn't serotonin syndrome, but I guess it's possible she could have had some other medication involvement in the past.

When I was there we took her off all her meds, cleared her system, and restarted anxiolytics and nothing was working. She was there about 2 weeks. After a second week of claiming she wasn't having SI she ended leaving AMA because we wouldn't give her as high a dose of benzos as she wanted. She was very obviously still extremely anxious, but my attending had seen her inpatient several times before and said that was about as calm as she ever got.

Just curious, do you know for certain she was taking her medication, or that the ECT had absolutely no effect apart from the fact that she reported it having no effect? Like even when she was inpatient were any medications given to her IM or IV, or were they taken orally (and did anyone check if she was actually swallowing them)? I'm just getting the feeling, from knowing others who have done and claimed similar 'untreatable' states, that there may be at least some component of a personality disorder at work, perhaps the idea of illness as identity that they don't wish to give up so therefore 'nothing works on them'. I once knew an anorexic patient who was tried on almost every medication for severe depression with suicidal intent that's in the arsenal, none of them worked for her, no matter what the dosage, what it was augmented with, different combinations and whatever else - it all came up zilch in terms of relieving her symptoms. So she agreed to undergo ECT and in her case it worked where the medications apparently hadn't; I say 'apparently', because it turns out she wasn't taking any of her medications, she never had been, she wanted to 'prove' to her treatment team that ECT was the only course of treatment left to her because she considered it the less fattening option.

 

[Stagg737]

Just curious, do you know for certain she was taking her medication, or that the ECT had absolutely no effect apart from the fact that she reported it having no effect? Like even when she was inpatient were any medications given to her IM or IV, or were they taken orally (and did anyone check if she was actually swallowing them)? I'm just getting the feeling, from knowing others who have done and claimed similar 'untreatable' states, that there may be at least some component of a personality disorder at work, perhaps the idea of illness as identity that they don't wish to give up so therefore 'nothing works on them'. I once knew an anorexic patient who was tried on almost every medication for severe depression with suicidal intent that's in the arsenal, none of them worked for her, no matter what the dosage, what it was augmented with, different combinations and whatever else - it all came up zilch in terms of relieving her symptoms. So she agreed to undergo ECT and in her case it worked where the medications apparently hadn't; I say 'apparently', because it turns out she wasn't taking any of her medications, she never had been, she wanted to 'prove' to her treatment team that ECT was the only course of treatment left to her because she considered it the less fattening option.

She was compliant with medications, and apparently would ask if there was anything else she could try. There was probably some kind of personality aspect to it (definitely not cluster B though, surprisingly), but ECT and all medications other than benzos had pretty much no effect. Even benzos only took her from a 9 or 10/10 to a 7 or 8/10. Idk about her total history, but I know that she definitely was med compliant when I saw her. I'm still a student so my experience is limited, but she's by far the most "hopeless" case I've seen, and I've already seen some pretty rough cases.

Edit: Just wanted to add that this a patient that had compliance issues with medications and she legitimately wanted help, which is part of what made the case so much worse imo.

 

[birchswing]

She was compliant with medications, and apparently would ask if there was anything else she could try. There was probably some kind of personality aspect to it (definitely not cluster B though, surprisingly), but ECT and all medications other than benzos had pretty much no effect. Even benzos only took her from a 9 or 10/10 to a 7 or 8/10. Idk about her total history, but I know that she definitely was med compliant when I saw her. I'm still a student so my experience is limited, but she's by far the most "hopeless" case I've seen, and I've already seen some pretty rough cases.

I wonder if genetic testing would be of any help. It seems like it might not be given that she's already run the gamut with so many meds. Could have like a low functioning serotonin transporter gene where they need a higher doses of SSRIs, etc. But like I said, I guess those tests are more relevant when you haven't already tried every med anyway. Then there's the MTHFR thing where apparently some people (but more so with depression not anxiety) have a miraculous change once they start taking methylated folic acid. I'm probably getting into the head shakes arena (as in this is out-there alternative BS), but I'm seeing more info on gut bacteria and mental health, with probiotics helping somewhat and I even just saw a study on fecal transplants helping reverse anxiety in rats.

 

[Shikima]

There is no blood test to tell us what medication/medications are necessary to create a stable brain.

 

[singasongofjoy]

There is no blood test to tell us what medication/medications are necessary to create a stable brain.

No, there aren't- but there are some cases where tests to determine whether someone is a poor metabolizer of various types of meds can be helpful in treatment planing. Mostly I've heard about this in the context of people who need much lower than standard doses (e.g., a guy with ID who was found to be overly sensitive to dopamine agonists at my first residential rotation) although I also know of one case where the opposite argument was made, of someone metabolizing a drug (I can't remember which- probably either a mood stabilizer or antipsychotic) too quickly making the half life too short. Marked improvement when med was given more frequently. A relevant article that comes to mind: http://online.liebertpub.com/doi/abs/10.1089/cap.2000.10.27

 

[Shikima]

No, there aren't- but there are some cases where tests to determine whether someone is a poor metabolizer of various types of meds can be helpful in treatment planing. Mostly I've heard about this in the context of people who need much lower than standard doses (e.g., a guy with ID who was found to be overly sensitive to dopamine agonists at my first residential rotation) although I also know of one case where the opposite argument was made, of someone metabolizing a drug (I can't remember which- probably either a mood stabilizer or antipsychotic) too quickly making the half life too short. Marked improvement when med was given more frequently. A relevant article that comes to mind: http://online.liebertpub.com/doi/abs/10.1089/cap.2000.10.27

Metabolization of medication doesn't tell us how the brain will act/react to a foreign substance being introduced when changing brain chemistry.

 

[singasongofjoy]

Metabolization of medication doesn't tell us how the brain will act/react to a foreign substance being introduced when changing brain chemistry.

No, that's true. We were talking about two different things- sorry!. 🙂

 

[feargift]

There is no blood test to tell us what medication/medications are necessary to create a stable brain.

I believe he is referring to pharmacogenomics testing.

 

[Shikima]

I believe he is referring to pharmacogenomics testing.

And I am too stranger.