, a personality disorder or both?

, a personality disorder or both?

Case 2: Volume 1, Case #7: The case of physician do not heal thyself

PATIENT FILE 69 The Case: The case of physician do not heal thyself The Question: Does the patient have a complex mood disorder, a personality disorder or both? The Dilemma: How do you treat a complex and long-term unstable disorder of mood in a diffi cult patient? Pretest Self Assessment Question (answer at the end of the case) Frequent mood swings are more a sign or symptom of a mood disorder than they are of a personality disorder A. True B. False Patient Intake • 60-year-old man • Chief complaint is “being unstable” • Patient estimates that he has spent about two thirds of the time over the past year being in a mixed dysphoric state and about one third as depressed, but waxing and waning every few days, or even every few hours Psychiatric History: Childhood and Adolescence • As a young child, had symptoms of generalized anxiety and separation anxiety • Also, as a child, remembers “emotional trauma” from mother, herself with recurrent episodes of either unipolar or bipolar depression who was often physically unavailable because of hospitalizations, or emotionally distant when depressed at home • Has had a lifetime of multiple turbulent interpersonal relationships since childhood, with family members, with friends and especially with women • As an older child and adolescent, continued to have not only subsyndromal generalized anxiety but developed at least subsyndromal levels of OCD with ruminations, checking and rigidity • He was told these were good traits and would make him a good student, which he was, with good grades through high school and college, gaining admission to medical school Psychiatric History: Adulthood • Diagnosed as major depression for the fi rst time at age 23, early in medical school – Was his worst depression so far, as other depressions previously Downloaded from http://stahlonline.cambridge.org by IP 192.168.60.239 on Wed Jun 14 08:38:53 BST 2017 Stahl’s Essential Psychopharmacology Online © 2017 Cambridge University Press. All rights reserved. Not for commercial use or unauthorized distribution. PATIENT FILE 70 characterized as unhappiness and transient depressed moods of a few days duration and with more anxiety than depression, improving without treatment – Actively suicidal and overdosed on his medications at this time but recovered – In retrospect, patient believes that he has long experienced rejection sensititivity with up to 2 depressive episodes per year since age 16 up to the present • No clear history of any full syndromal manic or hypomanic episodes • Since age 23, however, has had many episodes lasting a week or more of irritability, infl ated self esteem, increased goal-directed work activity, decreased need for sleep, overtalkativeness, racing thoughts, psychomotor agitation and risky behavior; could also experience euphoria or expansiveness to a signifi cant degree but only for 2 or 3 days at most and usually shorter • He interpreted these as good traits, indicative of creative persons, and were the reason he was productive as well as creative • In getting his history, it is not clear whether he has had an irritable dysphoric temperament since childhood, a superimposed episodic subsyndromal dysphoric mixed hypomania, or both • First marriage ages 32–33 – Depressive episode and overdosed again when fi rst marriage broke up • Second marriage between 35 and 36 – Another depressive episode after breakup of this marriage • Third marriage ages 46 to 58 – Another depressive episode after breakup of this marriage Medication History • Starting with his fi rst diagnosed episode of depression in medical school, treated off and on with TCAs and benzodiazepines, starting and stopping them over many years in relationship to his symptoms • First received lithium at age 43, 17 years ago • Unclear whether this was an augmentation strategy for resistant depression or for bipolar spectrum symptoms • Was not that helpful according to the patient • States he has had many, many medication trials since then • Valproate (Depakote) not tolerated • Clonazapam (Klonopin) helped sleep • Oxcarbazapine (Trileptal) caused dysphoria and agitation • Verapamil caused/worsened depression • Risperidone (Risperdal) caused depression • Fluoxetine (Prozac) caused rapid fl eeting relief of depression, but also insomnia and headache Downloaded from http://stahlonline.cambridge.org by IP 192.168.60.239 on Wed Jun 14 08:38:53 BST 2017 Stahl’s Essential Psychopharmacology Online © 2017 Cambridge University Press. All rights reserved. Not for commercial use or unauthorized distribution. PATIENT FILE 71 • Other SSRIs caused activation and were not tolerated and discontinued after a few doses • Presents now only taking methylphenidate (Ritalin), which he prescribes for himself as he does not think his physicians know as much about his case, or what he needs, as he does and they will not prescribe it for him Social and Personal History • Married and divorced 3 times, currently single • No children • Non smoker • No drug abuse, rarely drinks • Physician and successful businessman Medical History • Crohn’s disease Family History • Father: sleep disorder • Mother: either bipolar or unipolar depression, unsure, but successfully treated with ECT • Maternal uncle: depression • Maternal aunt: depression • Maternal grandmother: hospitalized for “manic depressive disorder” Current Medications • Azothiaprine and Remicaid for Crohn’s • Methylphenidate Based on just what you have been told so far about this patient’s history what do you think is his diagnosis? • Recurrent major depression with an anxious/dysphoric temperament • Bipolar II depression • Bipolar II mixed episode • Bipolar NOS • Bipolar NOS superimposed upon a personality disorder (narcissistic, borderline, other) • Primarily a cluster B personality disorder (antisocial/histrionic/ narcissistic/borderline) Downloaded from http://stahlonline.cambridge.org by IP 192.168.60.239 on Wed Jun 14 08:38:53 BST 2017 Stahl’s Essential Psychopharmacology Online © 2017 Cambridge University Press. All rights reserved. Not for commercial use or unauthorized distribution. PATIENT FILE 72 Attending Physician’s Mental Notes: Initial Psychiatric Evaluation • Here is a case that could be a complex combination of a mood disorder plus a personality disorder in someone who has never experienced mania and probably has never reached the threshold of experiencing unequivocal hypomania as defi ned by DSM IV or ICD10 • It is very diffi cult to separate the mood disorder from the personality disorder in a one hour initial evaluation session, plus looking at the medical records • A complete diagnosis will have to await spending more time with the patient, and if possible, having access to the input of other observers as well • However, seems likely that there is more to this case than a mood disorder, and probably cluster B personality traits if not personality disorder is comorbid How would you treat him? • Continue his methylphenidate • Discontinue his methylphenidate • Start an antidepressant • Restart lithium • Start an anticonvulsant mood stabilizer • Start an atypical antipsychotic • Make sure he agrees to weekly insight oriented psychotherapy • Consider psychoanalysis Attending Physician’s Mental Notes: Initial Psychiatric Evaluation, Continued • Since the patient lives in another city, psychotherapy will have to be an option via another mental health professional, although some supervision of that plus advice on medications can be possible as a consultant • The patient is open to pursuing psychotherapy as long as he respects the therapist • Before recommending psychopharmacologic treatment, it would be good to review what we know from the available history about his response to medications already taken • As shown from the history of this case, it can be impossible to determine with great accuracy the effects of the medications by taking a history. One should be skeptical of the information as it can be unreliably reported in records and by a patient because it is complex and the medication effects can be subtle Downloaded from http://stahlonline.cambridge.org by IP 192.168.60.239 on Wed Jun 14 08:38:53 BST 2017 Stahl’s Essential Psychopharmacology Online © 2017 Cambridge University Press. All rights reserved. Not for commercial use or unauthorized distribution. PATIENT FILE 73 – How many medications were taken long enough to have had a chance to work? – Did some medications provoke mood instability while others stabilized mood? – If the person has a mood disorder with an underlying personality disorder, will medications treat only the mood disorder and expose the symptoms of the personality disorder, or – Will treating the mood disorder with medications allow the patient to recompensate and thus have improvement not only in mood but in personality disorder symptoms? – These questions are better answered if you live the ups and down along with the patient and experience the signs and symptoms of such a patient in real time – However, the real question is what can you do to help such a patient and what are the realistic goals of treatment – Finally, is treatment defi ned as medications, insight oriented psychotherapy, or both? • About the only thing solid here is that antidepressants seem to be provocative at times in terms of causing activation and thus should be given cautiously and only concomitantly with mood stabilizing medication • Has taken numerous mood stabilizing medications that he reported cause depression, especially those that are used to treat mania • He has a demanding job and is not willing to put up with much sedation and will not accept weight gain • It is possible that he is a bipolar spectrum patient with more depression than mania and with more pure depressive states alternating with mixed states of dysphoria/irritability superimposed upon depression, but not full syndrome mixed bipolar disorder • Thus he has four needs” – Treat from “below” (i.e., antidepressant) – Stabilize from “below: (i.e. prevent cycling into depression) – Treat from “above” (in his case, not to treat euphoric mania, but to treat irritability) – Stabilize from “above” (i.e. prevent cycling into mixed states of dysphoric/irritable depression) • Highly unlikely that this will be possible with a single agent • For now, decided to avoid an antidepressant and to stop the methylphenidate which may help depression but at the expense of destabilizing him and causing cycling into irritable mixed states • For now, a low side effect mood stabilizing agent with antidepressant and maintenance potential (i.e., treating from below and stabilizing from below) such as lamotrigine seems to be a good bet Downloaded from http://stahlonline.cambridge.org by IP 192.168.60.239 on Wed Jun 14 08:38:53 BST 2017 Stahl’s Essential Psychopharmacology Online © 2017 Cambridge University Press. All rights reserved. Not for commercial use or unauthorized distribution. PATIENT FILE 74 • After this is given, might consider adding lithium which he has tolerated in the past although unclear what therapeutic actions it had for him; however, might treat and stabilize him from above in synergy with lamotrigine for a total therapeutic picture Case Outcome: First Interim Followup, Week 12 • Patient fl ies back for a followup appointment 3 months later • Has stopped methylphenidate and his psychiatrist in his home city started lamotrigine by slow upward titration, but a bit faster and to a higher dose than recommended and now taking 400 mg/day • Mood stabilized but at a level of low grade consistent depression with decreased libido and sexual dysfunction • Told to reduce lamotrigine to 200 mg and wait another month or two because it can take a while yet for lamotrigine’s antidepressant effect to kick in and its mood stabilizing effects may have already started Case Outcome: Second Interim Followup, Week 16 • Phone consultation • Learned that the patient decided that lamotrigine was making him depressed and ruining his sex life, so discontinued it and completely relapsed in terms of depression • Patient agrees to restart lithium after blood and urine tests from his physician Case Outcome: Third, Fourth, and Fifth Interim Followup Visits, Weeks 20, 24 and 28 • Phone consultations • Patient has normal labs and starts lithium at week 20 only has a blood level of 0.4, so told to increase dose • At week 24 calls and states that higher doses give him unacceptable diarrhea and exacerbates his Crohn’s disease symptoms, so he is back down to the low dose of lithium • Also, restarted methylphenidate as needed for dysphoric mood and low energy • Told to increase his lithium again, more slowly and not to 1800 mg/ day which caused diarrhea but only to 1500 mg a day or 1500 mg alternating with 1800 mg/day on alternate days and to stop his methylphenidate • Also told to restart lamotrigine titrating up to only half his previous dose, namely 200 mg/day with the strategy that both drugs together would allow him to take each in lower tolerable doses for him, yet working together to add their therapeutic effects Downloaded from http://stahlonline.cambridge.org by IP 192.168.60.239 on Wed Jun 14 08:38:53 BST 2017 Stahl’s Essential Psychopharmacology Online © 2017 Cambridge University Press. All rights reserved. Not for commercial use or unauthorized distribution. PATIENT FILE 75 Case Outcome: Sixth and Seventh Interim Followup Visits, Weeks 32 and 36 • Brief phone consults with the patient and his psychiatrist on the phone together • Getting regular psychotherapy “whatever” • Monitored by his local psychiatrist monthly face to face appointments • Lithium level 0.7, occasional tremor and diarrhea but mostly tolerable • Mood is stable and overall “feels much better” Case Outcome: Eighth Interim Followup, Week 40 • Emergency phone call • Can’t get a hold of his psychiatrist where he lives • Patient calls from a football stadium where his alma mater is playing in a big football game • “I’m in trouble” • Patient states he has been much troubled recently about always feeling somewhat dysphoric, not really worse recently, but just tired of never being “well”

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