Pretest self-assessment question (answer at the end of the case)
What are some usual benefits of slow-release preparation medications?
A. Lower blood plasma levels often allow for less severe adverse effects
B. Extended half-life often allows for once-daily dosing and improved adherence
C. Cost is usually lowered as once-daily dosing is less costly to manufacture
D. Improved effectiveness over the parent immediate-release preparation
E. A and B
F. A, B, and C
G. All of the above
Patient evaluation on intake
44-year-old woman with a chief complaint of “being confused”
Many clinicians have issued several diagnoses and she presents for a consultation
Patient states that she has been “depressed and anxious as long as she can remember”
Psychiatric history
The patient reports chronic and relapsing MDEs throughout her life
At the initial visit, she feels minor to moderate amounts of depressive symptoms
– She admits to poor sleep, mood, interest, energy, concentration, and appetite
– She has increased guilt and worthlessness at times
– She denies any active suicidal thinking
There is no evidence of psychosis; however, she does seem to have dissociative spells during times of stress
She may have had one episode of hypomania, but this was poorly defined, and she was smoking marijuana and drinking alcohol at the time
– She has been completely sober for three years
The patient does not meet full diagnostic criteria for GAD, but does worry excessively when depressed
She has occasional panic attacks, but does not meet criteria for PD as these are often induced by interpersonal stressors
Admits to suffering from AN in her teens and early adulthood but has had no weight-related symptomatology in last two decades
Longitudinally, she admits to many dependent personality traits and borderline personality traits
– She admits to having abandonment, dependency, and control issues, impulsive self-destructive behaviors, anger management problems, and she tends to see things in an “all-or-none” manner
– The patient experiences idealization and devaluation in her relationships, and this pattern is also noted when she deals with medical professionals
The patient had one suicide gesture by way of a minor overdose approximately a month and a half prior to consultation
Denies any current suicidal symptoms
She has had two psychiatric admissions, one as a teenager and the other after the recent overdose noted here
Social and personal history
Graduated high school and college
Gainfully employed at times but developed many medical problems, which prevents her working now
She has relatively few friends and relies heavily on her significant other for support
Does not use drugs or alcohol now
– Sober for more than three years
– In college, she misused barbiturates for a short time
Medical history
This patient sees multiple medical providers and suffers from:
– FM
– Temporomandibular joint (TMJ) arthritis
– Hypothyroidism
– GERD
– Osteoporosis
– Migraine headaches
– Myofacial dystonia
– Pelvic floor dysfunction
Family history
Bipolar disorder in one aunt
MDD throughout her family
GAD in one aunt
Medication history
The patient reports that she has tried, with minimal sustained improvements
– Three SSRIs: sertraline (Zoloft) 200 mg/d, citalopram (Celexa) 40 mg/d, escitalopram (Lexapro) 20 mg/d
– An NDRI: bupropion-XL (WellbutrinXL) 450 mg/d
– An SNRI venlafaxine-XR (Effexor-XR) 225 mg/d
– Two antiepileptic medications used for anxiolysis: divalproex sodium (Depakote) 1500 mg/d, gabapentin (Neurontin) 1800 mg/d
Has never had a trial of MAOIs, TCAs, NaSSAs, SARIs, lithium, stimulants, or atypical antipsychotics (serotonin–dopamine antagonists [SDAs])
– Sometimes, the atypical antipsychotics are classified as SDAs as they simultaneously block 5-HT2A and D2 receptors
She has not maintained a euthymic state for more than two months in many years
Psychotherapy history
Many years of weekly, individual eclectic psychotherapy
Most recently was seeing a psychiatrist for combined weekly supportive therapy and medication management
There is no clear course of dedicated PDP, DBT, or CBT
Little to no response to these psychotherapeutic interventions is noted, but acknowledges that she seems to function better when involved in psychotherapy
Patient evaluation on initial visit
Patient has chronic depressive symptoms with comorbid personality disorder and many somatic symptoms, which she has experienced for many years
Initially, she seems to be more debilitated by her medical complaints
She has been compliant with medication management and psychotherapy
She brings a case of medical records with her to her initial appointment to make sure everything is covered adequately
She has good insight into her MDD and the need to treat her symptoms, but less so with regard to her personality traits and her somatic symptoms
She denies current side effects on her psychiatric medications but states that she is often sensitive to side effects overall
There is no evidence of misuse of her controlled medication
She has no liver or renal disease, is normotensive, and has a normal body habitus
Current medications
Psychiatrically, she takes
Medically, she takes
– Fentanyl transdermal (Duragesic) 12 mcg/h
– Levothyroxine (Synthroid) 125 mcg/d
– Omeprazole (Prilosec) 40 mg/d
– Ibandronate (Boniva) 150 mg/mo
– Eletriptan (Relpax) 40 mg/d as needed for migraines
– Odansetron (Zofran) 8 mg twice a day as needed for migraines
– Naproxen sodium (Naprosyn) 500 mg twice a day
– Onaboutulinumtoxin-A injection (Botox) 300 units as needed for muscle spasm
Question
In your clinical experience, would you suggest that this patient’s symptoms were?
Psychic and “all in her head”
Depression and anxiety based with somatic features
Personality based with much somatizing
Attending physician’s mental notes: initial evaluation
She has a lot of comorbidity
– Anxiety
– Maladaptive personality traits
– Distant substance misuse
– Many somatic and real medical issues
Failure to remit on any of previous treatments
These failures may not be alarming in that she is side-effect sensitive and some of these treatments were likely not for a full dose or adequate duration
Her multiple comorbidities will increase treatment resistance and lower her likelihood of remission even in the face of excellent psychopharmacologic care
She has not had a bona fide trial of PDP, dynamic deconstructive psychotherapy (DDP), or DBT
Prognosis is only fair unless better pharmacological therapy and psychotherapy occurs and is adhered to
However, she is very compliant with office visits, is personable, and seems more motivated for care at this point
Question
Which of the following would be your next step?
Increase the duloxetine (Cymbalta) to the full FDA dose of 120 mg
Increase the alprazolam (Xanax) to a higher, more effective dose for anxiolysis
Augment the current medications with another agent that has antidepressant properties
Augment the current medications with another agent that has mood stabilizing properties
Augment the current medications with another agent that has antipsychotic properties
Augment the current medications with another agent that has pain dampening properties
Change nothing and refer for more specific psychotherapy
Attending physician’s mental notes: initial evaluation (continued)
It is unclear whether this patient has had therapeutic trials on all medications, although some are well documented
Will need to build rapport, increase trust, and try to enhance adherence
Need to get to a good dose/duration for her current SNRI (duloxetine [Cymbalta]) as it has the ability to treat depression, anxiety, and neuropathic pain
However, there is concern regarding her suicidal thoughts from one to two months ago, which will need further exploration and a discussion about safety planning
She joined the practice already on higher doses of BZ use
– There is no current indication of any misuse, but up until a few years ago, she had some substance misuse and was addicted to mechanistically similar barbiturate sedatives decades ago
– Will need to continue to closely monitor and likely try to discontinue her controlled prescriptions over time
– She states that her current treatment has helped her anxiety by at least 50%
Meets many criteria for various personality disorders, but on the mild to moderate severity spectrum
– Will have to keep these dynamics in mind, again to improve rapport and medication adherence
Further investigation
Is there anything else you would especially like to know about this patient?
What about details concerning her dissociative spells or mood swings?
– She reports that she will just “zone out” when stressed
She will lose track of time
These episodes may last minutes to a few hours
She does not “wake” up in new or different places and there is no evidence of personality change
She cannot remember what she was thinking about during these times
She often has mood swings that go from euthymia to sadness, anger, or excessive happiness
Case outcome: first interim follow-up visit eight weeks later
Patient has decided to leave her current provider and attend sessions for psychopharmacology medication management in this setting
She has now additionally been placed on modafinil (Provigil) 200 mg/d and pregabalin (Lyrica) 150 mg/d by her rheumatologist to treat her fatigue and pain from FM
– The other medications (duloxetine and alprazolam) remain unchanged
She feels no better and acknowledges the same symptoms as upon the first visit
She is experiencing a bit more fatigue on the alpha-2-delta calcium channel blocking neuropathic pain medication, pregabalin (Lyrica)
She states that she has no major, compliance-limiting side effects thus far and there is no misuse of any of her current controlled medications
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