Monday
Starting the week with a call night, I was summoned to the hospital to admit a partner's patient. A 14-year-old, KD, earlier had made a suicide gesture—swallowing 20 dextroamphetamine tablets. It seems that her mother had been planning a weekend getaway with her girlfriends and the daughter was miffed at being left out of the fun. What made this case a little more interesting was the teenager's uncontrollable and inappropriate laughing. I spoke with her neurologist who filled me in—KD has a hypothalamic hamartoma, which causes precocious puberty and gelastic seizures. When she is not taking her valproate, she laughs hysterically and inappropriately. It is really something to see. Unfortunately, there are also significant behavioral syndromes associated with the disease, and KD is in counseling for those already. In fact, after she finishes her charcoal cocktail, she has some more counseling coming to her. I encouraged Mom to take her trip and let Dad take over.
Tuesday
Today, BG came in for follow-up of a dosage change. BG, who had been on venlafaxine for a couple of months, called last week saying he felt like “electric shocks are zapping my head left and right.” He had been on 225 mg for a month, so I thought it strange that any adverse effects of a dosage increase would take so long to occur. We dropped him back 75 mg, and his symptoms went away—sort of. In actuality, today, he confessed that he had tried to stop his medication suddenly last week, and now, he realizes that his dysphoria may have been part of a discontinuation syndrome. I suppose I need to work on my mind reading now, since that one slipped by me. At least he is doing well on his current dose.
Wednesday
RY is a 24-year-old woman that reads from the “my life is perfect so why am I crying all the time?” script. Despite her mother's history of depression, she was very resistant to starting pharmacotherapy. As luck would have it, she has not responded to increasing doses of an SSRI. Anxiety and insomnia have been prominent in her symptoms, so today we are trying a class switch to mirtazapine. I hope we get some response soon. I feel I may be losing some credibility with her.
Thursday
In light of current events, the next case was not one to which I was looking forward. A 16-year-old adolescent, whose family I have been seeing for a year or so, came in today accompanied by his mother. PW was wearing a black t-shirt that read, “The voices are talking to me now.” That apparently was one of his complaints (No really, he says … all he hears is Mom).
This “A” student has a long history of interaction with the psychiatric community. His parents divorced and his mother remarried when he was 6. At that time, his teachers thought he had ADD. He was placed on stimulants and nothing changed. He became very rebellious and learned how to manipulate the family to suit his needs, frequently mentioning suicide. He then embarked upon a course of visits with many professionals, including a week-long stay at a psychiatric hospital. This was 2 years ago, and at the time, Mom was told, “He is just a very intelligent manipulative child who knows the buzz words that get the medical community to move.” Mom is at wit's end.
Today, he presents himself as a loner, declaring he has low self-esteem. He states that he has thoughts about death, but that he is too smart to hurt himself or anyone else. He says all of this almost with braggadocio. Interestingly, 2 years ago he was treated with paroxetine, which, in Mom's words, “Just made him more obnoxious.” Additionally, his father was diagnosed as bipolar last year. Throughout the interview, Mom refers to the similarity of the “cycles of moods” between PW and his father. Mom has checked the garage for incendiary devices.
After careful review and discussion with Mom, our plan is this. Since I have developed a rapport with PW (i.e., he has a little less disdain for me than previous doctors), we will try a course of bupropion with the intent of restarting some extensive counseling. The psychologist we use is affiliated with a psychiatrist with whom I frequently work, so a “hand-off” could be smoothly done if necessary. I am looking forward to his follow-up visit.
Friday
Oh, I feel vindicated! I received a letter today regarding an elementary school child that I refused to start on stimulants without formal testing. The child is dyslexic and has been enrolled in classes to help him cope with his disability. I like it when good news comes on Fridays.
Footnotes
Editor's note: Dr. Wolff is a board-certified family physician in private practice in Huntersville/Davidson, North Carolina. He finished his family practice residency in 1997. He has graciously consented to share stories from the trenches of primary care. While his practice diary is taken from actual patient encounters, the reader should be aware that some medication references may represent off-label uses. We at the Companion are certain that these vignettes will inform, entertain, challenge, and stimulate our readers in their effort to address behavioral issues in the everyday practice of medicine.