Patient Management Exercise for Psychotherapy

Vignette

You are a psychiatrist in private practice. A 20-year-old male patient was discharged from the psychiatric inpatient unit at the local university hospital 5 days ago and was referred to you for follow-up. He had been hospitalized for 7 days after he was involved in a motor vehicle accident. In the field sobriety test, he registered 0.08 on the Breathalyzer, and he was cited for driving under the influence of alcohol. He had a court date set for his DUI in 2 weeks, and his attorney said he would likely be sentenced to 1 year of probation. When he was brought to the emergency department for treatment of a broken wrist and numerous lacerations, he announced that he was suicidal. After he received treatment for his injuries, he was transferred to the psychiatric emergency room, where he was evaluated and admitted for treatment of major depression with suicidal ideation.

According to his self-reported history, he had trials of fluoxetine, paroxetine, lithium, divalproex, haloperidol, olanzapine, risperidone, clonazepam, lorazepam, and possibly other medications that he is unable to recall. He was not very clear on how long he was on each medication, nor precisely why he stopped each one. He just said that the drug didn’t work, or said that it made him gain 30 pounds, or said “I have no idea.”

During his stay on the inpatient unit, he was combative with staff, and he had to be placed in the isolation room three times for 4-hour periods because of violent threats and an attempt to harm himself with a plastic utensil he had stolen from the dining room. On one occasion he banged his head repeatedly against the wall in the bathroom, creating a laceration that required three stitches. He was given a lorazepam taper for the first 5 days to protect against withdrawal symptoms, and he was given haloperidol injections during his outbursts. To treat his depression, he was given fluoxetine, titrated to 40 mg by the end of his stay. He was also started on 100 mg of trazodone at bedtime for insomnia.

By day 6 of his hospital stay, he had calmed down considerably, participated in groups, and expressed a great deal of remorse about his behavior. By day 7, he was considered safe from suicidal thoughts and well enough to be discharged.

He arrives early for his appointment with you. When he enters your office, you observe that he is dressed in a suit and his hair is meticulously groomed. He has a cast on his right forearm and wrist. He is very polite and appears calm.

He takes his seat and you begin the interview. He tells you that his father passed away 2 months earlier after a 5-month battle with a neoplastic blood disorder that was not diagnosed appropriately in the hospital. Although he is unable to provide any details, he says that mistakes were made regarding his father’s treatment in the hospital that may have contributed to his death. He tells you that the hospital’s vice president visited the family to offer his apologies.

He was very close with his father, and his death affected him deeply. He had moved 7 months ago from his family’s previous hometown to be with his father in the hospital. Before that he had been unemployed, living with his mother. He did not continue school after graduating from high school. At first he stayed with his brother, who attends the local university, and then moved in with his mother after she took an apartment close to the hospital. While his father was in the hospital, the patient began drinking vodka from a flask he carried. He said he would step into the bathroom frequently and take nips from the flask and go out to the parking lot to refill it; soon he was drinking a fifth of vodka per day. Before that, he had been sober for 1 year from alcohol dependence, which he started abusing at age 16, although he continued to smoke marijuana daily, which he had also started at 16.

He has been in several inpatient and outpatient substance rehabilitation programs. He had attended AA meetings in the past and found them very helpful, but his father’s illness caused him to relapse. He says that he has smoked marijuana consistently during the past 4 years, increasing the amount he smoked from one joint at night before bedtime to about a quarter ounce per week. He spent a great deal of time finding ways to obtain marijuana, and although he wanted to stop using the drug, he was unable to. “I was losing my memory,” he said, “and I lost the desire to do anything with my life.” He had frequent fights with his mother about his marijuana use: “She kept sticking me in rehab.” Since age 16 he has also abused crack cocaine, powder cocaine, LSD, psilocybin mushrooms, and γ-hydroxybutyrate (GHB). “Pretty much anything anyone had, I would do,” he says.

He did very poorly in high school, although he did manage to graduate, and he enrolled in a few classes at his local community college before his father was hospitalized. He did not complete the courses, however; he could not get himself to go to class for fear of what others thought of him, and then he moved to be with his father. You ask him what he considers to be his biggest issue, and he replies, immediately, “Anger.” He explains that since the age of 14 he has increasingly been involved in physical fights, many involving injuries: he has sustained broken bones, he has a torn tendon and nerve damage in one hand that limits his ability to use two of his fingers, and his left shoulder easily dislocates. He has an appointment with an orthopedic surgeon to correct the shoulder problem in 2 months’ time.

You ask about legal issues, and he tells you he was taken to juvenile court at age 14 for “setting the woods on fire. But that was because my neighbor used to dump gasoline back there—and I didn’t even have to pay a fine. They basically slapped my wrist.” He also admits to stealing a cordless nail gun from an equipment rental store and, with his friends, running around for a week “blowing out car tires” until his parents found the nail gun and made him return it.

You ask more about the anger issue. He says he has road rage, and he will follow drivers who are foreign, especially Chinese, and try to get them to pull over so that he can “beat the shit out of them.” He once tried to force the driver of a tractor-trailer to pull over because he thought the man had cut him off. He drives excessively fast and uses his headlights and car horn as he weaves through traffic. The feeling of rage comes over him instantly, and he feels he cannot stop it.

The anger also affects him in public places. Over the past 5 months, he has stayed at his mother’s apartment as much as possible, mostly because he is afraid of starting fights. He started taking basic reading and writing classes at the community college, which he managed to attend sporadically, though he often left early or didn’t show up at all because of this fear. He says he has no idea what people truly think about him, and he assumes the worst. He also says, “I really don’t know who I am. This bothers me.”

He tells you that he suffers extreme mood swings, and has since age 15. He describes two instances as a teenager when he felt his “engine run wild” for at least 10 days; his sleep decreased to 2–3 hours a night, and then he did not sleep for 3 days in a row. He felt euphoric during this time but denies having used drugs or alcohol. He remembers that he thought he could speak directly with God and that he was told he had a specific mission to bring happiness to his friends because the devil had found his family and was attempting to destroy them. He recalls being told by friends that it was difficult to understand what he was saying at the time, that his speech was “too fast” and “all over the place.” There are gaps in his memory, periods when he does not remember exactly what he was doing, but he recalls that he “freaked out” his friends for a while. “They were afraid of me. I guess I got up into their faces about God even though I was never religious.” He remembers being hypersexual during these times, cheating on a girlfriend with “at least three other girls, I don’t know.” He also started driving recklessly around the woods near his house, “doing doughnuts and trying to melt my tires, until the engine block cracked.”

He says he started using drugs after the second such episode because it helped calm him down. After the second episode, he recalls his first extreme depressive episode where he felt suicidal. He lost interest in his friends for a time and became isolated; he did not leave his house except to go to school, but he did not talk to anyone there. He says, “It was weird; I just didn’t care about anything any-more.” He did not eat regularly and lost about 20 pounds in 2 months. His sleep was disturbed by frequent awakenings, during which he would feel the need to get up and pace around the house. “I just felt hopeless. I couldn’t stop thinking about killing myself. I wasn’t even doing drugs yet. That came later. I forced myself to meet a friend who got me high, and that seemed to help. I started going out more just to get high. But I was tired all the time. It took all my energy just to go out to get high with this dude, and I didn’t even like him much.”

He attempted suicide at age 16 by overdosing on his father’s nitroglycerine tablets and drinking a pint of vodka. He has repeatedly had suicidal ideation, and he has a long history of self-mutilating behaviors that include slashing his wrists (although not with the intent to commit suicide), slashing his thighs, punching walls, and banging his head until it bleeds. He says that he is not currently suicidal and was not actually suicidal in the hospital; he had claimed he was in order to be admitted to the psychiatric inpatient unit because he felt that his anger was out of control.

His family had previously been more affluent. They lived in a lakefront house worth half a million dollars and had three boats, and his father bought him a brand-new truck for his 16th birthday. But 2 years ago his father sold the house because he had run up some $300,000 in debts, and a large portion of the proceeds of the house sale went to paying the debt. The patient has two brothers, one who has major depression that is being treated with an antidepressant. His mother also has bouts of depression and panic attacks, for which she takes an antidepressant and alprazolam; she has shared the alprazolam with the patient when he has been anxious and could not leave the house.

Until 5 months ago, he says, he was very outgoing, always had a girlfriend, had many other close friends (although they were drug users or dealers), and liked to go out to clubs. He has good relationships with his mother and his brothers. One of his brothers is homosexual, and the patient says this never bothered him, although he never completely understood why his brother turned out this way. His brother was accepted by his family when he “came out,” and this was never an issue. The patient’s “racism,” which he describes primarily in terms of anger at Asians and Arabs, is very recent. He typically had friends from different cultural and racial backgrounds. However, he never kept any friends for more than 1 or 2 years. “They would do something to piss me off, I don’t know. Then I just blew them off. The same with my girlfriends. I wanted to marry my first girlfriend, but then I cheated on her.”

Lately, since his father died, he has asked his mother to drive him back to the hospital where his father died so he can spit in the parking lot, find the doctor who treated him and punch him, or find the hospital vice president’s car and slash the tires. He has even thought about killing himself by jumping off the hospital roof. Because of his overwhelming grief over his father’s death and his often violent plans to “get back” at the doctors he believes were responsible, he and his mother have begun to fight more frequently, and she has threatened to kick him out of her house if he does not get help. They have stopped talking the way they used to, and he says he does not know how to talk to her anymore. He says he feels as if he is “about to snap” all the time, has difficulty concentrating and focusing, and is unable to read or even watch television without getting up and pacing, and his sleep is still disturbed with initial and middle insomnia.

Decision Point A

Given what you know about this patient, what is your differential diagnosis? (Multiple diagnoses are possible. +2 points for correct answers, −2 points for incorrect answers. Points also given for appropriate rule-outs, deducted for inappropriate rule-outs.)

Decision Point B

Create a problem list and name the five most relevant problems you would attempt to treat, in the order of their importance.

Decision Point C

Given what you know about the patient’s diagnoses from Decision Point A, would you consider pharmacotherapy in addition to psychotherapy? If so, why? In what sequence? If not, why?

Decision Point D

The patient enters an outpatient substance abuse treatment program and starts attending AA meetings daily. He wants to work on his anger issue with you. What psychotherapy or psychotherapies would best address this problem?

Decision Point E

What are the four modules taught in dialectical behavior therapy?

Answers: Scoring, relative weights, and comments

High positive scores (+3 and above) indicate a decision that would be effective and would be required for diagnosis, and without it, management would be negligent. Lower positive scores (+2) indicate a decision that is important but not immediately necessary. The lowest positive score (+1) indicates a decision that is potentially useful for diagnosis and treatment. A neutral score (0) indicates a decision that is neither clearly helpful nor harmful under the given circumstances. High negative scores (−5) indicate a decision that is inappropriate and potentially harmful or possibly life-threatening. Lower negative scores (−2 and above) indicate a decision that is nonproductive and potentially harmful.

Decision Point A

Axis I

Bipolar I disorder, most recent episode depressed: The patient describes at least two distinct episodes of mania as a teenager, including a distinct period of abnormally and persistently elevated and expansive mood lasting at least 1 week. During this time he felt as though he had a special mission, appointed by God, which represents grandiosity; he had a decreased need for sleep; he was reportedly hyperverbal and possibly pressured in speech; he had increased goal-directed activity; and he had excessive involvement in risky sexual behavior and reckless driving. The second episode was followed by major depression, during which he made a suicide attempt, was anhedonic, unintentionally lost weight, suffered insomnia, had feelings of hopelessness, had recurrent thoughts of death, and suffered daily fatigue. He has strong antisocial personality traits that by definition make it difficult to take his story at face value. Additionally, he comes from a dysfunctional family, and his father may have had bipolar disorder; there is a chance that much of his behavior is the result of having been spoiled and rich, with one experience at juvenile court that was dismissed, but otherwise few consequences as a teenaged boy. You might prefer to write “provisional” next to the diagnosis, since this patient’s presentation and history are so complicated that even with what seems to be a clear diagnosis of bipolar disorder, you are nevertheless unsure given his poor recollection. However, given his symptoms, treating him as if he has bipolar disorder would likely help him rather than hurt him.

His most recent episode is depressed.

Rule out substance-induced mood disorder: Despite the onset of bipolar I symptoms prior to his abuse of alcohol and drugs, it continued in the context of substance abuse. It is unlikely, however, given the more clear-cut diagnosis of bipolar I, that this mood disorder would have been diminished by the substance abuse. The latter is more likely a coping mechanism for the former.

Alcohol abuse: The patient engaged in a maladaptive pattern of drinking alcohol that worsened over a period of 6 months, including recurrent use despite the knowledge that it was hazardous and (given his driving under the influence) illegal, and continued use despite getting into fistfights, some of which were fueled by alcohol. He does not meet criteria for alcohol dependence.

Cannabis dependence: The patient developed tolerance to cannabis, used it in increasing amounts over several years, was unable to quit despite wanting to, spent a great deal of time obtaining the substance, felt that he had lost the desire “to do anything with my life,” and continued using marijuana despite understanding that he was suffering physiological and psychological consequences (losing memory, amotivational syndrome).

Rule out generalized anxiety disorder: Given the concurrent use of substances and alcohol, it is difficult to make this diagnosis. However, the patient does express excessive anxiety and worry, especially since his father’s death at least 6 months earlier. He is unable to control these symptoms and consequently drinks alcohol and uses drugs. He is excessively irritable, expresses an anger control problem and a desire to take revenge on the hospital and doctors where his father died, has difficulty concentrating, is “about to snap” all the time, and has a sleep disturbance. The stress is clinically significant, but it may be due to substance and alcohol abuse, which, although the criteria are clearly met for generalized anxiety disorder, does not satisfy the final diagnostic criterion, which is that the disturbance is not due to the direct physiological effects of a substance.

Rule out anxiety disorder not otherwise specified: The patient’s symptoms meet the criteria for generalized anxiety disorder more fully.

Rule out substance-induced anxiety disorder: This is the alternative diagnosis to generalized anxiety disorder, given the patient’s excessive drug and alcohol abuse. Although it seems that the patient developed these problems as a result of significant psychosocial stressors, the amount and frequency of his alcohol and substance abuse are significant. His symptoms prior to his father’s death were more obviously bipolar I disorder, and he had no difficulty in social situations except during major depressive episodes.

Rule out malingering: The possibility that he is malingering is unlikely, as he is an alcohol abuser, is cannabis dependent, has strong antisocial traits stemming from a likely previous conduct disorder, and has current mood instability. These psychiatric conditions are not likely by intention for secondary gain. In this case, the secondary gain would be to stay out of jail for his DUI offense, as he assumes that he will be placed on probation. The patient was not referred by the courts or an attorney but by the hospital, and he came to you on his own for help. There is no discrepancy between his claimed stress or disability and objective findings. He is cooperative, and the likelihood of antisocial personality disorder is in the differential. These criteria suggest that malingering is unlikely.

Rule out adjustment disorder: This patient has had emotional and behavioral symptoms that were possibly exacerbated by identifiable stressors, such as the loss of his previous high standard of living and the loss of his father, but the stress-related disturbance better meets criteria for bipolar I disorder or any of the substance-induced mood disorders.

Axis II

It is too early to make a diagnosis of a personality disorder, especially in the context of a more obvious axis I diagnosis. Also, it is not in the patient’s interest or helpful to the treating physicians to label him, for example, as having borderline personality disorder at this point, given the stigma that accompanies this diagnosis.

Rule out antisocial personality disorder: The patient does exhibit a pervasive pattern of disregard for and violation of the rights of others by his assaulting people, chasing other drivers on the highway, impulsivity, irritability and aggressiveness, reckless disregard for the safety of himself and others, and setting the woods on fire at age 14. He also engaged in reckless disregard for the property of others by stealing a nail gun and damaging the car tires of strangers.

Rule out borderline personality disorder: The patient has a pattern of unstable and intense interpersonal relationships, switching friends almost yearly, then “blowing them off” when they “piss him off.” He reports that he does not know what people think of him and he does not understand himself, which suggests an identity disturbance. He has impulsivity as described above, involving sex, substance abuse, and reckless driving. He has had recurrent self-mutilating behaviors, affective instability, inappropriate, intense anger and difficulty controlling his anger, and some possibly stress-related paranoid ideation.

Rule out histrionic personality disorder: He has been inappropriately sexually seductive and provocative, cheating on his girlfriend, acting out hypersexuality; has rapidly shifting and shallow expression of emotions; and comes to his appointment dressed in a suit.

He does not exhibit substantial symptoms of narcissistic personality disorder.

Note: Many of these symptoms are confluent with bipolar disorder and the various substance-related disorders, so a diagnosis of a personality disorder is not necessarily accurate. The traits may exist or may have existed prior to the onset of the axis I disorder, such as setting the fire at age 14, which is suggestive of conduct disorder. However, since the picture is so complicated by the more clear diagnosis of bipolar disorder and the overwhelming influence of drug and alcohol abuse, these traits may represent exaggerations of personality styles.

Decision Point B

The purpose of this section is to help you consider how to approach a patient with such a complicated presentation, given all the treatment modalities in your armory. There are no perfect solutions, just some that may be more effective than others.

Although this patient’s symptoms meet criteria that would categorically assign his problems into a more convenient array of DSM-IV-TR diagnoses, it is useful to think of the individual’s problem list separately. After careful consideration of the patient’s biological factors, psychosocial factors, and motivation as well as your resources, including the time you have to spend with him, you must somehow reach a working strategy for how best to help him. There will inherently be variability according to the practitioner’s own experience with each of these issues or with combinations of these issues. There are regional differences in the way psychiatrists and therapists approach dual-diagnosis patients. Some advocate a harm reduction approach, whereas others insist on sequencing treatment (under the assumption that, for example, the depression cannot be addressed until the substance use is under control). There is no evidence that one strategy is significantly superior to another.

For example, whether to treat the drug and alcohol addictions before beginning treatment of any other issues is the standard of care for some clinicians, while treating both at the same time works well for others. The idea behind the former is that you cannot understand what the underlying psychiatric conditions are until you remove the confounding interference of mood-altering substances and alcohol. At that point, many would argue, the mood disorders or other symptoms might abate, rendering their treatment redundant.

However, others find that the reason for discriminating between diagnoses—and in fact calling them dual diagnoses—is that there are now two problems to treat, no matter which one came first. For the purposes of this particular exercise, there are multiple correct answers, although points are deducted for misdiagnoses. This patient has numerous issues that need treatment, and much more data must gathered. Because of the nature of his potential diagnoses, the symptoms he admits to, the manner by which he presents, the possible undiagnosed conduct disorder as a teen and now the potential for antisocial personality disorder, and his needing you for legal purposes if he is on probation, you must be skeptical of everything he says.

Decision Point C

Decision Point D

This patient’s alcohol abuse and cannabis dependence must be addressed at the beginning. You will not be able to work on anything else with him until he is sober. Additionally, given your limited knowledge of his previous psychopharmacotherapy trials, you do not know enough to judge whether he will respond to a different agent, whether he did not have adequate trials of the medications he tried in the past, or whether his use of drugs and alcohol made any previous psychopharmacotherapy trials irrelevant.

With this patient, you have to build trust, develop a rapport, and establish a solid working therapeutic relationship, or else you will undoubtedly fail no matter what you try. He has been manipulative in the past and is very possibly being manipulative right now, since he needs to be involved in therapy for legal reasons; given his antisocial traits, you cannot completely trust what he says. You have to give him the impression that you respect him to a degree but that your respect has its limits. He must feel that he is working with you, not for you, and that he is not doing things just because you tell him to. Jumping straight into more structured cognitive behavior therapy-type exercises will be lost on him until he decides he can and wants to work with you. At that point, cognitive behavior therapy or dialectical behavior therapy would be excellent choices for working with his anger issues.

The following is a helpful way of summarizing the different psychotherapy modalities.

Dialectical behavior therapy: This is good therapy for just about anyone. However, it is especially suited to patients whose coping skills are damaged in very basic ways. It is also good for patients who do not have a great deal of insight. It entails learning how to feel, how to emote, how to react, how to trust, and how to cope with feelings with a larger palette of emotions and responses. The therapy includes homework in which newly learned skills and coping strategies are practiced.

A dialectic involves understanding the opposing perspectives of a thesis and an antithesis with the purpose of creating a synthesis that is more adaptive. In the case of dialectical behavior therapy, the thesis may be the “emotional mind,” the way the patient feels. The antithesis is the “rational mind,” or the facts surrounding the circumstances—often what the patient experiences as a crisis—that brought about the emotions. The synthesis represents the middle ground where the patient learns to use the emotions, combine them with his or her understanding of the facts, and develop a more adaptive strategy for thinking about the circumstances that brought on the crisis. Dialectical behavior therapy addresses the negative environment felt by the patient with careful, empathic validation techniques and helps the patient regulate his or her emotions, have more meaningful and understandable relationships with others, and tolerate the stressors that are inherent in the patient’s world.

Cognitive behavior therapy: This therapy requires patient participation; homework is an important component. The patient may have to write things or try things. The patient should have some insight and the determination to make changes. Cognitive behavior therapy can be adaptable to many problems and is good for all types of patients. It may involve exposure and desensitization, techniques for addressing one’s fears and anxieties, and then practicing greater mastery of them through more rational thoughts and behaviors. Cognitive behavior therapy can be seen as a supportive psychotherapy, supporting the ego. Mastery of anxiety and depression comes when the ego is strengthened to deal more effectively with situations previously perceived as dangerous—that is, as new skills are learned, the ego can better differentiate distortions. From a behavioral perspective, there is a delinking of affect from various situations so that, for example, by your 1,000th exposure to heights, you are not anxious about, but are now indifferent to, being on the 10th floor.

Interpersonal therapy: In this approach, depression is theorized to stem from one or more typical issues: a role transition, loss of a loved one, loss of a relationship. The issue is postulated to be the cause of the depression. It is a short-term therapy where the end is always in sight. It makes use of dynamic theories for the therapist, but no interpretations are offered as they would be in psychodynamic therapy.

Psychodynamic therapy: This approach requires higher-functioning patients who have good object relations, good superego function (a conscience), good impulse control, as well as the time and money for intensive psychotherapy. These patients do not require direct interventions. The therapy is directed toward understanding why they got to this particular place in their mental or emotional life; by understanding themselves better, they can move past it. Freud talked about making behavioral interventions with his agoraphobic patients in order for their dynamic therapy to proceed.

Supportive psychotherapy: This is psychotherapy that supports “ego function”—building up a patient’s trust in you and in him- or herself, building ego strength, validating feelings, building a working alliance, and helping the patient through a difficult time with listening, advice, and validation. Much of it is “being there” for your patient. There are techniques that are specific to supportive psychotherapy but that also spill over into many other forms of therapy. Thus, techniques such as clarification, encouragement, suggestion to elaborate, empathic validation, advice, and praise are used not only when doing supportive therapy but in doing all “higher” forms of therapy as well.

Decision Point E