You Are Touching Your Face
This exercise is designed to test your comprehension of material relevant to this issue of Focus as well as your ability to evaluate, diagnose, and manage clinical problems. Answer the questions below to the best of your ability with the information provided, making your decisions as if the individual were one of your patients.Questions are presented at “consideration points” that follow a section that gives information about the case. One or more choices may be correct for each question; make your choices on the basis of your clinical knowledge and the history provided. Read all of the options for each question before making any selections. You are given points on a graded scale for the best possible answer(s), and points are deducted for answers that would result in a poor outcome or delay your arriving at the right answer. Answers that have little or no impact receive zero points. At the end of the exercise, you will add up your points to obtain a total score.
A 40-year-old woman sees you in your private practice. She arrives on time, is apparently overweight, and is dressed formally, and as she walks past you into your office you are hit by a cloud of strong, citrusy perfume and fresh cigarette smoke. She tells you she forgot to fill out the intake packet you provided her by e-mail because she was so busy arranging child care. You invite her to sit down and relax, and you explain to her that there are a few forms she will have to sign for legal purposes but that you’ll try to obtain as much background information as you can during the interview. She doesn’t look at you while she laughs nervously and reprimands herself for having forgotten to fill out and bring the intake packet.
Then she abruptly turns to you and explains that she meant to bring the packet but she left it on her kitchen table. She tells you that it was all filled out and “ready.” Again you explain that she will have to sign a few legal forms while she is with you. You ask her how many children she has. She looks at you quizzically. “I don’t have any children,” she tells you. “I have one younger sister and one older brother. They live in North Dakota, I think.” She laughs. “Actually, only my brother lives in North Dakota. He went up there for all of the oil.” She smiles, then opens her purse. “It’s in here somewhere,” she tells you. Then she snaps her purse shut and looks off to her right. After a long silence she sighs. “I take two milligrams of Xanax three times a day, 30 milligrams of Adderall three times a day, and I can’t sleep.” She laughs. “I know that’s just what you want to hear: I can’t sleep at all. I haven’t slept in months. It’s torture.” She smiles, and then opens her purse. “I have some old bottles in here. It’s for the ADD. I was tested when I was a little girl. I’m sure I have ADD, whatever it’s called these days.”
She breathes deeply, crosses her legs, uncrosses them, holds her stomach with her right hand, seems to freeze for a moment, and then sighs. “I have cancer,” she tells you. “I saw my GI doctor and he wants to run more tests. Do you want to speak with him?” She looks at you. “Really. I don’t care if you do. I did figure it out and I made the diagnosis myself. I have all of the symptoms. It’s ovarian cancer. It’s that or Crohn’s disease. I know you’re a doctor but sometimes doctors don’t know something. Well, you do, I’m sure.”
She explains she lives alone but she did care for her nephew before he moved in with his girlfriend. Again, she pauses, looks off to her right, seems to wait for a signal, then turns toward you and says, “They want me to live with my parents but they’re crazy. Is that okay to say? Crazy? I have PTSD.” She laughs. She tells you she has a therapist but he told her she needs to see a psychiatrist. “It’s all money,” she says.
Decision Point A
Given what you know about the patient and the behaviors you are witnessing, what is the most appropriate first step you should take in managing her care? Points awarded for correct and incorrect answers are scaled from best (+5) to unhelpful but not harmful (0) to dangerous (−5).
A1
To best help this patient, make sure she is in a safe and controlled environment so that you can call 911 and commit her to an inpatient psychiatric unit.
A2
Prescribe Xanax 2mg b.i.d. and Adderall 30mg b.i.d., and then tell her you need to obtain more information about her before you prescribe stronger doses of those two medicines since they are considered to be drugs of abuse.
A3
Do not prescribe any medication for her anxiety and ADD symptoms. Prescribe risperidone 2mg qHS because she is having difficulty sleeping and you are concerned about psychosis.
A4
To best help this patient, make sure she is in a safe and controlled environment; recommend a day treatment program to provide ongoing supportive care.
A5
Do not prescribe any medication.
Vignette Continues
You take the two empty prescription bottles. “These have your name and the drug, but they’re old,” you tell her. “Do you have anything more recent?” One was for dextroamphetamine-amphetamine 30mg t.i.d., the other for alprazolam 2mg b.i.d.
She takes the bottles from you and puts them into her purse. “I’m sorry,” she tells you, “I have the wrong bottles. The other ones are …” she looks off to the side, swallows, then looks at you. “My parents live here, but I don’t live with them. Can you imagine? They do help me out with money, but that’s it.”
You ask her if she uses drugs or drinks alcohol. “I used to drink a lot when I was younger,” she tells you. “I think I drank because I was depressed. I read that later, that people drink when they’re depressed. I don’t smoke pot. I know it’s legal here but I don’t like it. I smoked it once and that was it.”
You smile at her. “How many cigarettes do you smoke per day?”
“Oh, I smoke a pack a day. That’s it, though. I think I got that from my parents. Both of them smoke. A lot.” She asks you to explain what psychosis means. Then she asks you if you think she is psychotic. She twists her lips and holds her stomach. “I swear this is the worst pain I’ve ever felt.” She tells you her gastrointestinal doctor performed an ultrasound of her abdomen. “He told me I was fine, but I called it. I told him I diagnosed myself and that’s why I went to the hospital. They said it was my ovaries, not my appendix, and that I’d have to have surgery. I called it.” She asks you if she could have pain because she took birth control pills for many years. She tells you her parents started her on birth control pills when she was in high school. “Ever since then,” she tells you. She looks off to one side again and does not say anything.
“I’m not married, I don’t have any kids, but I was married to a guy for a few years. I’m glad that’s over. He tried to kill me with a hammer and I was lucky one of my friends stopped him. Then I was in a hospital. “
She tells you she has been hospitalized three or four times but says she can’t remember the names of the doctors. She tells you she was hospitalized because she tried to kill herself once but the other times were because she was depressed. She says she was on risperidone, olanzapine, quetiapine, gabapentin, sertraline, fluoxetine, venlafaxine, alprazolam, clonazepam, methylphenidate, and dextroamphetamine-amphetamine combination. She is unable to provide dates or dosages but states that “nothing worked.”
Decision Point B
Given what you know about this patient, what is your differential diagnosis?
B1
Schizophrenia
B2
Mood disorder with psychosis
B3
Schizophreniform disorder
B4
Schizotypal personality disorder
B5
Borderline personality disorder
Vignette Continues
The patient tells you that she was last in the hospital because she tried to kill herself, and at that time she was told that she has schizophrenia. She remembers she was put on strong medication, which made her very tired but also seemed to slow down her mind. She remembers she used to hear two different voices arguing with each other or telling her what she was doing. She placed a finger on her cheek and told you the voice would say, “You are touching your face.” She tells you she took this medicine for about a month and then stopped because “My brother tried to poison me.” She looks at you and says, “I know you think everything I tell you is crazy. It really happened. And the only thing that helps me is the Xanax. I’m out of it and I need more.”
Decision Point C
Given what you know about this patient so far, what would be your next steps in assessing her condition?
C1
The patient clearly has schizophrenia and needs to be taking antipsychotic medications.
C2
The patient clearly has schizophrenia and needs to be taking antipsychotic medications. From her description that the medication was strong and made her very tired and seemed to “slow down her mind,” you assume that the medication was given to her in a hospital setting and that it must have been olanzapine. You prescribe a month’s worth of olanzapine 5mg tabs and arrange for her to return to see you.
C3
You order the following laboratory values and studies: rheumatoid factor, antinuclear antibodies, erythrocyte sedimentation rate, vitamin B12, folate, Lyme disease titer, complete blood count with differential, Chem-7, liver function tests, thyroid-stimulating hormone, urinalysis, urine toxicology screen, CT scan of the head without contrast, and an electrocardiogram (EKG). You also obtain further history, including a family history of psychiatric illness.
C4
You assume this patient is at least prediabetic because she takes antipsychotic medications. In addition to prescribing an antipsychotic, you prescribe metformin.
C5
In addition to prescribing antipsychotic medication, you refer this patient to a day treatment program and arrange a follow-up appointment to reevaluate her medications in foue weeks.
Answers: Scoring, Relative Weights, and Comments
High positive scores (+3 and above) indicate a decision that would be effective, would be required for diagnosis, and without which 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 helpful nor harmful under the given circumstances. High negative scores (−5 to –3) 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.
This question reflects the initial problem of establishing a solid therapeutic relationship with the patient, while considering issues of safety. This patient has come to you for help and while it may not yet be clear how you will best achieve this goal, you attempt to balance your need to define this situation. You want to maintain mutual trust but also identify what you imagine are this patient’s barriers to her ability to participate in treatment.
A1
(–3) Your inclination to control what appears to be a confusing situation by placing this patient in a confined space may seem rational, but you have not been given any information to suggest she is a danger to herself, a danger to others, or gravely disabled. Subsequently, you may lose any chance of establishing a therapeutic alliance.
A2
(0) Your concern about withdrawal from a benzodiazepine or stimulant medication is not based on any current information. All you have is her telling you that she has taken these medications; there is no actual proof.
A3
(0) If this patient has a primary psychotic disorder, then treatment with an antipsychotic medication such as risperidone is indicated. It is also true that the side effects of risperidone include somnolence.
A4
(+3) This patient has suggested that her symptoms concern her, and her ability to provide a reasonable personal history is at best confused. You wish to help this patient best by placing her in a relatively confined day treatment program so other professionals have the opportunity to observe her over the course of many days.
A5
(+5) Not prescribing medication in this context is always a good approach.
Decision Point B
B1
(+3) This patient certainly appears to have schizophrenia, but you cannot be sure without first ruling out any possible general medical causes of her symptoms. Also, you do not have any clear understanding of the duration of symptoms to determine whether she has the illness or whether this is a prodrome of an illness.
B2
(+4) First you must evaluate her for any general medical causes (as in B1). You also have no clearly defined mood symptoms or indication of interaction with psychotic symptoms.
B3
(+5) First you must evaluate her for any general medical causes (as in B1). Although the symptoms of schizophreniform disorder are very similar to schizophrenia, without knowing the specific time course you cannot make this diagnosis. Schizophreniform disorder features the same criterion A symptoms (two or more of the following symptoms: delusions, hallucinations, disorganized speech, grossly disorganized or catatonic behavior, negative symptoms) with a caveat of their lasting approximately one month.
B4
(–3) Without more specific details regarding time courses, it is also fair to consider this patient’s symptoms to be the result of a personality disorder (in this case, from cluster A). However, without knowing more details about her specific functional decline or cognitive abilities, it is not possible to make this diagnosis. A fact in the patient’s favor is that she is not currently hospitalized.
B5
(–3) Without more specific details regarding time courses, it is also fair to consider this patient’s symptoms to be the result of a personality disorder. Borderline personality disorder is part of cluster B and can present very similarly to schizophrenia, but individuals demonstrate more ability to function. Psychosis occurs but more typically is related to periods of more significant stress.
Decision Point C
C1
(–5) Before you make any diagnosis, you must first rule out general medical causes of her symptoms. It is true that schizophrenia should be treated with antipsychotic medication.
C2
(–5) As above, you must first rule out any general medical causes of her symptoms. Although olanzapine is commonly used in psychiatric emergencies, you also cannot prescribe medications on the basis of a hunch.
C3
(+5) Medical conditions associated with psychosis include neurological, infectious, metabolic, oncological, and immunological processes, as well as alcohol and drug intoxication or withdrawal and vitamin deficiency. An official list of such diagnostic studies typically varies from doctor to doctor and from hospital to hospital. Commonly, however, many psychiatrists will order a complete blood count with differential, liver function tests, thyroid-stimulating hormone, urinalysis, and urine toxicology screen for most psychiatric patients to help rule out organic causes of psychiatric symptoms and to check organ function if medications are to be used. Ordering an EKG has become especially important because many of the antipsychotics (as well as other classes of psychoactive medications) affect cardiac conduction, often by widening QTc intervals. For younger, healthy patients with no known history of heart disease, obtaining an EKG is not as important as initially thought. Many neurologists would prefer an MRI scan for evaluating more temporally distant insults as well. Even though the yield for a positive result is quite low, most clinicians prefer to rule out a general medical cause to the symptoms no matter the cost because the results affect treatment decisions.
C4
(–3) Without any evidence, you cannot assume a person has a significant medical condition such as diabetes. However, the concurrent prescription of a drug like metformin along with an antipsychotic medication has become increasingly common. Antipsychotic medications have a reputation for causing significant weight gain, as well as insulin resistance and diabetes. Metformin also has been demonstrated to be useful in treating polycystic ovarian syndrome. In this case, however, although the patient’s story of cancer or Crohn’s disease is not definitive, she complains of significant abdominal pain. Side effects to metformin include abdominal pain and diarrhea.
C5
(0) The approach of prescribing an antipsychotic for the treatment of schizophrenia is definitely indicated, but you cannot be sure of this diagnosis for this patient at this time. In addition, referring this patient to a day treatment program, where professionals can monitor her to help establish a more definitive diagnosis, would be enormously helpful. Also, establishing a follow-up appointment helps you establish a more reliable therapeutic alliance. Without first ruling out general medical causes of her symptoms, this approach would likely be more harmful than helpful.
Resources
Caine ED: Clinical perspectives on atypical antipsychotics for treatment of agitation. J Clin Psychiatry 2006; 67(Suppl 10):22–31
Cicero AF, Tartagni E, Ertek S: Metformin and its clinical use: new insights for an old drug in clinical practice. Arch Med Sci 2012; 8:907–917
Conley RR, Buchanan RW: Evaluation of treatment-resistant schizophrenia. Schizophr Bull 1997; 23:663–674
Diagnostic and Statistical Manual of Mental Disorders, 5th ed. Washington, DC, American Psychiatric Association, 2013
Dubin WR: Rapid tranquilization: antipsychotics or benzodiazepines? J Clin Psychiatry 1988; 49(Suppl):5–12
Heres S, Davis J, Maino K, et al: Why olanzapine beats risperidone, risperidone beats quetiapine, and quetiapine beats olanzapine: an exploratory analysis of head-to-head comparison studies of second-generation antipsychotics. Am J Psychiatry 2006; 163:185–194
Miyamoto S, Duncan GE, Marx CE, et al: Treatments for schizophrenia: a critical review of pharmacology and mechanisms of action of antipsychotic drugs. Mol Psychiatry 2005; 10:79–104
Sadock BJ, Sadock VA: Kaplan and Sadock’s Comprehensive Textbook of Psychiatry, 8th ed. Philadelphia, Lippincott Williams & Wilkins, 2005
Information & Authors
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Published in print: Summer 2016
Published online: 13 July 2016
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Dr. Levine reports no financial relationships with commercial interests.
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