Tips and pearls

As in this case, sometimes treating the MDD often alleviates or lowers the impact of comorbid anxiety disorders

It is unclear then if the TRD is creating or driving the anxiety symptoms or if the agents used to treat the MDD treat the anxiety primarily as well

In treatment-resistant cases, aggressive psychotherapy may be helpful in both further symptom reduction and at least improving quality of life issues

Device-based neuromodulation treatments should always be considered in TRD

• – Introducing initial informed consent earlier in the course of TRD treatment as a later possibility likely keeps the shock of hearing about ECT, brain pacemakers, and brain magnets lower, and patients may be more accepting of these treatments when they are truly warranted (… pun intended)

Neuropsychiatric moment

Primer on Lyme disease

Causes, incidence, and risk factors

Lyme disease is caused by a bacterium (B. burgdorferi)

Ticks carry this bacterium and bite mice or deer, which become infected as an animal vector

Humans get the disease when bitten by an infected tick

• – Deer ticks can be so small that they are almost impossible to see

• – Many people with Lyme disease never even see a tick

The first case was reported in 1975 in Connecticut, and has spread to most of the northeast and now to some mid-Atlantic, mid-West, and Pacific coast states

Lyme disease is usually seen during the late spring, summer, and early fall

Symptoms

There are three stages of Lyme disease

• – Stage 1 is called primary Lyme disease

• – Stage 2 is called secondary Lyme disease or early disseminated Lyme disease

• – Stage 3 is called tertiary Lyme disease or chronic persistent Lyme disease

Not everyone infected with the bacterium becomes clinically ill

• – Most bitten patients do not develop the infection

• – If a person does become ill, the first symptoms resemble the flu and include

  • Chills

  • Fever

  • Headache

  • Lethargy

  • Muscle pain

• – There may be a “bull’s eye” rash

  • A flat or slightly raised red spot at the site of the tick bite

  • Often there is a clear area surrounding the center of the bite with another red ring beyond that

  • It can be larger than one to three inches wide

Symptoms in people with early infection and then later stages of the disease include

• – Fatigue

• – Low grade fevers, “hot flashes”, or chills

• – Night sweats

• – Sore throat

• – Swollen glands

• – Stiff neck

• – Migrating arthralgias, stiffness, and less commonly, frank arthritis

• – Myalgia

• – Chest pain and palpitations*

• – Abdominal pain, nausea*

• – Diarrhea

• – Sleep disturbance*

• – Poor concentration and memory loss*

• – Irritability and mood swings*

• – Depression*

• – Back pain

• – Blurred vision and eye pain

• – Jaw pain

• – Testicular/pelvic pain

• – Tinnitus

• – Vertigo

• – Cranial nerve disturbance (facial numbness, pain, tingling, palsy, or optic neuritis)

• – Headaches

• – Lightheadedness

Headache, stiff neck, sleep disturbance,* and problems with memory and concentration* are findings consistently associated with more chronic neurologic Lyme disease

Other symptoms associated with Lyme disease have been identified, although these have not been consistently present in patients

• – Numbness and tingling*

• – Muscle twitching

• – Photosensitivity

• – Hyperacusis

*Notice many of these symptoms are associated with DSM-5 diagnosed depressive and anxiety disorders.