Case outcome: interim follow-ups through nine months

The patient’s therapist makes contact and states that patient became increasingly suicidal due to social stress and was admitted to an inpatient facility with superficial wrist cuts

The inpatient psychiatrist calls to inquire about the patient’s previous psychotic history

• – None of which she exhibited in sessions, nor admitted to at initial evaluation

• – Patient currently states that she “feels like other people”

• – She will act like a “little girl” or an “angry big girl”

• – She is deemed to have dissociative identity disorder (DID) and placed on risperidone (Risperdal) up to 4 mg/d and these symptoms resolve while in the inpatient unit

Question

What would you do when the patient returns to your office?

Continue risperidone (Risperdal) despite its AAWG and relatively poor metabolic profile

Switch to a more metabolically friendly atypical antipsychotic

Refer to an appropriate therapist with experience reuniting dissociative personality alters

Discuss with the patient why she did not confide in you regarding her alter personalities

Attending physician’s mental notes: nine-month follow-ups

This is tough as somehow this dissociative process was missed in the initial presentation

The inpatient team has possibly undone rapport with this prescription and attempts to minimize this patient’s AAWG by using a metabolically unfriendly atypical antipsychotic

Wonder if the patient is actually depressed and psychotic instead of DID?

How can one tell dissociative symptoms from psychotic symptoms?

Dissociative symptoms often do not remit with antipsychotic treatment, but psychotic symptoms do!

Dissociative symptoms are often predated by childhood, or even more recent trauma, and may be associated with PTSD and borderline personality

Dissociative symptoms tend to be associated with time losses where patients may be unaware of their behavior or “wake up” in different places

Attending physician’s mental notes: interim follow-up, nine months (continued)

This patient has no clear trauma, PTSD, or personality disorder conditions after re-evaluation

She had a fairly robust response to the atypical antipsychotic

However, when interviewed, she stated that she was “hearing voices” of a little girl or a grownup girl and the voices were telling her to act in certain ways

She denied time losses and there were no reports, even on the inpatient unit, of her regressing, acting like a little girl or taking on a new distinct personality

Conclusion: she is not DID, but unfortunately in some ways has become more severely depressed and with psychotic symptoms

Her new atypical antipsychotic medication is effective, but will likely cause more weight-gain issues in the future

Case outcome and multiple interim follow-ups to 24 months

The patient does gain another 15 lbs, but the use of the atypical antipsychotic helps the depression resolve back to her baseline moderate levels, altough she still has the same residual vegetative symptoms

We agree to a washout of her ineffective medications and to “start over”

The TCA nortriptyline (Pamelor) is tapered off and she is titrated to 300 mg/d of the SNRI, desvenlafaxine (Pristiq)

Augmentation with tri-iodothyronine (Cytomel) is initiated in the hope of lowering her weight gain and finally treating her residual vegetative depression symptoms, as SNRI monotherapy is failing again

The risperidone (Risperdal) dose is also lowered as her psychosis associated with her depression has solidly remitted

Unfortunately, her depression and some minimal hallucinations return. Risperidone (Risperdal) is cross-titrated to the approved antipsychotic/antidepressant augmentation aripiprazole (Abilify) up to 30 mg/d

The SNRI plus thyroid augmentation plus atypical antipsychotic augmentation resolves her psychosis. Her depression returns to its partially responded, baseline state

After treatment now with SSRI, SNRI, TCA, stimulants, thyroid hormone, atypical antipsychotics, and an MAOI, the patient has not improved over her baseline partial response

She starts and completes a one-year course of dialectical behavior therapy (DBT) to improve her coping and stress management as these were felt to play a part in inducing her depressive psychosis

This helps alleviate social stress but she continues with her vegetative presentation

Develops orofacial TD on the atypical antipsychotic aripiprazole (Abilify) and it is systematically lowered

This time with the antipsychotic tapering off, there is no return of psychosis

ECT is offered for the residual symptoms, which is declined

She next agrees to lithium carbonate augmentation and is titrated to 1200 mg/d allowing for a therapeutic level of 1.1 mEq/l

Affective range changes from blunted to minimally constricted. Her motivation increases and she starts dating

She continues with low energy and poor concentration

This partial response is not at the remission stage but is now improved from her baseline at her first appointment

Currently, she takes

• – lithium 1200 mg/d, desvenlafaxine (Pristiq) 300 mg/d, metformin (Glucophage) 2000 mg/d, orlistat (Xenical) 360 mg/d, and ramelteon (Rozerem) 8 mg as needed for insomnia, which is transient

• – AAWG halted and she experienced a 10–15 lbs weight loss