Psychotherapy history

Many years of weekly, individual eclectic psychotherapy

Most recently was seeing a psychiatrist for combined weekly supportive therapy and medication management

There is no clear course of dedicated PDP, DBT, or CBT

Little to no response to these psychotherapeutic interventions is noted, but acknowledges that she seems to function better when involved in psychotherapy

Patient evaluation on initial visit

Patient has chronic depressive symptoms with comorbid personality disorder and many somatic symptoms, which she has experienced for many years

Initially, she seems to be more debilitated by her medical complaints

She has been compliant with medication management and psychotherapy

She brings a case of medical records with her to her initial appointment to make sure everything is covered adequately

She has good insight into her MDD and the need to treat her symptoms, but less so with regard to her personality traits and her somatic symptoms

She denies current side effects on her psychiatric medications but states that she is often sensitive to side effects overall

There is no evidence of misuse of her controlled medication

She has no liver or renal disease, is normotensive, and has a normal body habitus

Current medications

Psychiatrically, she takes

• – Duloxetine (Cymbalta) 60 mg/d (SNRI)

• – Alprazolam (Xanax) 6 mg/d (BZ)

• – Hydroxyzine (Vistaril) 125 mg/d (antihistamine)

Medically, she takes

• – Fentanyl transdermal (Duragesic) 12 mcg/h

• – Levothyroxine (Synthroid) 125 mcg/d

• – Omeprazole (Prilosec) 40 mg/d

• – Ibandronate (Boniva) 150 mg/mo

• – Eletriptan (Relpax) 40 mg/d as needed for migraines

• – Odansetron (Zofran) 8 mg twice a day as needed for migraines

• – Naproxen sodium (Naprosyn) 500 mg twice a day

• – Onaboutulinumtoxin-A injection (Botox) 300 units as needed for muscle spasm

Question

In your clinical experience, would you suggest that this patient’s symptoms were?

Psychic and “all in her head”

Depression and anxiety based with somatic features

Personality based with much somatizing

Attending physician’s mental notes: initial evaluation

This patient has chronic MDD

She has a lot of comorbidity

• – Anxiety

• – Maladaptive personality traits

• – Distant substance misuse

• – Many somatic and real medical issues

Failure to remit on any of previous treatments

These failures may not be alarming in that she is side-effect sensitive and some of these treatments were likely not for a full dose or adequate duration

Her multiple comorbidities will increase treatment resistance and lower her likelihood of remission even in the face of excellent psychopharmacologic care

She has not had a bona fide trial of PDP, dynamic deconstructive psychotherapy (DDP), or DBT

• – DDP is a psychodynamic therapy specifically geared to treat BPDO that is comorbid with AUD

Prognosis is only fair unless better pharmacological therapy and psychotherapy occurs and is adhered to

However, she is very compliant with office visits, is personable, and seems more motivated for care at this point

Question

Which of the following would be your next step?

Increase the duloxetine (Cymbalta) to the full FDA dose of 120 mg

Increase the alprazolam (Xanax) to a higher, more effective dose for anxiolysis

Augment the current medications with another agent that has antidepressant properties

Augment the current medications with another agent that has mood stabilizing properties

Augment the current medications with another agent that has antipsychotic properties

Augment the current medications with another agent that has pain dampening properties

Change nothing and refer for more specific psychotherapy