Posted on Thursday 24 September 2015

I’m not old enough to have been around during the days of Bromides [Nervine], or Barbiturates, or Meprobamate [Miltown], or Methaqualone [Quaalude]. I grew up in the age of Benzodiazepine [Librium, Valium, Klonopin, Xanax]. We all know what they do so we don’t have to have any clinical trials. We all know they’re effective short term for anxiety and we all ought to know what’s up ahead with longer term [or even medium term] use. These are the "damned if you do and damned if you don’t" drugs and the skill of the everyday clinician can be partially gauged by his/her ability to use them [or not use them] effectively without causing future problems. Some say never use them. Others ignore the warnings. But this post isn’t about that. It’s about something else:

    She was brought to the clinic by her aunt who was taking care of her temporarily. She was a woman in her fifties with a cast on her lower leg from a fall. She was calm, alert, but couldn’t answer many questions. She was blitzed. She told me she’d fallen and broken her hip. But she knew neither the date nor the season. By history, she was obviously the ‘black sheep’ of the family – a failed marriage, no contact with her kids, psych hospitalizations, multiple rehabs for alcohol, benzodiazepine detox, etc. – moving from family member to family member. Her aunt had a piece of paper with her medications written out neatly:
    • Seroquel 600 mg/day
    • Trazadone 450 mg/day
    • Depakote 2.5 Grams/day
    • Neurontin [I forget how much too much]/day
    • Cogentin 4 mg/day
      among other things…
    …an outrageous cocktail! I can think of no medical/psychiatric condition where that’s an appropriate regimen. No wonder she fell and broke her leg. No wonder that she got her injury wrong. Little wonder that she didn’t know the season [I’m surprised she even knew her name]. Where does one even start? So I saw her at the end of each day I was in the clinic, and tried to figure out what I could get away with coming down on without precipitating some withdrawal state. Over a couple of months, I got her down to…
    • Seroquel 200 mg/day
    • Depakote 500/day
    • Cogentin 4 mg/day
    …without incident. But she was still pretty fuzzy [season "yes" – month "no"]. That was two weeks ago. I had noted her pupils were dilated every visit but  wanted to decrease the Seroquel before taking on the Cogentin. This time they were so widely dilated I could barely tell her eye color [why it wasn’t that dramatic earlier isn’t clear to me] and she complained about her vision being blurred. So I stopped the Cogentin by coming down a mg/every couple of days. Yesterday, I had stepped out to return a phone call. When I got back, the nurse had put she and her Aunt in the office because she was so agitated. She was in the middle of a full scale hyperventilation episode with carpal-pedal-spasm – throwing her glasses across the room breaking them and yelling about…well, about everything.

    It took a while to get her breathing slowed. In the barrage of things that followed  [a litany of a lifetime of woes and symptoms], I noticed that her pupils were down to size; that she was fully oriented with intact memory, past and present; and that she was mad as hell about many [if not all] things. As she calmed down, I could see that she had some subtle but none-the-less definite involuntary movements of her tongue. In addition, her legs were never totally still.

    She knew about both things: "My restless legs are back – pacing all night. I haven’t slept for four days!" "It’s that Tardive thing I get from the medicine. It comes and goes [pointing to her tongue]." So I had unmasked her Akathisia and her Buco-Lingual symptoms by dropping the neuroleptic dose and discontinuing the Cogentin too quickly. At least her cognitive apparatus was working, in fact, working overtime.

Yesterday was actually my first opportunity to take a history as she had been non compos mentis earlier. I can’t discuss it here except to say that the presumptive diagnosis is Borderline Personality Disorder. There was no evidence of a major affective or psychotic disorder. That this patient was overmedicated goes without saying. In an earlier era, overmedication might have happened with the anti·anxiety drugs. Such patients are always anxious, and when people begin to treat them with medication there is a tendency for doses to go up and up. It’s never enough. In her case, besides the pan·anxiety, she experiences the now discarded diagnostic criteria from the DSM-III – intolerance of being alone. When she’s living alone, she has great difficulty sleeping, and a lot of the overmedication has to do with that complaint. But now there’s something else. Over the years, her anxiety and insomnia have been treated with various antipsychotic medications, and she now has Akathisia and involuntary tongue movements suggesting Tardive Dyskinesia, emergent on reducing the dose and the Cogentin. I won’t know for sure for a while, but I think this might well be the kind that doesn’t go away – even if I can get her off of the Seroquel.

These patients are very difficult and are often overmedicated [and have been as long as there have been medicines] – with all the medications listed in the first paragraph. That’s a bad thing. She’s gotten medications that are used in conditions she doesn’t have [Depakote and Neurontin]. That’s a bad thing too. But this patient has been given escalating doses of antipsychotics and now she may well have signs of a permanent iatragenic neurological condition called Tardive Dyskinesia. And our literature says that’s a good idea – using Atypicals Antipsychotics in Borderline Personality Disorder – based on short-term Clinical Trials funded by industry. That’s a very bad thing, maybe a forever thing:


[see Atypicals in Borderline Personality Disorders, an anachronism…, Academic Industrial Complex II…, Academic Industrial Complex III…, and not really given the chance…] These studies came from Dr. Charles Schulz‘s Department at the University of Minnesota. Dr. Schulz has recently stepped down [or been stepped down] in the wake of the Dan Markingson affair – essentially being accused of running an industry funded Clinical Trial Mill. We know a lot about the Borderline conditions, and none of what we know would suggest to me that using these medications might be a good idea. This case is an example of why. She was on a maxi-dose to treat anxiety and insomnia giving us now two disorders to deal with.

With these patients, there is often nothing right to do. If you don’t treat the anxiety, they act out in dangerous ways. If you do treat it, they overdose or take too much and still want more. They defeat most treatments and yet they need to be treated. I’m not a bit surprised that they respond to Atypical Antipsychotics in short-term trials. But like anything in these cases, the drugs run out of juice and so up goes the dose. We know that pattern from their general response to any and all treatments. And these drugs can leave permanent sequela for no particular gain that I can see. We can do so much better than this, even with these difficult cases…
    Bernard Carroll
    September 24, 2015 | 9:12 PM

    It would be nice to learn who exactly prescribed this extreme regimen of medications. I would be embarrassed to learn that it was a psychiatrist – what was s/he thinking? And I would be even more concerned if it was a primary care physician – because that suggests that this scenario is destined to be repeated many times over. As long ago as the late 1960s I recall chastising a general internist for too heavy a hand with Haldol for an inpatient with anxiety and agitation. I placed a note in the patient’s chart to the effect that Haldol should not be viewed as a broad spectrum psychotropic agent, analogous to a broad spectrum antibiotic. These days, that same meme has resurfaced with the atypical antipsychotic drugs as well as some of the mood stabilizers. As Dr. Mickey discussed, the minimization if not frank denial of risk for tardive dyskinesia is especially deplorable. The casual use of these drug cocktails by non-psychiatrist physicians goes largely under the quality assurance radar.

    September 24, 2015 | 9:39 PM

    I’m going to have to get back to you on who, but you and the medical board will hear at about the same time.

    September 24, 2015 | 9:49 PM

    You know what, after 20 plus years of practicing both in community mental health, private practice, and in other more specialized elements of mental health, I can say this without any hesitation: treating people who are primarily Axis 2 with medication is a disaster until proven otherwise!

    Ironically, there may actually be some biological issue with giving meds, especially polypharmacy, to people who are characterologically disordered.

    I’m seeing this more and more, as I believe there’s more Axis 2 in mental health these days than there was 15 years ago.

    So, it’s fairly much ridiculous that psychiatrists are so quick to label these personality disordered people primary Axis 1 mood disorders, and then provide polypharmacy like it’s Pez!!!

    Think about it, who are the most outrageous and indignant people in your office, as providers, with meds complaints?! It’s almost always someone who, if you take a good history, has a lot of interpersonal strife.

    Just my opinion, but it is one of 20 plus years of experience!

    Laurie Oakley
    September 24, 2015 | 10:54 PM

    Truly scary what is happening to people. I don’t want to come off wrong but I’d just like to comment on the benzos.

    When you say “we know what they do,” I respectfully disagree. You might know, but many prescribers just don’t recognize all that benzos are doing right under their noses. It seems every doctor is aware that addiction can develop, but it’s a rare doctor that can seperate tolerance withdrawal symptoms from what looks to most practitioners like worsening anxiety/mental illness/somatic complaints.

    When having 0.5 klonopin in your chart for years on end doesn’t raise a red flag, when it just sits there as the most insignificant detail while tolerance withdrawal goes unrecognized and is treated as bonafide mental illness, when you can’t think straight or remember what you just learned, when your life is slowly going down the drain until you figure it out your own self, and then you are told there is no support for coming off and that you don’t need to taper, and after the trauma of withdrawal, alone, you tell doctors what you’ve been through and they just stare at you like you’re some kind of nut… it seems very little is known at all about benzodiazepines and that things are far from settled.

    This is such a dangerous class of drugs and what makes them so dangerous, still after 55 years, is a medical system full of overconfident professionals who *think* they know all about them *act* like they have everything under control. Their patients and clients fumble in a chemical darkness and they don’t even know.

    September 24, 2015 | 11:46 PM

    Hi Mickey and Bernard
    Re: “you and the medical board will hear at about the same time” – please let me know how this goes. This regimen is pretty typical here in Australia from psychiatrists for difficult anxiety / depression / personality / anything. And i’m sure our medical board would look to a consensus of peers, i.e. it’s okay. Of course it’s terrible, AND it’s standard practice. Again, please advise of any professional consequences which may accrue in the US and may hence be helpful, albeit just maybe, here in Australia.

    September 25, 2015 | 7:16 AM

    I am amazed that the medical professionals on this board are so shocked at this medication regimen. It is more common than you think.

    I know someone who had horrific withdrawal symptoms from a med and ended up on a cocktail of meds that made the situation worse. I am not going to get into details but this person’s life is ruined.

    Sadly, I fear we will be having the same discussions 10 years from now because nothing every happens to psychiatrists/doctors who do this. And many times, physicians don’t want to speak out against other doctors because they will be blacklisted. Easier to blame the patients.

    September 25, 2015 | 10:34 AM

    Yeah, this medication regimen doesn’t sound so out of the ordinary to me — lots of docs out there who write prescriptions like they’re in a particularly morbid nursery rhyme. You know the one, it goes, “I know an old lady who swallowed a fly…

    Drugs for the side effects of the drugs for the side effects of the drugs…

    So, to hazard a guess, Neurontin for the “restless legs,” Cogentin for the Seroquel side-effects, Depakote off-label for borderline, and increases in dosage whenever something doesn’t seem to work. I guess we can be thankful you stepped in before the doc hit the last verse and prescribed a horse.

    James O'Brien, M.D.
    September 25, 2015 | 11:04 AM

    Look at the sales figures for Abilify and Seroquel. Also look at Seroquel use in the military for PTSD (as opposed to the rare use of Prazosin which admittedly is not a miracle drug by any means). The proliferation of atypicals for everything is one of the most bizarre developments in medicine and yes it is mostly in the world of nonpsychiatrists.

    There is this strange corrosion of conformity around these ideas too. I know some psychiatrists who are really bothered by experimental ideas such as MDMA assisted psychotherapy for PTSD or even simple low dose Prazosin (worried about hypotension I guess) but have no problems with chronic Seroquel and attendant risk of TD. It’s kind of like the paralyzing fear of tyramine reactions with MAOIs without similar commensurate concern about serotonin syndrome or NMS.

    September 26, 2015 | 12:29 PM

    Although your example is on the extreme side, I agree with the other commenters that polypharmacy blitz isn’t rare. I sometimes warn psychiatry residents that blind symptomatic treatment can quickly result in a 6-drug regimen: antidepressant, mood stabilizer, neuroleptic, benzodiazepine, stimulant, and a sleeper. (Or other combinations, like 2 neuroleptics instead of the stimulant.) Long before this point, the cure is worse than the disease, so to speak, and our role is to detox the patient. And yes, this mostly happens in the character-disordered.

    I doubt such polypharmacy will be punished by a medical board. As Rob Purssey wrote, it’s standard practice (and terrible). Physicians by nature and training want to do something, and adding a med is all too easy. At the same time, many careful clinicians help patients these days by taking them off meds that were prescribed in haste. In effect, our profession (psychiatry, or medicine more broadly) is fighting itself, and patients are caught in the crossfire.

    September 26, 2015 | 12:52 PM


    I doubt they will punish, but they usually investigate and that is often a wake-up call.

    James O'Brien, M.D.
    September 26, 2015 | 7:38 PM

    This kind of thing is the rule not the exception. Except that there are no opioids on the list nor Soma for that matter.

    October 1, 2015 | 5:56 AM

    “But like anything in these cases, the drugs run out of juice and so up goes the dose.”

    But the drugs stay the same. The brain changes.

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