Posted on Wednesday 23 March 2016

"Are you sure it’s not a chemical imbalance?"

He came to the clinic the last time I worked saying he’d had a show-stopping anxiety attack last Fall – one of those race-to-the-ER-I’m-dying anxiety attacks. Since then, he’s had several others and has had a background sense of doom. The story was in contrast to his appearance, a late twenties construction worker blessed with good looks. He wondered if it was a chemical imbalance, as both parents were nervous worried types. Nothing like this had ever happened. On those ER visits, he’d had EKGs, and had seen a Cardiologist with no findings of note. He was married and had a five year old. I probed around but couldn’t find anything that might explain his symptoms. He had some anti-anxiety medication which he rarely took. He went home with instructions to focus on what was going on before he felt anxious and have his wife check his pulse [?arrhythmia?]. I mention him here, because he was preoccupied with the chemical imbalance worry.

He returned with a page of normal pulse rates from when he was feeling anxious. He had thought hard about the period in the Fall when all of this started and came up with nothing much. "Are you sure it’s not a chemical imbalance?" He seemed really worried I was going to miss the diagnosis of chemical imbalance. With urging, there was something after all. Back in the Fall, he had been home for a couple of weeks between jobs, and he recalled feeling kind of "down – remorseful." He’d thought back to his high school years a lot and wished he spent more time thinking about his future instead of just having fun. He wished he’d finished college instead of just going to work in construction. That was the first I’d heard about college and I asked about that. He had gone to a small college in a nearby town but didn’t finish. "Are you sure it’s not a chemical imbalance?" he asked again.

So I told him what I was looking for, something that might have come up, something from before, something that might be haunting him. He said, "I feel haunted," and he became more engaged with my questions. When I asked why he didn’t finish college, he was quiet for a while and then told a story. When he’d moved to the town where he was going to be in college, he’d met a girl who was also starting school. They quickly became an item and it lasted for the next three years [both working their way through school, so it took longer]. They’d planned a move to another town with a full college, getting an apartment together, and finishing their education. They’d been accepted, and were working to save up for the move. One day on the job, he got a call from her dad. She’d just been killed in a head-on collision during a rainstorm. He’d talked to her on the phone 15 minutes before she died. That was in September, 10 years before the anxiety attack we were discussing – the one last September.

I won’t go on. You can figure out the rest, like why he stopped college. As best I could tell, one of the forces keeping him from connecting the dots between the past and present himself was that he didn’t want his wife to feel he was disappointed with her or their life. But that’s just a guess. I expect I’ll hear about that next time. Whatever comes, it was clear we were on the right track.
Even after all these years, I’m still in awe how the mind can not make such an obvious connection. Once you find it, it seems so simple. But if it’s you, and your life, it’s a different story. The other thing that’s equally amazing is that after the link was made, he just went on talking as if our topic had been his unacknowledged anniversary reaction all along.

Driving home, I was thinking about his preoccupation with that chemical imbalance meme [which he stopped mentioning]. If that notion hadn’t been introduced into our world, would he have more quickly gotten to the mental pain he is avoiding? I doubt it. Back in the day, he would’ve probably fixated on his cardiac concerns. The problem with the chemical imbalance idea is that doctors respond by giving medications. In his case, he’d had a course of an SNRI by his PCP along the way, which he stopped because of the sexual side effects [and it being no help].
a follow-up

Back in September, I mentioned a case, a woman who had presented in a mentally obtunded state on an outrageous regimen of medications, prescribed by a telepsychiatrist at a contract mental health clinic [see blitzed…]. By October, we were making progress tapering her medications but it was becoming apparent that underneath it all, she had a movement disorder that looked for all the world like Tardive Dyskinesia [see some truths are self-evident…]. I mentioned her in December and the TD was full blown [a story: getting near the ending[s]…] and occupied the center stage.

Over the winter, the TD mercifully gradually lessened. She could voluntarily suppress the hand wringing, and "control" the jaw movements. I had a story from her reports and from her aunt and mother who had only come into her life recently. I knew snatches, but getting a clear timeline eluded me. And her mental state had cleared, but it became apparent that cleared wasn’t altogether clear. She still had a lot of signs of brain dysfunction. She tried to drive to appointments, but it took hours because she frequently got lost [a few miles with few turns]. She kept a spiral notebook and wrote everything down, "I’ll forget." She confabulated when she couldn’t recall things and perseverated on symptoms like depression, or confusion, or anxiety. Over the sessions, I was only able to piece together something of a timeline.

She had been married for twenty-three years, working as a dental hygienist and had three daughters. The marriage was difficult and she had divorced [been divorced?] eight years ago. About a year later, she was driving to see her kids for Christmas and had a head-on collision. She’d been unconscious. She was in the hospital for a while, having surgery on her neck [collar bone?]. A neurosurgeon had been involved and she had a scan [MRI? CAT?]. After a time, she went home, lived in an apartment, and worked in a hardware store. She had been in a relationship with a "military man" that ended very badly. She began to drink heavily. About two years ago, she fell on her patio and was unconscious "for seven hours" until being found by a neighbor. She was in a hospital for an unknown period of time. It was in the years since then when she seemed confused, couldn’t work, began to go to the mental health center, and got put on all that medication.

Looking at it in retrospect, I think the story is much different from the one I started with. I had presumed a personality diagnosis, mainly from family reports, and didn’t know about the head injuries. It’s now 6 months later, and I think the key point is that two years ago, she sustained a traumatic brain injury from that fall. The resulting confusion and emotional lability were interpreted as some kind of mental symptoms, and she was medicated [by someone who has since been fired] further complicating her cognitive impairment. The inappropriate overmedication with neuroleptics resulted in TD. We’ve figured out which hospitals she was in and records have been requested. We’ve set up a disability evaluation in a week, so hopefully she’ll have resources for the full neurocognitive work-up she needs. Surprising to me, benzodiazepines have helped her TD some and she can sleep [also my thanks to the blog follower who sent along a helpful article about TD Rx, and we’re pursuing it further].
I don’t mention cases here often. And the ones I do mention are disguised a bit and used with permission, but it’s a HIPAA world, and even that’s shaky. On the other hand, I find that focusing on groups of patients misses the essence of something vital. If I didn’t still see patients, I don’t know if I could even write this blog – too sterile, too disconnected from what matters. So sometimes, I guess I try to ground things with a case report or two, if only for myself.

I don’t know how to code that first case. He certainly feels ill in his mental, so I guess it’s a mental illness. And I don’t know how long I’ll need to see him. It depends on what comes next. I laughed out loud thinking about how we would fare in Collaborative Care where I would be talking to a Clinical Coordinator who would be talking to the Primary Care Physician who would be talking with him. I could and have coded the second case. There’s an ICD-10 code for Traumatic Brain Injury with residual Cognitive Impairment and one for Tardive Dyskinesia [though those codes don’t do this story justice]. In either case, I wonder how many sessions Managed Care might allow for each case if they were involved.

Our little [formerly] free charity clinic is growing. There’s a new clinic building next to the trailers we’ve operated out of [I stayed in the trailer]. We now take Medicare, Medicaid, ACA insurance from those who have it. It’s still free for those that don’t have resources or insurance. There are now "employees" working with the volunteers. Some of the doctors are "providers" and we charge the insured for their services. Some of us won’t sign up as "providers," so the clinic can’t be reimbursed for our services [nobody seems to mind]. There’s a new Electronic Health Record [EHR] system. That’s where my musings about coding come from.  I’m reluctantly using it for notes and prescriptions [most of the time], but it was designed by a fiend. I entertain my patients by talking to it when I use it, saying things like, "In medical school, I was taught to always maintain eye contact with patients, but now it’s ‘oh yeah, and do all this computer stuff on every patient’." My main beef is that I have to link to a diagnostic code for every prescription. I suspect there’s an epidemic of Major Depressive Disorder, Mild in the offing, treated with all kind of things, since this avenue is unavailable.

These days, I find myself often thinking of Cormac McCarthy’s book title, No County for Old Men
    March 24, 2016 | 8:07 PM

    Great post! Love case histories! (And particularly the one about anxiety attacks, because I might be or have been working with a man or woman who might be 32 or 78 years old presenting with panic attack or PTSD, I couldn’t say here due to the need to protect confidentiality. The CAMFT or AAMFT magazine last month had a similar article about the importance of identifying a traumatic or “hidden” event or feeling.)

    Yes, it is very hard to even reference an anecdote about a case without risking a HIPAA violation, and I feel waves of guilt even when I change the gender, age, clinic and city I was working at, etc.

    In the same spirit, I would like to add a “case history” for a particular EMR, and I am disguising the clinic I worked at and any terminology which would enable someone to identify the software provider. Basically, the system arrived without any documentation, so I wound up doing a small technical writing job for the Mental Health Department describing data entry for an intake.

    The manual I wrote *just for intake* was a 30-STEP procedure! Here are the first six steps, again, disguising the terminology. In particular, this speaks to your concern about diagnostic coding (though it is DSM IV). Step 6 was always my favorite!

    1) Important: Open a new session on the day of your Assessment and leave it open until the Assessment is complete. To open the session, click on “Appointments” in the right hand pane of the screen (if you are not already there) and double click on the appointment for the Assessment. Often, the client will have no other open sessions, the session will open immediately and you may skip ahead to step 3. Sometimes, however, the client will have other open sessions, and the “Session Selection” dialog box will open.

    2) Highlight in the “Session Selection” dialog box, and click on “OK.”

    a) Sometimes, a “Patient Safety Alert” may appear. Read this briefly, and if it does not apply to you, exit that window by clicking on the “x” in the upper right hand corner.

    3) Click on “Assessment/Plan” in the left column of the active window.

    4) Click on “Note”. Detailed narrative is critical to appropriate referral and treatment. Type in:

    a) Why the client is seeking therapy in their own words
    b) Your general assessment—primary presenting issues, the most effective modality of treatment, the reason for any referrals (such as DV or Substance Abuse Recovery) and reason for dx.

    5) Click on “Okay”

    6) Double click on “DSM V Diagnosis”, double click on each axis, open any necessary subfolders, and select the appropriate diagnoses; do not defer any diagnoses except Axis II. Note:

    a) For Axis I, (and all others) use only new diagnoses, even if client has been previously diagnosed with the same code.
    b) For Axis II, you will almost always click on “AXIS II: DEFERRED DIAGNOSIS (V71.09)”
    c) For Axis III, double-click on “AXIS III: CLIENT REPORTED”. When “AXIS III: CLIENT REPORTED” appears in the box under “Current Plans”, double-click on it. Enter the diagnoses in the “Description:” field (for example, “AXIS III: CLIENT REPORTED: Diabetes, HIV”.)
    d) For Axis IV: If there are no Axis IV problems, double-click “AXIS IV: NO PSYCHOSOCIAL OR ENVIRONMENTAL PROBLEMS.” If there are Axis IV diagnoses, first double-click on “AXIS IV: PSYCHOSOCIAL AND ENVIRONMENTAL PROBLEMS” then double-click on any relevant problems.
    e) For Axis V: GAF, double click on “AXIS V”, double click “AXIS V: GAF (CURRENT/HIGHEST)” and enter the GAF after “Description” in the top part of the dialogue box.

    As we often say while waiting in line at Airport Security, “I feel so much safer now!”

    James O'Brien, M.D.
    March 25, 2016 | 10:23 AM

    Epic Systems is like a villain in an Ayn Rand novel. They’re not even trying to be a good product. Medical IT is all about political connections.

    James O'Brien, M.D.
    March 25, 2016 | 10:26 AM

    And were exporting it to other countries. Clearly Cambridge has to have someone in IT who can do a better job than this:

    March 25, 2016 | 11:03 AM

    When I first started practicing, we had a secretary who billed for us. Her system was maddening. We looked at medical practice software and it was unusable. So I wrote a program in dBASE III+ by looking over her shoulder. It was kind of a fun hobby, and it came out okay. That was 30 years ago, and some friends still use it [DOS!]. But this modern software is really awful, more like playing a computer role playing game where you’re working enigmatic puzzles.

    James O'Brien, M.D.
    March 25, 2016 | 12:24 PM

    No doubt some 1982 software is better than what we have today.

    I review a lot of medical records and I look forward to hand written notes by some of the grid because I at least understand the thinking process.

    In other words, I prefer illegible to inane. The new stuff isn’t even interoperable which was sold as the number one reason to require it.

    Joseph Arpaia
    March 25, 2016 | 6:17 PM

    Beautiful work Mickey.

    March 25, 2016 | 11:30 PM

    “But this modern software is really awful, more like playing a computer role playing game where you’re working enigmatic puzzles.”
    Beautifully put. Really beautifully put.

    March 26, 2016 | 12:08 AM

    I don’t always agree with O’Brien, but Obama’s massive federal incentives for EHRs really have warped the system in terrible terrible ways. EPIC and their ilk would not have been as successful in inflicting such ridiculous IT upon us if not for that money.

    James O'Brien, M.D.
    March 26, 2016 | 10:05 AM

    Because after all, it’s important to restate every four pages that the patient never smoked


    Fiend is a nice way to describe the designer of this EHR garbage. I can think of a few other F words including fascist, which in this case is literally true.

    March 26, 2016 | 11:35 AM

    1bom,you know, Pharma inflicted damage on our literature and CME, but EHR companies have inflicted direct damage on the clinical encounter itself. Ugh

    James O'Brien, M.D.
    March 26, 2016 | 12:01 PM

    1BYM is correct. Eye contact, RIP.

    March 26, 2016 | 12:03 PM

    I wonder who it’s for? It sure doesn’t help me. I asked our Clinic Director and she seemed puzzled by the question. One might’ve thought the answer would be other doctors in the clinic. But it appears that their notes can’t be accessed without their passwords. Surely that’s not right, but that’s the way it looked when I tried. Weird…

    March 26, 2016 | 12:27 PM

    1bom, Ever seen the movie Brazil? Not sure that answers your question. But maybe it does?

    James O'Brien, M.D.
    March 26, 2016 | 1:41 PM

    1BYOM, Brazil is one of the great underappreciated movies of all time.

    Practicing medicine today is like being Robert DeNiro in that film.

    Eaten alive by the paperwork:

    March 26, 2016 | 6:28 PM
    March 26, 2016 | 7:14 PM

    And speaking of De Niro

    Damnit. Wakefield is just never going to go away.

    Some days it feels like one step forward and two steps back. So much discourse energy wasted on stuff like this that in the end benefits almost no one. De Niro doing a disservice giving the Wakefield film such a platform.

    Happy Saturday.

    BTW, if any MIA contributors champion this film in the site it is my sincere hope that some of their collegues cry foul. I continue to believe that if there was more peer to peer self correction we would be avoiding at least some of the problems we are having right now. Both in academic psychiatry and in whatever the heck one wants to call Wakefield and his ilk.

    March 27, 2016 | 1:14 PM

    Great comments. I was particularly fond of Dr. O’s comparing Epic to a “villain in an Ayn Rand novel.” (Of course, I think all characters are villains in Ayn Rand novels, but even so, it’s a stunning analogy.)

    I also appreciated the comment that eye contact is RIP though I am fortunate in that this is only true for me during intake. But what better way to drive a stake through the heart of psychotherapy itself?

    And as Mickey asks, who does it benefit? It almost feels like the EMR is what happens when there are too many hands on the Ouija board planchette. Except the Ouija board doesn’t kill anyone if you haven’t mastered its secrets, and the EMR definitely will. And has.

    I cannot tell you how many times the film “Brazil” has been mentioned in conversations among my friends and colleagues from all my current and former careers over the last six months. I was in New York visiting a school teacher who mentioned it five days ago. It came up talking to a film maker I was visiting in London in January. There is an AA meeting in Hollywood on Sunset Boulevard that takes place in a community room where the ceiling is covered by ducts of all sizes and shapes, and people talk about “Brazil” there every week.

    James O'Brien, M.D.
    March 29, 2016 | 1:47 AM

    Judith Faulkner of Epic, meet Wesley Mouch:

    Classic talentless rent-seeker.

    The real purpose of EHR is data collection, BTW.

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