1 Boring Old Man

"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.

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 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.