{"id":60140,"date":"2015-09-24T19:52:38","date_gmt":"2015-09-24T23:52:38","guid":{"rendered":"http:\/\/1boringoldman.com\/?p=60140"},"modified":"2015-09-24T19:52:38","modified_gmt":"2015-09-24T23:52:38","slug":"blitzed","status":"publish","type":"post","link":"https:\/\/1boringoldman.com\/index.php\/2015\/09\/24\/blitzed\/","title":{"rendered":"blitzed&#8230;"},"content":{"rendered":"\n<div align=\"justify\" class=\"small\">I&#8217;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&#8217;t have to have any clinical trials. We all know they&#8217;re effective short term for anxiety and we all ought to know what&#8217;s up ahead with longer term [or even medium term] use. These are the &quot;damned if you do and damned if you don&#8217;t&quot; 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&#8217;t about that. It&#8217;s about something else:<\/div>\n<ol><sup><font color=\"#200020\"><\/p>\n<div align=\"justify\">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&#8217;t answer many questions. She was blitzed. She told me she&#8217;d fallen and broken her <em>hip<\/em>. But she knew neither the date nor the season. By history, she was obviously the &#8216;black sheep&#8217; of the family &#8211; a failed marriage, no contact with her kids, psych hospitalizations, multiple rehabs for alcohol, benzodiazepine detox, etc. &#8211; moving from family member to family member. Her aunt had a piece of paper with her medications written out neatly:<\/div>\n<ul>\n<li>Seroquel 600 mg\/day<\/li>\n<li>Trazadone 450 mg\/day<\/li>\n<li>Depakote 2.5 Grams\/day<\/li>\n<li>Neurontin [I forget how much too much]\/day<\/li>\n<li>Cogentin 4 mg\/day<br \/>                 among other things&#8230;<\/li>\n<\/ul>\n<div align=\"justify\">&#8230;an outrageous cocktail! I can think of no medical\/psychiatric condition where that&#8217;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&#8217;t know the season [I&#8217;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&#8230;<\/div>\n<ul>\n<li>Seroquel 200 mg\/day<\/li>\n<li>Depakote 500\/day<\/li>\n<li>Cogentin 4 mg\/day<\/li>\n<\/ul>\n<div align=\"justify\">&#8230;without incident. But she was still pretty fuzzy [season &quot;yes&quot; &#8211; month &quot;no&quot;]. That was two weeks ago. I had noted her pupils were dilated every visit but&nbsp; 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&#8217;t that dramatic earlier isn&#8217;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 &#8211; throwing her glasses across the room breaking them and yelling about&#8230;well, about everything.<\/div>\n<p align=\"justify\">It took a while to get her breathing slowed. In the barrage of things that followed&nbsp; [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.<\/p>\n<div align=\"justify\">She knew about both things: &quot;My restless legs are back &#8211; pacing all night. I haven&#8217;t slept for four days!&quot; &quot;It&#8217;s that Tardive thing I get from the medicine. It comes and goes [pointing to her tongue].&quot; 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.<\/div>\n<p><\/font><\/sup><\/ol>\n<div align=\"justify\" class=\"small\">Yesterday was actually my first opportunity to take a history as she had been non compos mentis earlier. I can&#8217;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&middot;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&#8217;s never enough. In her case, besides the pan&middot;anxiety, she experiences the now discarded diagnostic criteria from the DSM-III &#8211; <em>intolerance of being alone<\/em>. When she&#8217;s living alone, she has great difficulty sleeping, and a lot of the overmedication has to do with that complaint. But now there&#8217;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&#8217;t know for sure for a while, but I think this might well be the kind that doesn&#8217;t go away &#8211; even if I can get her off of the Seroquel. <\/div>\n<p align=\"justify\" class=\"small\">These patients are very difficult and are often overmedicated [and have been as long as there have been medicines] &#8211; with all the medications listed in the first paragraph. That&#8217;s a bad thing. She&#8217;s gotten medications that are used in conditions she doesn&#8217;t have [Depakote and Neurontin]. That&#8217;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&#8217;s a good idea &#8211; using Atypicals Antipsychotics in Borderline Personality Disorder &#8211; based on short-term Clinical Trials funded by industry. That&#8217;s a very bad thing, maybe a forever thing: <\/p>\n<p align=\"center\" class=\"small\"><img loading=\"lazy\" decoding=\"async\" width=\"499\" height=\"468\" border=\"0\" src=\"http:\/\/1boringoldman.com\/images\/schulz-1.gif\" \/>&nbsp;<\/p>\n<p align=\"justify\" class=\"small\">[see <a target=\"_blank\" href=\"http:\/\/www.medscape.org\/viewarticle\/479929_5\">Atypicals in Borderline Personality Disorders<\/a>, <a href=\"http:\/\/1boringoldman.com\/index.php\/2014\/07\/02\/an-anachronism\/\">an anachronism&hellip;<\/a>, <a href=\"http:\/\/1boringoldman.com\/index.php\/2015\/04\/19\/academic-industrial-complex-ii\/\">Academic Industrial Complex II&hellip;<\/a>, <a href=\"http:\/\/1boringoldman.com\/index.php\/2015\/04\/20\/academic-industrial-complex-iii\/\">Academic Industrial Complex III&hellip;<\/a>, and <a href=\"http:\/\/1boringoldman.com\/index.php\/2015\/08\/03\/not-really-given-the-chance\/\">not really given the chance&hellip;<\/a>] These studies came from <font color=\"#200020\">Dr. Charles Schulz<\/font>&#8216;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 &#8211; 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.  <\/p>\n<div align=\"justify\" class=\"small\">With these patients, there is often nothing right to do.  If you don&#8217;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&#8217;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&#8230;<\/div>\n","protected":false},"excerpt":{"rendered":"<p>I&#8217;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&#8217;t have to have any clinical trials. We all know they&#8217;re effective short [&hellip;]<\/p>\n","protected":false},"author":2,"featured_media":0,"comment_status":"open","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"_bbp_topic_count":0,"_bbp_reply_count":0,"_bbp_total_topic_count":0,"_bbp_total_reply_count":0,"_bbp_voice_count":0,"_bbp_anonymous_reply_count":0,"_bbp_topic_count_hidden":0,"_bbp_reply_count_hidden":0,"_bbp_forum_subforum_count":0,"footnotes":""},"categories":[5],"tags":[],"class_list":["post-60140","post","type-post","status-publish","format-standard","hentry","category-opinion"],"_links":{"self":[{"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/posts\/60140","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/users\/2"}],"replies":[{"embeddable":true,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/comments?post=60140"}],"version-history":[{"count":26,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/posts\/60140\/revisions"}],"predecessor-version":[{"id":60166,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/posts\/60140\/revisions\/60166"}],"wp:attachment":[{"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/media?parent=60140"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/categories?post=60140"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/tags?post=60140"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}