TREATMENT: Escalating symptoms
While hospitalized, Mrs. P focuses solely on receiving pain medication. She does not know why she is in the hospital. She is easily distractible, intermittently intrusive, and disorganized and tangential in her thought process.
Two days after admission, her uncontrolled behavior escalates and she has marked psychomotor agitation. She is confused but remains oriented to time, place, and person. We start treatment with risperidone, 0.5 mg each morning and 1 mg at bedtime, because this agent is well tolerated, efficacious, and easily titrated to symptom response. Mrs. P’s symptoms improve, but she does not return to her reported baseline. Two days later, we increase risperidone to 1 mg every morning and 2 mg at bedtime. On the 6th day of hospitalization, Mrs. P is more organized and able to follow simple commands. She denies auditory or visual hallucinations. On the 10th day, she improves markedly and is back to her baseline level of functioning.
We perform psychological testing, including the Wechsler Adult Intelligence Scale (WAIS III) and the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS, Form A). The results show global neurocognitive deficits. Mrs. P’s intellectual skill is significantly below average, with verbal abilities reflecting functioning in the mildly retarded range. Nonverbal skills were stronger but still below average. Mrs. P’s capacity to learn and retain new information and to understand even modestly complex concepts is quite limited.
Because of Mrs. P’s long history of poly-substance abuse, inability to process information, and chronic back pain, we judge her to be at high risk for relapse. However, Mrs. P and her family are not interested in chemical dependence treatment.
This left us facing a difficult clinical situation. Mrs. P had a pattern of presenting to multiple physicians and eventually receiving narcotics. Her family provided transportation for her to these appointments but also was concerned about her drug use. With the patient and her family, we carefully outline Mrs. P’s treatment needs, including:
- medication monitoring by a psychiatrist after discharge
- a single, consistent primary care physician to manage her care
- a treatment plan shared by all clinicians involved in her care.
We review with Mrs. P and her family the benefits of behavioral approaches to chronic pain management. They agree to our recommendation that the family control Mrs. P’s medication supply. We discharge her on risperidone, 0.5 mg each morning and 1 mg at bedtime, and she is scheduled for follow-up with a local psychiatrist.
Related resource
- Krauthammer C, Klerman GL. Manic syndromes associated with antecedent physical illness or drugs. Arch Gen Psychiatry. 1978;35(11):1333-1339.
Drug brand names
- Alprazolam • Xanax
- Amitriptyline • Elavil
- Citalopram • Celexa
- Desipramine • Norpramin
- Diazepam • Valium
- Fluoxetine • Prozac
- Fluvoxamine • Luvox
- Haloperidol • Haldol
- Hydrocodone • Vicodin, Lortab, others
- Lorazepam • Ativan
- Methadone • Dolophine, Methadose
- Olanzapine • Zyprexa
- Paroxetine • Paxil
- Propoxyphene • Darvon, Darvocet, others
- Risperidone • Risperdal
- Sertraline • Zoloft
- Tramadol • Ultram
Disclosure
The authors report no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.