BACKGROUND
This week, a 43-year-old white male presents at the office with a chief complaint of pain. He is assisted in his ambulation with a set of crutches. At the beginning of the clinical interview, the client reports that his family doctor sent him for psychiatric assessment because the doctor felt that the pain was “all in his head.” He further reports that his physician believes he is just making stuff up to get “narcotics to get high.”
SUBJECTIVE
The client reports that his pain began about 7 years ago when he sustained a fall at work. He states that he landed on his right hip. Over the years, he has had numerous diagnostic tests done (x-rays, CT scans, and MRIs). He reports that about 4 years ago, it was discovered that the cartilage surrounding his right hip joint was 75% torn (from the 3 o’clock to 12 o’clock position). He reports that none of the surgeons he saw would operate because they felt him too young for a total hip replacement and believed that the tissue would repair with the passage of time. Since then, he reported development of a strange constellation of symptoms including cooling of the extremity (measured by electromyogram). He also reports that he experiences severe cramping of the extremity. He reports that one of the neurologists diagnosed him with complex regional pain syndrome (CRPS), also known as reflex sympathetic dystrophy (RSD). However, the neurologist referred him back to his family doctor for treatment of this condition. He reports that his family doctor said “there is no such thing as RSD, it comes from depression” and this was what prompted the referral to psychiatry. He reports that one specialist he saw a few years ago suggested that he use a wheelchair, to which the client states “I said ‘no,’ there is no need for a wheelchair, I can beat this!”
The client reports that he used to be a machinist where he made “pretty good money.” He was engaged to be married, but his fiancé got “sick and tired of putting up with me and my pain, she thought I was just turning into a junkie.”
He reports that he does get “down in the dumps” from time to time when he sees how his life has turned out, but emphatically denies depression. He states “you can’t let yourself get depressed… you can drive yourself crazy if you do. I’m not really sure what’s wrong with me, but I know I can beat it.”
During the client interview, the client states “oh! It’s happening, let me show you!” this prompts him to stand with the assistance of the corner of your desk, he pulls off his shoe and shows you his right leg. His leg is turning purple from the knee down, and his foot is clearly in a visible cramp as the toes are curled inward and his foot looks like it is folding in on itself. “It will last about a minute or two, then it will let up” he reports. Sure enough, after about two minutes, the color begins to return and the cramping in the foot/toes appears to be releasing. The client states “if there is anything you can do to help me with this pain, I would really appreciate it.” He does report that his family doctor has been giving him hydrocodone, but he states that he uses is “sparingly” because he does not like the side effects of feeling “sleepy” and constipation. He also reports that the medication makes him “loopy” and doesn’t really do anything for the pain.
MENTAL STATUS EXAM
The client is alert, oriented to person, place, time, and event. He is dressed appropriately for the weather and time of year. He makes good eye contact. Speech is clear, coherent, goal directed, and spontaneous. His self-reported mood is euthymic. Affect consistent to self-reported mood and content of conversation. He denies visual/auditory hallucinations. No overt delusional or paranoid thought processes appreciated. Judgment, insight, and reality contact are all intact. He denies suicidal/homicidal ideation, and is future oriented.
Diagnosis: Complex regional pain disorder (reflex sympathetic dystrophy)
Decision Point One
Neurontin (gabapentin) 300 mg orally at BEDTIME with weekly increases of 300 mg per day to a max of 2,400 mg if needed
RESULTS OF DECISION POINT ONE
• Client returns to clinic in four weeks
• Client returns to the office today and seems to be in agony. He states that the Neurontin did not help him at all. He also states that he is foggy in the morning. His current pain level is a 9 out of 10. You question the client on what would be an acceptable pain level. He states, “I would rather have no pain but don’t think that is possible. I could live with a pain level of 3.” The client is also asked what would need to happen to get his pain from a current level of 9 to an acceptable level of 3. He states, “I guess I would like this achiness and throbbing in my right leg to not happen every day or at least not several times a day. I also could do without my toes curling in like they do. That really hurts.”
• Clientis denies suicidal/homicidal ideation and is still future oriented. He does seem to be discouraged throughout the interview about his current pain
Decision Point Two
Increase the Neurontin dose to 900 mg orally TID and add on Celexa 20 mg orally daily. Increase dose to a max of 40 mg daily
RESULTS OF DECISION POINT TWO
• Client returns to clinic in four weeks
• Client returns today even groggier than the last time but his pain is under better control with a current pain level of 5 out of 10
• Client is complaining of problems getting an erection but states “at least I am not in as much pain. I wish I wasn’t so tired all the time.” The lancinating pain down his right leg is less frequent and not as intense or of the same duration as it was on his last appointment. He doesn’t know if there is anything you can give him to wake him up. If it wasn’t for the grogginess, he thinks he could live with this pain level
Decision Point Three
Reduce dose of Neurontin to 300 mg at bedtime over the next 3 weeks through dose de-escalation strategies. Change the Celexa 40 mg to Prozac (fluoxetine) 40 mg orally daily and escalate dose as needed for pain control by 20 mg once every 3 weeks to a max of 80 mg daily
Guidance to Student
The addition of a stimulant (Nuvigil) is never a good option in clients when the drowsiness is the result of a medication side effect. Only in select cases is this a good treatment modality. Since the Neurotin is the most likely cause of the grogginess/drowsiness, a reduction in dose is a good option to help with this side effect. Although Neurontin is markets for neuropathic pain, many clients will tell you that it doesn’t “seem” to work. The expectation of pain management must be laid out before treatment begins and that expectation must be a focus on reduction as opposed to elimination with an increase in daily function. When changing from one therapy to another within the same class (such as Celexa to Prozac), you can discontinue one medication and substitute with another at a higher than normal starting dose. This is an additional switching strategy as compared to a cross-taper (decrease dose of one medication as doses of the new medication are escalated). A valuable less at the close of this case is that sometimes there are no good options, just better versions of bad options. In any event, the one therapy that would not be considered a good therapeutic decision would be the addition of a stimulant to treat the side effect. The other two options could be equally efficacious depending on the client (interclient variability) and could therefore be good choices in this scenario.
Review the interactive media piece assigned by your Instructor.
• Reflect on the patient’s symptoms and aspects of the disorder presented in the interactive media piece.
• Consider how you might assess and treat patients presenting with the symptoms of the patient case study you were assigned.
• You will be asked to make three decisions concerning the diagnosis and treatment for this patient. Reflect on potential co-morbid physical as well as patient factors that might impact the patient’s diagnosis and treatment.
By Day 7 of Week 8
Write a 1- to 2-page summary paper that addresses the following:
• Briefly summarize the patient case study you were assigned, including each of the three decisions you took for the patient presented.
• Based on the decisions you recommended for the patient case study, explain whether you believe the decisions provided were supported by the evidence-based literature. Be specific and provide examples. Be sure to support your response with evidence and references from outside resources.
• What were you hoping to achieve with the decisions you recommended for the patient case study you were assigned? Support your response with evidence and references from outside resources.
• Explain any difference between what you expected to achieve with each of the decisions and the results of the decision in the exercise. Describe whether they were different. Be specific and provide examples.
