Complex Cases, Part II

Our current focus at the Center for Collaborative Psychiatry, Psychology and Medicine is on “complex cases.” The complexity to which we refer may derive from a number of sources, including difficult to sort out diagnostic issues (“technical complexity”) and complexity introduced by factors extraneous to the technical issues associated with diagnosis (part of the broader category we call “inherent complexity”). Adding to the complexity of the case may also be multiple, entwined dynamic issues and the involvement of several social or professional systems, including the patient and family. *

In this article, we turn to complexity “inherent” in a system within which a patient was treated. In this situation, complexity was introduced by collusion between two family members and reinforced when the patient’s current psychiatrist was compelled to bypass the findings of other clinicians who had worked with the patient. The patient, Todd, 19 years old, had developed academic and emotional difficulties during his first semester at college. Ostensibly, the major factor in his decline was ADHD, diagnosed in a clinical assessment years earlier.

His history includes getting by in high school without studying and assuming the same strategy would work in college. Unevenness in his mood and fascination with illicit substances resulted in referral for psychotherapy beginning at age 14. During the interim, an antidepressant (Sertraline = Zoloft) was tried in addition to participation in a drug rehabilitation program.

During this past summer, Todd’s psychiatrist instituted stimulant medication. Todd — admirably — responded by assiduously researching the drug and fervently, albeit temporarily, embracing it. However, at the beginning of his second college year he began to fail again, reverting to street drugs and alcohol, progressively unable to stay a constructive course.

In spite of his difficulties, Todd was described by professionals who treated him and provided neuropsychological testing as “impressively insightful and articulate.” In contrast, by self-report, he saw himself as “impaired” and was aware that a pattern of entering a new situation and quitting was repeating itself, replicating the difficulties he had encountered during his freshman year of college. In his language, “I feel lost, paralyzed as I look at others… because I’m so unsure, I mimic others and then get more discouraged.”

Last summer, his psychiatrist, Paul Gilbert, was appointed to pick up the pieces of Todd’s problematic school year and deal with Todd’s alleged ADD/executive function problem. Surprising to all, neuropsychological testing by Diane Engelman during this period refuted the ADD/learning disability hypothesis, underscoring the central place of anxiety in his difficulties. Nothing neurological, no specific biological etiology, was identified.

A careful, retrospective, review of Todd’s family history revealed that anxiety and depression run throughout Todd’s family. Among those afflicted are Todd’s three siblings, one with “disabling anxiety and panic attacks,” one with “OCD,” and one with “depression.” Further probing, underscoring the importance of anxiety in explaining Todd’s pattern of failure, revealed that during Todd’s freshman year in college, he needed to speak to his mother by phone six or seven times a day. (Suggesting a symbiotic relationship or a “somatizing” family, where anxiety is translated into somatoform symptoms and converted into pathological dependencies?)

With this new information available, Paul adjusted Todd’s medications before he returned to school. However, after a brief period, Todd again found himself on a failing trajectory. In reaction, and quite unexpectedly, Todd’s mother became ambivalent about Paul and Diane’s findings and recommendations, insisting they get a second opinion and bypassing the referral Paul made to a new psychiatrist located near Todd’s college. According to Todd and the mother, Todd’s problem had to be ADD.

This pattern is familiar to us: a careful assessment leading to conclusions that aren’t appealing to the patient or family, resulting in their attempts to find other professionals whose opinions are more pleasing to them. Over time, this sequence of ostensible commitment to treatment followed by sabotage, repeats and repeats.

In this case the most confounding, “complicating” factor seems to have been collusion between the mother and Todd, resulting in their unwitting effort to discount any information they regarded as unpalatable. This kind of interpersonal collusion prevents outside influence, including that by the treating physician or evaluating psychologist, from being effective. But, the blame is always exported, generally to treating professionals.

In addition to underscoring the requirement that we as clinicians must have a thick skin, one principle this case highlights is the importance of obtaining information — no matter how difficult it is to get — from others who have known or worked with a patient you are beginning to treat. In this case, with the proper permissions in place, contacting those who treated Todd in the past might have exposed the mother-son, treatment-lethal interpersonal pattern that was at work. Unfortunately, Todd and his mother languished in providing these authorizations, so treatment went forward without Paul being able to make those contacts.

Dedicated collaboration in this case occurred between Paul, the treating psychiatrist, and, Diane, the testing psychologist. They met several times as the case unfolded. Additional meetings that could have included the mother and Todd were resisted by them, however.

Think of a similar situation clinical process as it impacts the work in a medical office, pediatrics or family medicine, for example. This is a situation that concerns us at the Center, since our associates include representatives from these specialties. Outside specialists brought into medical situations for their opinions are usually used as consultants, not collaborators, supplying their input only in response to specific requests by the primary treating physician. Because of time limitations and reimbursement issues, true collaboration — ongoing, repeated discussions between primary care providers and these colleagues — is unlikely to occur.

However, without this kind of collaboration, how could a subtle “psychosocial” issue like collusion between Todd and his mother be unearthed and incorporated into an ongoing treatment strategy? Situations like these, whether they occur in medical cases or psychotherapy, illustrate why we at the Center hold that ongoing collaboration is so critical to the management of complex cases involving multiple professionals.

Clearly, there are a plethora of knotty diagnostic and treatment challenges that can and often do plague complex cases. We will continue to identify and explore these clinical situations in future newsletters.

* As background for our use of the terms “clinical complexity” and “complex cases,” we repeat a paragraph from Complex Cases, Part I: “When looked at closely, clinical work is astonishingly complex. We are referring to the multiple determinants that shape a case formulation and the way we come to our moment-to-moment decisions about how to treat. There are at least two primary sources of clinical complexity. The first, which we will call ‘inherent complexity,’ reflects the treatment variables selected to define the case and the assortment of interpersonal factors always at work in clinical situations. The second which we call ‘technical complexity’ refers to the mixture of psychological, psychiatric, and, at times, medical diagnostic categories contributing to the final clinical picture.”