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Nidal Moukaddam, MD, PhD
Roberto D. Sanchez, DO; Benjamin Li, MD; Nidal Moukaddam, MD, PhD
Treating patients who may be perceived as “unlikeable” can be difficult.
Tales of the Clinic: The Art of Psychiatry
In this installment of Tales of the Clinic: The Art of Psychiatry, we discuss a patient who was construed as difficult to manage by multiple standards and elicited strong feelings from the treatment team. Ms Grant is a 29-year-old female with a history of alcohol use disorder (AUD) and complicated alcohol withdrawal. This case presentation spans 4 years and highlights the importance of behavior shaping and personality trait management to achieve stability. The focus is treating patients who are at risk of being perceived as “less than likeable, disruptive, and uncooperative.”
Like many others with complex AUD, Ms Grant describes her life as wrought with chronic anxiety and depression, with a frequent desire to self-medicate with alcohol. Her story includes multiple rehabilitation programs, inpatient psychiatric hospitalizations, and suicide attempts in the context of alcohol use. Borderline and antisocial traits seemed to influence her clinical presentation. She became well-known to the clinic and hospital staff for one incident that involved her throwing a shoe directly at a police officer’s face.
Social and family history was significant for intergenerational substance use, involving her mother, father, and maternal grandfather. Ms Grant relates fond memories of her father, yet reports a childhood dominated by physical abuse and neglect, with the notable absence of her mother. She struggled in school and had suspensions and behavioral problems. Ms Grant became pregnant at 17 years of age and dropped out of school. Her partner left during her pregnancy, so she had to stay with her father.
Substance use and psychiatric history started early, with her first drink during her high school freshman year. She describes peers and boyfriends, whom she shared drinks with, as the support system she never got from family. She abstained from alcohol with her first pregnancy but developed postpartum depression and relapsed when her child turned 5 months old. The stressors of raising her child alone exacerbated feelings of abandonment and loneliness. Family support was limited, and her romantic relationships did not last long because of alcohol-associated behaviors. Ms Grant had her second child at the age of 20 while in a verbally and physically abusive relationship. Child protective services were involved. When she was 26, her two children were taken away and placed under a cousin’s care; the relationship ended as well.
Her treatment course included striking, intense episodes of intoxication with agitation and suicidality. One involved being verbally aggressive towards employees and customers while intoxicated at a gas station. In the emergency department, declarations of suicidal ideations, a blood alcohol level > 300 mg/dl and a history of complicated withdrawals led to inpatient hospitalization. She was discharged back to outpatient care, having consistently denied suicidality when no longer intoxicated, and declined transfer to a rehabilitation program at the time.
The second incident involved being caught stealing a wallet from another patient in the clinic. Ms Grant denied the theft despite confrontation, so police were called. The police asked to search Ms Grant’s backpack, but she escalated, cursed, and swung at the officers. This led to a physical scuffle in the psychiatrist’s office, that ultimately culminated in Ms Grant sustaining scratches and bruises. She was handcuffed, brought into police custody for refusing to comply with the search, and subsequently charged and incarcerated for a week.
The psychiatrist felt ongoing empathy for the patient struggling with anxiety and alcohol use disorder who had no one else for support. At the same time, it was a difficult decision on whether to continue treatment following the incarceration. Despite a strong desire to maintain a working relationship that had lasted for years, there was a sense of disappointment, and even anger, towards the dishonest and illegal behaviors that directly affected other patients. There were concerns about the potential for further covert theft or altercations if she were to continue treatment in the clinic. In addition, the psychiatrist had vivid, uncomfortable memories of the office scuffle.
Yet, Ms Grant, just like many with co-occurring disorders, was at very high risk of acute decompensation with perceived abandonment, which cessation of treatment would have been to her. The psychiatrist considered evaluating the decision-making process from a harm-reduction approach. If Ms Grant were to no longer receive treatment in the clinic, she would likely decompensate, with possible increases in aggressive, antisocial behaviors, and substance use. The psychiatrist felt sharing and processing this case with other colleagues was helpful, especially regarding countertransference.
Another consideration was that Ms Grant, as a woman, faced unique challenges to obtaining substance use treatment. Women are less likely to seek treatment for AUD, and multiple barriers have been identified among women compared to men, including gender stereotype roles and societal expectations, even though women are more predisposed to medical complications from alcohol use.1,2 Women face gaps in employment, economic challenges, and more parental responsibilities compared to men.3 Along with logistic barriers to treatment including transportation issues, limited childcare resources and insurance, and fear of losing children to child protective services, women are more likely than men to attribute alcohol use disorder to character flaws rather than to genetic disposition.4 With these pressures and beliefs, the fact that women have lower rates of substance use treatment compared to men is unsurprising.
Fortunately, recent research indicates that the gender gap of AUD has been narrowing,5 with studies indicating higher satisfaction in women-only treatment programs. Ongoing challenges include limited access to these types of programs and the necessity of further research to identify the effects on engagement and response to treatment.5
Nidal Moukaddam, MD, PhD
Roberto D. Sanchez, DO; Benjamin Li, MD; Nidal Moukaddam, MD, PhD
A Second Chance
Ultimately, considering all these factors, the psychiatrist decided to allow Ms Grant to continue clinic treatment, despite reservations from the clinical staff. They worked through these feelings of anger towards Ms Grant, which was helpful not only for a sense of closure for the psychiatrist and to help promote setting treatment boundaries, but also to help Ms Grant identify the consequences of her actions through behavioral chain analysis. It also helped to visualize that despite all that had happened, Ms Grant was doing “the best that she could,” relying on her limited coping skills, unfortunately stunted by childhood neglect and abuse. This step is essential to avoid judging the patient from a moral standpoint, where maladaptive or disruptive behaviors are viewed as entirely volitional. With this approach, work was able to resume, with her goals largely revolving around maintaining employment to regain custody of her children, and maintaining her current relationship.
The treatment team and Ms Grant’s deeper understanding of her own motivations and avoidance served as a catalyst towards treatment adherence and sobriety. She had chronic difficulty trusting and building new relationships, including those with mental health providers. This issue could be compounded by the concept that patients with substance use disorder (SUD) and personality disorders have often encountered judgmental stances and behaviors, even if subtle or unconscious, from healthcare providers. Bias against patients with SUD, legal histories, and personality disorders can occur easily, especially when the patient is perceived to be “behaving badly.”
Organizationally, clinics are rarely set up with enough support to manage severe personality pathology and navigate psychosocial stressors stemming from complex addiction histories. As the development of AUD is complex and multifactorial, treatment is variable and has to incorporate multiple contributing factors including psychological factors, genetics, personality traits, traumatic events, and family dynamics.6 Research indicates some benefits of regular attendance of Alcoholics Anonymous meetings, but this may not be a treatment that works for everyone.6 Project MATCH, sponsored by the National Institute on Alcohol Abuse and Alcoholism compared 3 different types of therapies and found some positive results with each therapy modality, implying that multiple therapeutic approaches can be utilized in addition to medications.
Support for treating physicians and therapists is essential, as patient relapses and failed treatment trials can contribute to feelings of helplessness, anger, and frustration for both patient and treatment provider. Identifying this in our own self, as well as any subconscious biases, may provide the space to combat the reactions that come with our countertransference and redirect attention towards meeting the patient’s needs
On a biological level, typologies and classifications have been developed to further classify the development and presentations of alcoholism. Ms Grant’s family history, early onset of alcohol use, and history of legal problems correspond with Cloninger type II alcoholism, which has increased genetic predisposition compared to type I.7
Cloninger type I alcoholism is typically associated with adult-onset and harm-avoidance behaviors. Differences in personality traits may underscore drinking motivation; type I alcoholism associates alcohol use with anxiety reduction, while type II corresponds to sensation-seeking behaviors. Neurobiological differences between alcoholism subtypes (serotonin levels, monoamine oxidase activities) are also known. However, the type II subset, under the Stockholm study, was found more commonly in men compared to women, whereas type I affects both genders equally. Identifying topology helps clinicians conceptualize a patient’s presentation, anticipate treatment needs, and may help guide medication selection. For example, off-label use of ondansetron works better for early-onset.8 Patients treated with sertraline may respond better if they have less severe AUD.9
Biological Treatment Options
Personalized treatment plans work best and should include medication in conjunction with psychotherapy. Naltrexone has the benefit of different routes of administration; intramuscular formulation leads to improved compliance/better outcomes compared to oral. Acamprosate, a hepatically safe option, can help increase time to relapse; however, 3 times daily administration may deter adherence. Disulfiram, an example of aversive therapy, can provide physical discomfort to curb drinking, but effectiveness is limited by poor compliance and risk of induced hepatitis/psychosis. Of note, Ms Grant had already tried all of the FDA-approved options for AUD treatment with little success or tolerability.
Thus, off-label medication was considered. Off-label medications for AUD mirror our understanding of the neurobiology of alcohol use. Varenicline (effects on nicotinic acetylcholine receptor), baclofen (GABA receptors), and ondansetron (serotonin 5-HT3 receptor antagonist), are just a few of the many suggested potential treatments given the complex effect of alcohol on the neural pathways.10 Ms Grant was eventually started on topiramate as further studies report improvement of drinking outcomes and quality of life with adjunct therapy with topiramate compared to placebo.11 The addition of topiramate, with an off-label indication, helped reduce Ms Grant’s cravings and days of heavy drinking. The risks of inadequate treatment of AUD, including frequent rehospitalizations, emergency room visits, and further hepatic injury from drinking, were considered much more dire than off-label potential side effects.
The efficacy of selective serotonin reuptake inhibitors for cravings has been sparse, and use for AUD does not follow American Psychiatric Association guidelines; however, studies have also indicated that patients with mental health conditions are more vulnerable to substance use. It is not uncommon to have a comorbid mental health disorder and substance use. Depressive and anxiety symptoms can also stem from alcohol use.
In addition, research indicates that the chronic use of alcohol, repeat periods of abstinence, and withdrawal results in changes in the prefrontal–striatal–limbic (PSL) circuit, which plays a significant role in emotion regulation, decision making, and modulating reward and stress.12 Therefore, the role of antidepressants on serotonin may have potential effects on obsessional thoughts and impulsivity with chronic alcohol use.10 Open discussions with patients regarding current availability of medications and setting realistic expectations of the effects of medications may mitigate the frustrations arising from continued cravings, a common complaint in SUD patients, and counteract the belief that medications alone lead to remission.
When a patient walks out of the office, one question lingers, did this visit help? This may especially be the case in AUD treatment. AUD is complex, multifactorial, and treatment includes taking into consideration biological, psychological, and socioenvironmental factors. We must gently process and elicit the details of one’s life that they might be the most shameful of, in order to address the deeper underlying issues. Identifying our own defenses and countertransference can potentially improve the therapeutic alliance. The presence of personality disorders can also provide an additional challenge while balancing limited resources and constraints a patient may also have that prevent them from utilizing these options. Thankfully, in addition to off-label options, there are 3 FDA approved medications to treat AUD, though they remain woefully underused.
There are many patients with stories like Ms Grant; however, with prodding, patience, and exploration, positive outcomes can be achieved. Lastly, systemic and organizational structures ought to take into account the complex treatment needs for SUD, and thoughtfully target resources.
Three years after the office scuffle, the outlook has been much brighter; Ms Grant has found stable and supportive housing and has been in remission from alcohol use for the past 2 years. She lives with her husband and cat and attends online 12-step groups. She clearly recalls the struggles she went through during treatment and uses that to prevent her from drinking again. While her past struggles may have been a reason to abandon hope, she is grateful that neither she, nor her psychiatrist, gave up. Her psychiatrist also realizes that while complex cases can be challenging, they also include the most meaningful work and lead to the most personal growth and satisfaction.
Dr Tea is a psychiatry resident at the Baylor College of Medicine. Dr Li is an associate professor and addiction-boarded faculty at Harris Health System in the Menninger Department of Psychiatry and Behavioral Sciences at Baylor College of Medicine.
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