Patient Intake

• 26-year-old female arrives with both her parents

• Chief complaint: “I’m here because of my parents; I’m completely normal and I do not need medications”

• The patient has a four-year history of psychotic illness; and according to her parents has had a progressive downhill course following the onset of her illness

• She has delusions and hallucinations, which seem not to be treatable in a robust way with usual doses of antipsychotics

Patient Intake

• 33-year-old man diagnosed with schizoaffective disorder, bipolar type, polysubstance abuse in remission in a controlled environment and antisocial personality disorder

• Diagnosed as conduct disorder prior to age 18 with criminal activity, then after age 18 as a psychotic and mood disorder for the past 15 years, with intermittent assaultive behavior, grandiose and grossly disorganized thinking and behavior

• Truancy, fighting, abuse of alcohol, methamphetamine and other drugs, continuing minor criminal activity

• Dropped out of college age at 21 when drinking heavily and initially diagnosed as bipolar disorder and treated with lithium and carbamazepine (Tegretol); also later diagnosed as schizoaffective

• Developed deviant sexual fantasies involving coerced sexual activity with adult women linked to grandiose delusions associated with hypersexuality in the context of mania but also without empathy or remorse

• Then became intoxicated and joined a group in a park which raped and sodomized a woman; following arrest his charges were reduced to assault with a deadly weapon

• Was convicted of this charge, sentenced to state prison, but required psychiatric treatment so that at the time of parole he was declared to be a mentally disordered offender and hospitalized in a forensic facility

Patient Intake

• 83-year-old-man

• Chief complaint: none

• Patient is brought in by his wife saying she has noticed changes in her husband's memory and behavior for the past year

Patient Intake

• 49-year-old woman

• Chief complaint: difficulty with problem solving and concentrating

Patient Intake

• 48-year-old man diagnosed with schizophrenia, disorganized type, has a 31-year history of psychotic illness

• Referred by his treating psychiatrist for consideration of augmentation of clozapine with another agent because he continues to have breakthough symptoms of threatening behavior to himself and to others with a history of acting upon these threats

• Hospitalized in a forensic unit with hallucinations, ideas of reference, bizarre behavior, severe psychomotor agitation and self destructive behavior, including numerous suicide attempts in the past such as swallowing razor blades and jumping from a motorcycle; also elopement from psychiatric facilities and assault on others, including murdering his friend by hammering him in the head because he thought he was a vampire

• Found mentally incompetent to stand trial and now resides in a forensic facility

Patient Intake

• 32-year-old woman diagnosed with bipolar 1 disorder

• Current chief complaint

• – Patient's mania has been relatively stable for four months but she experienced 50 pounds of weight gain on olanzapine (Zyprexa) just before getting pregnant and is now 60 pounds overweight 2 months into her pregnancy

• – Uncertain about whether the weight gain is unsafe or if stopping her olanzapine would be unsafe

Patient Intake

• 27-year-old corporal

• Returns from Afghanistan after a Humvee accident in which he suffered a head injury

• Upon his return to the US one week later, experiences tremors and heart palpitations and feels that his surroundings are unreal

Patient Intake

• 69-year-old man

• Chief complaint: unremitting, chronic depression

Patient Intake

• 22-year-old man brought to the office by both parents

• Complains of depression

• Parents complain of his drinking

Patient Intake

• 26-year-old woman

• Has a daughter with ADHD

• Psychiatrist noted symptoms in the mother and suggested she come in for her own evaluation

• See the previous Case 13, p 133 for presentation of the daughter’s case

Patient Intake

• 9-year-old boy

• “I am here for new medications to make me behave”

Patient Intake

• 58-year-old man with a history of chronic pain

• Referred to you by his primary care physician who also specializes in chronic pain, for new ideas regarding psychopharmacologic pain management for this patient

Patient Intake

• 12-year-old girl

• Chief complaint: “fear”

Patient Intake

• 18-year-old male adolescent

• Chief complaint: Depressive mood, with deterioration of social and cognitive performance at school

Patient Intake

• 53-year-old female

• Chief complaint: “I’m always tired”

Joining the Essential Psychopharmacology series here is a new idea – namely, a case book. Essential Psychopharmacology started in 1996 as a textbook (currently in its third edition) on how psychotropic drugs work. It then expanded to a companion Prescriber's Guide in 2005 (currently in its fourth edition) on how to prescribe psychotropic drugs. In 2008, a website was added (stahlonline.org) with both of these books available online in combination with several more, including an Illustrated series of several books covering specialty topics in psychopharmacology. Now comes a Case Book, showing how to apply the concepts presented in these previous books to real patients in a clinical practice setting.

Why a case book? For practitioners, it is necessary to know the science of psychopharmacology – namely, both the mechanism of action of psychotropic drugs and the evidence-based data on how to prescribe them – but this is not sufficient to become a master clinician. Many patients are beyond the data and are excluded from randomized controlled trials. Thus, a true clinical expert also needs to develop the art of psychopharmacology: namely, how to listen, educate, destigmatize, mix psychotherapy with medications and use intuition to select and combine medications. The art of psychopharmacology is especially important when confronting the frequent situations where there is no evidence on which to base a clinical decision.

What do you do when there is no evidence? The short answer is to combine the science with the art of psychopharmacology. The best way to learn this is probably by seeing individual patients. Here I hope you will join me and peer over my shoulder to observe 40 complex cases from my own clinical practice. Each case is anonymized in identifying details, but incorporates real case outcomes that are not fictionalized. Sometimes more than one case is combined into a single case. Hopefully, you will recognize many of these patients as the same as those you have seen in your own practice (although they will not be the exact same patient, as the identifying historical details are changed here to comply with disclosure standards and many patients can look very much like many other patients you know, which is why you may find this teaching approach effective for your clinical practice).

Patient Intake

• 56-year-old man

• Chief complaint of unremitting depression, unresponsive to treatments

Patient Intake

• 44-year-old woman with a chief complaint of anxiety