Ms. K is a 60-year-old woman who was referred to our outpatient treatment services for evaluation and treatment. She has a history of alcohol dependence that began in her 20s; she met criteria for dependence in her early 30s by criteria of tolerance, more than intended use, and withdrawal. Her maximum drinking was in her late 50s, when she was drinking up to a liter of vodka daily. She has had two significant periods of sobriety since the onset of dependence, the first at age 56 and the second at age 60. The first sober period was 4 months, and at presentation, she had been sober for 6 months.
Ms. K reports a lifelong history of depressive symptoms, with three major episodes of depression. The first one came at age 12 in the context of sexual abuse. Ms. K attempted suicide at that time by trying to cut her wrists. Her second episode of depression occurred when she was raped in her early 20s; that time, she attempted suicide by overdosing on pills. Her latest episode has been the longest and the worst, with worsening of her depressive symptoms for the previous 2 years. Her main depressive symptoms include feeling unhappy, thoughts of guilt, initial and intermittent feelings of hopelessness, worthlessness, decreased appetite, and loss of about 55 pounds during the previous 3 months.
Ms. K has untreated chronic post-traumatic stress disorder (PTSD) from childhood sexual and physical abuse and emotional neglect. Her main PTSD symptoms include re-experiencing phenomena (nightmares and flashbacks), increased arousal, and avoidance behaviors.
She also has been diagnosed with a personality disorder at different points in her life for unclear reasons. A chart review indicated a diagnosis of cluster B traits, with attention-seeking behaviors mainly due to her persistent medical complaints, which included gait difficulty. Some providers noted that her leg weakness and difficulty standing and walking was subjective and could not be attributed to neurological facts.
Ms. K had a difficult childhood. She was physically abused by her mother and sexually assaulted by a Catholic priest. She was emotionally neglected and had a difficult and strained relationship with her mother all her life. She has one biological sister with whom she has close ties. Ms. K's father has alcohol dependence, and her mother died of probable Alzheimer's disease.
Ms. K has never been married and has worked as a job planner with the same company for 20 years. Two years ago, she resigned from her job and went on disability due to her numerous medical problems. Her multiple medical comorbidities include Stage 1 cancer in the left breast, for which she has undergone a left mastectomy and lymph node dissection; hysterectomy and bilateral oophrectomy; liver cirrhosis due to chronic hepatitis C; hyper-tension; type 2 diabetes; and pancytopenia due to spleenomegaly secondary to hepatitis.
Ms. K has had one outpatient addiction treatment program when she was 56 years old that led to 4 months of sobriety. She had one psychiatric hospitalization in July 2004 and was started on 15 mg of mirtazapine per day. She responded well to mirtazapine; however, she continued to have pancytopenia. She was discharged from the hospital after 2 weeks.
Ms. K has continued to have low-grade depressive and PTSD symptoms. One day, she received the news that she had a recurrence of her breast cancer, and mastectomy with chemotherapy were recommended. She took the news well, but her sister was fearful that she might relapse.
A neurology consult was done at this time, and Ms. K was diagnosed with proximal myotonic dystrophy, which was confirmed by electromyography and genetic testing. The electromyography showed low-frequency repetitive stimulation over the facial nerve and right accessory nerve were normal, without any decrement. The right biceps, deltoid, vastus lateralis, and psoas also were examined. All showed short myotonic discharges, increased insertional activity, fibs, positive sharp waves, and myopathic potentials (decreased amplitude, early recruitment). Ms. K was found to have genuine gait difficulty and temporal balding; she continued to be weak and had multiple falls.
These options could be considered appropriate management strategies for the clinician.
Increase dose of mirtazapine.
Switch to a different selective serotonin reuptake inhibitor and admit to extended-care services, with referral to addiction services.
Admit Ms. K to a hospital
Start supportive psychotherapy.
In this case, Option 2 was chosen. This case illustrates that the so-called “personality diagnosis” should not be taken at face value, because many times, there are biological underpinnings to it. Proximal myotonic dystrophy is an autosomal dominant multisystem disorder linked to trinucleotide repeats. Some studies have demonstrated avoidant personality traits in patients with proximal myotonic dystrophy, which are related to frontal and parietal lobe dysfunction. Other studies have shown an increased risk of depressive symptoms and anxiety in patients with myotonic dystrophy.
Ms. K's “personality” symptoms could be a component of her PTSD, depression, long alcohol abuse, or myotonic dystrophy spectrum. Therefore, a combination of psychotherapy and medications was determined to be the most helpful treatment. Ms. K was admitted to an extended-care service, where she was in a monitored setting. She began attending an intensive day treatment for her addictions. Her mirtazapine was discontinued due to her ongoing neutropenia. She was started on citalopram, which was increased to 20 mg. She also received supportive and interpersonal psychotherapy once a week and was referred to breast cancer support groups.
An important part of Ms. K's ongoing treatment has involved processing her shame and guilt related to her sexual traumas and her dys-functional relationship with her mother. Discussions on issues related to death and dying also were found to be very helpful. Ms. K continues to do well.
Editor's Note: This monthly feature is based on a series of talks from the annual Psychiatric Annals Symposium in New York, NY. Each presentation describes a case of a psychiatric disorder, discusses past treatment attempts, offers options for continuing treatment, and explains the reasons the solution was selected. The third annual Psychiatric Annals Symposium, focusing this year on treatment-resistant and bipolar depression, will be held April 1–3, 2005, in New York.
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This case was provided by Nirmaljit Kaur MD, staff psychiatrist, Veterans Administration Palo Alto Health Care System, Palo Alto, CA.