Change in Disposition
A forty five year old woman with severe ankle and foot pain following several fractures was referred by her orthopedist to me. She had a many year history of depression and was under psychiatric care taking the drugs Pozac and Welbutrin.
On interview, I searched, as I always do for some clue to the bipolar spectrum. It is usually there, in bits and pieces, in those with chronic pain. She acknowledged distractibility and lack of mental focus (symptoms of ADD, part of the spectrum) and also preoccupation with obsessive cleanliness (obsessive compulsive disorder, also a part). She suffered occasional very vivid dreams where she would wake up emotional (narcolepsy, also a part). All these in addition to chronic and largely treatment resistant depression add up to me to "soft" bipolarity. I prescribed hydrocodone and told her to continue the Prozac and Welbutrin and I would forward my notes to her psychiatrist.
On her return she offered some intresting news. She told me that the hydrocodone was doing very little for her pain. She then reminded me that she had always been very tolerant of pain medicines, even telling me that her dentist had great difficulty giving her enough anesthetics to perform dental work. (I am really not sure what all this means but I do hear this kind of historical information occasionally) She also told me that her psychiatrist was discontinuing her care since she was seeing me. I asked if she gave any reason. I was told the by the patient that I could take over the prescribing of the psychiatric drugs or she could find another psychiatrist more willing to work with me.
O, well.
I told her that I would take over prescribing the other medicines and that I would double the dose of hydrocodone.
When I saw her next she said that she was getting some pain relief but not enough and also that her depression was somewhat better. In fact, she said she was feeling better than she had in several years.
I was pleased with our progress and I increased the hydrocodone dose again, in hope that I would witness another opiate cure (which the psychiatrist had denied herself the opportunity.)
We said our goodbyes and as she was leaving she volunered "I am a lot more tolerant now."
Ding, ding, ding.
The sucessfully treated bipolar offers descriptors like "I'm even", or "balanced", or "level" when their disease is in control. They also, with great regularity comment on changes in disposition. "I'm more patient now" or "I'm not agry anymore", or even "I'm more empathetic". "I am more tolerant now" tells me that my patient is indeed bipolar and that I was witnessing another opiate cure.
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