NEIL'S PECULIAR PROBLEM

This was the follow-up office visit for Neil, 34, a little overweight, slender shoulders, and sporting a thin chin beard. And one tiny earring, left ear. He could’ve worked in a dry cleaners or sold women's shoes, but he didn’t work in either. I saw him for the first time a month earlier. He’d complained about general nervousness, anxiety, and had made a point that this was very unsettling.
 
“Hello. Good morning,” I said.
“Hi.”
“You enjoying this fall weather?”
“Yeah. It’s kinda nice. Didn’t know if it would ever get here.”
Opening his chart I asked, “So how’s it going? Is the Klonopin doing its job?”
“Well, at first it helped some but only for about a week or so. Then it seemed to wear off. I just feel like…it’s hard to explain….like uneasy…I don’t know.”
I said, “Do you mean like being apprehensive? As if something’s going on just around the corner?”
“Well…kinda like that, but more like maybe…I don’t know…like maybe being restless or something. I’ve been having some headaches like I used to have, and…I don’t know, I’m tired and just…just don’t feel right…like in a funk or something.”
“When did you have headaches before?”
“Ahh…I guess it was about three or four years ago. I was prescribed Fioricet and it worked for a little while, then it too seemed to quit working.”
“What happened to the headaches?”
“They just slowly went away,” he said.
“Okay, so is your nervousness, or how you’re feeling…is it affecting the way you work, or affecting you at work?”
“Nah…I don’t think so.”
“You’re not missing work, or having to leave early, or is it affecting your quality of work?”
“No, not really.”
“Okay, well, you’re on the lower dose of Klonopin. So we can increase the dose to 1 milligram and…”
“I don’t think that’s going to help.”
“Why not?”
“Well, it doesn’t seem to be working now and quit working after only a few days when I took it.”
“Okay…well, is this the first time you’ve ever taken Klonopin?”
“Ahh…well,…no, not really. I had it prescribed about four or five years ago.”
“Why didn’t you share that with me at the first visit.”
“I don’t know…I thought it might maybe work this time.”
“So,” I said, “Okay, so…well, let’s try a different category of medicine. Since you’re feeling tired and say you’re in a funk, then maybe something like Lexapro would be a good choice. It can help with the anxiety as well as help with some melancholy you might be having.”
Neil sighs, and shakes his head. “Nah, that didn’t work. I’ve taken that before and it didn’t work.”
“You’ve taken Lexapro before?”
“Yeah.”
“What about Prozac, and…”
“No, none of those work. I’ve taken all the SSRIs and none of them work.”
“So, why didn’t you tell me about this during the first office visit? So this anxiety that you told me on the first visit that you’ve been having for a month or so, you’ve really had over several years and it’s been treated, or attempted to be treated by other doctors?”
“Yeah. Well, maybe a couple.”
“So basically you’ve been complaining or suffering from chronic anxiety and have failed to respond to multiple medications, including all the SSRIs, Klonopin, and even Fioricet for headaches.”
“Yeah, I guess so.”
“Then, I’m not sure I could recommend any medication that would help you only to say further that it’s been my experience that people who have no therapeutic response to any of the SSRIs and benzodiazepines usually have something deeper, something more complex. Something that usually requires counseling or a referral to a psychiatrist.”
Neil stared at the baseboard.
I said, “Okay well, I think it would be a good idea, if you’re in agreement, to get you an appointment with a psychiatrist. Are you okay with that?”
“Ahh…I don’t know…yeah, I guess so.”
I finished writing my note and marked the reference for the psychiatric consult.
Rising from our chairs, and trying to leave the visit on a lighter note, I asked, “Got any big plans for the weekend?”
“Oh, I’d like to go to the Peter Anderson Festival," he said. "But I need to see first if it’s okay with my husband.”