A Difficult Patent Asks Who Am I?

By | July 23, 2011

The level of the pain was out of proportion to the small central disc protrusions present on MRI.

A woman came into the office recently who asked this question, but not in exactly these words. Her story is illustrative of several problems related to treatment side effects and the ethical questions attendant to the use of psychotropic medication for both psychiatric and non-psychiatric purposes. After presenting the basic facts of the case today we will examine the subtleties of treatment, side effects and personal identity in the following days.


Joan (not her real name) is a 40-year-old woman who initially presented with the relatively sudden onset of severe lower back pain after athletic exertion but without definite injury. There was minimal radiation of the pain, which was completely out of proportion to the mild central disk protrusions seen on MRI. A single interlaminar lumbar epidural steroid injection done on epistemological grounds brought little relief.


With the working diagnosis of functional back pain, which I believe is a fibromyalgia variant, I prescribed a trial of tricyclic antidepressant therapy, nortriptyline 25mg three times a day. The patient took the medicine for about 5 days and reported a significant decrease in her pain. Unfortunately she also experienced significant side effects including sedation, dry mouth, weight gain involuntary movement of her arms and an episode of what sounded like either loss of consciousness or a state of altered consciousness, but without either bowel or bladder incontinence. Joan was instructed to discontinue the medication and return to the office for reevaluation.

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