Anosognosia and doctor treatment

[Jane16]

I happy to say my partner finally allowed me to join him to his psychiatrist appointment. He thinks she does not have his best interests in mind and sometimes also believes she’s paid off by his “enemies” and I encouraged him to let me come see for myself and help advocate for him for better treatment.
She asked him blunt questions that I can’t picture anyone answering honestly. Staring at her computer screen the whole time and typing away with his response to each question she rattled off her list… have you had thoughts of committing suicide? Of hurting anyone else? Are you experiencing hallucinations? Are you angry? All like she had no concern for him. He didn’t answer any of them honestly bc there was no room to open up about them, no interest in him as a person.i saw why he is frustrated with her.
I was able to voice many of his symptoms and press for more answers to many questions so we had for a better understanding of what to do. I also made sure she knew he is smart talented and normally very productive when he is at his best.

We are now going to try zyprexa as he has severe agoraphobia now and has been on risperdal for over a month or two now. Later on in the meeting she told him (again, apparently as she made it known she had told him before) that he has anosognosia. Even as she started to bring it up I gave her a look, told her I was familiar with what it is she was about to say and silently implored her to leave it alone (she didn’t catch my drift). I just don’t feel that telling him he can’t comprehend his illness is the right route to helping him see it. He brought up after how upset he is that she implies this. He does not think his beliefs that his neighbors are out to get him and that a rich powerful man is using electronic harassment to control his thoughts and has plans to hurt him could be related to his mental illness. And he would never tell her that he has these thoughts.
But he did tell me how grateful he was to see me in there defending him, asking lots of questions and requiring her to hear out what he is experiencing and the negatives of his medications.
His biggest complaint was that she doesn’t actually listen to him and i have to say he was right. He also is beginning to admit to me that he now realizes he has something going on mentally, he refers to it as being bipolar (and maybe that is the case- the mood stabilizer meds cover bp and sz). He’d been waking up every day with severe anxiety and mostly sleeps, can’t leave the house and had days where we didn’t talk bc it was too much for him to try acting “normal”. Today waking up from his first dose of Zyprexa he acknowledged that it was a better morning than they had been.
Anyone have any wins with Zyprexa? She did mention it is not a longterm drug and didn’t seem.to know how to tell me what side effects could occur (thank goodness for Google). Also any stories about dealing with crappy doctors or ones that are blunt about telling a patient they have symptoms they just don’t believe are there (she got this info from his mom’s statement to doctors when he went to ER). I am working on helping him see this possibility but I know it’s gonna take some time

[Maggotbrane]

A couple things: that list of questions is a collection of screening questions. I get some of them from my Internist who knows my SZA diagnosis every once and a while. Some of this has to do with liability concerns and might be considered maintenance questions after an initial diagnosis. A little odd she rattled through all of them at once. There’s a degree of looking for reactions, aspects of tone and body language that often goes into sessions. I tend to think that psychiatrists bake a degree of withholding and dissembling into sessions and they don’t consider the object of this part of a session to be rapport building.

I’m amused that the psychiatrist would directly mention an anasognosia diagnosis to the patient. Seems pretty pointless by definition. I’ll have to look for a link to the description of my first visit to a psychiatrist versus my first psychologist.

Psychiatrists generally don’t consider getting people to open up about their problems a significant part of their jobs. They are largely psychopharmacologists. They tend to make quick assessments, don’t want to hear stories and especially details. They want to cut to the chase, prescribe a medication and move on. And the cycle repeats at the next session. I like to say they treat patients like they are golf holes, and the medications are their golf clubs. They keep swinging until they get near the hole in their opinion, or the patient gives up on them.

Frankly, if you are expecting a psychotheroputic approach, you may be looking at the wrong practitioner. My recovery was with a Jungian Psychologist as lead and a psychiatrist handling medication. It’s not a widely accepted method, but it works in some cases. Nowadays I have just a psychiatrist who knows my last psychologist, and he’s indulgent of my need to talk things through in periodic hour-long sessions.

The psychiatrist is correct that Zyprexa isn’t an ideal long term medication. It’s notorious for causing weight gain, high lipid levels, blood pressure and blood sugar also known as metabolic syndrome. However, it’s pretty effective at clearing up psychosis, so the motive may be to quickly clear things up and moving on to another medication for maintenance.

Edit: him admitting he may have bipolar disorder is a win. There’s a lot of overlap AP medication-wise nowadays. I personally don’t think there’s much value in sharing specific medical labels as far lay people are concerned. More important is progress under treatment.

[Jane16]

Thanks, your advice is always so very appreciated! I guess our next step is encouraging him to trust that a psychologist can be useful, he is definitely anti-therapy as one would expect with anasognosia and feeling he cant trust anyone/ assumes they are part of the plot against him.

Can you answer this for me… in your experience would finding the right med/therapy combo help him to gain insight that these beliefs hes had for years could be caused by mental illness? Or is it more realistic to expect that they will only be effective in stopping any new thoughts or voices from gaining traction?

[Maggotbrane]

@Jane16

would finding the right med/therapy combo help him to gain insight that these beliefs hes had for years could be caused by mental illness? Or is it more realistic to expect that they will only be effective in stopping any new thoughts or voices from gaining traction?

It’s difficult to say. It’s generally believed time spent unmedicated means a SMI will be degenerative, potentially compounding anasognosia and putting insight further from reach. If feeling “heard” could help motivate him to continue medication and learn coping mechanisms as medication clears his positive symptoms, then additional talk therapies would be beneficial. But I’d view any insight gained along that path as a bonus.

I’m skeptical that insight itself is found in a bottle, although some Clozapine success stories suggest that possibility. More that an undercurrent of healthy doubt and skepticism may lurk beneath delusional systems and thinking, and medication may push out the distractions of delusions, hallucinations and thought disorders to reveal it, or possibly not. And it takes a process of going through various drugs to find out which of these is true. And even if you find that “perfect” drug, that doubt and skepticism may take time and work to develop into insight or not at all.

I think it boils down to whether his anasognosia is a physical and irreversible phenomenon, or it can be modulated by retraining or chemically altering the functioning of his brain. Pragmatically, I’d argue that you’ll never know until you try, and you’ll reach your destination when you stop trying. I’d also argue that you have little to lose but time (and depending on your insurance, money) in that trying. This said, my understanding is the intended goals of Dr. Amador’s LEAP techniques are to improve the relationship of caregivers with people with anasognosia, and perhaps persuade them to take medication, not necessarily to develop insight.

I’ve experienced agoraphobia along with my illness, and my experience is it exists on a spectrum and the size of my “bubble” expanded under both medication and behavioral training and varied depending on my stress levels. I feel medication may help modulate symptoms like delusions, hallucinations and thought disorders that may make him fearful to go outside, but behavioral training is helpful as gradually increasing exposure to outside environments allows you to develop, test and refine coping strategies to manage it over time. While CBT either wasn’t available or I was unaware it existed, I sort of “rolled-my-own” based on exposure to behaviorism and the scientific method in college and I employed it to develop and practice coping strategies. Perhaps we could all use a little help with this now as the world opens up and the pandemic eases.

I advocate for as many treatments as can be tolerated and feasible, since my recovery strategy was scattershot and I can’t separate which components of my “special sauce” were effective for me. I feel rising tides lift all boats.

However, there’s one huge advantage that couples have over individuals if their relationship can weather the storm. That’s shared history, context and experiences. If I had to chart my progress of my recovery, my relationship with my first therapist was key, medication helped from there, and developing work and social relationships were a long slog, but then as I developed trusting personal and intimate relationships things got so much easier for me. Agoraphobia is easier to tackle as a couple or within groups and having two heads is better than one with reality-checking and problem-solving. My focus would be continuing as you have been going, listening to your partner, supporting and advocating for him, suggesting other options, all the while building trust and continuing to nudge each other forward to keep trying to find things that work, and not giving up.

[Hanginginthere]

Wow! Talk about terrible bedside manner.
Good for you for advocating for your loved one right then and there.
Our son had a lot of success on Zyprexa. It seemed to calm him down as well as lessen his delusions. He was on it for 7 years with an increasing dosage. When he reached the max dosage (after 7 years) he was taken off Zyprexa and put on Clozapine which he likes a lot and he seems as close to his old self as I have ever seen. This is in combination with a kind and non judgmental therapist.