Agoraphobia...anyone with experience?

[AngelfireRN]

Greetings! I would like some input on a situation we are dealing with.

Patient X has lately been denied their disability claim, because they refused to attend the court hearing for the continuation of the benefits. The disability claim reason is reportedly agoraphobia. The patient states that they are unable to attend the hearing because the location of the trial requires them to travel over a bridge and into another city. They state that their agoraphobia won't allow them to go to the hearing. They further state that they have tried to speak to the disability board by telephone but, "they hung up on them when they could not stop crying".

Patient repeatedly requests that Doc write them a note that states they cannot attend. Doc's position is that if the patient can stand to leave their house to come to the clinic, then they can go to their hearing.

Some other tidbits...

*The patient was seen by the entire office eating out at restaurant, in no apparent distress.

*The patient has two children that always accompany them to appointments, with various excuses about why they are not in school. (We are currently making inquiries regarding a truancy violation.)

My question:

Is agoraphobia selective? Can it be that the patient is comfortable coming to clinic and eating out, but for some reason can't tolerate a courtroom?

We are of the opinion that the patient simply does not want to put forth the effort, and is using this complaint as a crutch. However, having limited experience with this particular diagnosis, I would be very glad for some other views. Thank you.

[AngelfireRN, MSN, RN, APRN]

Agoraphobia and all phobias for that matter can be selective. It is very possible that this patient can be comfortable in a certain "safe area" be it a block or a few miles from her home, and be able to travel no further than that. It is also possible that the children are in fact serving as a "support" if she forces them to miss school just to accompany her to an appointment. The child does not have to be in close proximity to make them a "safe person", they can just be in the hall or in the building or even next door---again, this disorder can be selective in how it manifests itself.

In terms of disability, I would encourage the patient to see a psychiatrist who has some familiarity with anxiety disorders in order to determine if they are eligible for disability and to provide proper documentation. I doubt a GP or NP could reasonably make this call as there are so many variables with this disorder. For example, the patient might be able to attend court if they were prescribed a benzodiazapine and one would have to wonder why they were not able to get an Rx for klonopin before the court date. If a trial of klonopin was not sucessful at controlling the attacks then that would have to be noted in the report as it is also possible that someone can not face their fear even with klonopin in their system. It is not for anyone to judge this patient without the full scope of their symptoms and history. They need to be under the care of a mental health provider that can attend to this issue IMHO.

For those that wonder, here's the answer, lol. She IS taking a benzo, three times a day. Claims that doesn't help. She refuses to see a psych. She refuses to do anything other that exactly what she wants to do. We have referred her, to no avail. She cancels the appointments, or just no-shows. This has been documented. It's my suspicion that those notations in her chart, coupled with her refusal to attend the hearing, were what ultimately tipped the scale.

I should preface the rest by saying, while we do do pain management, Doc sees patients for primary care as well. Most, however, are pain patients.

Neither he nor I will even consider attesting to this person's complaint of agoraphobia. We have no way of knowing if she's having us on or legit. It's been YEARS since I did psych.

So, until something gives, I guess we're just where we are.

[AngelfireRN, MSN, RN, APRN]

What state do you live in? Can NP's in your state even sign disability papers? I am in Michigan, and an NP or PA cannot sign any papers for disabilty claims...you better check before you get yourself involved in this.....there is a great site that has all the states scope of practice summarized, and from what I see, most states restrict an NP's ability to sign these forms. Just my advice....I have seen several patients in our area who went to court with papers filled out by NP's, and their case was thrown out of court. There are physicians and psychiatrists who specialize in evaluating patients for disability...I would refer the patient to one of them.

Good luck!

I'm in Alabama. I am not certain about whether or not I am even able to sign off on disability...Doc won't do disability cases, period. He refers to a third-party physician who has no vested interest and therefore cannot be accused of favoritism.

I don't blame him. It's seems like it could be quite the sticky wicket if you determine that a regular patient is not as disabled as they claim to be.

Oh, and we did refer. She won't go. Sigh.

[zenman]

Where is she getting her benzos from?

[AngelfireRN, MSN, RN, APRN]

Doc agreed to treat her anxiety. This was before she refused to continue seeing her psych ( who did not Rx for an unknown reason). Since then, I have suggested ceasing her benzos until she complies with seeing a psych. Doc is considering this measure.

[Corey Narry, MSN, RN, NP]

For the Psych guys, are benzos first line treatment for anxiety disorders? I just have been seeing more SSRI's as home meds in our hospitalized patients with a history of anxiety disorders.

[AngelfireRN, MSN, RN, APRN]

I'm not sure what the entire regime was. I can say that, since my inception, I have offered and ordered at least 3 different SSRI meds. Either she claimed they didn't work, or she outright refused to take them.

I'm truly about at my wit's end with her. A part of what I'm dealing with... Doc has historically babied a significant percentage of our people, and as such, they feel they have carte blanche to do or not do whatever.

Makes for a difficult course. It's working with most, the adherence to rules. Some, however, he doesn't want to deal with anymore, so I inherited them. I still discuss every patient with Doc, as per state requirements. Just some things require a 'Stern Mommy' approach. I do Stern Mommy very well.

[Psychcns]

I'm not sure what the entire regime was. I can say that, since my inception, I have offered and ordered at least 3 different SSRI meds. Either she claimed they didn't work, or she outright refused to take them.

I'm truly about at my wit's end with her. A part of what I'm dealing with... Doc has historically babied a significant percentage of our people, and as such, they feel they have carte blanche to do or not do whatever.

Makes for a difficult course. It's working with most, the adherence to rules. Some, however, he doesn't want to deal with anymore, so I inherited them. I still discuss every patient with Doc, as per state requirements. Just some things require a 'Stern Mommy' approach. I do Stern Mommy very well.

Has she had a full psych diagnostic evaluation? Is she in therapy? She seems to need more treatment than you can give her at a pain clinic. Also, it doesn't seem like the benzos are working.

Does she have strategies to cope with her anxiety? Substance abuse hx etc.

[AngelfireRN, MSN, RN, APRN]

I agree that she needs more treatment. But I can't make her go. She refuses. She says she's seen a psych and been worked up. She refuses to go back.

As far as the meds...she's on the max Doc will Rx.

I'm really at a loss.

[Psychcns]

I agree that she needs more treatment. But I can't make her go. She refuses. She says she's seen a psych and been worked up. She refuses to go back.

As far as the meds...she's on the max Doc will Rx.

I'm really at a loss.

Get releases for her psych records. does she think the benzos are working?? Is she abusing them?? Ie running out early, calling for refills before they are due etc?? Can you see her more frequently and teach coping skills?? And sort out why she doesn't want psych tx. I don't think benos without therapy is working for her--she is still agoraphobic..

[zenman]

For the Psych guys, are benzos first line treatment for anxiety disorders? I just have been seeing more SSRI's as home meds in our hospitalized patients with a history of anxiety disorders.

Depends on situation but SSRIs are preferred treatment if possible along with therapy. Sometimes I'll use Vistaril also. You tell her you're going to drop the benzos and she may go elsewhere which then means you won't need any.

[AngelfireRN, MSN, RN, APRN]

Get releases for her psych records. does she think the benzos are working?? Is she abusing them?? Ie running out early, calling for refills before they are due etc?? Can you see her more frequently and teach coping skills?? And sort out why she doesn't want psych tx. I don't think benos without therapy is working for her--she is still agoraphobic..

No, she says that they don't, constantly requesting/demanding more. As far as the more frequent visits and teaching coping skills, neither Doc nor I has training in that. She's not receptive to any sort of therapy, period.

She wants to dictate her own care and will only do what she wants to do.

[AngelfireRN, MSN, RN, APRN]

Depends on situation but SSRIs are preferred treatment if possible along with therapy. Sometimes I'll use Vistaril also. You tell her you're going to drop the benzos and she may go elsewhere which then means you won't need any.

Ultimately, that's what we've decided to do, after much discussion. She's consistently noncompliant, which is enough to dismiss her outright, but usually ceasing the RX of controlled substances is enough to make them leave the practice.

I guess I sound cold, but I can't help her if she's not going to make the least effort to help herself. And I'm not going to vouch for her reported complaint when all we have seen is evidence to the contrary.