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Dr. Michael
Dr. Michael, Psychologist
Category: Mental Health
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Experience:  Licensed Ph.D. Clinical Health Psychology with 30 years of experience in private practive and as a clinical psychology university professor.
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If I am on a multiple of pharmaceutical drugs to include (ambien,

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If I am on a multiple of pharmaceutical drugs to include (ambien, clonzapam, gabapentin, fiorcet IBUPROFIN, and prozsasn; suffer from depression, post concussion syndrome, mild-traumatic brain injury, cognitive disorder, chronic-post traumatic stress disorder, brain damage in 6 out of the 8 lobes of the brain if you consider right/left side.

Is it beyond a reasonable doubt that the way I think and act is impaired and not fully functional?
Submitted: 2 years ago.
Category: Mental Health
Expert:  Dr. Michael replied 2 years ago.
Hello. I believe I can be of help to you with this issue.

You are taking so many drugs that it is impossible to assess how your brain is truly functioning on its own, versus with the drugs. The medication effects tend to have global, mild to moderate effects on cognitive functioning , but high doses of these drugs or significant combinations of drugs can cause severe attention, concentration , learning and recall impairments. Some of these medications such as ambien and clonazepam cause cognitive slowing, for example. All individuals---even those without brain injury, are not supposed to drive or use machinery if they are on significant doses, for example.

Now, the only way to really tell whether you are cognitively impaired due to brain injury or chemical problems in your brain, versus the medication effects, would be to work with your physician and a neuropsychologist. In this case, the physician would agree to taper all of your medication significantly, down to nearly nothing if possible, for a short time. Once withdrawal and side effects are largely absent, you would undergo a thorough neuropsychological assessment, which would only take a few hours to a day. You could then reassess whether you needed to go back on some or all of your medications.

So this would be a formal way of finding out more conclusively, which of your problems are due to brain injury and mental illness, or due to the effects of taking so many medications. But to find this out is a bit of along process----the medication tapering process might take several weeks or even a month or two, and your physician would have to agree that this is a good thing to do, or to find out i.e., impairments due to brain injury and mental disorder, versus impairments associated with the combination of medications you are taking. Now, having said this, if you had many cognitive problems before you started these medications---some or all, then this answers the question---you have impairment that is independent of the medication. Also, if certain impairments are particularly severe e.g., near complete inability to learn new information, under any circumstance, then this points to brain injury and not medication effects. What do you think? Are you clearly impaired even without any medications? How do you know this?
Customer: replied 2 years ago.
Doctor,

Thank you for replying back to me with a very detailed response. To answer your final questions to help render any other conclusion.

It was proven through testing of cognitive function that I suffered from cognitive defect. A more intense study was done when I was medically evacuated out of Afghanistan for chronic-PTSD. I saw a neuro-psychologist who conducted a cognitive test that was about 4 ours long. This was coordinated through my Occupational Therapist and to a Doctor specializing in neuro-psychology. His test found the following results:

"Demonstrates mild impairment in cognitive performance and evidence of moderate psychopathology symptoms. Evidence of cognitive deficit was noted on measure soy confrontation naming, sustained concentration, visual memory, and scanning ability. The service member demonstrated some difficulty retaining information over time. This included trouble recognizing visual details when provided with cues by the examiner. The service member also had moderate difficulty naming pictures of objects, although no evidence of impairment in global in language abilities was indicated. In terms of his sustained concentration ability, the service member performed attentions tasks somewhat hastily, and was noted to be significantly error prone. He was however able to inhibit competing responses during his performance. He had no difficulty completing measures of visuospatial processing, receptive language, executive functioning, and processing speed. Bilateral deficits were noted in motor strength, while speed was noted to be mildly impaired on the left upper extremity. Mild errors in finger localization were also noted on the lett, while the service member had some bilateral difficulty recognizing objects placed in the hand in the absence of visual input. Visual fields were full to confrontation with no evidence of extinction. Basic auditory perception was noted to be intact with no evidence of sensory neglect. Achievement perfomance fell slightly below average in the areas of sentence comprehension, spelling, and math computation. Emotionally, the service member reported moderate symptoms of depressed mode including sadness, pessimism, and guilt. Clinically significant symptoms of Posttraumtic Stess Disorder were also indicated. These symptoms included disturbing memories and dreams of combat related events, increased startle response, and extreme physical reactions to traumatic reminders (i.e. heart pounding, trouble braining, sweating) Validity assessment suggest that motivational factors were not likely to be infuelntial in the test performance. While demonstrating a low average range of overall cognitive ability, the service member's general intellectuals skills are measured to be somewhat lower than expected given his estimated premorbid level of functioning. Results suggest a mild decline in mental functioning plausibly influenced by history of traumatic brain injury events. Present evidence suggests that despite report of right sided paresthesia following IED injury, there is minimal evidence of a residual pattern of unilateral deficit upon neuropyschological examination. While the service member does show moderate impairment in confronting naming, this appears to represent an isolated language deficit with minimal indication of other impairments in the front lobe functioning. Given evidence of moderate PTSD and depressive symptoms. the service member's present neuropyschological status is also thought likely to be significantly influenced by these factors. Several medications prescribed at the time of evaluation are also thought potentially to impact findings. Consider all of the factors, the service member's present cognitive status is not through to be full indicative of his long term functional outcome."

Sorry for that long response.

There is far more from psychiatrist, physical therapist, occupational therapist, neurologist etc. that explain different impairment as well.

Question is: Should I have been closely monitored in a hospital setting or daily check up while on all of the heavy medications, with PTSD, depression, etc.? Should a provider have restricted me from driving? Would I be able to make rational decisions and accurate statements with reported trauma?

Basically why would all of the multiple providers not have implemented any safety precautions considering the severity of my mental defect?

I will tip you largely for your response, I know this is probably a more than detailed question you normally receive. I could be wrong.
Expert:  Dr. Michael replied 2 years ago.
It is unlikely that any health care expert would have required hospital-setting monitoring or even daily check-ups on medication. There wouldn't, based on this neuropsych eval, have been any apparent need for keeping you in the hospital beyond this evaluation period. My guess is that they would have released you but determined to have follow up appointments on a regular basis, as an outpatient. What would be the extent of the monitoring and outpatient appointments? I think it would have been normal for them to have you walk away from this evaluation with a definite follow-up appointment to check on you and any meds you were on---maybe a few weeks or month---I can't specify when. However, they would have viewed someone with the description presented in the neuropsych eval you presented in this evaluation to be capable of self-care, able to function with many daily activities (though fulfilling a full time job at the time of the eval would be questionable).

They'd believe they could send you on your way from the appointment with the simple instruction to alert them ASAP if any new symptoms arose, and particularly, if they had any serious side effects began due to the medications. So, if asked now, they would likely claim that they told you they'd set up an appointment immediately or ASAP if you experienced new symptoms, or they would assess the problems immediately as you reported them over the phone and suggest a medication dosage adjustment during the phone conversation. I wouldn't have expected to have daily monitoring as an outpatient in this case, however, based on the profile of symptoms you report in the neuropsych eval. There would have to be other symptoms or problems missed by the neuropsychologist, but detected your physician for this to occur.

They wouldn't have checked up on you daily but would have expected that you would check with them if you were having any problems. You would have almost certainly been told to not drive while on these medications. Now, these days, the other health care providers e.g., physical therapist, occupational therapists, counselors, nurses, would not have cautioned you about the drugs but whoever prescribed them would have, especially if they were the sole prescriber. If the were one of several doctors prescribing they may not have had a clear picture of all of the meds you were taking at once, and might not have assessed possible drug interaction effects. With this list of drugs you cited in your post however, one wouldn't expect significant interactions. Your physician will probably claim that he/she told you about possible side effects during your consultations with them (and did so verbally) and that you received all of the needed dosage and side effect information about the medications when you got the prescriptions filled---from the pharmacist. These usually come in written form on a print out with each prescription, or might be printed on the container itself. I suspect if you read the drug information you received when you got the prescriptions, they'll specifically say things such as 'don't drive while or use machinery or equipment while taking this medication' or 'do not consume alcohol if taking this medication'.

I would not expect the physical therapist or occupational therapist to have the level of expertise needed to really evaluate your overall psychiatric and physical status. They just do not have the training to do this. They function in their limited specialty and are able to see just a 'slice' of your overall status. The psychiatrist, being a physician, should have the best overall perspective of your cognitive functioning, physical functioning, brain injury status, and mental health, of the people you mention. He or she would have been the primary provider, or perhaps the neurologist. They would have made the major decisions about how to treat you going forward.

I interpret the final lines of the neuropsychology report as suggesting that your cognitive functioning would be expected to improve over time, as would your overall functioning, as the PTSD and other problems are treated, and (presumably) improve. Now treating PTSD and associated depression with medication alone is not the preferred route. Forms of cognitive behavioral therapy plus medication would be what I'd normally recommend. This is because situational cues in the environment and conditioning/learning factors play a huge role in maintaining the symptoms of these problems. Pills can't teach skills, to put it simply.

I hope this information is helpful to you. It may not be what you hoped to read, but I do see a lot of social security disability case appeals for example, that involve serious health problems combined with mental disorder issues and I think I know how physicians and other health care providers think and plan and try to allocate the resources they have a their disposal, their time, etc. This is what I think they'd be considering or thinking about you, given the neuropsych report.

Let me know if I can be of further assistance. Thanks. Please click on the green Accept button at the bottom of the screen.

Dr. Michael, Psychologist
Category: Mental Health
Satisfied Customers: 2177
Experience: Licensed Ph.D. Clinical Health Psychology with 30 years of experience in private practive and as a clinical psychology university professor.
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