Roughening— When Treatment Fails
Once patients with elevated mood are stabilized with psychotherapy, psychoeducation, lifestyle management, and medication, they may remain stable for an extended period. It is not uncommon, however, to have breakthrough mood episodes, the severity of which may vary. Breakthrough symptoms can consist of elevated mood symptoms, depressive symptoms, or mixed states. When these symptoms are significant, we label them as relapse; when they are mild to moderate, a descriptive, frequently used term is “roughening.” When roughening or relapse occurs, many practitioners automatically reach for the prescription pad to change or add medication. Although an alteration of medication may remedy the problem, a structured format to assess all the possible causes for re-emergence of symptoms is desirable. The elements for this format are outlined in Table 9.1.
Although this acronym, TRACCCC, is useful to remember the elements that need to be considered, most clinicians would apply these actions in a different order of priority (Reevaluation, Alcohol, Compliance, Talking therapy, Changing medication, Combination therapy, Consultation).
The emergence of symptoms, whether new or previously experienced, is an ideal opportunity to reconsider the clinician’s initial assessment. In addition to the initial diagnosis, the patient’s medication regimen, lifestyle issues, alcohol and drug use, and compliance should be addressed and reevaluated.
TABLE 9.1 Getting back on TRACCCC
The initial assessment could have been incorrect or only partially correct. In an elevated mood patient, a depressive episode, dysthymia, or mixed state may have emerged. New anxiety symptoms such as panic attacks, social anxiety, or generalized anxiety may appear. Especially if there has been a lengthy interval since the initial evaluation, the clinician should conduct a fresh assessment of symptomatology. Queries about symptoms that may have been given negative responses in the past may now be answered positively. It is surprising how often during a reevaluation the patient’s recollection of his or her condition and history may be different from that initially described. There are several reasons for this: