Beware the hyper-intellectual who fails to commit to treatment

[novopsych]

I have recently had hyper-intellectualization rear its ugly head causing a problem in a patient of mine, which is now causing me a problem. We live in a society where people are addicted to thinking, and like other addicts the hyper-intellectual harms those around him.

I should state that what I do is the opposite of top-heavy therapy. What happens in the dance is not meant to be remembered. It is not meant to be judged. While there are dance moves, you never really know where a dance will take you. Each moment is an actualization of life itself.

Of course in our legalese society, I’ve been burdened with a client who has taken to remembering and judging what took place during one particular dance, which signals to me that he was not truly present in the dance. I cannot be held accountable for what takes place between two people when they are on two completely different planes—one committed and the other not. My client was apparently lost in his head, and I was in the dance. I cannot be held accountable for what happens when a client fails to commit to treatment. It would be as if a patient sued for adverse effects to a drug taken in a way other than prescribed.

When he told me of his concerns, I could tell the problem was hyper-intellectualization—what I refer to as being “top-heavy.” I know there’s no code for it, but I treat the patient before me. I wanted to treat him with Zyprexa to attenuate his obsessive rumination, but he chose to run away from working out his issues through dance therapy and medication and is now suing my practice.

I am sharing this difficult time in my life with you all because I want you all to be aware, as well, of the hyper-intellectual. They have no regard for context, and I believe they are in a way addicted to their thoughts. And it leads them to becoming rather legalese, which is pretty much the saddest state a human being can be in. I actually feel sorry for him. What a sad person that lives in the past.

The ironic thing about the hyper-intellectual is how stupid they can be. Why would you sue someone who knows some fairly personal details about you—details that if released could hurt your relationships and employment? Of course, I’m not going to break the law and reveal information he confided in me. But if someone is so lost in their head as to overthink what happens during the dance, why wouldn’t they stop to ruminate over the risk of their personal information being leaked?

I would advise that if you notice a patient showing signs of hyper-intellectualization that you begin attenuation treatment before the condition grows out of control and the patient refuses treatment, or even worse, sues.

---

Members don't see this ad.

 

[notdeadyet]

Smart money's on the plaintiff...

 

[whopper]

A problem with residency is the typical patient is an under-educated, poor person. Most residents get an exposure to this type of patient.

What about the rich, hyper-entitled, spoiled, and cluster B patient? Oh you see trends in those patients too. Just that most residents won't see that patient much unless you work in a private elite facility (such as a few advertised in some the APA periodicals) or a private practice catering to the rich.

Some problems I've had with some of these types
-Getting calls from the patient's lawyer time and time again with threats to be sued when I did nothing wrong and the patient wanted to keep me as their doctor (Then freaking tell your lawyer to stop calling me when even she knows I did nothing wrong).
-Expecting me to have all the previous physicians that treated the patient all have a conference call about the patient when these doctors were literally over 10 in number and across the country and none of them were returning phone calls, nor could bill for such a meeting, then explaining to the person and his family for over 2 hours why this was not feasible.
-Having a patient with an expensive outpatient psychiatrist still do interviews via SKYPE while bilking the patient (cough cough, excuse me, billing) while the guy was inpatient and pretty much intentionally spending as much time as possible with the guy so he could bill as much as he could.
-Phone calls without warning that the patient was going on an expensive vacation to (insert here: France, the Carribean, Japan, etc) and will be gone for a month so I have to make sure the patient can get the medication in less than 60 minutes because they will leave to board their plane despite that I'm not available at that moment, then hearing from the patient and the family screaming at me for being a bad doctor.
-Demands from the patient's family that I do this or that in direct violation with HIPAA, and when I tell them I can't give them any information, oh, they just won't hang up, they got to keep screaming at me or my staff members.
-Seeing an anorexic patient, the father believes there's a medication to fix this, the rich father screams at me to prescribe it, I tell him there isn't a medication that gets rid of anorexia, and he starts yelling with an angry voice, "what is it that you want? More money? I'll give it to you!" He then goes to a local ER and pulls the same stunt, and their psychiatrist is telling him that inpatient really isn't going to help his daughter and she needs an ED specialist and she's not hospitalizable becuase her weight is not much below normal. Then the guy calls up my office screaming at me, demanding that I fault the ER psychiatrist. All of this takes about 5 hours while he's screaming at everyone. (Hmm, I wonder just why she has anorexia? Could it be...anyone? Anyone?)

This is a reason why I generally don't suggest people start seeing rich patients as some type of mana-from-heaven type of patient. (Maybe I should because I figure the people here wanting a quick-buck are not in psychiatry for the right reasons and curse them with these entitled types!)

 

[PistolPete]

Wow… guess certain sides of psych can be pretty awful… How do you suggest weeding these types of patients out at the first visit?

 

[Doctor Bagel]

Sounds like an exciting dance. Perhaps you could provide us with more details, novo, although I understand there are limitations on discussing current litigation.

Are there studies on the combined benefits of Zyprexa and dance therapy? The orthostatic hypotension, sedation and weight gain could all make dance difficult, yet I guess dance could help as well with these side effects. Perhaps this will be on my board exam ...

 

[nitemagi]

In a psychoanalytic/psychodynamic model, intellectualizing is a coping strategy like any other. When overdeveloped it keeps ppl stuck.

 

[whopper]

During intake for these types, you often-times don't see it yet because they want you as a doctor so you're giving them what they want-a new doctor.

But sooner or later (likely sooner) you won't give them what they want, and they're used to getting what they want at a moment's notice. That's when the sparks fly.

My advice is you weed them out if it goes out too far, but you got to be careful about this. Many of these people are litigious and can hire lawyers out of spite and can afford to pay the lawyer while most poor to middle class people will just say "screw it" and get on with their lives. So when you do terminate them, do so after you've been able to document why you did so and that it was not for a flippant reason. The patient whose lawyer called me up, for example. After the third time she called me up, I believed that even if I were sued, I could then reasonably argue that I gave the patient a chance. One time could be mere luck. Two times coincidence. Three times-most judges will see this as a malignant pattern on the part of a manipulative person. that's when I terminated the patient.

Each time the lawyer called me, she insisted she spend extended periods of time talking to me, some of them lasted over an hour, I couldn't bill for it, and I knew that if sued, I could argue that this lawyer's interventions were reasonably prohibiting me from practicing as a psychiatrist.

Here's an example of that lawyer being unreasonable. The patient's husband was suing a former doctor of that same patient. That doctor refused to provide the patient or her husband with his psychotherapy notes and legally he is not entitled to do so. Remember, psychotherapy notes are different from medical notes. The patient's husband requested that I talk to the doctor, get his psychotherapy notes, and then give them to him. I told him no because I am not his partner in a legal battle. I am merely his wife's healer. His wife didn't even want the guy to sue the former doctor but acquiesced to his demands because she didn't want to deal with it anymore. So anyways, I call up the doctor, and he lets me read the notes because we relayed to each other our frustration with her husband who happened to be a very wealthy investor, and most of the content with the notes are that he can't really treat her because every time he gets somewhere with her, the husband inserts his authority into their treatment, the doc tells him not to but then he tells his wife he wont' pay for her bills anymore, so either let him insert himself or she gets no one paying for her to see a doctor.

So anyways, then the guy's lawyer calls me up and demands that I assist them in their efforts to get the former doctor's psychotherapy notes or she'll sue me for malpractice. Literally, I told her that I am a forensic psychiatrist, I've been in court thousands of times, and I know that this is NOT MALPRACTICE and she was giving me an empty threat thinking that I'd cringe to her request. She asked for my malpractice insurance contact info that I gladly gave to her.

I told the patient and her husband that I could not treat her given that they were playing these legal battles, trying to shove me into it that was outside of my place as a healer, and their lawyer was costing me several hours while she tried to every single hotshot-legal, punch the guy below the waist trick she could think of that was not working on me but wasting my time.

And when I terminated the patient, I followed the state protocols TO THE LETTER. Not that you have to know this if you're practicing outside of Ohio but here are the guidelines...
http://codes.ohio.gov/oac/4731-27
You got to send the termination via certified AND regular mail, keep a copy of the receipts, provide a script for one month of the medications, etc.
I did it to the letter cause I knew the patient's husband that was actively pursuing suing every doctor he ever met would consider doing so against me.

I've never been sued yet.

But I have gotten demands from patients to have their records sent to a lawyer and I knew the intent was to sue me. So I sent the records, all of it including that I followed every procedure to the letter and with proof such as receipts, copies of scripts, etc.

And guess what? I never heard from those lawyers again. I know enough of forensic psychiatry and malpractice suits to be able to guesstimate that in the majority of the cases the lawyer spent a few hours looking over the case with a fine tooth comb and telling his/her client that he could find NOTHING I did that was actionable so he would not participate in a lawsuit.

Enough about me, I want to hear more about Novopsych's situation.

 

[Ceke2002]

What happens in the dance is not meant to be remembered. It is not meant to be judged.

So I guess you were off somewhere tripping the light fantastic when they taught the illumination and evaluation stages of dance therapy. If you weren't such a FOS Troll you'd be a fantastic case study for prospective Dance Therapists on how NOT to run a practice.

 

[Ceke2002]

Sounds like an exciting dance. Perhaps you could provide us with more details, novo, although I understand there are limitations on discussing current litigation.

Are there studies on the combined benefits of Zyprexa and dance therapy? The orthostatic hypotension, sedation and weight gain could all make dance difficult, yet I guess dance could help as well with these side effects. Perhaps this will be on my board exam ...

I do understand this comment is replete with sarcasm; however, as a point of interest I was using dance as an adjunctive therapy when I was on Zyprexa (along with other things like yoga and meditation). In Dance Therapy, when it's practiced legitimately, there are four stages - Preparation: Warm up stage, establishment of safety, Incubation: The dance proceeds and this is the point where you enter a state of relaxation and let go of conscious control in order to evoke movements from the subconscious mind, at this stage movement becomes symbolic. Illumination: The stage where you start to actualise and understand the symbolic movements and where meanings start to become apparent, and Evaluation: which is where you discuss the significance of progress, and prepare to end the session (sort of like the cool down stage). The trouble with using Zyprexa in Dance Therapy, in my opinion and based on my own experience, is that you can't really achieve the second state, because you have to maintain awareness. It's not really feasible to let go and slip into a state of active meditation where you give up conscious control of your movements when the medication you're on can cause side effects life Orthostatic Hypotension, because you need to be monitoring your physical state to make sure you don't fall over and injure yourself. For me at least, when I was on Zyprexa, dance was purely a physical exercise, something to get me up and moving and doing something I enjoyed - anything else though was off the table lest I find myself taking an impromptu trip to the floor. I mean I could still dance, I could still do other exercise as well, I just had to keep an eye on how I was feeling and if I started to get dizzy or feel off balance or any other similar symptoms began to appear then I'd have to stop and either sit down or lie down until the feeling had passed. But as for actual Dance Therapy, especially in terms of the Incubation phase, no I can't really see that working too well with someone on Zyprexa.

 

[erg923]

I AM curious how you defend your treatments in a deposition though. Would be a fun cross, I'm sure. "I'm mean, in not responsible because I was too busy dancing?!"

Ok. Give that a try...

 

[Bartelby]

Interesting stuff Whopper, and something to think about for private practice!

Novo, if this story is indeed true there is either more you aren't telling us or the guy doesn't have a case. A malpractice lawsuit requires demonstrating that (1) the psychiatrist's duty toward the patient was breached and (2) harm resulted directly from this breach. You recommended a medication which it sounds like the patient declined. I see no actionable harm from that breach. If, say, the patient had gone home and committed suicide and the family sued you for failing to provide standard of care that would be an example of something that could go to trial, but from your post I'm not hearing anything.

 

[Ceke2002]

I AM curious how you defend your treatments in a deposition though. Would be a fun cross, I'm sure. "I'm mean, in not responsible be hard I was too busy dancing?!"

Ok. Give that a try...

Yes, and don't forget to include a character deposition from your non medically trained, foal delivering secretary. I mean what medical board in their right mind could fault someone so dedicated to their practice that they continued to dance within the therapeutic frame, whilst a lay person was tasked with the duty of providing medical care to an 80 year old with a broken hip. Why it would be near sacrilegious of them not to take your secretary's words to heart and immediately throw the current case out. Not to mention the truly deep and abiding kindness you showed a bereaved patient's family when you offered to dance on their dearly departed's grave whilst your secretary let ponies galavant through out the cemetery grounds. So very touching, they'll be nary a dry eye in the house.

 

[smalltownpsych]

Is Zyprexa helpful for obsessive rumination? (which is a redundancy by the way)

 

[Ceke2002]

Is Zyprexa helpful for obsessive rumination? (which is a redundancy by the way)

Personal opinion only of course, but I found it was. Not so much in the way that it made the ruminations go away completely (although that may have been dose related) it just seemed to sort of turn the volume down to a point where I was then better able to utilise other therapeutic strategies. Kind of like being able to hold a conversation with some quiet music playing in the background versus having to shout over the top of a Led Zeppelin concert.

 

[smalltownpsych]

Personal opinion only of course, but I found it was. Not so much in the way that it made the ruminations go away completely (although that may have been dose related) it just seemed to sort of turn the volume down to a point where I was then better able to utilise other therapeutic strategies. Kind of like being able to hold a conversation with some quiet music playing in the background versus having to shout over the top of a Led Zeppelin concert.

When I hear ruminations, I tend to think of the negative thought patterns associated with depression and ACT has a few ways of helping with that, too. I am thinking that a prescription for ETOH might also be an effective tool for loosening up the old inhibitions and shutting down the over-active frontal cortex in an intellectualizing patient to help get the full benefit of the dance. That's how they did it back in the day.

 

[Ceke2002]

When I hear ruminations, I tend to think of the negative thought patterns associated with depression and ACT has a few ways of helping with that, too. I am thinking that a prescription for ETOH might also be an effective tool for loosening up the old inhibitions and shutting down the over-active frontal cortex in an intellectualizing patient to help get the full benefit of the dance. That's how they did it back in the day.

ACT? Alliance for Cannabis Therapeutics? Well I suppose that might work as an adjunctive treatment to the ETOH, maybe throw in some N2O as well just to keep things interesting. Hang on a sec, let me go reconnect with one of my old friends and let him know his behemoth of an all in one bong+alcoholic beverage receptacle+nitrous oxide delivery system is now potentially on the cutting edge of advances in Psychiatric treatment, he may want to take out a patent.

 

[erg923]

Acceptance and Commitment Therapy.

This novo poster reminds me of that shrink from A Clockwork Orange. Scary.

 

[Ceke2002]

Acceptance and Commitment Therapy.

This novo poster reminds me of that shrink from A Clockwork Orange. Scary.

Cheers for that, just read up on it briefly and I believe my Psychiatrist incorporates it into my overall treatment plan, along with several other psychotherapeutic modalities, I just didn't know the exact name of the technique until now.

(edited to add: Mindfulness Based Cognitive Therapy is one of the other treatment modalities that my Psychiatrist uses with me as well)

And yes, troll in the dungeon or not I agree the principals Novopsych is espousing are quite frankly more than a tad on the disturbing side. Yikes!

 

[jakeislove]

Wouldn't higher socioeconomic status reinforce the sense of entitlement present in some mental diseases?

 

[nancysinatra]

In a psychoanalytic/psychodynamic model, intellectualizing is a coping strategy like any other. When overdeveloped it keeps ppl stuck.

In the psychoanalytic model, is all intellectualizing a coping strategy, or just intellectualizing that serves to direct attention away from some source of anxiety? What if someone is just doing a math problem? They are using their intellect in that situation. Is that considered "intellectualizing?"

I have to say, if someone goes to a psychiatrist and they are offered some dimwitted form of dance therapy, I hope they will use their intellect to look up the name of an attorney. This seems like a pretty good coping strategy to me.

 

[whopper]

Is Zyprexa helpful for obsessive rumination? (which is a redundancy by the way)

Atypicals at low dosages are supposed to help reduce OCD, though from my knowledge because they act as as an augmentation agent, not because they're doing it in and of themselves.

 

[smalltownpsych]

In the psychoanalytic model, is all intellectualizing a coping strategy, or just intellectualizing that serves to direct attention away from some source of anxiety? What if someone is just doing a math problem? They are using their intellect in that situation. Is that considered "intellectualizing?"

I have to say, if someone goes to a psychiatrist and they are offered some dimwitted form of dance therapy, I hope they will use their intellect to look up the name of an attorney. This seems like a pretty good coping strategy to me.

In psychoanalytic terms, intellectualizing is considered a defense as opposed to a coping strategy which to me the main distinction between the two would be in a defense, the anxiety becomes unconscious whereas a coping strategy or mechanism tends to be volitional because one is aware of the emotion. I have been seeing more of this dynamic recently as I have been working within a cultural context that is more akin to pre-Freud, it is amazing how unaware people can be of their affective state. Heck, I wish I would see more intellectualizing than somaticizing, but either way these people are much more unaware of their anxiety than the typical post-Freudian urban population.

 

[erg923]

Regarding intellectualizing and other psychoanalytic concepts/speak: There are less ridiculous theories of mind (with supporting evidence from developmental psychology and experimental psychopathology research), I would suggest psychiarty move on, as most of it's clinical psychologist brethren did a couple decades ago.

 

[Ceke2002]

When I hear ruminations, I tend to think of the negative thought patterns associated with depression and ACT has a few ways of helping with that, too.

I've been giving a lot of thought to this. I know I'm not supposed to go into too much detail on here with regards to my actual symptoms, but seeing as this might be relevant to the topic and I will only be giving one specific example...

Okay, I'll try to tread as carefully as possible here:

In my case most of what I think of as 'ruminations' tends to be triggered off by ideas of reference, or at least what I understand to be 'ideas of reference', that can occur during a depressive episode where psychotic fx are also present. So for example during one particular episode back in 2004, among other symptoms I felt like I was receiving coded messages through the TV telling me I needed to 'watch for signs' in order to save the world from a coming disaster. Over a number of years I've used a variety of techniques, mostly learnt through CBT, in order to sort of 'teach' myself to retain insight at times like this - so of course I immediately went into my usual routine of reality checking, compare and contrast (how were other people in the household responding to these so called 'messages', contrasted against my own experience were they responding in any way at all), self analysing the validity of such thoughts, etc etc, and then distract, ignore, and so on. Until the boxing day Tsunami hit and I spent the next several days in a fit of guilt and grief, obsessively ruminating over the 250,000 or so deaths I'd caused.

Had I been on Zyprexa or another atypical at the time the rumination/guilt might have still occurred but instead of it being several days before I managed to regain insight and think more appropriately/realistically, it might have only taken an hour or so, or I might have even been able to stop the rumination in its tracks before it really had a chance to take hold (obviously with this example I can only offer conjecture). I personally find it depends a lot on the severity of my symptoms at any one time though. If my symptoms are more low key, for want of a better expression, then I can typically manage without medication by continuing to utilise both CBT and now ACT techniques to sort of tune out, or switch off these types of thoughts or ruminations if and when they occur. My Psychiatrist keeps a fairly close eye on any recurrence of symptoms when I'm not on medication, and if I'm getting to a point where any symptomology is starting to reach a level whereby I'm having to devote a greater and greater amount of time and mental effort toward retaining insight, and being able to keep myself distracted, that's usually when the recommendation to recommence medication is given. At that point when the medication kicks in, as I said previously, it's like the volume on everything just gets turned down.

Definitely with mild to moderate symptoms I find stuff like CBT and/or ACT techniques to be very effective, it's just if things do get to a more 'severe' level then I can still utilise CBT/ACT techniques, but I kind of also need the medication alongside that to bring things back down to a more manageable level. If and when a return to medication does become necessary I do tend to try and not rely on that alone, it's always medication in conjunction with other non pharmacological management strategies - or at least that's how both I and my Psychiatrist prefer to approach things.

Just my personal experience of course, absolutely not saying it's the same in the case of all patients.

 

[smalltownpsych]

This is a bit of an oversimplification, but the way I tend to conceptualize, is that with mild to moderate symptoms, psychotherapeutic interventions tend to be more effective and safer, and as symptoms range from moderate to severe, then medications have more effect and the cost/benefit profile shifts to where the potential side effects are less worrisome than the symptoms. Regardless of this gross metric, it is up to the physician and patient to decide what treatments make sense for each given individual in each unique situation. Or you could just dance your troubles away.

 

[Ceke2002]

This is a bit of an oversimplification, but the way I tend to conceptualize, is that with mild to moderate symptoms, psychotherapeutic interventions tend to be more effective and safer, and as symptoms range from moderate to severe, then medications have more effect and the cost/benefit profile shifts to where the potential side effects are less worrisome than the symptoms. Regardless of this gross metric, it is up to the physician and patient to decide what treatments make sense for each given individual in each unique situation. Or you could just dance your troubles away.

Yep, this is pretty much the way my Psychiatrist seems to work, more looking at symptoms along a spectrum rather than a fixed point. And dance, always dance. Personally we begin and end all our sessions with an Irish jig or a Can-Can. Oh and don't forget to promenade your patient to and from the room as well, because that really helps set the tone of the session.

 

[nancysinatra]

Regarding intellectualizing and other psychoanalytic concepts/speak: There are less ridiculous theories of mind (with supporting evidence from developmental psychology and experimental psychopathology research), I would suggest psychiarty move on, as most of it's clinical psychologist brethren did a couple decades ago.

Hey thanks for your suggestions.

 

[jakeislove]

In the psychoanalytic model, is all intellectualizing a coping strategy, or just intellectualizing that serves to direct attention away from some source of anxiety? What if someone is just doing a math problem? They are using their intellect in that situation. Is that considered "intellectualizing?"

I have to say, if someone goes to a psychiatrist and they are offered some dimwitted form of dance therapy, I hope they will use their intellect to look up the name of an attorney. This seems like a pretty good coping strategy to me.

Leaving while singing "These boots are made for walking" would be better.

 

[PikminOC]

A problem with residency is the typical patient is an under-educated, poor person. Most residents get an exposure to this type of patient.

What about the rich, hyper-entitled, spoiled, and cluster B patient? Oh you see trends in those patients too. Just that most residents won't see that patient much unless you work in a private elite facility (such as a few advertised in some the APA periodicals) or a private practice catering to the rich.

Some problems I've had with some of these types
-Getting calls from the patient's lawyer time and time again with threats to be sued when I did nothing wrong and the patient wanted to keep me as their doctor (Then freaking tell your lawyer to stop calling me when even she knows I did nothing wrong).
-Expecting me to have all the previous physicians that treated the patient all have a conference call about the patient when these doctors were literally over 10 in number and across the country and none of them were returning phone calls, nor could bill for such a meeting, then explaining to the person and his family for over 2 hours why this was not feasible.
-Having a patient with an expensive outpatient psychiatrist still do interviews via SKYPE while bilking the patient (cough cough, excuse me, billing) while the guy was inpatient and pretty much intentionally spending as much time as possible with the guy so he could bill as much as he could.
-Phone calls without warning that the patient was going on an expensive vacation to (insert here: France, the Carribean, Japan, etc) and will be gone for a month so I have to make sure the patient can get the medication in less than 60 minutes because they will leave to board their plane despite that I'm not available at that moment, then hearing from the patient and the family screaming at me for being a bad doctor.
-Demands from the patient's family that I do this or that in direct violation with HIPAA, and when I tell them I can't give them any information, oh, they just won't hang up, they got to keep screaming at me or my staff members.
-Seeing an anorexic patient, the father believes there's a medication to fix this, the rich father screams at me to prescribe it, I tell him there isn't a medication that gets rid of anorexia, and he starts yelling with an angry voice, "what is it that you want? More money? I'll give it to you!" He then goes to a local ER and pulls the same stunt, and their psychiatrist is telling him that inpatient really isn't going to help his daughter and she needs an ED specialist and she's not hospitalizable becuase her weight is not much below normal. Then the guy calls up my office screaming at me, demanding that I fault the ER psychiatrist. All of this takes about 5 hours while he's screaming at everyone. (Hmm, I wonder just why she has anorexia? Could it be...anyone? Anyone?)

This is a reason why I generally don't suggest people start seeing rich patients as some type of mana-from-heaven type of patient. (Maybe I should because I figure the people here wanting a quick-buck are not in psychiatry for the right reasons and curse them with these entitled types!)

This is a very interesting thread. I do not speak to patients when they are inpatient. I only speak to the inpatient doc with prior relevant history and recommendations. This is esp relevant bc one of my outpatients has these obsessive thoughts and I recommended zyprexa which she wouldn't take as an outpatient but has started taking it as an inpatient after I talked to the ip psych doctor. I tell patients not to contact me when they are inpatient as they are under care of the inpatient team.

I do not respond to anything from lawyers. Recently, I told one that I will await a subpoena before any further response.

The item about talking to all the other docs: I had records from the prior PCP and I had spoken to the prior therapist. Family and lawyer are pissed that I didn't talk to the pcp to verify patient doesn't abuse drugs. The patient failed a pill count so then we were done. This speaks to Whopper's point of having a good reason to discharge the patient. And I was so relieved it turned out this way.

Then the patient's mom called me to say she will pay me to take him back (full adult patient). No thank you.

Regarding HIPAA information, you cant win either way. I had to give information during an acute situation to a family member and then I called the police on the patient. The family member then said I had violated the HIPAA rights of the patient. Whatevs.

 

[PikminOC]

I have recently had hyper-intellectualization rear its ugly head causing a problem in a patient of mine, which is now causing me a problem. We live in a society where people are addicted to thinking, and like other addicts the hyper-intellectual harms those around him.

I should state that what I do is the opposite of top-heavy therapy. What happens in the dance is not meant to be remembered. It is not meant to be judged. While there are dance moves, you never really know where a dance will take you. Each moment is an actualization of life itself.

Of course in our legalese society, I’ve been burdened with a client who has taken to remembering and judging what took place during one particular dance, which signals to me that he was not truly present in the dance. I cannot be held accountable for what takes place between two people when they are on two completely different planes—one committed and the other not. My client was apparently lost in his head, and I was in the dance. I cannot be held accountable for what happens when a client fails to commit to treatment. It would be as if a patient sued for adverse effects to a drug taken in a way other than prescribed.

When he told me of his concerns, I could tell the problem was hyper-intellectualization—what I refer to as being “top-heavy.” I know there’s no code for it, but I treat the patient before me. I wanted to treat him with Zyprexa to attenuate his obsessive rumination, but he chose to run away from working out his issues through dance therapy and medication and is now suing my practice.

I am sharing this difficult time in my life with you all because I want you all to be aware, as well, of the hyper-intellectual. They have no regard for context, and I believe they are in a way addicted to their thoughts. And it leads them to becoming rather legalese, which is pretty much the saddest state a human being can be in. I actually feel sorry for him. What a sad person that lives in the past.

The ironic thing about the hyper-intellectual is how stupid they can be. Why would you sue someone who knows some fairly personal details about you—details that if released could hurt your relationships and employment? Of course, I’m not going to break the law and reveal information he confided in me. But if someone is so lost in their head as to overthink what happens during the dance, why wouldn’t they stop to ruminate over the risk of their personal information being leaked?

I would advise that if you notice a patient showing signs of hyper-intellectualization that you begin attenuation treatment before the condition grows out of control and the patient refuses treatment, or even worse, sues.

You can document informed refusal of standard treatment.
Only after looking through all of OP threads do I realize he means literally "dance". I had no idea.

 

[PikminOC]

Wouldn't higher socioeconomic status reinforce the sense of entitlement present in some mental diseases?

Entitlement crosses all economic status..

 

[PikminOC]

Interesting stuff Whopper, and something to think about for private practice!

Novo, if this story is indeed true there is either more you aren't telling us or the guy doesn't have a case. A malpractice lawsuit requires demonstrating that (1) the psychiatrist's duty toward the patient was breached and (2) harm resulted directly from this breach. You recommended a medication which it sounds like the patient declined. I see no actionable harm from that breach. If, say, the patient had gone home and committed suicide and the family sued you for failing to provide standard of care that would be an example of something that could go to trial, but from your post I'm not hearing anything.

He is purposely not giving enough information. There are lots of reasons for malpractice and negligence suits....All that matters is that a lawyer takes the case....

 

[whopper]

In the case above, the patient's husband was a wealthy person and was all too willing to hire a lawyer who was all too willing to bill him for even the most ridiculous requests. Most lawyers will tell their clients something to the effect of, " Don't pursue this, it won't get you or I anywhere."

But when people have money, it means less. $100 means more to a poor person than to a multi-millionaire. Both the lawyer and the patient's husband, I presumed, were in a relationship where both were feeding the other's ego. The rich husband got-off on the lawyer intimidating others, and the lawyer got-off because she was making good money not doing any real work and just intimidating people and billing this guy for it.

Rich people with psychiatric issues have their own iconic types just as the poor patients we see in residency. E.g. the poor malingerer, the malingerer who is withdrawing so claims he's suicidal to gain hospital care while he's on his cocaine-crash, the borderline prostitute, the drug-addict with no Axis I disorder other than drug abuse diagnosed with bipolar disorder. These are the common types we see in psych units in all cities.

One of the rich types you will encounter is the rich guy with a personality disorder that can afford to have one. Most people with PDs usually overcome them because they cannot afford to have it, lest they be fired, fail out of school, lose their friends, etc. When one is wealthy, you could afford to have a PD if rich and powerful enough.





By the way Neil Gaiman, a highly respected sci-fi and comic book writer also commented independently that Jon Peters insisted on inserting a giant spider into a movie version of Gaiman's Sandman despite that there's no appropriate reason to do that.

 

[endrun]

I have recently had hyper-intellectualization rear its ugly head causing a problem in a patient of mine, which is now causing me a problem. We live in a society where people are addicted to thinking, and like other addicts the hyper-intellectual harms those around him.

I should state that what I do is the opposite of top-heavy therapy. What happens in the dance is not meant to be remembered. It is not meant to be judged. While there are dance moves, you never really know where a dance will take you. Each moment is an actualization of life itself.

Of course in our legalese society, I’ve been burdened with a client who has taken to remembering and judging what took place during one particular dance, which signals to me that he was not truly present in the dance. I cannot be held accountable for what takes place between two people when they are on two completely different planes—one committed and the other not. My client was apparently lost in his head, and I was in the dance. I cannot be held accountable for what happens when a client fails to commit to treatment. It would be as if a patient sued for adverse effects to a drug taken in a way other than prescribed.

When he told me of his concerns, I could tell the problem was hyper-intellectualization—what I refer to as being “top-heavy.” I know there’s no code for it, but I treat the patient before me. I wanted to treat him with Zyprexa to attenuate his obsessive rumination, but he chose to run away from working out his issues through dance therapy and medication and is now suing my practice.

I am sharing this difficult time in my life with you all because I want you all to be aware, as well, of the hyper-intellectual. They have no regard for context, and I believe they are in a way addicted to their thoughts. And it leads them to becoming rather legalese, which is pretty much the saddest state a human being can be in. I actually feel sorry for him. What a sad person that lives in the past.

The ironic thing about the hyper-intellectual is how stupid they can be. Why would you sue someone who knows some fairly personal details about you—details that if released could hurt your relationships and employment? Of course, I’m not going to break the law and reveal information he confided in me. But if someone is so lost in their head as to overthink what happens during the dance, why wouldn’t they stop to ruminate over the risk of their personal information being leaked?

I would advise that if you notice a patient showing signs of hyper-intellectualization that you begin attenuation treatment before the condition grows out of control and the patient refuses treatment, or even worse, sues.

Yes, the hyperintellectual.....in other words, the patient who shows you up intellectually....well yes, that tends to knock down our sense of power at least a notch now does it not?

 

[birchswing]

Since people are still commenting on this thread, I should probably clarify that the original post was a joke, one that I didn't think was terribly subtle: a psychiatrist is dancing with her patient, the patient alleges that something inappropriate happened during the dancing, and the psychiatrist's response was that the patient was thinking and remembering too much. I thought it was funny at least; I apologize for the humor being less than obvious.

 

[NickNaylor]

RIP @novopsych - gone but not forgotten.

 

[whopper]

Ouch. Never met Novopsych, didn't know him/her too well. Some of the posts were odd. Dance therapy is odd but I can't fault it if there's data supporting it. The Botox post where there was mention it was profitable. OK, hey let's not pretend we don't want money, but the two combined, plus mention that the dance patients got money, it's not hard to push botox and is a profitable move....hmmm.

 

[jakeislove]

".... a fellow of infinite jest..."

 

[splik]

if anyone had to be banned, it should have been birchswing. bring back novopsych!

 

[birchswing]

if anyone had to be banned, it should have been birchswing. bring back novopsych!

This really messes with my head in a weird way, lol.

 

[jakeislove]

if anyone had to be banned, it should have been birchswing. bring back novopsych!

I agree!

 

[birchswing]

You know I could take this the wrong way.

Having said that, I wouldn't mind continuing to have novopsych as an outlet if she were allowed. I'm not asking, though. I think that character did help me to deal with some of the things I find "twilight zone" like about medicine or Kafka-esque perhaps--something intangible I'm obviously throwing words at--and to have the freedom of being on the other side of it with great confidence, without concern. It's an empowering way to look at the world (to live with the spoils of the way things are rather than be confounded by the way things are), one I'm not personally familiar with. But there are people who do just seem to grab something in life and take it farther than you would think possible. People who make success where there was no path and have every confidence in what they do. Back in the Bush administration, I always used to remark how much I admired Bush's self-esteem. There are good people who are very self-doubting. There are people who drive over their ex-boyfriends (Laura) send hundreds to be executed (George) and send hundreds of thousands to war (George) and maintain such equanimity, poise, and happiness. Such was novopscyh.

 

[jakeislove]

^ Perhaps you're just more comfortable in the feminine role.

 

[birchswing]

My comedy writing has tended to feature a female whom I often imagine myself playing, so you may be right. I formed an acting/improv group (that quickly dissipated—I had never acted before and I live in a small town) and I wrote sketches with female leads yet assumed I would play them, which was only pointed out as odd when we went to rehearse. In my mind, I easily imagined myself as the various leads or in this case as novopsych. When I was young, I was very resistant to male terms (son, boy, etc.). They seemed too familiar. I didn't say mother or father, though, either, as those seemed too familiar (I always called my parents by their first names for as long as I can remember). I was always more comfortable with girls, but unlike people who identify as transgendered I never hated or felt trapped in my body. In retrospect, it's easy to see how I did feel conflicted though as I went to school and saw how my identity as male, which I had been comfortable with, was in contrast with others' conception of male. I think that if I had been left to my own devices, not socialized in a school environment, or had lived in Sweden for most of my childhood where you don't notice gender as much, that I would have been less confused about the role of gender.

Romantically it's easier to imagine myself as a woman in a relationship (I've never been in one). I have no sexual arousal toward people, but I do feel warmth toward men. But I don't want them sexually. It's easier to imagine wanting a man, then, as a woman, to be pursued with warmth. Otherwise, I would rather just be near men. I was never been quite sure growing up if I wanted to be like other guys or with them or both. When I was younger and had male friends they did treat me quite kindly, almost as if I was the lone girl in the group. As I became older, I had mostly close female friends and also a small group of "weird" male friends, who didn't strike me as traditionally male. Those bonds were not very close, though. I decided a long time ago that if I ever realized I was transgendered I wouldn't be able to do with the bother and hassle of a sex change. So I'm not quite sure. I don't strongly identify as anything. I think I would be comfortable as a woman, but I'm not uncomfortable as a male to the extent that I want to do anything about it.

I only found out in my late 20s that my testosterone level varies from around 110-220 (that's the highest it's been measured at). It's possible that I never entirely went through puberty. I'm having an MRI in december to look at my pituitary gland. My testicles are normal size, but my pituitary gland is sending out almost no FSH or LH. I tested myself for XXY, but I am XY. That actually surprised me. My endocrinologist refused an MRI and it's taken me almost a year to find someone who would agree to prescribe one. The doctor I found now thinks my testosterone is low from taking Ativan, Paxil, and Seroquel for over a decade. My psychiatrist thinks that's bunk. I do remember thinking when I went on psych drugs (Ativan and later Paxil) at around 14 or 15 that they would interrupt puberty. I was a hypochondriac, so it's not surprising that I thought that.

I don't want to take exogenous testosterone (it's been prescribed) until I know what the cause of the problem is. I've learned from experience not to take something unless you need it. Exogenous testosterone would dampen the little endogenous testosterone I make. I'm also interested in alternatives like having my DHEA tested and possibly using Clomid. And obviously finding out first if I have a pituitary tumor, which for some reason my endocrinologist was not interested in. She just wanted me on testosterone. Also having anxiety, I would want to start testosterone very slowly if I do end up taking it.

Anyhow, I suppose all that was to say, that once again I was oblivious to the fact that my natural instinct was to write as a woman and that you have a good point.

 

[Ceke2002]

You know I could take this the wrong way.

Having said that, I wouldn't mind continuing to have novopsych as an outlet if she were allowed. I'm not asking, though. I think that character did help me to deal with some of the things I find "twilight zone" like about medicine or Kafka-esque perhaps--something intangible I'm obviously throwing words at--and to have the freedom of being on the other side of it with great confidence, without concern. It's an empowering way to look at the world (to live with the spoils of the way things are rather than be confounded by the way things are), one I'm not personally familiar with. But there are people who do just seem to grab something in life and take it farther than you would think possible. People who make success where there was no path and have every confidence in what they do. Back in the Bush administration, I always used to remark how much I admired Bush's self-esteem. There are good people who are very self-doubting. There are people who drive over their ex-boyfriends (Laura) send hundreds to be executed (George) and send hundreds of thousands to war (George) and maintain such equanimity, poise, and happiness. Such was novopscyh.

But Novopsych is you, everything she said as herself you can say as well. I find it interesting that you feel better able to express certain concepts under the guise of a character who was invariably mocked. Perhaps you're afraid if you express things as yourself, that people will scoff at it or mock you, so it's easier to hide behind a false persona at times. If that's the case, then the Novopsych character isn't necessarily good for you in terms of any ongoing treatment goals you might have.

 

[jakeislove]

The response to Novo (in frame) was entertaining.

Novopsych should focus on writing a "Dance therapy" book, in character. Look at the money that nitwit made writing books for black women as the fat grandma!

 

[birchswing]

The response to Novo (in frame) was entertaining.

Novopsych should focus on writing a "Dance therapy" book, in character. Look at the money that nitwit made writing books for black women as the fat grandma!

Not sure who that is.

Have you heard Phil Hendrie's radio show?

 

[jakeislove]

Not sure who that is.

Have you heard Phil Hendrie's radio show?

The "Madea" guy wrote an advice book for black women.