Vegetarian diet

[Armadillos]

I don't get it. Are you saying that, as the treating psychiatrist, you do not have the authority to discharge a patient you've determined to be malingering?

I think his theory is its better for everyone if the malinger chooses to leave because the food sucks than if cops have to drag him kicking and spitting to the sidewalk.

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[whopper]

Armadillos answered what I would've wrote but also already wrote. It's, unfortunately, hidden in a lot of my verbiage.

Often times the police will not intervene even if asked because they'll state the hospital has it's own security. It likely would've been safer for the police to arrest and cuff them.

So then security can be placed in the unsavory position of literally throwing the person out to a sidewalk. Should the person not suffer an injury from the act of being thrown out, the patient will likely be very upset and do something out of anger that could be dangerous that can then escalate the situation to harm to self or others not due to a true psychiatric disorder that warrants hospitalization but due to a cluster B/immature defense mechanism response.

 

[whopper]

As others have stated already, its pretty clear that the core reason for this veg diet isn't for treatment of any psychiatric d/o, but to encourage malingerers out. I'm just an amateur nutritionist, but I think vegetarian/vegan diets are not healthy. Yes, ALA, a form of Omega-3 PUFA can convert to EPA/DHA, but does so in a very inefficient manner. You're better off getting your EPA/DHA from marine/animal sources and/or supplements. Furthermore, theres more evidence supporting the benefits of not just Omega-3 PUFA, but saturated fats in maintaining cardiovascular, neurological, and mental health.

As for malingering, I think there are better methods. But yea, it sucks that EDs have been the place to go when people get kicked out of housing. Usually its because they simply don't want to follow certain rules such as...not being high or drunk.

How sad it is that there are people who are willing to get stuck, change into paper scrubs, and be forced to lie to a bunch of people so they can get shelter and food. What an existence.

The problem isn't lack of shelter or food for many as you stated. If there was absolutely no shelter or food, I'd be much more open to taking people in. The problem is the patient often times prefers not to be in the shelter because they find the hospital more aesthetically pleasing. Sometimes the patient was in a shelter but was kicked out because they sexually assaulted (or did some other anti-social behavior) and now sees the hospital as their next recourse. Oh great, now I've got to allow this sexually dangerous guy on to a unit when I don't even believe with strong certainty that he's severely mentally ill? No way.

(By the way, if you think such as guy should be on the unit, please tell me why cause I see a lot of doctors still admit this type of patient while even agreeing with me that he is not mentally ill in a sense that warrants hospitalization. Please give me your reasoning.)

Homeless shelters, while we're at it, are usually better places for such people because 1-in accordance with Linehan's work the person should suffer the consequences of their actions as part of the learning experience and 2-Many homeless shelters have programs that will lead to the true path of elevating the person. That is incentives and programs to get such as person an education, jobs, and structure.

For someone with immature defense mechanisms, the diet could ultimately be of some use. Malingerers often times have emotional issues, but yes, that's not the primary purpose I'm proposing it. If it provides the patient with a benefit, so be it and that's a good thing.

What you said is true regarding the theory behind omega FAs. EPA is the main known omega FA that provides benefit. There are vegetarian sources of it such as sea algae oil though they are not as readily available in the market or as cheap as fish oil. One could simply remedy that by providing a vegetarian diet plus a fish oil supplement.

Furthermore, theres more evidence supporting the benefits of not just Omega-3 PUFA, but saturated fats in maintaining cardiovascular, neurological, and mental health.

There's always some data that can emerge that can go against the medical establishment. Sometimes this data even turns out later to be the real truth vs what was previously held as convention. E.g. Accupuncture was widely rejected by western medicine despite the plethora of scientific data that it worked that later emerged.

Yes there's some argument here or there with some actual data that a saturated fat diet could have some benefits though this has not broken the convention as far as I know. When I say convention, I mean evidenced-based held beliefs. There's plenty of data that, for example, high LDLs are bad for you, but then you occasionally see a study showing that saturated fats are not bad or even possibly beneficial. The debate goes on.

 

[smalltownpsych]

Armadillos answered what I would've wrote but also already wrote. It's, unfortunately, hidden in a lot of my verbiage.

Often times the police will not intervene even if asked because they'll state the hospital has it's own security. It likely would've been safer for the police to arrest and cuff them.

So then security can be placed in the unsavory position of literally throwing the person out to a sidewalk. Should the person not suffer an injury from the act of being thrown out, the patient will likely be very upset and do something out of anger that could be dangerous that can then escalate the situation to harm to self or others not due to a true psychiatric disorder that warrants hospitalization but due to a cluster B/immature defense mechanism response.

As I think about this discussion, and being in the middle of it myself when doing ED consults, I can't help but think of the parallels to many of my patients who struggle with dealing with relatives like this. In other words, coming up with a solid plan and boundaries and clear limits is crucial to dealing with manipulative people, especially substance abusers. Like I told the ER doc the other day, these aren't really my patients, my patients come to see me for help and rarely end up in the ER, these people are addicted to drugs and don't want to stop. This all just really points to the fact that we need better strategies for dealing with these types of patients.

 

[smalltownpsych]

The problem isn't lack of shelter or food for many as you stated. If there was absolutely no shelter or food, I'd be much more open to taking people in. The problem is the patient often times prefers not to be in the shelter because they find the hospital more aesthetically pleasing. Sometimes the patient was in a shelter but was kicked out because they sexually assaulted (or did some other anti-social behavior) and now sees the hospital as their next recourse. Oh great, now I've got to allow this sexually dangerous guy on to a unit when I don't even believe with strong certainty that he's severely mentally ill? No way.

(By the way, if you think such as guy should be on the unit, please tell me why cause I see a lot of doctors still admit this type of patient while even agreeing with me that he is not mentally ill in a sense that warrants hospitalization. Please give me your reasoning.)

Homeless shelters, while we're at it, are usually better places for such people because 1-in accordance with Linehan's work the person should suffer the consequences of their actions as part of the learning experience and 2-Many homeless shelters have programs that will lead to the true path of elevating the person. That is incentives and programs to get such as person an education, jobs, and structure.

Right on the money with this. I don't want the predator on the unit when I have other patients who really do need stabilization. Also, I imagine that the standing orders for lorazepam they get on our unit helps to keep them coming back too.

 

[whopper]

Just for clarification I do not get some type of right-wing euphoria out of seeing people begging to be placed in the hospital and then I gleefully kick them out while I then go to the doc's lounge, smoke a stogie and listen to Rush Limbaugh.

I think some people are assuming that because this type of approach is new and goes against our initial-default impulse to be hospitaliers. I mean that not in the sense of the word "hospital" but in the sense that if you work in hotel management where you keep the person happy with high-fat food, wide screen TVs, and massages, a Broadway show, you work in the hospitality industry. We do not do that, nor are we supposed to do so.

I only think we should act upon malingering when we have good evidence of such, the person should be offered treatment options that can deal with the real problem at hand. E.g. if homeless, a referral to a shelter, if a drug abuser, a referral to a rehab though if we can get them into one do that instead.

A few times in the last month I was very confident a malingerer that made it into the inpatient unit was allowed to go to stay in a few days because sometimes they got entry into rehab that wouldn't open for a few days. So I told the team just let the guy stay in until then because his odds of success of sobriety are better once he gets into rehab.

A lot of the complaints to my approach are valid. "Too gamey" for example IMHO is valid. I do think some of the complaints are more of a shock reaction. I still haven't heard anything that would change my mind and I am open to hearing such opinions.

 

[Ibid]

I feel one of the underlying difficulties teasing out the issues here is because it is like trying to tease out some of the differences between forensic psychiatry and general adult psychiatry..... what might be acceptable in one setting wouldn't be acceptable in the other.....

 

[Ibid]

The problem isn't lack of shelter or food for many as you stated. If there was absolutely no shelter or food, I'd be much more open to taking people in. The problem is the patient often times prefers not to be in the shelter because they find the hospital more aesthetically pleasing. Sometimes the patient was in a shelter but was kicked out because they sexually assaulted (or did some other anti-social behavior) and now sees the hospital as their next recourse. Oh great, now I've got to allow this sexually dangerous guy on to a unit when I don't even believe with strong certainty that he's severely mentally ill? No way.

(By the way, if you think such as guy should be on the unit, please tell me why cause I see a lot of doctors still admit this type of patient while even agreeing with me that he is not mentally ill in a sense that warrants hospitalization. Please give me your reasoning.)

Homeless shelters, while we're at it, are usually better places for such people because 1-in accordance with Linehan's work the person should suffer the consequences of their actions as part of the learning experience and 2-Many homeless shelters have programs that will lead to the true path of elevating the person. That is incentives and programs to get such as person an education, jobs, and structure.

For someone with immature defense mechanisms, the diet could ultimately be of some use. Malingerers often times have emotional issues, but yes, that's not the primary purpose I'm proposing it. If it provides the patient with a benefit, so be it and that's a good thing.

What you said is true regarding the theory behind omega FAs. EPA is the main known omega FA that provides benefit. There are vegetarian sources of it such as sea algae oil though they are not as readily available in the market or as cheap as fish oil. One could simply remedy that by providing a vegetarian diet plus a fish oil supplement.



There's always some data that can emerge that can go against the medical establishment. Sometimes this data even turns out later to be the real truth vs what was previously held as convention. E.g. Accupuncture was widely rejected by western medicine despite the plethora of scientific data that it worked that later emerged.

Yes there's some argument here or there with some actual data that a saturated fat diet could have some benefits though this has not broken the convention as far as I know. When I say convention, I mean evidenced-based held beliefs. There's plenty of data that, for example, high LDLs are bad for you, but then you occasionally see a study showing that saturated fats are not bad or even possibly beneficial. The debate goes on.

Yes.... some of the fanciest and most expensive research in physical medicine translates into eat good food and exercise to maintain good health into old age...... shocking news.,..

 

[smalltownpsych]

Just for clarification I do not get some type of right-wing euphoria out of seeing people begging to be placed in the hospital and then I gleefully kick them out while I then go to the doc's lounge, smoke a stogie and listen to Rush Limbaugh.

I think some people are assuming that because this type of approach is new and goes against our initial-default impulse to be hospitaliers. I mean that not in the sense of the word "hospital" but in the sense that if you work in hotel management where you keep the person happy with high-fat food, wide screen TVs, and massages, a Broadway show, you work in the hospitality industry. We do not do that, nor are we supposed to do so.

I only think we should act upon malingering when we have good evidence of such, the person should be offered treatment options that can deal with the real problem at hand. E.g. if homeless, a referral to a shelter, if a drug abuser, a referral to a rehab though if we can get them into one do that instead.

A few times in the last month I was very confident a malingerer that made it into the inpatient unit was allowed to go to stay in a few days because sometimes they got entry into rehab that wouldn't open for a few days. So I told the team just let the guy stay in until then because his odds of success of sobriety are better once he gets into rehab.

A lot of the complaints to my approach are valid. "Too gamey" for example IMHO is valid. I do think some of the complaints are more of a shock reaction. I still haven't heard anything that would change my mind and I am open to hearing such opinions.

My gut response to the "gamey" criticism would be "I'm not very good at my job if I can't out-manipulate the manipulators". After all, don't we use lots of tricks to get people to do what is in their own best interests. It echos what some of my more codependent (don't really like that term btw) patients will say, "but I don't want to be manipulative". I tell them it is about being smart and not being a victim.

 

[Ibid]

My gut response to the "gamey" criticism would be "I'm not very good at my job if I can't out-manipulate the manipulators". After all, don't we use lots of tricks to get people to do what is in their own best interests. It echos what some of my more codependent (don't really like that term btw) patients will say, "but I don't want to be manipulative". I tell them it is about being smart and not being a victim.

The fly in the ointment here is that this final approach can be interpreted as first I'm going to victimise you then tell you not to be a victim. Its victim blaming jim but not as we know it.....

The other problem with this approach is that it is predicated on you being smarter than your patient and thats not always going to be the case..... and just to make it worse when they are smarter than you, you wont know about it because..... they are smarter than you.

 

[smalltownpsych]

The fly in the ointment here is that this final approach can be interpreted as first I'm going to victimise you then tell you not to be a victim. Its victim blaming jim but not as we know it.....

The other problem with this approach is that it is predicated on you being smarter than your patient and thats not always going to be the case..... and just to make it worse when they are smarter than you, you wont know about it because..... they are smarter than you.

You make some good points, especially about being able to outsmart my patients! I don't want to bank on that too much.

One flaw though is that we are not trying to victimize. First, I am trying to help the patient get the right treatment, second I am trying to protect other patients, and third I am trying to triage an overloaded system to provide the maximum benefit to individuals and the community.

 

[Ibid]

You make some good points, especially about being able to outsmart my patients! I don't want to bank on that too much.

One flaw though is that we are not trying to victimize. First, I am trying to help the patient get the right treatment, second I am trying to protect other patients, and third I am trying to triage an overloaded system to provide the maximum benefit to individuals and the community.

I understand what you are saying..... mostly i'm being cheeky..... when their is a line I tend not some much to cross it as skip about from one side to the other.... lifes more fun that way I find..... and it sounds better than owning up to cynicism as well....

 

[whopper]

An aspect I can find wrong with the approach is when being "gamey" with a patient it can lead to a lot of counter-transference. The counter-transference can lead to anger which can then lead to acting out of that anger.

For that I recommend that 1-think about this issue slowly and carefully. Don't jump the gun and act out of anger. 2-Only act on the opinion that the patient is malingering if you have very strong evidence. E.g. you or staff members witnessed the patient malingering (more specifically-boasted to another patient that he's going to fool the doctor and was overheard), or it's based on days of evaluation, not just a one time thing, malingering testing of course could help and if there's a psychologist in your department utilize them though testing could be exhaustive and time consuming. 3-If in doubt have a second opinion ready that the patient is or is not malingering.

As for confusing it with forensic psychiatry, in that field we are usually not the treating doctor, so we are more open to tell the truth even if that truth damns the evaluee.

But as a treating doctor, I'm of the opinion that Linehan offers. That the patient is to experience the natural consequences of his/her actions as part of the learning experience. I think it needs no argument that we should not engage in insurance fraud and write a false dx and admit simply to make our day go easier when we do not even believe in that dx. Unfortunately lots of docs appear to simply be writing in the false dx and admitting. It seems to be the status quo. As much as anyone wants to criticize me, I challenge them to have those others stop doing the false dx/admit option. I don't see people doing that.