Impossible situations

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whopper

whopper

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I was thinking of writing up a list of impossible situations in psychiatry, and inviting people to chime in on what they would do. Here are some that have truly happened to me.

1) Guy comes in demanding to be made an inpatient because he uses cocaine. He doesn't have an Axis I other than cocaine abuse. The psychiatric emergency staff refer him to an outpatient substance abuse treatment center, but he wants to be admitted as an inpatient.

He is discharged by the psychiatric emergency treatment team, and then walks across the street, goes up the parking garage and threatens to jump off unless he's admitted. The police pick him up, refuse to arrest him, and drop him off back to your doorstep (the psychiatric emergency center).

What do you do? He is not mentally ill except the cocaine abuse.

2) Patient is discharged from a hospital and is still suicidal. She is referred to your private practice office. While in your office she denies she is suicidal, but you hear her make a suicidal statement to her family in the waiting room. You tell her to go into your office and ask her if she's suicidal, she again denies it and denied making the statement. You're about to call 9-1-1, but the family hears what's going on, and insist you not have her sent back to the hospital because while she was there the inpatient doctor was rude to her, even dared her to commit suicide, and called her a loser for not being able to do so.

You've been working in this area for some time and you've heard other patients tell you this same doctor does treat patients like this, leading you to believe even if the police show up, she will likely just get the same doctor, he'll discharge her within 24 hours, and try to refer to your office again. The family tells you that they believe you are their only hope to get the daughter better.

3) Guy comes into the ER claiming he's suicidal. This is his 4th time in the ER in the last 4 months. Each time he comes in, he's depressed, suicidal, and has a plan to shoot himself. Each time he's admitted, his treatment team discharged him without getting rid of his guns. You admit him.

So he's now inpatient, refuses to tell you where his guns are, that he gave them to a friend, and won't tell you that friend's whereabouts or where to contact him. You contact the other treatment teams asking why they discharged him without resolving the gun issue and they all tell you he refused to give up the guns or tell where they were, so they just discharged him.

Due to above pattern, and he is always noncompliant, you believe he will stop his meds again, get access to his guns again, and therefore will be depressed again in a few weeks with full access to his guns, and will be suicidal again.

You can't find where his guns are but he is no longer depressed. Do you discharge him? You can't force him to give up his guns.
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whopper said:
I was thinking of writing up a list of impossible situations in psychiatry, and inviting people to chime in on what they would do. Here are some that have truly happened to me.

1) Guy comes in demanding to be made an inpatient because he uses cocaine. He doesn't have an Axis I other than cocaine abuse. The psychiatric emergency staff refer him to an outpatient substance abuse treatment center, but he wants to be admitted as an inpatient.

He is discharged by the psychiatric emergency treatment team, and then walks across the street, goes up the parking garage and threatens to jump off unless he's admitted. The police pick him up, refuse to arrest him, and drop him off back to your doorstep (the psychiatric emergency center).

What do you do? He is not mentally ill except the cocaine abuse.
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This happened to me during residency, except that while the patient was in the ED the second time (I didn't see him the first time-- he was seen by another resident on the day shift, and I was coming on at night) I felt protected enough by my history and exam, which were quite inconsistent with any suicidal thinking; evidence of future orientation and activities the patient planned to do later that week (he just needed housing for the weekend); two of the ED nurses overheard him explicitly telling a friend on his cell phone that he was not suicidal and that he was just doing this to find a place to stay; and I had records from another ED where he had just attempted to obtain admission (and where he made similar threats). He rejected a number of very reasonable treatment alternatives that were appropriate for his diagnosis (cocaine abuse, no evidence of active intoxication). The extent to which an inpatient hospital stay would alter his course of illness was uncertain at best.

I booted him. He became verbally abusive, even lunged at me while the police were escorting him out, and he began escalating his suicidal claims while he was being escorted out. He's going to hang himself, he's going to walk in front of a subway car, he's going to do it right in the parking lot in front of the police, you're all going to be sorry, you just wait and see, etc. The ED attending said that she did not feel comfortable discharging a suicidal patient; I told her that she did not have to discharge him but that I was simply declining to admit him upstairs (and that she could attempt to have him admitted elsewhere).
 
BTW thanks for posting these. I hope to learn a lot from subsequent posts.
 
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(1) This happens fairly frequently at the ER I worked at. Per the director of the ER, the general guideline is to discharge. But there is now also a "rehab van", where homeless people get to rehab directly from ER. Also, there are also a number of medicaid inpatient units in the area, where they make money per admission, so they are happy to take these people.

(2) I can see this happen. One alternative is an IOP instead of inpatient, but I imagine you are talking about an area that's very resource scarce. In theory if the family is super on top of things you could manage this outpatient, but yah I agree it's kind of stressful.

(3) This doesn't happen in my area, because almost nobody has a gun.

It's very interesting because a lot of these issues appear to be regional, and operate at a systems level
 
These are all quite common where I train.

1) 12-24 hours of "chair therapy" in the psych. ER. That normally helps with malingerers.

2) I highly doubt there is only one attending available. I would call admissions and ensure that the pt be assigned a different attending.

3) Call the police. Police will normally do a "home check" and remove all guns at home. Once they are aware of an erratic patient with a firearm, they get more nervous about homicide versus suicide. If the pt refuses to to give up the whereabouts of the firearms, warn him that police will be questioning him and possibly be detaining him upon discharge. This is a typical VA situation.

whopper said:
I was thinking of writing up a list of impossible situations in psychiatry, and inviting people to chime in on what they would do. Here are some that have truly happened to me.

1) Guy comes in demanding to be made an inpatient because he uses cocaine. He doesn't have an Axis I other than cocaine abuse. The psychiatric emergency staff refer him to an outpatient substance abuse treatment center, but he wants to be admitted as an inpatient.

He is discharged by the psychiatric emergency treatment team, and then walks across the street, goes up the parking garage and threatens to jump off unless he's admitted. The police pick him up, refuse to arrest him, and drop him off back to your doorstep (the psychiatric emergency center).

What do you do? He is not mentally ill except the cocaine abuse.

2) Patient is discharged from a hospital and is still suicidal. She is referred to your private practice office. While in your office she denies she is suicidal, but you hear her make a suicidal statement to her family in the waiting room. You tell her to go into your office and ask her if she's suicidal, she again denies it and denied making the statement. You're about to call 9-1-1, but the family hears what's going on, and insist you not have her sent back to the hospital because while she was there the inpatient doctor was rude to her, even dared her to commit suicide, and called her a loser for not being able to do so.

You've been working in this area for some time and you've heard other patients tell you this same doctor does treat patients like this, leading you to believe even if the police show up, she will likely just get the same doctor, he'll discharge her within 24 hours, and try to refer to your office again. The family tells you that they believe you are their only hope to get the daughter better.

3) Guy comes into the ER claiming he's suicidal. This is his 4th time in the ER in the last 4 months. Each time he comes in, he's depressed, suicidal, and has a plan to shoot himself. Each time he's admitted, his treatment team discharged him without getting rid of his guns. You admit him.

So he's now inpatient, refuses to tell you where his guns are, that he gave them to a friend, and won't tell you that friend's whereabouts or where to contact him. You contact the other treatment teams asking why they discharged him without resolving the gun issue and they all tell you he refused to give up the guns or tell where they were, so they just discharged him.

Due to above pattern, and he is always noncompliant, you believe he will stop his meds again, get access to his guns again, and therefore will be depressed again in a few weeks with full access to his guns, and will be suicidal again.

You can't find where his guns are but he is no longer depressed. Do you discharge him? You can't force him to give up his guns.
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What about this:

Can a person have a delusion that they have delusional disorder?

Following on that a bit, what if someone had a delusion that they were in a psychiatric hospital? And then what if the treatment for that was to hospitalize them?
 
I think a person having a delusion they have delusional disorder is more along the lines of hypochondriasis. As we know, delusions tend to follow trends, e.g. paranoia, the FBI being after the person, the President being involved in their lives. Very few people have delusions that tend to go outside the major trends such as a delusion that the couch is eating Captain Crunch at 2AM on Tuesdays.

I've yet to see a delusion where someone believed they were in a psych hospital.

But I have seen delusions of paranoia where the patient thought the government was after them, then they do something that gets the police involved, the police bring them into the hospital, the person is involuntarily committed with them at a hearing where a judge tells them they need to be in a hospital, and all of this just reinforces the delusion.
 
1) Guy comes in demanding to be made an inpatient because he uses cocaine. He doesn't have an Axis I other than cocaine abuse. The psychiatric emergency staff refer him to an outpatient substance abuse treatment center, but he wants to be admitted as an inpatient.

He is discharged by the psychiatric emergency treatment team, and then walks across the street, goes up the parking garage and threatens to jump off unless he's admitted. The police pick him up, refuse to arrest him, and drop him off back to your doorstep (the psychiatric emergency center).

What do you do? He is not mentally ill except the cocaine abuse.
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I'll tell you what we did in that situation: we did chair therapy as mentioned above. After the patient being in the emergency center for about 20 hours he wanted discharge and contracted for safety.

Where I did residency, this wouldn't have worked because we had too many chicken attendings that admitted everyone or admitted people just because it was easier for them to dump to inpatient. Some of the attendings there didn't give a damn that they were dumping their problem onto someone else. Where I work now, we have enough committed staff members and attendings to work together as a team to all mutually realize we can't do this. This patient was held for several hours, with each attending and staff member all agreeing this was pure manipulation on the patient's part and we weren't going to give into it.

Again this only works if the team as a whole is on the same page. Where I did residency, very few of the attendings would've worked together on this. This is certainly a situation where a better department is going to come up with better results.

Comparison: Where I did training: attendings wouldn't have consulted with each other, attendings wouldn't have called each other up to make a mutual agreed-upon treatment plan, the doctor heading the psych emergency center was rarely contact ever when these types of situations occurred, the inpatient attending and the emergency psych attending were often upset with each other and didn't work together well. Staff members from the emergency center were often-times angry with the inpatient nurses and vice-versa. The nurse manager of the psych emergency center was seen as the real person in charge (even over the head attending there) and everyone in the hospital hated her and thought she was dysfunctional.

Where I am now: the complete opposite. Some of the country's top doctors occasionally work in that psych emergency center, I'm not joking. The doctor heading the emergency center is very accessible and doctors frequently consult with each other to make sure we're all on the same page. The nurses were also on that same page too and were very savvy and skilled. A nurse I work with regularly was Paul Keck's head research nurse. I have more faith in her clinical skills than I do than almost every attending I worked with in residency.

3) Guy comes into the ER claiming he's suicidal. This is his 4th time in the ER in the last 4 months. Each time he comes in, he's depressed, suicidal, and has a plan to shoot himself. Each time he's admitted, his treatment team discharged him without getting rid of his guns. You admit him.

So he's now inpatient, refuses to tell you where his guns are, that he gave them to a friend, and won't tell you that friend's whereabouts or where to contact him. You contact the other treatment teams asking why they discharged him without resolving the gun issue and they all tell you he refused to give up the guns or tell where they were, so they just discharged him.

Due to above pattern, and he is always noncompliant, you believe he will stop his meds again, get access to his guns again, and therefore will be depressed again in a few weeks with full access to his guns, and will be suicidal again.

You can't find where his guns are but he is no longer depressed. Do you discharge him? You can't force him to give up his guns.
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In this case, I had the court discharge the patient. In Ohio, the way the involuntary commitment laws are, a doctor can hold a patient for 72 hours if the patient is dangerous to themselves, others, cannot care for themselves, or infringes on their own rights or the rights of others to the degree where a court believes they need to be hospitalized, and all of this has to be due to mental illness.

But it also mentions that even if the patient is now free from mental illness, I can hold the patient if I believe the patient is an "immediate risk" using the same above reasons. E.g. A patient who always stops his meds, becomes psychotic relatively quickly when this happens, and is known to be violent. A problem here is the law never defined the duration of "immediate risk."

I argued to the court that since there is no legal definition of immediate risk, and that this patient always stops his meds, always becomes suicidal within a few weeks, and we were not allowed to take his guns away from him (the police told us they could only search his place and he told us they were not in his place), I wasn't going to discharge the patient unless they gave me clarity of the duration of the "immediate risk" clause. If the court discharged him--so be it. Now if anything happened to him, it's their liability not mine.

They discharged him.

A few colleagues of mine told me they thought his gun story was BS. I didn't. The guy was from Texas and moved to Ohio. Further, when I told him that him not telling me where the guns were was going to hurt his ability to get discharged, the guy flipped out, and was found by staff members in a dissociative state in his shower, having been there for literally hours with his skin wrinkling up. He then told me the next day that it was his God-given right to own a gun and they were in his family for generations and that no Texan was going to be separated from his guns. My sister used to live in TX and guess what? In several parts of the state almost everyone has guns. I believed it.

When he got out, he vowed he was never going to go back into the hospital and he wasn't going to stop his meds ever again. I reinforced to him that if he ever pulled a suicidal attempt with his guns again, the Court may very well do something he might not like with his guns. I've never seen any legal decision where a court gave clear guidance on this issue because the standard is to take away the guns but the second amendment clearly states people have a right to own them.

As for #2, I'll answer that one later.
 
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whopper said:
In this case, I had the court discharge the patient. In Ohio, the way the involuntary commitment laws are, a doctor can hold a patient for 72 hours if the patient is dangerous to themselves, others, cannot care for themselves, or infringes on their own rights or the rights of others to the degree where a court believes they need to be hospitalized, and all of this has to be due to mental illness.
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I agree this is a very good way (probably the best way) to handle a case like this, though I do wonder what the risk of being charged with false imprisonment would be. I imagine it would be fairly low (and the risk of conviction probably even much lower), but it's something I hear more and more about, and not a lot of clear things written about it. It can be either a criminal matter (would be almost impossible to convict a psychiatrist of this when reasonably doing their job--as would be the case here), but in the case of a civil tort, I could imagine a scenario in which the plaintiff could make a case. I don't think that would necessarily be covered under malpractice insurance, as it's not malpractice as usually defined.

I dunno. Our job is frequently picking the least bad option.
 
A buddy of mine was sued, not for malpractice, he didn't do malpractice, but for a civil violation.

And guess what? That's not considered something covered by malpractice insurance. As a mentor of mine told me, thank God that the university's insurance covered this. Had the guy been in private practice...ouch. The legal fees from his lawsuit so far, from what I've been told by my mentor are now about 150K with the university paying for all of it.

though I do wonder what the risk of being charged with false imprisonment would be
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In my particular case, I don't think I would've fit a false imprisonment charge. I kept the guy based on his own repeated behavior and his own claims he had guns, and he was found to do suicidal acts with his guns such as a friend claiming he saw the guy with a gun in his mouth.

Of course, anyone could sue anyone for anything. Just that in my own particular case with this patient, everything I did, there was a law saying I could do it, with the exception of the "immediate risk" thing where I've seen several judges struggle with the definition because they don't want to put a specific definition on it, because doing so will force their hand to draw a line in the sand and they like keeping it gray should they have to use it as a safety net to keep someone in the hospital.

When I worked on the forensic unit, the hospital was frequently put in a position where it needed to decide to discharge a person where there was no clear guidance. E.g. a bipolar disordered patient who stalked, and attempted to rape someone someone high profile and high up in the local government when he stopped his meds, and he always stopped his meds, but was fine in the hospital. Do you discharge him? He also stopped his meds months after discharge, creating a situation where if you DC the guy, he'd inevitably stalk this person again, possibly rape and kill the person, but he didn't meet the immediate risk clause (although it was never defined, most agree months down the road doesn't count), and he didn't meet the involuntary commitment guidelines given that his mental illness was in remission in the hospital.

Would you want to discharge that guy? Now there's an impossible situation. Guess what? I was placed in the oh so awesome and great position of being his doctor in the forensic unit and having to make a decision. (I'm being sarcastic). I told the administration I was going to recommend the guy be discharged, and that if the stalker's victim was raped or killed, it was the fault of the legal system not having a safeguard in place for people in his category who stop their meds months after discharge from the hospital, and that I could only follow the law, not ignore it even if I believed it was the safer thing to do. The law allows me to hold people if I believe they are an immediate risk due to mental illness. It does not allow me to hold someone that I believe will be a risk in the non-immediate future. I was also going to completely acknowledge that I thought the law wasn't doing enough but the legislature or the judicial system was not going to touch this issue, thus my hand was forced. I was also going to make a plea to the judicial system to do everything it can to find something to use to keep the stalker in (knowing they wouldn't--remember I'm a forensic psychiatrist, I've read those laws inside-out).

Thank God for me the administration was too chicken to let this come to a head and transferred the guy off my unit, intentionally giving the patient to a doctor that they knew would be too chicken to allow this guy out. They knew I was going to follow the law, knew the Court would be forced to do what I recommended because I was following the law, and they cannot change the law, only enforce it. I was perfectly happy with the guy being transferred off. My own sense of ethics believed the lady deserved to be protected by the stalker but I also could not lie under oath, and if under oath, I would be forced to say I could not keep the guy the way the laws are written.

If the Court discharged the guy, I would've used the Tarasoff ruling, and called up the stalker victim, warning her this guy was back out in the community. Thank God it didn't come to that.

I knew months down the road if that poor woman was raped or killed, the news would be on me saying I was the doctor that released this guy.
 
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whopper said:
Of course, anyone could sue anyone for anything. Just that in my own particular case with this patient, everything I did, there was a law saying I could do it, with the exception of the "immediate risk" thing where I've seen several judges struggle with the definition because they don't want to put a specific definition on it, because doing so will force their hand to draw a line in the sand and they like keeping it gray should they have to use it as a safety net to keep someone in the hospital.
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Agreed. I haven't seen anybody actually convicted criminally or receive a negative outcome on a tort case, but I've heard of many folks having the suits filed against them.

Also, since every state has slightly (or drastically) different commitment laws, I'm sure it could vary a lot, and there's probably some statute out there that wouldn't give the psychiatrist adequate protection to handle the case properly like this.
 
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2) Patient is discharged from a hospital and is still suicidal. She is referred to your private practice office. While in your office she denies she is suicidal, but you hear her make a suicidal statement to her family in the waiting room. You tell her to go into your office and ask her if she's suicidal, she again denies it and denied making the statement. You're about to call 9-1-1, but the family hears what's going on, and insist you not have her sent back to the hospital because while she was there the inpatient doctor was rude to her, even dared her to commit suicide, and called her a loser for not being able to do so.

You've been working in this area for some time and you've heard other patients tell you this same doctor does treat patients like this, leading you to believe even if the police show up, she will likely just get the same doctor, he'll discharge her within 24 hours, and try to refer to your office again. The family tells you that they believe you are their only hope to get the daughter better.
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This case was my second suicide. The patient IMHO was dangerous but if I called emergency services she'd be sent back to the same hospital where the doctor treated her terribly.

The safe thing to do would've been to do that, not give a damn that she'd see the psychiatrist that apparently is so jaded he should've retired years ago, he would've discharged her and I could've refused to take her back being that I believed she needed a case manager.

The problem there, besides that I knew she wasn't going to get good care is the way her insurance was, there was no provider in the area with case management that could've taken her case.

I only allowed her to leave the office because her father was home 24/7 due to a broken arm and I told her and her family my fears and that the only reason I didn't put her in the hospital was because we all believed she would get bad care in the hospital and because the father was home all the time. We did a referall to IOP, and our office called the closest IOP program to have her start treatment there. Despite that she still managed to kill herself.

What lesson I learned from that event was to never accept patients again from that specific hospital. Using hindsight, I still believed if I called 9-1-1, and if she was sent back to the hospital, it wouldn't have helped her at all given the quality of the a-hole psychiatrist at that hospital. That's another reason why I recommend to anyone starting private practice to get a lay of the land before you do this. You start bare and green, you'll be some a-hole doctor's train-wreck patient trash dumpster before you figure out this guy is to not be trusted with safe discharges.

As for the suggestion that I could've called the hospital up and recommend she see a different psychiatrist, I already tried that before when a different patient of mine was sent there. They don't care and see this as intrusion and a boundary violation. All things being equal I'd agree if they actually had a competent psychiatrist.
 
The patient's family sued the hospital. They left me out of it telling their lawyer I was the only doctor they felt that actually gave a damn and was trying to do the right thing.

That a-hole doctor I mentioned no longer works at that hospital. I don't know if this lawsuit had anything to do with it. I can tell you that even several mental health providers in the area know this guy blows. I've told several of my patients who had horror stories with this guy to contact the state medical board and complain about him.
 
whopper said:
I think a person having a delusion they have delusional disorder is more along the lines of hypochondriasis. As we know, delusions tend to follow trends, e.g. paranoia, the FBI being after the person, the President being involved in their lives. Very few people have delusions that tend to go outside the major trends such as a delusion that the couch is eating Captain Crunch at 2AM on Tuesdays.

I've yet to see a delusion where someone believed they were in a psych hospital.

But I have seen delusions of paranoia where the patient thought the government was after them, then they do something that gets the police involved, the police bring them into the hospital, the person is involuntarily committed with them at a hearing where a judge tells them they need to be in a hospital, and all of this just reinforces the delusion.
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Whopper, you are the greatest. I have asked that question about delusional delusional disorder so many times and no one could even comment. But I think you're right that it would be more similar to hypochondriasis (as opposed to a psychotic disorder like delusional parasitosis, say).

Another thing I've always wondered is if you can have pseudopseudoseizures. There is pseudopseudohypoparathyroidism after all.
 
so in cases such as this, where firearms are involved...where does the jurisdiction of a mental health professional begin and end? In clear cut terms, what can we do to protect our patients, society at large, and ourselves?
 
Thruster said:
so in cases such as this, where firearms are involved...where does the jurisdiction of a mental health professional begin and end? In clear cut terms, what can we do to protect our patients, society at large, and ourselves?
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Don't people need a license to have a gun? Can't the license in most states be revoked if they have a documented mental illness? Similar to how it's a violation of the law (I believe) to drive if you've been diagnosed with a seizure disorder?

Or am I wrong and mentally ill people can have guns?
 
nancysinatra said:
Don't people need a license to have a gun?
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Forgive me, Nancy, but ... :rofl:

nancysinatra said:
Can't the license in most states be revoked if they have a documented mental illness? Similar to how it's a violation of the law (I believe) to drive if you've been diagnosed with a seizure disorder?

Or am I wrong and mentally ill people can have guns?
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The epilepsy lobby isn't nearly as effective as the NRA. :rolleyes:

Depending on the state, you need to be committed involuntarily to lose your Sacred Right to Bear Arms. So your garden-variety, voluntarily-treated bipolar with antisocial traits still has his full Second Amendment Right to Cause Mayhem. One does (most places) need a license for concealed carry, but realistically, we're pretty much counting on folks to exercise good judgment. And good luck with that...
 
Another thing I've always wondered is if you can have pseudopseudoseizures
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I think this too could be hypochondriasis.

Depending on the state, you need to be committed involuntarily to lose your Sacred Right to Bear Arms. So your garden-variety, voluntarily-treated bipolar with antisocial traits still has his full Second Amendment Right to Cause Mayhem. One does (most places) need a license for concealed carry, but realistically, we're pretty much counting on folks to exercise good judgment. And good luck with that...
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In Ohio, if one was involuntary committed due to psychiatric reasons, they cannot buy guns from a registered dealer. But they could buy a gun from an unregistered dealer and that happens all the time with gun shows, and it's legal.

Where the law ends and begins with psychiatric patients owing guns is a grey area, and this is not a grey area where there's no bad consequences if you screw up.

Another impossible case that truly happened to me.

What do you do with a patient that's always stopped his meds right when he's discharged, he's been hospitalized 6 times, and during each hospitalization he was there due to a violent crime committed while psychotic. The guy's known to be a perfect gentleman while on his meds, and then it turns out he put a $800 lay-away deposit on a Desert Eagle pistol? I've been in that situation.

Turns out by the state guidelines, the treatment team is allowed to take away his receipt. But guess what? I told campus police to seize his receipt but then a guy higher up than me in the state dept. of mental health told them we were not allowed to do this even though I was able to show the exact page in the manual saying we were.

Then, since the guy was stabilized, I was going to discharge him, and use the Tarasoff case to call up the gun store. Guess what? We didn't know what store it was, and then the state told me I was not allowed to do this even though in my interpretation of the laws I was.

I held the guy until his next court hearing and the court discharged him. Here was a situation where the guy was going to buy this gun, he always becomes psychotic within a few days of being discharged, and he is always violent when psychotic.
Do the math. X+Y+Z = psychotic patient with a gun shooting someone.

If you are in a legal grey area, I'd recommend you consult your hospital lawyer (In this case the lawyer stone-walled me at every opportunity, telling me we couldn't do something I knew we could. What really ticked me off is while I'm not a lawyer, I knew enough of the law to know he was wrong. Problem there was if I went above him, I lose the protection of the hospital and I'd be going against their orders). I contacted the state medical board. They too offered no real help. If you still don't know what to do, and consulting with colleagues doesn't help, leave it to the court. Let them decide.

You wear a white coat (doctors), you can be sued. Black coats (judges) are immune to lawsuits.
 
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splik said:
pseudopseudoseizures: http://www.sciencedirect.com/science/article/pii/S0033318211002854

I will return to the point about why a delusion about delusional disorder would not be hypochondriasis but a monosymptomatic hypochondriacal delusional disorder in itself...
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Yeah, but if you have a delusion that you have delusional disorder, then you're not really deluded because your fear that you have a delusion is actually correct. So then what do you have?

If I'm just neurotic or hypochondriacal and afraid that I might have delusional disorder, that's different. That does not rise to the level of an actual delusion, although it seems way more plausible.
 
Regarding situation (1) I think it depends on where you're working.

At the VA that's part of my residency (which I think is a very good VA), substance abuse is treated like a mental illness. We just admit people with substance abuse problems and get them into substance abuse treatment. It's kind of nice to see addiction treated like a disease.

Now it's totally different in the university and private hospitals.
 
nancysinatra said:
Yeah, but if you have a delusion that you have delusional disorder, then you're not really deluded because your fear that you have a delusion is actually correct. So then what do you have?

If I'm just neurotic or hypochondriacal and afraid that I might have delusional disorder, that's different. That does not rise to the level of an actual delusion, although it seems way more plausible.
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You seem to be a bit contradictory. If you fear you have a delusional disorder you have hypochondriasis, if you have a delusion you have delusional disorder, you do have a monosymptomatic hypochondriacal delusional disorder. Delusions are NOT delusions because they are false (though they usually are), a belief is delusional because of a) the way the belief is held and b) the reasoning behind the belief. For example if a man believes his wife is having an affair because she keeps coming home late from work and seems distance, we can understand where he's coming from. If a man believes he wife is having an affair because he read an article about mitt romney and then 'just knew' his wife was having an affair he is probably delusional. Whether or not his wife actually is having an affair is irrelevant. Make sense? In this way being delusional about having a delusional disorder would be a delusional disorder if the belief was delusional even if it were true (the reason it would be true would be entirely different to the patient's belief as to why it were true).

The major problem with the DSM is that most US residents don't learn descriptive psychopathology properly anymore (although they never learned it during the psychodynamic years either so I guess it never really caught on here except a few places like Iowa, Hopkins, WashU). If you are feeling brave, have a look at the Karl Jaspers' Algemeine Psychopathologie (General Psychopathology) although many psychiatrists did not understand Jaspers' point on the un-understandability of delusions as delusions more often than not can be understood in context, even if they are bizarre and I don't think Jaspers meant to imply this was not the case. Otherwise, have a look at the old edition of Fish's Clinical Psychopathology (2nd not 3rd edition), or Symptoms in The Mind by Andrew Sims (again old edition).
 
splik said:
The major problem with the DSM is that most US residents don't learn descriptive psychopathology properly anymore (although they never learned it during the psychodynamic years either so I guess it never really caught on here except a few places like Iowa, Hopkins, WashU). If you are feeling brave, have a look at the Karl Jaspers' Algemeine Psychopathologie (General Psychopathology) although many psychiatrists did not understand Jaspers' point on the un-understandability of delusions as delusions more often than not can be understood in context, even if they are bizarre and I don't think Jaspers meant to imply this was not the case. Otherwise, have a look at the old edition of Fish's Clinical Psychopathology (2nd not 3rd edition), or Symptoms in The Mind by Andrew Sims (again old edition).
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Sims is a good text.

I think a more particular issue is understanding a phenomenological approach (understanding the experience of the person). Otherwise you end up giving antipsychotics to alzheimer's pt's with "delusions" that family members stole something (when really they've forgotten where they placed it, so latched onto an idea someone stole it). Technically could be classified as a delusion, but without understanding the processes that led to it, one might believe an antipsychotic would help.
 
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