Axis I: Start jogging

[DJspreadsheet]

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Sometimes I feel as though I have to put a diagnosis when I see a patient, even if I don't think they're suffering from any pathology.

Don't feel good because you have a ****ty job, don't exercise, and eat like a trucker? Major depressive disorder!

When in reality, I think they are "unhappy" for very good reason - a consequence of unhealthy habits and not realizing their ideal self. Assuming they don't fit the criteria for MDD, but instead suffer from the predictable and expected malaise of poor life choices, what on earth can I use to indicate that in my formulation?

 

[heyjack70]

Sometimes I feel as though I have to put a diagnosis when I see a patient, even if I don't think they're suffering from any pathology.

Don't feel good because you have a ****ty job, don't exercise, and eat like a trucker? Major depressive disorder!

When in reality, I think they are "unhappy" for very good reason - a consequence of unhealthy habits and not realizing their ideal self. Assuming they don't fit the criteria for MDD, but instead suffer from the predictable and expected malaise of poor life choices, what on earth can I use to indicate that in my formulation?

You're basically describing the start of a decent clinical formulation. From the perspective of the bio/psycho/social model the person certainly has some reasons for low mood. Poor diet and no exercise (bio), crappy job, possibly poor finances (social), psych (not living up to personal expectations of ideal self).

If it's low mood due to the job, but not meeting MDD criteria, you could say adjustment d/o? Or a depression NOS. Discuss your diagnostic thoughts. Then move on to interventions: The treatment might be "exercise", or investigating what makes the person happier and doing some behavioral activation. Referral to a nutritionist or personal trainer. The treatment doesn't have to be pills.

Some of this seems simple, like exercise. But if it was so simple, why is the patient not doing it themselves? They're coming to you, the expert, for help. You get to make sense of it all and make recommendations so the patient can improve.

 

[DJspreadsheet]

You're basically describing the start of a decent clinical formulation. From the perspective of the bio/psycho/social model the person certainly has some reasons for low mood. Poor diet and no exercise (bio), crappy job, possibly poor finances (social), psych (not living up to personal expectations of ideal self).

If it's low mood due to the job, but not meeting MDD criteria, you could say adjustment d/o? Or a depression NOS. Discuss your diagnostic thoughts. Then move on to interventions: The treatment might be "exercise", or investigating what makes the person happier and doing some behavioral activation. Referral to a nutritionist or personal trainer. The treatment doesn't have to be pills.

Some of this seems simple, like exercise. But if it was so simple, why is the patient not doing it themselves? They're coming to you, the expert, for help. You get to make sense of it all and make recommendations so the patient can improve.

Yeah I hear you. I guess cause I'm doing inpatient that stuff typically isn't bandied about, including the biopsychosocial formulation. Too bad. Then again, inpatient psych patients typically do have more classic boilerplate psychiatric diagnoses. I guess it would apply more to consults.

 

[heyjack70]

Yeah I hear you. I guess cause I'm doing inpatient that stuff typically isn't bandied about, including the biopsychosocial formulation. Too bad. Then again, inpatient psych patients typically do have more classic boilerplate psychiatric diagnoses. I guess it would apply more to consults.

Thinking about the bio/psycho/social on all your patients is good practice. Once it become second nature, it will help you make sense of a patient's presentation and recommend treatment. Now, the formulation of, say, delirium on the consult service, is pretty heavily bio. But the psych unit folks will undoubtedly fit the model. To expand on the Bio/Psycho/social model, you should look up the four P's, which adds some depth to BPS.

 

[Armadillos]

Don't feel good because you have a ****ty job, don't exercise, and eat like a trucker? Major depressive disorder!

It's worth noting that your description here literally describes half of Americans, yet somehow most of us manage not to end up on an inpatient psych unit, so I would challenge you to dig a little deeper.

 

[michaelrack]

Sometimes I feel as though I have to put a diagnosis when I see a patient, even if I don't think they're suffering from any pathology.

Don't feel good because you have a ****ty job, don't exercise, and eat like a trucker? QUOTE]

V69.0 Lack of physical exercise

(won't get you paid, though)

 

[BobA]

Too bad you don't talk about bio/psycho/social formulation on the inpatient unit. I'm an inpatient attending at an academic center and encourage discussion about this. Lifestyle intervention is very important (has similar effect sizes to medication interventions). Have you tried bringing this up with your team?

 

[billypilgrim37]

It's worth noting that your description here literally describes half of Americans, yet somehow most of us manage not to end up on an inpatient psych unit, so I would challenge you to dig a little deeper.

👍👍👍

 

[Jorje286]

It's worth noting that your description here literally describes half of Americans, yet somehow most of us manage not to end up on an inpatient psych unit, so I would challenge you to dig a little deeper.

It's a bit outside the point but that's the thing with psychiatry. It's not only relevant for people who end up in the inpatient psych unit or the depressed patients who can't go to their jobs. A large majority of people can suffer from low mood and they can still be functional. They can benefit tremendously from behavioral changes, and those behavioral changes would definitely improve the condition of patients with more severe psychopathology. I literally notice a 50% improvement in my mood and my energy levels when I'm regularly exercising. It would be interesting to compare outcomes with SSRI in people with depression (surely that has been done). But there's really NOTHING easy about regular exercising. It's certainly easier to swallow a pill then to get yourself over a treadmill and do a serious exercise at the end of the day.

 

[Bartelby]

It would be interesting to compare outcomes with SSRI in people with depression (surely that has been done).

Indeed it has. A good starting point would be the following Cochrane review: http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD004366.pub6/abstract (including 30+ trials addressing exercise and depression). Exercise or a structured group physical activity is also a part of the initial treatment recommendations put out by NICE for mild to moderate depression (http://www.nice.org.uk/nicemedia/pdf/cg90niceguideline.pdf).

The evidence suggests that exercise is an efficacious treatment for depression, especially mild to moderate. You can also check out a book titled Spark for more, it's available in audiobook format from Audible and is a fun, straightforward read.

 

[primadonna22274]

I would call this dysthymia and code it as such. Exercise Rx, better diet, and LOTS of CBT. 🙂

 

[billypilgrim37]

When in reality, I think they are "unhappy" for very good reason - a consequence of unhealthy habits and not realizing their ideal self. Assuming they don't fit the criteria for MDD, but instead suffer from the predictable and expected malaise of poor life choices, what on earth can I use to indicate that in my formulation?

I would love to hear an orthopedist say, "You know, buddy, we shouldn't treat your broken leg, because it's obviously the result of you getting hit by a truck. Since we know what's causing it, it's obvious we should just build a time machine and teach you the dangers of getting hit by a truck."

I spend a lot of time counseling my patients on the importance of exercise, social rhythms, diet, etc, and I clearly think they are important. I also think it's ridiculous for us to say, "Well, oh, if you just made better life choices, all of these things would go away!" If people could make better choices, they probably would, but apparently it's harder for them than you think, because they aren't!

I also encourage everyone with an appropriate indication to see a therapist, full well knowing that most of the therapists in the community are not good, and that therapy is a big commitment, probably a bigger commitment than most of my patients can make, or a commitment that they already made and it hasn't worked out, so they're seeing me.

People see us because the skills they have are overwhelmed by the skills that are needed for their situation. They don't see us saying "if only somebody had told me I should get a job and eat good and jog everyday and date nice girls, everything would be great! Thanks doc! I would have never thought of those things!"

Using appropriate motivational strategies, you can help people resolve their ambivalence towards these things by meeting them where they actually are. But if you're walking in judging folks for being screw-ups who are getting what they have coming to them because they are weak and lazy, you aren't going to help many people.

 

[whopper]

Forgive my rant.

I've seen several clinicians put down an Axis I disorder where none exists. A lot of it is billing. E.g. a couple is brought to the ER by the police because they got into an argument. These people, in short, have a dysfunctional marriage but by no means do they have psychosis or bipolar disorder.

Then the idiot psychiatrist diagnoses them with bipolar disorder.

I've seen institutions not get on a movement to stop this type of practice, some even encourage it by saying that to help these people we need to give them a diagnosis even if it is false. In turn many of these patients end up getting meds that don't help them, cost a lot of money, and then just cause side effects.

There are patients we can help that don't have severe mental illness such as cyclothymia, mild depression, dysthymia, adjustment disorder, etc. There appears to be a subset of psychiatrists that don't know to look for this disorders, and/or don't know when to just say there is no mental illness.

 

[DJspreadsheet]

Forgive my rant.

I've seen several clinicians put down an Axis I disorder where none exists. A lot of it is billing. E.g. a couple is brought to the ER by the police because they got into an argument. These people, in short, have a dysfunctional marriage but by no means do they have psychosis or bipolar disorder.

Then the idiot psychiatrist diagnoses them with bipolar disorder.

I've seen institutions not get on a movement to stop this type of practice, some even encourage it by saying that to help these people we need to give them a diagnosis even if it is false. In turn many of these patients end up getting meds that don't help them, cost a lot of money, and then just cause side effects.

There are patients we can help that don't have severe mental illness such as cyclothymia, mild depression, dysthymia, adjustment disorder, etc. There appears to be a subset of psychiatrists that don't know to look for this disorders, and/or don't know when to just say there is no mental illness.

Thank you - this is exactly what I'm referring to. Putting "No mental illness" on my ER consult doesn't seem like it would be considered acceptable. And that's what I'm asking.

 

[OldPsychDoc]

..
There are patients we can help that don't have severe mental illness such as cyclothymia, mild depression, dysthymia, adjustment disorder, etc. There appears to be a subset of psychiatrists that don't know to look for this disorders, and/or don't know when to just say there is no mental illness.

There's also a false conventional wisdom that was passed down that "you can't bill for adjustment disorder".

 

[michaelrack]

I would love to hear an orthopedist say, "You know, buddy, we shouldn't treat your broken leg, because it's obviously the result of you getting hit by a truck. .

On the other hand, an orthopedist might say, "your pain is being caused by playing baseball. Since you are not an elite athlete, I am going to advise you to stop playing and I do not advise Tommy John surgery."

There is really no point in my post other than to point out an imperfect analogy. Carry on

 

[nitemagi]

There's also a false conventional wisdom that was passed down that "you can't bill for adjustment disorder".

BAM.

In addition, what you're complaining about is the agnostic approach the DSM takes to etiology, with everything except stuff like PTSD (a rant for another time).

Implicit in your concern is also the idea of "organic" depression being the only type of depression that we should be diagnosing and treating.

How would you code for a guy who gets fired and then that day has a suicide attempt? It's not MDD per the DSM, either. That doesn't lessen the severity of it.

If we take a step back and think about what the DSM (which we all agree is quite flawed) is attempting to describe, it's the idea of severe depression, and so created arbitrary criteria. It was created by the BOGSATS method (Bunch Of Guys Sitting Around Talking), and then researched. Don't miss the forest for the trees.

Of course it's perfectly acceptable to tell someone they don't have a mental illness. But I suspect the bigger issue is getting caught up in a categorical approach to mental illness, where either they have it or they don't. And yet mis-coding or mis-diagnosing can give someone an identity of an illness they don't have, potentially for life.

I believe it's better to not be teaching patients that they have a "disease," which will never go away. That perpetuates an investment in a sick role for the individual, and lessens the real weight that external circumstances always have.

Finally, there's an element you're touching on about the level of narcissism in our culture. We feel entitled to get what we want when we want. When reality starts challenging that, with physical health, financial woes, or not becoming the rock star we thought we would be, there are emotional consequences. Call it a narcissistic injury, a swift kick in the teeth from reality, or adjustment disorder, it's a phenomenon where people need some help.

 

[shan564]

On the other hand, an orthopedist might say, "your pain is being caused by playing baseball. Since you are not an elite athlete, I am going to advise you to stop playing and I do not advise Tommy John surgery."

There is really no point in my post other than to point out an imperfect analogy. Carry on

Agreed. Fracture secondary to getting hit by a truck in orthopedics is like PTSD secondary to a history of severe child abuse in psychiatry. It's something that happened in the past, led to long-term complications, and now probably requires medical intervention. Asking for SSRIs because you don't get enough exercise is more like asking for Tommy John surgery so that you can play for your office softball team.

When a person with hypertension or early DM2 goes to the PCP, you're supposed to recommend lifestyle changes. The same should be true for mild psychiatric symptoms. The problem is that psychiatric symptoms can interfere with the ability to make lifestyle changes, so we feel the need to throw drugs at people... as somebody mentioned already, most therapists suck. I don't have enough experience to know the right answer, but I'm interested to continue to see how more experienced psychiatrists treat these patients effectively.

 

[BlueLotus]

Great topic! I'm so glad to read these perspectives. B.Pilgrim + whopper - gosh glad to see your input!

A Good read for the topic: Boost your brain by Majid Fotuhi. It summarizes a lot of the studies in an accessible way for patients regarding the effects of exercise, nutrition, meditation, supplements, and medications on the brain. It was a good review for me with a few new ideas in there. I love neuro + psych regardless of the path I may pursue in medicne. Yes, indeed, research exists on exercise and the brain.

Regarding the idea that one may be upset from unhealthy habits or that one has not realized their ideal self, to me, reflects the human condition. Also, while plenty of wrong paths may be pursued in life, i think that often it may not be the issue of whether a choice is poor but rather the ability to succeed in the adverse situations that occur in life which requires having the resources within one's self and one's environment to, in fact, make lemonade from lemon-like life events. The pt hx/background, economic, social, religious, and educational influences in the person's life would likely give more clues for why a pt may struggle to realize their full potential self. Of course, in my opinion, if we are fully honest with ourselves, realizing our best/ideal self should remain one of our life's purposes to ensure that we live to our fullest potential each day.

 

[billypilgrim37]

Agreed. Fracture secondary to getting hit by a truck in orthopedics is like PTSD secondary to a history of severe child abuse in psychiatry. It's something that happened in the past, led to long-term complications, and now probably requires medical intervention. Asking for SSRIs because you don't get enough exercise is more like asking for Tommy John surgery so that you can play for your office softball team.

A four dollar/month prescription for Prozac vs. finding the motivation to do something you've never been able to do multiple times per week indefinitely? Really? Antidepressants are treatment. The fact that we don't want to prescribe them because they're "easy" is being unnecessarily judgmental. Prescribe the Prozac and throw in all the motivational interviewing you can. Do all the behavioral activation/CBT you can or get them in w/ a good CBT therapist who will facilitate this. They'll be a lot more likely to exercise once their mood starts improving, and then 6-12 months later, maybe they both don't need the prozac AND have a new exercise habit.

Nobody is asking for an SSRI because they don't get enough exercise. They're asking for an SSRI because they're depressed! Depression isn't an exercise-deficiency any more than it is an SSRI-deficiency, though exercise and SSRIs are both helpful. These aren't either-or interventions. If exercising were easy for these folks, they'd probably already be exercising! Exercising is really hard (for people who don't exercise). I just signed up for a half-marathon, and honestly, retaking the MCAT and Step 1 tomorrow sounds a lot easier than this half-marathon!!!

The point is, just because you know why something happens, and just because the "why" looks easy to fix FOR YOU, doesn't mean that the "why" is easy to fix for the patient, and doesn't mean you shouldn't treat using a multimodal approach.

To be fair, I use the "hit by a truck" analogy most often for when I have teenagers admitted to my unit who have clearly been depressed for a while, tried to commit suicide, and their parents try to blame it on their friends/music/skateboard/"normal teenage stuff." Then they want to "just try therapy first," which, if you've ever read the TADS study, is a bad idea, since, you know, YOUR KID JUST TRIED TO KILL HERSELF, and I don't want to wait 6 months for her "therapy" (inevitably with someone who can't spell CBT out in the suburbs) to catch up with meds+therapy. Granted, you have to use a very particular tone to make it clear you're not being a smart ass (and this has worked well for me), so I wouldn't recommend the analogy unless you are sure you can pull it off with empathy. Parents are scared to death when their kids try to commit suicide, and most of their psychoeducation has come from the Today Show, and they're taught implicitly that psychiatrists are evil because they want to treat their kids depression with "pills" instead of "getting to the real reason behind the suicide attempt" (as if the "real reason" isn't "depression" which, again, responds best to multimodal interventions).

 

[whopper]

I was thinking of amassing data for an article showing false BS diagnosis practices, but I'm wondering how I can do it without literally exposing some of my colleagues and pointing the finger at them as frauds.

One thing I was thinking of doing was getting college students to go into several offices or ERs, say they did something completely within a cultural norm that clinicians often times use to cut corners to get a bipolar diagnosis, (e.g. "I go to sleep late at night all the time," "Yeah I get a lot of sex in colleage, it's awesome," "yeah last week a bunch of my buddies and I went skydiving"), but at the same time do not really allow for a a real DSM IV or V diagnostic criteria of the disorder, and see how many of them get some BS diagnosis.

Part of my responsibilites as a forensic psychiatrist for the university is to do a lecture a year at the local state institution, and one of them I've been doing is false diagnosis, and how this cycle hurts patients and the justice system.

 

[heyjack70]

Thank you - this is exactly what I'm referring to. Putting "No mental illness" on my ER consult doesn't seem like it would be considered acceptable. And that's what I'm asking.

You can certainly diagnose
Axis I: No diagnosis

Although DSM 5 doesn't use the Axes anymore.

 

[Armadillos]

If the problem is needing something to stick on axis 1 for billing why not just adjustment disorder? Or does that not cut it for getting insurance to pay?

 

[BlueLotus]

I was thinking of amassing data for an article showing false BS diagnosis practices, but I'm wondering how I can do it without literally exposing some of my colleagues and pointing the finger at them as frauds.

...

Part of my responsibilites as a forensic psychiatrist for the university is to do a lecture a year at the local state institution, and one of them I've been doing is false diagnosis, and how this cycle hurts patients and the justice system.

I am glad to hear that someone is interested in doing an updated Rosenhan-style experiment. That would be good although I understand the dilemma of exposing one's colleagues + the likely repercussions. Yikes!
(The Rosenhan study: http://www.sciencemag.org/content/179/4070/250)

I was not aware of the problems within the psychiatric/mental health field prior to entering medicine. It is most upsetting for me when I see children labelled with diagnoses made to allow the prescriber to give anti-psychotic medications. The child will likely learn helplessness and drug dependency rather than how to live amidst the adversities of the child's life and how to overcome the child's potentially bad the situation.

To be sure, there are some adults + children who need the intense dx + tx. I like BPilgrim's input. Well said. Really surprising to discover the dearth of competent providers from the vantage pt. of a new intern. Who would otherwise know! The therapist/CBT statement was funny! So glad to see that there are some providers who may not seek to keep people on SSRIs indefinitely. I understand that there is a place for the rx approach + that it can help a person to start + stick to healthy lifestyle habits. No problems with that : )

1/2 marathon? Way to go!

 

[birchswing]

What do you all think of exercise therapy (something formal and scheduled)? I think such a thing is offered for people with certain heart conditions. I assume it's some sort of outpatient gym.

I personally think it's easier to commit to something once it's scheduled and becomes a norm. If I sign myself up for a class at a university, I push myself really hard to learn the material and do well because I've voluntarily tied my hands. On the other hand, when I say that I want to teach myself computer programming, I never get around to it. I think a lot of people probably go to therapy because once they start it, they've created a norm. It could be the same, I think, for exercise.

I've had every type of doctor under the sun tell me to exercise more, and I don't. I have me every day telling myself I should exercise more and I don't. It sounds like an excuse (and it is), but I would exercise more if I had it scheduled each week where I had to meet with someone and it had that authoritative feeling that a doctor's appointment does.

 

[rkaz]

Do any of you know residency programs that invest a lot of resources/research into looking at lifestyle risk/protective factors with mood? As an applicant, I'd be really interested in such programs, as this is something I'm 1,000% interested in (and would like to find mentors in the field, as this type of research is something I want to do with my life). I've applied widely and have many interviews already, but if there are programs that do a lot of integrative approaches to psychiatry, I'd be VERY interested in those and want to keep an eye out for interviews at such places. I figure that more of this type of research would happen at academic programs (as opposed to community), but which?

PS~ Sorry for asking a somewhat off-topic question, but since we were discussing lifestyle approaches here, I thought I'd take the liberty to ask. Thanks!

 

[whopper]

(The Rosenhan study: http://www.sciencemag.org/content/179/4070/250)

Oh yes I'm aware of that study and it's one that actually made me wanted to go into psychiatry because I was sick and tired of bull$hit psychiatrists putting on fake labels. I wanted to go into a field where there was an adversarial system to rip such a psychiatrist to shreds.

IMHO that study should be required reading in residency.

I remember having a guy that was found not guilty by reason of insanity that clearly was not that and he committed a rather violent and malicious crime. I spent five hours a day on him for about 1 month and couldn't find anything wrong with him in an Axis I sense of the word. He was transferred off of my unit and transferred to another where he was labelled as psychosis NOS. I wrote a very long note in his chart, about 5 pages long (remember this is a progress note) explaining that I didn't think the guy was mentally ill. That's when the administration had this guy transferred out.

(I sensed they were playing politics becuase the psychologist that wrote his insanity report worked in the same hospital and I was literally pointing out the other guy as writing a bogus report, and it was bogus. I guess they wanted everyone in the hospital nicey-nicey even though a serious miscarriage of justice ocurred, and didn't want to make waves with the judge that ruled on the guy's case).

I asked the psychologist on the new unit what made him psychotic. She said something to the effect of, "well he doesn't like to associate with others and just the fact that he was willing to make that poor girl's life hell (the victim of the cry) shows he has to be psychotic. The psychiatrist put him on a low dose of Abilify and he told me he felt a little better so that convinces us he's psychotic." The other psychologist that wrote the sanity evaluation that I thought was bogus gave me a dirty look for the rest of my days at that hospital. I never regretted doing what I did but it bugged me that this psychologist did it more so than usual because I did some very good work with him for two years and until then considered him a mentor and a friend. I knew the guy knew what he was doing was wrong. I never completely found out why he wrote a bogus report but I did know that the patient's family were extraordinarily wealthy, I'm talking owning mansions in several other countries type of wealthy. Yes the thought did cross my mind that that my colleague was paid off but I knew I wasn't going to push it to that level, nor did I have the power to do so, so I mentally dropped it out of my head.

My last day in the state hospital, he approached me, shook my hand, and told me it was an honor working with me, but was very cold about it, where as before we had a warm relationship.

 

[BlueLotus]

Oh yes I'm aware of that study and it's one that actually made me wanted to go into psychiatry because I was sick and tired of bull$hit psychiatrists putting on fake labels. I wanted to go into a field where there was an adversarial system to rip such a psychiatrist to shreds.

Oh, now that is a great attitude! Now that I see the various responses within the field, I'm interested! The field perpetually fascinates me. Perhaps I will be fortunate enough to receive an interview this season.

My last day in the state hospital, he approached me, shook my hand, and told me it was an honor working with me, but was very cold about it, where as before we had a warm relationship.

That sucks, that stinging feeling of losing a mentor to the dark side is still fresh for me.

 

[DebDynamite]

I have found in populations like this that the rate of sexual SE tends to be more like 80% than the quoted 25-30% that I was taught in med school. For this reason I go to sertraline first, so that I can later recommend drug holidays (vs the blue pill vs switching). I have also seen much higher rates of activation on all SSRIs with patients like this. I think it's because they need more therapy, more exercise, better sleep and nutrition... and then an SSRI.

I work as a consultant to an ambulatory care clinic for a VA, so I see about three or so of these patients a day. ER/PCP calls it something much more severe and then they send them to me when 10 of celexa didn't work (really happened), or yes they tried prozac in 1997 and it kept them awake so obviously SSRIs don't work (yes that was also sent to me). Most of the patients I consult need better sleep and nutrition first. It's a different population than the ones who initially seek out a psychiatrist on their own. I think this is the context of what the OP was seeing clinically that led to this post. I diagnose adjustment disorder all day long.

 

[Droopy Snoopy]

I would love to hear an orthopedist say, "You know, buddy, we shouldn't treat your broken leg, because it's obviously the result of you getting hit by a truck. Since we know what's causing it, it's obvious we should just build a time machine and teach you the dangers of getting hit by a truck."

I spend a lot of time counseling my patients on the importance of exercise, social rhythms, diet, etc, and I clearly think they are important. I also think it's ridiculous for us to say, "Well, oh, if you just made better life choices, all of these things would go away!" If people could make better choices, they probably would, but apparently it's harder for them than you think, because they aren't!

Just tell them to Stop It!
[YOUTUBE]Ow0lr63y4Mw[/YOUTUBE]

 

[sunlioness]

You can certainly diagnose
Axis I: No diagnosis

Although DSM 5 doesn't use the Axes anymore.

Heh. I was just thinking, "Axes are so DSM-IV."

 

[birchswing]

Just tell them to Stop It!
[YOUTUBE]Ow0lr63y4Mw[/YOUTUBE]

Perfect example of CBT.

 

[heyjack70]

Heh. I was just thinking, "Axes are so DSM-IV."

For real. I miss the Axes. So many people I talk to say they're glad the axes are gone. I think the axes are great. They're bad if you don't care, or don't put in effort.

For example: I read a note once that read "Axis IV: psychosocial stressors". Are you kidding me? The psychiatrist just described the axis, but didn't mention any specific stressors.

The axes kept that stuff in a nice easy to find place, as long as you used it correctly.


I concede that GAF is crap.

 

[whopper]

I used to think the GAF was useless.

That is until my forensic psychiatry PD made me do it....for real. Use the actual two-step methodology explained in the DSM-IV on how to do it.

Then the problem became that no one else did it right.

And now it's gone. Despite what I just wrote, my opinion is quite singular.

 

[splik]

you can use the WHODAS which is a subjective measure of functioning now though.

 

[masterofmonkeys]

I miss Axis I-III and will continue to use them dammit. It just flows better. Also, problem lists are the devil.

 

[Shikima]

There's also a false conventional wisdom that was passed down that "you can't bill for adjustment disorder".

👍👍

I heard this time and time again as the Attending was billing for Bipolar d/o.

 

[Shikima]

I miss Axis I-III and will continue to use them dammit. It just flows better. Also, problem lists are the devil.

The just tuned it to match ICD billing and develop more conformity with our medicine colleagues.

Disclaimer: This is what I believe, I have no factual evidence.