Care-seeking patients who over-identify with diagnoses

[Osminog]

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I’m a PGY-2 psychiatry resident. I wanted to ask for people's thoughts on a particular type of patient I've encountered with relative frequency so far during my training.

The typical patient is a woman or a man with prominent feminine traits. She carries a growing list of psychiatric diagnoses, which she has fully embraced and incorporated as central features of her identity. When she loses focus during an uninteresting conversation, her ADHD flares up. If she argues with her partner, she becomes transiently manic. If she misplaces her car keys, it’s due to neurocognitive issues that have baffled previous doctors. The patient seems to almost derive joy from identifying with these psychiatric labels and linking them to every small aspect of her daily life. When discussing her history and symptoms, her language is steeped in psychiatric jargon that she’s absorbed from years in the mental health system.

She has an outpatient psychiatrist (who has some narcissistic traits) and sees her as a “complex case.” His ego is stroked by her dependence and ongoing care-seeking behavior, which forms the foundation of their relationship. Consequently, she ends up on an ever-changing regimen of medications, one for each symptom and diagnosis. There’s a continuous conversation between her and the psychiatrist about the side effects she’s experiencing and her independent research into how each medication relates to her conditions.

I am tempted to reduce this behavior to "care-seeking," or "neuroticism," or some sort of "psychiatric hypochondria." But these terms don't really seem to capture the full picture. There seem to be a variety of interconnected elements at play—suggestibility, hypersensitivity toward one's own internal states, dependent traits, etc. I’m still not sure how to conceptualize it.

Has anyone else encountered this type of patient? How do you approach cases like this?

 

[jbomba]

All the time. They are extremely exhausting. They need someone for ongoing therapy who is more skilled than I to really get at the root of the issue. My guess is the having these illnesses help fill some deeper need that, in my experience, is often related to a.previously emotionally or physically absent parent.

 

[splik]

This is just good old fashioned hysteria. Dramatic, emotionally shallow, suggestible patients with identity diffusion who cling to diagnostic labels to provide validation. ADHD is one of the latest hysterical diagnoses*. Behind many a hysterical patient is a dubious psychiatrist or therapist whose own narcissistic supply is provided by the imagined complexity of such patients. "special patients" need special psychiatrists who reinforce these dysfunctional patterns and create additional iatrogenic mess. The whole MPD and satantic ritual abuse scandals of the not too distant past are only one example of that.

*Which is not to say there are many non-hysterical cases of ADHD but the diagnosis has been co-opted as an identity and way of life. There is now no facet of mental life that cannot be explained by hitherto undiagnosed ADHD.

 

[mistafab]

This is just good old fashioned hysteria. Dramatic, emotionally shallow, suggestible patients with identity diffusion who cling to diagnostic labels to provide validation. ADHD is one of the latest hysterical diagnoses*. Behind many a hysterical patient is a dubious psychiatrist or therapist whose own narcissistic supply is provided by the imagined complexity of such patients. "special patients" need special psychiatrists who reinforce these dysfunctional patterns and create additional iatrogenic mess. The whole MPD and satantic ritual abuse scandals of the not too distant past are only one example of that.

*Which is not to say there are many non-hysterical cases of ADHD but the diagnosis has been co-opted as an identity and way of life. There is now no facet of mental life that cannot be explained by hitherto undiagnosed ADHD.

Yes, exactly this.

This is a classic hysteria patient. Modern training has gutted our ability to care for these patients. This is something where over time psychiatry is getting worse at dealing with the pathology. Biological approaches are not helpful for these patients.

 

[Osminog]

This is just good old fashioned hysteria. Dramatic, emotionally shallow, suggestible patients with identity diffusion who cling to diagnostic labels to provide validation. ADHD is one of the latest hysterical diagnoses*. Behind many a hysterical patient is a dubious psychiatrist or therapist whose own narcissistic supply is provided by the imagined complexity of such patients. "special patients" need special psychiatrists who reinforce these dysfunctional patterns and create additional iatrogenic mess. The whole MPD and satantic ritual abuse scandals of the not too distant past are only one example of that.

*Which is not to say there are many non-hysterical cases of ADHD but the diagnosis has been co-opted as an identity and way of life. There is now no facet of mental life that cannot be explained by hitherto undiagnosed ADHD.

Yes, exactly this.

This is a classic hysteria patient. Modern training has gutted our ability to care for these patients. This is something where over time psychiatry is getting worse at dealing with the pathology. Biological approaches are not helpful for these patients.

Do you have any articles or books you'd recommend to learn more about this topic? I'd like to gain a better understanding of what is going on with these patients and how I could actually help them.

 

[Fan_of_Meehl]

Do you have any articles or books you'd recommend to learn more about this topic? I'd like to gain a better understanding of what is going on with these patients and how I could actually help them.

I'd recommend:

- Be vigilant about these patients pushing boundaries and be consistent with politely but firmly enforcing professional boundaries with them
- Realize that their pathology will try to do things to get you emotionally off-balance and upset and react with emotion. Don't.
- When you're dealing with them, realize that you're dealing with, essentially, two entities: (a) the 'real' person underneath the pathology who actually does have some inherent drive to get better and mature psychologically...make friends with this part and reinforce the hell out of it for adaptive/mature functioning; and (b) the pathological part that will try to manipulate you, split with other staff, etc.; seeing the pathology part of the patient (b) as a separate 'thing' (clinical phenomenon) from them (their selves) may help you have empathy for the person even when their pathology is pushing your buttons
- Take a very behavioral approach with them, understanding that behavior is a function of its consequences (e.g., operant conditioning principles of reinforcement and punishment...reinforce adaptive behavior, ignore and/or punish maladaptive behavior)
- Realize that it's not your job to necessarily 'save' them from themselves or their pathology; you can only provide the best professional mental health interventions that you can and contribute (hopefully) to nudging them toward a better life
- if you're trying to do psychotherapy with them, you may have to constantly (at least at first) redirect and socialize them to the central tasks of psychotherapy of (a) self-evaluation and (b) self-change

 

[mistafab]

Do you have any articles or books you'd recommend to learn more about this topic? I'd like to gain a better understanding of what is going on with these patients and how I could actually help them.

First paper: Understanding the quantitative features of hysteria patients - gain ability to recognize them immediatley

PURTELL, J. J., ROBINS, E., & COHEN, M. E. (1951). Observations on clinical aspects of hysteria; a quantitative study of 50 hysteria patients and 156 control subjects. Journal of the American Medical Association, 146(10), 902–909. https://doi.org/10.1001/jama.1951.03670100022006

second paper: see how importnat just informing care team is, educating patient and everyone, and avoiding medical intervention

Smith, G. R., Jr, Monson, R. A., & Ray, D. C. (1986). Psychiatric consultation in somatization disorder. A randomized controlled study. The New England journal of medicine, 314(22), 1407–1413. https://doi.org/10.1056/NEJM198605293142203

 

[Jules A]

I am seeing this in a fair amount of adolescents especially those in private school who have taken a psychology course and frequent TikTok. Recently educated mom and kid that if in fact they are "dissociating all the time" as opposed to experiencing what is described as anxiety symptoms it is clearly unsafe for them to drive until the dissociation resolves. I am anticipating a speedy recovery.

 

[ObsequiousAplomb]

I am seeing this in a fair amount of adolescents especially those in private school who have taken a psychology course and frequent TikTok. Recently educated mom and kid that if in fact they are "dissociating all the time" as opposed to experiencing what is described as anxiety symptoms it is clearly unsafe for them to drive until the dissociation resolves. I am anticipating a speedy recovery.

I'm hopeful too. Unless they really enjoy the dependent role and mom and dad will drive them anywhere if they "dissociated" that day.

 

[romanticscience]

I appreciate the reference to hysteria. Many patients have true identity diffusion or an unconscious motivation. Similar to the other functional neurological disorders (conversion/hysteria), they present with la belle indifference and openly submit to an evaluation of their symptoms. However, many patients not only have symptoms but consciously want a diagnosis and resist re-formulations of their symptoms.

I've wondered to myself: how is this not malingering? The diagnosis either provides the person with cognitive enhancement medication or mitigation of social responsibility.

In my practice, in addition to using structured clinical interviews, I utilize symptom/performance validity testing and hypnotizability testing (assumption that valid ADHD is low and "hysteria" is high) to help differentiate.

Here are some readings that helped me:
1. Saunders, C. Psychiatric Diagnosis as Recognition in Disorder Identified Individuals. Philos., Psychiatry, Psychol. 30, 263–277 (2023).
2. Lane, R. Expanding boundaries in psychiatry: uncertainty in the context of diagnosis‐seeking and negotiation. Sociol. Heal. Illn. 42, 69–83 (2020).
3. Chan, D. & Sireling, L. ‘I want to be bipolar’…a new phenomenon. Psychiatr. 34, 103–105 (2010).

 

[splik]

In my practice, in addition to using structured clinical interviews, I utilize symptom/performance validity testing and hypnotizability testing (assumption that valid ADHD is low and "hysteria" is high) to help differentiate.

You definitely should not use hypnotizability scales like this. ADHDers probably score higher on measures of hypnotizability than controls and alert hypnosis can be used to treat ADHD.

Conversely, while Charcot believed hypnotizability was a cardinal feature of hysteria this is probably not true to today and certainly not for patients who overly identify with diagnoses they don’t have. In the intervening years, the authority of the physician, upon which much of hypnotizability was dependent on has eroded. And this is especially true for the hysterical patients of today whose very existence poses a challenge to and against the moral authority of the physician. If the hysteric of the 19th century sought to submit to the physician, the hysteric of the 21st century seeks to destroy him.

 

[futureapppsy2]

Are you seeing these types of patients in-patient (since you said that they already have an outpatient psychiatrist)? If so, what’s the reason for admission?

 

[futureapppsy2]

I am seeing this in a fair amount of adolescents especially those in private school who have taken a psychology course and frequent TikTok. Recently educated mom and kid that if in fact they are "dissociating all the time" as opposed to experiencing what is described as anxiety symptoms it is clearly unsafe for them to drive until the dissociation resolves. I am anticipating a speedy recovery.

Freshman Psych Student Diagnoses Roommate With Bipolar Disorder

PORTLAND, OR–In a breakthrough discovery Monday, Portland State University freshman and Psychology 101 student Steve Wenger diagnosed roommate Chad Doane with bipolar disorder.

theonion.com

I guess they can also now diagnose themselves too!

 

[ObsequiousAplomb]

Freshman Psych Student Diagnoses Roommate With Bipolar Disorder

PORTLAND, OR–In a breakthrough discovery Monday, Portland State University freshman and Psychology 101 student Steve Wenger diagnosed roommate Chad Doane with bipolar disorder.

theonion.com

I guess they can also now diagnose themselves too!

That article is old enough that some people born after it was published are practicing psychiatrists. Still true every semester

 

[Osminog]

Are you seeing these types of patients in-patient (since you said that they already have an outpatient psychiatrist)? If so, what’s the reason for admission?

Yes, I’ve encountered these patients in the inpatient setting. The reasons for admission vary. Some present with "mania" or "psychosis" (usually self-reported in the ED), concerns about severe medication side effects requiring monitoring, or suicidal ideation, often triggered by interpersonal conflicts and the feeling that others "don’t understand what I’m going through."

I’ve also seen cases on the C/L service. Once medical teams hear the extensive list of psychiatric diagnoses and medications, they almost reflexively consult psych.

 

[romanticscience]

You definitely should not use hypnotizability scales like this. ADHDers probably score higher on measures of hypnotizability than controls and alert hypnosis can be used to treat ADHD.

Conversely, while Charcot believed hypnotizability was a cardinal feature of hysteria this is probably not true to today and certainly not for patients who overly identify with diagnoses they don’t have. In the intervening years, the authority of the physician, upon which much of hypnotizability was dependent on has eroded. And this is especially true for the hysterical patients of today whose very existence poses a challenge to and against the moral authority of the physician. If the hysteric of the 19th century sought to submit to the physician, the hysteric of the 21st century seeks to destroy him.

Thanks for the tip. It does seem that ADHD has been associated with higher hypnotizability.

IMO Charcot's hysteria was a non-specific group. Didn't his favorite patient, Blanche Wittman, end up cured when he died?

To me, Charcot's hysterics now take the forms of both cluster B personality disorders AND highly hypnotizable "histrionic/hysterical" patients. The latter is the hypnotic virtuosos (honest liar syndromes) who present with conversion (auto-hypnotizing themselves?), which is almost always cured with hypnosis.

The former, in my experience, do very poorly with hypnotizability testing and hypnotic treatment because of their suspiciousness or hypervigilance with submission to authority. It's as if the motivation for their symptoms is more mixed with malingering/aggression/resentment instead of exclusive dissociation. So, even though they have unexplained symptoms, they don't exhibit suggested phenomena either. These patients, I consider to be primarily cluster B (borderline, narcissistic, antisocial). Much of my thinking is influenced by Herbert Spiegel and his use of the HIP for differential diagnosis.

Your insight is appreciated here because of your interest in conversion/FNS.

 

[clausewitz2]

Thanks for the tip. It does seem that ADHD has been associated with higher hypnotizability.

IMO Charcot's hysteria was a non-specific group. Didn't his favorite patient, Blanche Wittman, end up cured when he died?

To me, Charcot's hysterics now take the forms of both cluster B personality disorders AND highly hypnotizable "histrionic/hysterical" patients. The latter is the hypnotic virtuosos (honest liar syndromes) who present with conversion (auto-hypnotizing themselves?), which is almost always cured with hypnosis.

The former, in my experience, do very poorly with hypnotizability testing and hypnotic treatment because of their suspiciousness or hypervigilance with submission to authority. It's as if the motivation for their symptoms is more mixed with malingering/aggression/resentment instead of exclusive dissociation. So, even though they have unexplained symptoms, they don't exhibit suggested phenomena either. These patients, I consider to be primarily cluster B (borderline, narcissistic, antisocial). Much of my thinking is influenced by Herbert Spiegel and his use of the HIP for differential diagnosis.

View attachment 393560
Your insight is appreciated here because of your interest in conversion/FNS.

I think this topic is very interesting and would also love for folks with experience to talk more about it. I'm not gonna lie, though, that diagram has some serious Time Cube energy.

 

[splik]

IMO Charcot's hysteria was a non-specific group. Didn't his favorite patient, Blanche Wittman, end up cured when he died?

She was cured because he died. He trotted her out like a performing seal which no doubt reinforced her symptoms by affirming how "special" she was. Which goes to my point in the previous post of there being a narcissistic doctor lurking behind every hysterical patient.
Charcot believed that hypnotizability was a feature of hysteria so all his patients were highly hypnotizable. I also believe patients back then were more hypnotizable because of the status and power the physician had which has been eroded over time.

Today's FND we see only a subset of such patients are highly hypnotizable. Personally i don't use the HIP or other measure for hypnosis anymore in assessing these patients (I did when I was a resident), though they still do at Stanford. It can be help for treatment, but should not be used for diagnostic purposes with some exceptions. I would very rarely induce symptoms under hypnosis in the assessment of functional seizures. However, this was rarely necessary since 96% of such patients will have an event within 48 hours of vEEG monitoring and usually much sooner (i.e. admission for VET is hypnotic induction enough). And about 20% of FS patients you won't be able to induce a seizure with hypnosis.

 

[romanticscience]

Thanks for the thoughts! I feel I've devoted so much time to understanding that time cube picture up there. It's hard to abandon the HIP (sunk costs!). It's cool that they're still using the HIP in pharmacogenomics and TMS research. Freud's dynamic therapy has never been submitted to research in the same way as hypnosis has; hence, it is a reason for my leaving the guild.

The Charcot--Blanche duo reminds me of Quimby--Baker Eddy and Breuer--Anna O. We don't get these cool dynamics now that psychiatry is so biological!

 

[comp1]

This appears to be a mix of Cluster B personality pathologies. These are indeed bread and butter CL and inpatients. I can't help with outpatient and it sounds like they're set there anyways. The patient described sounds like they aren't acutely suicidal, homicidal or unable to feed/clothe/shelter themselves. If they are, you're leaving something out. So they need to discharge from an inpatient psychiatric setting ASAP. There's lot of literature on the importance of reducing psychiatric hospitalization number and duration in Cluster B personality pathology. If you are seeing them in CL, you need to reduce the number of providers involved. Just having consulted you is adding to the problem. Advise the team they need to change nursing staff as little as feasible for this patient and in terms of medical teams, they need a single clinician who will relay all information to the patient from other specialists. That should hopefully be someone they have positive regard for, but that may not always be possible and it likely won't last regardless. Beyond this, indeed provide the treatment team education that this is not bipolar/schizophrenia/schizoaffective. Make sure they know for sure there is no pill that will fix this. In fact, unless there is major danger, don't change whatever random regimen the outpatient MD started. Tell the one clinician who interacts with the patient that they need to set firm boundaries and generally offer concrete dichotomous options for any decisions to be made. Finally, these patients also need to discharge as quickly as their medical condition allows. The medical team should know from the beginning that there is no likelihood of any sort of transfer to psych.

 

[futureapppsy2]

This appears to be a mix of Cluster B personality pathologies. These are indeed bread and butter CL and inpatients. I can't help with outpatient and it sounds like they're set there anyways. The patient described sounds like they aren't acutely suicidal, homicidal or unable to feed/clothe/shelter themselves. If they are, you're leaving something out. So they need to discharge from an inpatient psychiatric setting ASAP. There's lot of literature on the importance of reducing psychiatric hospitalization number and duration in Cluster B personality pathology. If you are seeing them in CL, you need to reduce the number of providers involved. Just having consulted you is adding to the problem. Advise the team they need to change nursing staff as little as feasible for this patient and in terms of medical teams, they need a single clinician who will relay all information to the patient from other specialists. That should hopefully be someone they have positive regard for, but that may not always be possible and it likely won't last regardless. Beyond this, indeed provide the treatment team education that this is not bipolar/schizophrenia/schizoaffective. Make sure they know for sure there is no pill that will fix this. In fact, unless there is major danger, don't change whatever random regimen the outpatient MD started. Tell the one clinician who interacts with the patient that they need to set firm boundaries and generally offer concrete dichotomous options for any decisions to be made. Finally, these patients also need to discharge as quickly as their medical condition allows. The medical team should know from the beginning that there is no likelihood of any sort of transfer to psych.

Yeah, it sounds like Cluster B, especially with the self-reported “mania” and reactive SI. I’m guessing a lot of these patients have “never had such an understanding doctor” until they decide that said doctor is “a narcissist, actually”.

 

[brosa]

I agree with splik that this is the classic hysteria. This was very clear when I was studying psychodynamics. Unfortunately the DSM took the diagnosis away and created hundreds useless more. There are some patients that fit the picture of hysteria perfectly, but now instead we just say "cluster B and other stuff".