Clinical pet peeves?

[futureapppsy2]

What are your clinical pet peeves?

My top ones:
-People being diagnosed with both MDD and bipolar disorder, without noting that bipolar also explains the MDEs.

-Autism (ASD) diagnoses being given on parent report and/or brief, informal observation alone.

-PTSD diagnoses with no index traumatic event noted.

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[ExecutiveDysfunction]

I see “client reported racing thoughts, rule out Bipolar” in consults ALL THE TIME. That’s one symptom of many and just because a someone feels their thoughts race doesn’t mean they are/have ever been manic. Grinds my gears, a few follow up questions from the referring provider can clear that up.

 

[Therapist4Chnge]

1. Dx of PTSD and/or ADHD based only on patient report and little to no documentation.

2. “History of multiple TBIs”...which ends up being “dozens of concussions”....which ends up being undocumented reports of concussion w/o +LOC, etc.

 

[Mindfulpsych22]

1) Sloppy diagnoses in general- the worst being Bipolar, ADHD, ASD. Even MDD when the only sx is that the person “reported feeling depressed” or that feelings of depression lasted <1 day or 1-2 days.

2) seeing sloppy work in general from other providers- I’ve talked with some of my client’s previous providers who couldn’t tell me what tx goals or tx plan were beyond vague things like “address their anxiety”

3) patients over-using diagnosis words (anxiety, depression, PTSD) to describe things. Patient making judgments about their capabilities or abilities based on their diagnoses.

4) Parents who constantly tell their child’s therapist how to treat their child yet do not follow through on implementing their part of treatment plans (Contingency plans, etc).

5) Parents trying to get the therapist to fix all their child’s behaviors they don’t like (when some are irrelevant to the tx goals or presenting problems) or over pathologize normal child/adolescent behaviors.

6) Psychiatrists who won’t return phone calls to collaborate on a mutal patient’s care, yet keep inserting opinions about the patient’s therapy.

I’m sure there are more that will come to me........

 

[psyched2graduate]

1. "complex trauma"

2. overuse of unspecified depressive and anxiety disorders

3. dx of panic attacks = patient said they have panic attacks

4. dx of GAD = patient has anxiety

 

[AbnormalPsych]

The acronym "ADD." And then having to explain that is not a thing.

Dementia dx being given to patients based off screeners and pretty much nothing else (hunches?).

Lack of understanding of the very low base rate of true flashbacks (vs. just vivid memories). "Oh, no flashbacks? Can't be PTSD then."

People that go out well out of their way to incorrectly claim that all variables/scores from the Rorschach are invalid for purposes across the board, even with the R-PAS advances.

Clinicians that don't care to keep their skills sharp or those who work outside of their competency areas. I had a provider in a major medical center clinic I used to train in tell me they hadn't read a journal article in over 3 years.

 

[LadyHalcyon]

What are your clinical pet peeves?

My top ones:
-People being diagnosed with both MDD and bipolar disorder, without noting that bipolar also explains the MDEs.

-Autism (ASD) diagnoses being given on parent report and/or brief, informal observation alone.

-PTSD diagnoses with no index traumatic event noted.

Let's just say if I never hear the term "mindfulness" again I won't consider it a loss

Diagnosing Bipolar when it is really Boderline (mood swings DO NOT equal mania)

People completely missing personality disorders in general, diagnostically speaking

Psychiatrists over medicating

A diagnosis of schizoaffective anytime the patient reports auditory hallucinations

Just to name a few. Honestly, I can think of 10 others. Maybe I'm just cranky



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[AcronymAllergy]

Any and everything being tied to h/o remote concussion (particularly when it's the provider suggesting it)

 

[WisNeuro]

I'll second AA's thing ^, I see that all of the time.

Bipolar diagnoses in the chart when it is exceedingly clear that the patient has borderline PD

Massive amounts of polypharmacy, and then asking me what's due to medications and what could be a neurocog disorder. Honestly, when they are that snowed on meds, I'm surprised they wake up every morning.

Terrible community "npsych" evals. mostly by psychologists who do testing, rather than actual neuropsychs.

The pseudoscience that still makes it's way into clinical practice (e.g., EMDR, qEEG, MBTI, most projectives, etc).

 

[PsyDr]

1) adult adhd with zero history of childhood problems
2) #1 with comorbid benzo use, osa, alcohol use, ridiculous sleep hygiene
3) sleeping meds mixed with stimulants
4) saying someone is disabled with zero idea about how disability is determined and why it’s super unlikely for a psych dx to be disabling due to the ada
5) trying to explain all criminal behavior by mental illness. Some people are just jerks.
6) trying to explain other bad behaviors because of mental illness. People are capable of doing bad things without a mental illness
7) diagnosing Bipolar disorder even though the prevalence rate is 1%, biggest mortality rate for psych, many meds have significant life altering side effect potential, and has a lower quality of life than pediatric cancer.
8) #7 with stimulants and benzos in board
9) #7 with borderline personality disorder, antisocial personality disorder, or intermittent explosive disorder.
10) finding something calming or fun or stress releasing and adding “therapy” after it. Looking at you equine therapy, music therapy, dance therapy, etc. I’m gonna end my career with “punching bad therapists therapy”.
11) not understanding the difference between attention, concentration, and memory.
12) who insist MDD and the like causes memory loss. Ever heard of pseudodmentia?
13) idiots who don’t read the literature
14) saying you use “cbt” when you really mean, “I add aspects of cbt to therapy when I can put it into my supportive therapy, sometimes, maybe.”
15) confusing coaching with therapy.
16) confusing soothing with therapy
17) old practitioners remaining in the field well past 65 so the younger can’t move up.
18) doing neuropsych on the side. It’s too complex to do that
19) lifespan neuropsych. I doubt the people who do this are actually able to be good at adults and good at kids.
20) confusing psychotherapy for personal growth as psychotherapy for treating illness.
21) adding your own religion or sexuality or interests into your practice.
22) bad testing in general
23) people who sell their opinions for forensics, educational, or other nonclincal uses.
24) the constant “I was trained by Lurias great grandfather”. Do something on your own and stand up as an adult in your own right.
25) “trauma”. There’s a very specific definition in the dsm. Being dumped can’t give you ptsd.
26) trauma therapy- we dropped the cathartic method a hundred years ago.
27) not confronting Pts on obvious bs. That’s demeaning.
28) “self medication”. Hint: there is next to no evidence to support this idea, and Europe doesn’t use this stupid idea in treating substance abuse.

(More to come)

 

[LadyHalcyon]

1) adult adhd with zero history of childhood problems
2) #1 with comorbid benzo use, osa, alcohol use, ridiculous sleep hygiene
3) sleeping meds mixed with stimulants
4) saying someone is disabled with zero idea about how disability is determined and why it’s super unlikely for a psych dx to be disabling due to the ada
5) trying to explain all criminal behavior by mental illness. Some people are just jerks.
6) trying to explain other bad behaviors because of mental illness. People are capable of doing bad things without a mental illness
7) diagnosing Bipolar disorder even though the prevalence rate is 1%, biggest mortality rate for psych, many meds have significant life altering side effect potential, and has a lower quality of life than pediatric cancer.
8) #7 with stimulants and benzos in board
9) #7 with borderline personality disorder, antisocial personality disorder, or intermittent explosive disorder.
10) finding something calming or fun or stress releasing and adding “therapy” after it. Looking at you equine therapy, music therapy, dance therapy, etc. I’m gonna end my career with “punching bad therapists therapy”.
11) not understanding the difference between attention, concentration, and memory.
12) who insist MDD and the like causes memory loss. Ever heard of pseudodmentia?
13) idiots who don’t read the literature
14) saying you use “cbt” when you really mean, “I add aspects of cbt to therapy when I can put it into my supportive therapy, sometimes, maybe.”
15) confusing coaching with therapy.
16) confusing soothing with therapy
17) old practitioners remaining in the field well past 65 so the younger can’t move up.
18) doing neuropsych on the side. It’s too complex to do that
19) lifespan neuropsych. I doubt the people who do this are actually able to be good at adults and good at kids.
20) confusing psychotherapy for personal growth as psychotherapy for treating illness.
21) adding your own religion or sexuality or interests into your practice.
22) bad testing in general
23) people who sell their opinions for forensics, educational, or other nonclincal uses.
24) the constant “I was trained by Lurias great grandfather”. Do something on your own and stand up as an adult in your own right.
25) “trauma”. There’s a very specific definition in the dsm. Being dumped can’t give you ptsd.
26) trauma therapy- we dropped the cathartic method a hundred years ago.
27) not confronting Pts on obvious bs. That’s demeaning.
28) “self medication”. Hint: there is next to no evidence to support this idea, and Europe doesn’t use this stupid idea in treating substance abuse.

(More to come)

#27 all day

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[WisNeuro]

13) idiots who don’t read the literature

(More to come)

What about the idiots who read the literature, but cannot understand the literature?

 

[smalltownpsych]

1) adult adhd with zero history of childhood problems
2) #1 with comorbid benzo use, osa, alcohol use, ridiculous sleep hygiene
3) sleeping meds mixed with stimulants
4) saying someone is disabled with zero idea about how disability is determined and why it’s super unlikely for a psych dx to be disabling due to the ada
5) trying to explain all criminal behavior by mental illness. Some people are just jerks.
6) trying to explain other bad behaviors because of mental illness. People are capable of doing bad things without a mental illness
7) diagnosing Bipolar disorder even though the prevalence rate is 1%, biggest mortality rate for psych, many meds have significant life altering side effect potential, and has a lower quality of life than pediatric cancer.
8) #7 with stimulants and benzos in board
9) #7 with borderline personality disorder, antisocial personality disorder, or intermittent explosive disorder.
10) finding something calming or fun or stress releasing and adding “therapy” after it. Looking at you equine therapy, music therapy, dance therapy, etc. I’m gonna end my career with “punching bad therapists therapy”.
11) not understanding the difference between attention, concentration, and memory.
12) who insist MDD and the like causes memory loss. Ever heard of pseudodmentia?
13) idiots who don’t read the literature
14) saying you use “cbt” when you really mean, “I add aspects of cbt to therapy when I can put it into my supportive therapy, sometimes, maybe.”
15) confusing coaching with therapy.
16) confusing soothing with therapy
17) old practitioners remaining in the field well past 65 so the younger can’t move up.
18) doing neuropsych on the side. It’s too complex to do that
19) lifespan neuropsych. I doubt the people who do this are actually able to be good at adults and good at kids.
20) confusing psychotherapy for personal growth as psychotherapy for treating illness.
21) adding your own religion or sexuality or interests into your practice.
22) bad testing in general
23) people who sell their opinions for forensics, educational, or other nonclincal uses.
24) the constant “I was trained by Lurias great grandfather”. Do something on your own and stand up as an adult in your own right.
25) “trauma”. There’s a very specific definition in the dsm. Being dumped can’t give you ptsd.
26) trauma therapy- we dropped the cathartic method a hundred years ago.
27) not confronting Pts on obvious bs. That’s demeaning.
28) “self medication”. Hint: there is next to no evidence to support this idea, and Europe doesn’t use this stupid idea in treating substance abuse.

(More to come)

29) Psychologists who make really long lists.
Kind of set me up for that one. Seriously though, I agree with all of the above.

 

[ClinicalABA]

I'll second AA's thing ^, I see that all of the time.
Terrible community "npsych" evals. mostly by psychologists who do testing, rather than actual neuropsychs.

Just reveiwed a report titled "Neuropsychological Testing." Assessment involved and ABACS and an attempt at a WPPSI (kid wouldn't comply). That's all.

 

[WisNeuro]

Just reveiwed a report titled "Neuropsychological Testing." Assessment involved and ABACS and an attempt at a WPPSI (kid wouldn't comply). That's all.

I saw one that was for a "brain injury" eval that just consisted of the WAIS and WMS. The WMS scaled scores ranged from 2 to 13. No consistency, no PVT/SVTs administered. The "neuropsychologist" opined that the lower scaled scores were indicative of the pts true functioning, and didn't even try to explain away the delayed memory scores that were well within normal limits. Needless to say, this patient bombed all of my PVTs. Below chance levels.

 

[AbnormalPsych]

Just reveiwed a report titled "Neuropsychological Testing." Assessment involved and ABACS and an attempt at a WPPSI (kid wouldn't comply). That's all.

I saw one that was for a "brain injury" eval that just consisted of the WAIS and WMS. The WMS scaled scores ranged from 2 to 13. No consistency, no PVT/SVTs administered. The "neuropsychologist" opined that the lower scaled scores were indicative of the pts true functioning, and didn't even try to explain away the delayed memory scores that were well within normal limits. Needless to say, this patient bombed all of my PVTs. Below chance levels.

Not to derail the thread...but as an early career psych, I am curious. How are these clinicians getting away with providing services like this?

 

[WisNeuro]

Not to derail the thread...but as an early career psych, I am curious. How are these clinicians getting away with providing services like this?

There's a good market for incompetent providers who will agree that a patient is disabled/irreparably injured/etc without any compelling evidence. Plaintiff lawyers know where to go to get shady evals done. Just like defendant lawyers know where to go to get things done the right way and shred these people in court. Also, state licensing boards pretty much only go after the most egregious violations in many jurisdictions, so there's not much other people can do in complaining to state boards.

 

[StellaB]

18) doing neuropsych on the side. It’s too complex to do that

Agree with almost all of your list - and will add:
- doing forensic evaluation on the side, when not keeping up with current case law
- using inappropriate tests to answer the referral question
- drawing inappropriate conclusions from test results (no joke - I have seen digit-span interpreted as a projective personality measure)
- not doing effort testing when effort is an important factor to consider

 

[WisNeuro]

- not doing effort testing when effort is an important factor to consider

Effort is always an important factor to consider.

 

[StellaB]

There's a good market for incompetent providers who will agree that a patient is disabled/irreparably injured/etc without any compelling evidence. Plaintiff lawyers know where to go to get shady evals done. Just like defendant lawyers know where to go to get things done the right way and shred these people in court. Also, state licensing boards pretty much only go after the most egregious violations in many jurisdictions, so there's not much other people can do in complaining to state boards.

Where it's really scary is in criminal forensics, where you see really incompetent evaluations but neither side (defense, DA) typically has the money or know-how to recognize them for how bad they are. You hear about the big, expensive cases, but there are thousands of small-fry ones where these awful practitioners can really do harm with relative impunity.

 

[StellaB]

Effort is always an important factor to consider.

I agree in both our sub-fields it is always relevant, but I guess I could see some testing scenarios where it might not be as critical (maybe vocational assessment?).

 

[WisNeuro]

I agree in both our sub-fields it is always relevant, but I guess I could see some testing scenarios where it might not be as critical (maybe vocational assessment?).

Some, maybe, but I'd argue that most assessment scenarios should be concerned with the validity of responses.

 

[AbnormalPsych]

- drawing inappropriate conclusions from test results (no joke - I have seen digit-span interpreted as a projective personality measure)

!!!

 

[LadyHalcyon]

Where it's really scary is in criminal forensics, where you see really incompetent evaluations but neither side (defense, DA) typically has the money or know-how to recognize them for how bad they are. You hear about the big, expensive cases, but there are thousands of small-fry ones where these awful practitioners can really do harm with relative impunity.

This is also a major pet peeve of mine. I have seen some horrific forensic evaluations

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[temppsych123]

People who want to do therapy who think that they therefore don't need assessment training. HOW CAN YOU EFFECTIVELY TREAT SOMEONE WITHOUT ASSESSING WHAT IS WRONG ugh sorry this makes me so mad...

Related to people doing assessments poorly:
- Assuming that self-injury and suicidality = BPD 100% of the time
- Not asking about suicide because you don't know what to do with the information
- Not doing at least SOME standardized assessment with new clients ("oh no, I didn't ask about psychosis or mania or risk of violence, they didn't mention it as an issue...")
- Intentionally not disclosing a patient's diagnoses to them

 

[PsyDr]

29) Idiots who notice they repeated themselves and are too lazy to renumber #29
30) Jerkface older people who suddenly decide that there's new entry requirements to a specialty, that they never had to do, who don't see the hypocrisy. Is that route necessary of just necessary to you? Because there's a lot of neuropsychologists I can point to..... Rehab you're coming up.
31) Idiots with obvious obsessive tendencies who write on message boards for psychologists.
32) MY GOD, THE TERRIBLE CLOTHES. how hard is it to dress like every other professional in the USA? Ladies, if I wear your top and someone calls it a t-shirt, it's a t-shirt. Men, I am mad as hell that I know what fashion sweatpants are.
33) The endless dumb articles that find the most minute cognitive problem in serious illnesses. Knowing that people with frotteurism have trouble spelling the states that start with the letter K is like asking a guy whose house is on fire if he's troubled by the gas mileage in his new car.
34) Not asking tough questions because its awkward.
35) Not taking epidemiological evidence/base rates into consideration. Rare things should be rare. You should be seeing about as many redheads as individuals suffering from bipolar disorder and schizophrenia. Unless you are in Scotland.
36) Having dogs/cats in the office.
37) Professionals, that report that their feelings about a treatment or illness is important. Either there's evidence for something or not.
38) Idiots who don't have good boundaries or have multiple relationships. Not okay to socialize with pts.
39) That one "neuropsychologist" who did a blindfolded tasting menu on a reality show Kitchen Nightmares. I super hate you.
40) Those that hypocritically opine about the psych stuff of public figures because they have personal issues with a politician/rock star/etc despite the then president of the APA saying its not okay.
41) THE INCREDIBLY LOW PRODUCTIVITY! Look at how much an established office visit pays for a physician. It's not actually that much. They're just really really really good at being productive. And I refuse to accept the being emotionally drained explanation, unless someone can explain how an ER/ED physician can go 12hr shifts. If everyone showed up, worked an 8 hr day, billed $100, the median gross would be on par with most physicians.
42) Why isn't august on the cape still a thing?!
43) What happened to behaviorism?!!! Not CBT. Behaviorism. Not in autistic people.
44) People who don't learn the lingo of the area in which they practice. Looking at you, idiot whose report said someone had an MI in their brain.
45) Whoever the red sox psychologist is.
46) People who don't know how much drinking is considered heavy drinking.
47) People who don't know that onset of dementia in some pathologies means your patient about to die. Respect what you are doing.

 

[ClinicalABA]

-Psychologists who don’t recognize that the term “psychologist” refers to their occupation, not their personality/identity.
-psychologists who act superior to mid-level practitioners or providers in other fields. I trust the judgement and insight of the teacher who spends 30 hours per week with the child more than you, who has only seen the kid once or twice, even if you do call yourself “Doctor.’
-Use of the term “work” preceded by any presenting problem/symptom/diagnosis. For example, “we’re doing trauma work”
-Any use, at all, of the word “issues” (yes, even if you are referring to journals or magazines, just out of spite and hatred for the term)
-assumption that any history of trauma=psychopathology. People are pretty resilient.
-referring to “famous” psychologists by their first names. You don’t know her- don’t refer to her as “Marsha”
- not putting assessment materials back in the correct spot or order when your done with them
- not letting the right person/anyone know when you’re running low on or even out of protocols
- pretty specific, but I hate when people tear of the male or female face sheet from the SRS and stick it back in there with the rest of the unused protocols.
- not changing the batteries in the flipping dog or bubble gun
- leaving the lid off the play-doh


-I’ll echo PSYDR in regards to fashion, particularly for men. Dress like a professional. If you don’t know how to, that’s ok- it’s not part of your training. In suc a case, go to freakin Men’s Wearhouse on 2 for 1 day and ask them to match a shirt and tie for you. Look at how their ties are tied. Notice that the fat part (but not too fat part- it’s not the 90s after all) totally covers the thin part underneath. Top button is buttoned- if you can’t, you need a bigger shirt. Tie ends at top of belt (you better be wearing a belt) not at crotch or mid belly! Also- your a child psychologist, not a child! Don’t wear things with cartoons or Disney characters on them. Build a real relationship with the child using your actions and training, rather than leaving it up to your minions tie.

 

[mypointlesspov]

Having to provide a dx for Medicaid after the first session.

 

[PsyDr]

48) post concussion syndrome. Goddamn, if you’re gonna use a bs diagnosis at least put in the effort to use the right term. Icd and dsm-iv had it as “post concussional”. Two letters, *****s.

 

[Therapist4Chnge]

@PSYDR is on Fire!!!

 

[calimich]

doorknob therapy

"well, our time's up for this week"

"oh, there is this one (huge) thing I wanted to talk about..."

 

[Justanothergrad]

Most of these are clinical, but a few are research as well

1. dropping disorder from PTSD so its PTS
2. everytime someone says 'I went into psychology because medicine was too hard'. That's not a reason to do something- that's a reason not to do a different thing
3. when people think neuropsych testing is needed for ADHD. Just no.
4. when people say 'I dont believe in diagnosing'
5. when people used to list Axis 6 on the DSM-4 diagnoses
6. Refusing to update knowledge beyond what you learned in graduate school (I've seen people STILL coding MMPI1 profiles back from mmpi2 responses)
7. When providers can't be timely to appointments
8. 99% of meetings run by psychologists
10. Reading reports written in incoherent psychobabble
12. "Marginal significance". Either she agreed to go to prom with you or she didnt- no half successes there.
13. When a case conference turns into a "and then he said... and then I said... and then he said". Meehl knew what was up.
15. mTBI obsession
16. The fear of saying Veterans can have motivation for secondary gains publicly
17. EMDR. Explain to me again why the eye movement is incremental.
18. People who expect testing results to all be normal and obsess over a single subtest variation
19. MBTI

 

[cara susanna]

1. Someone saying they have PTSD (or being referred for PTSD eval) when they don't have an index event.
2. People calling people with BPD "a borderline"
3. EMDR
4. People thinking that my being a psychologist means I can read minds. Like asking me referral questions that I can't possibly solve.
5. Having to treat and coddle clearly unmotivated patients (VA thing, yes)
6. Speaking of VA things, people engaging in MH services or treatment solely because they think it will help them get or keep their benefits
7. Assuming that suicidal ideation is the same thing as high risk for suicide. Also conflating chronic risk with imminent risk.
8. Treating NSSI the same as suicidal behavior, risk assessment wise
9. No show calls (VA thing)
10. Patients saying that they have goals and then not actually doing any of the work.
11. The discrepancies between what PTSD research suggests we do and what we actually do in the "real" clinical world--e.g., step-based approach to complex trauma histories
12. Benzos
13. The fact that the way we're expected to handle suicidal patients actually reinforces suicidal behavior overall
14. Not being able to see some patients as often as I'd like because my caseload is taken up by people who just want to come in and vent.
15. Having new patients assigned into slots that aren't designated for new patients (the ONE way that I am able to control my caseload, pretty much)
16. How completing training, with supervision, in a specific EBT on internship or post doc seems to not matter in the VA unless you've been "VA certified."
17. Patients forgetting their homework. Like, I get it, but then what are we supposed to do all session?
18. Patients not doing their homework.
19. People perpetuating the idea that talking about a trauma can "retraumatize" someone. I usually encounter this outside of the field, but sometimes within it as well.
20. Assuming that eliminating suicide altogether is an entirely reasonable and attainable goal.

 

[cara susanna]

Shoot, I forgot one of my biggest ones!

21. SERVICE DOGS FOR PTSD.

 

[RejectClinical]

Shoot, I forgot one of my biggest ones!

21. SERVICE DOGS FOR PTSD.

THIS!!! Also....that cannabis is the cure-all for just about anything and everything under the sun. Not only is it not effective for treating a lot of disorders, but it can be counter-productive (e.g., anxiety, PTSD).

To add insult to injury....these same people then coming in complaining they have memory problems. Well, you were high all last night. What did you expect?

 

[WisNeuro]

THIS!!! Also....that cannabis is the cure-all for just about anything and everything under the sun. Not only is it not effective for treating a lot of disorders, but it can be counter-productive (e.g., anxiety, PTSD).

To add insult to injury....these same people then coming in complaining they have memory problems. Well, you were high all last night. What did you expect?

To be fair, there is some preliminary research coming out that CBD can be somewhat effective for pain relief. Well, as effective as what we're already doing, anyway. It would infinitely better for my elderly patients to be on CBD than the Norco that they are actually on when it comes to cognitive side effects.

 

[blakjak12]

A lot of good points related to important clinical issues that I agree with and also find annoying (e.g., PTSD diagnosis with no criterion A trauma; calling people "borderlines"; diagnosing bipolar based on "moodiness"). I also will make a humble request not to judge those of us (i.e., slobs like me ) who do not wear suits and ties too harshly. Maybe that's why sloppy people like me go into academia, as ties seem too formal to me for most work-related occasions.

Additionally, I would like to point out that I think a lot of our issues and complaints regarding diagnoses are related to systematic issues and are a result of a very flawed diagnostic system. I certainly agree that there are numerous cases where clinicians do a poor job, as evidenced by my examples above and the large number of other examples provided. That being said, I think we need to remember that there is a lot of accumulating research highlighting the flaws of the DSM. So, in some ways, these issues appear to with our diagnostic conceptualizations, which are as much, if not more, expert- (and based mostly on the expert opinions of older, wealthy, white men from psychiatry backgrounds) rather than empirically-based. For example, when reliability estimates are so poor even for our common diagnoses (e.g.,depressive and anxiety disorders) across top-notch clinical training and treatment sites where we have the "experts" conducting assessments, how can we expect the average community clinician to apply these diagnoses effectively? Related to this issue, a ton of research again shows that many of the distinctions across different disorders are arbitrary. For example, is MDD truly qualitatively different from an unspecified depressive disorder or persistent depressive disorder (the latter of which now has a specifier allowing clinicians to include MDD on top of a persistent depressive disorder diagnosis)? The empirical evidence suggests no. Is MDD with an anxious distress specifier added qualitatively different from MDD + GAD? Just some things to consider. Again, this is not to bash any prior comments in anyway (I can sympathize: I write this as I had a referral this week for an "unspecified mental disorder"), but also to consider pet peeves that are related to systematic issues as well.

 

[RejectClinical]

To be fair, there is some preliminary research coming out that CBD can be somewhat effective for pain relief. Well, as effective as what we're already doing, anyway. It would infinitely better for my elderly patients to be on CBD than the Norco that they are actually on when it comes to cognitive side effects.

Yeah....that's why I used the word "a lot of disorders." I'm not saying it isn't good for anything, but people act like it is the all-encompassing cure-all, which it is not. Agreed that there are worse things. I'd much rather have a patient using CBD than alcohol for example.

 

[erg923]

The field's obsession with "mindfulness" and motivational interviewing. The latter is an important style to have in clinical interactions, but I think it gets too much play as an approach/technique. The former is useful in life in general, but just not fitting with my personality (I admit I have never truly mediated or eaten an orange slowly) or my approach to treating true pathology. I'm probably just not greatly skilled at either, and this is all counter-transference.

The Dx stuff is true too, but I think we also needs to admit that most our treatments work better on symptoms than they do on any of the "disorders" we have come up with over the decades.

If the same question were posed to an internist or pretty much any other field of clinical medicine, you might expect just as many gripes. Although, quality control within the field is probably much more of concern for us than it is for other medical fields. Its easy/easier to practice clinical psychiatry and clinical psychology poorly, and get away with it....IMHO.

 

[ClinicalABA]

Additionally, I would like to point out that I think a lot of our issues and complaints regarding diagnoses are related to systematic issues and are a result of a very flawed diagnostic system...

A valid point, but in the absence of some diagnostic system, what heuristic are these clinicians using to decide on diagnoses? Seems that often they are picking a few most obvious symptoms, and calling it a day without other attempts at differential diagnosis or- gasp- not making a diagnosis.

 

[Justanothergrad]

And to be fair, index events aren't %100 rock solid. They are not always super predictive of PTSD symptoms (Robert's et al., 2012) and folks in prolonged high stress events have similar stress reactions.

 

[blakjak12]

A valid point, but in the absence of some diagnostic system, what heuristic are these clinicians using to decide on diagnoses? Seems that often they are picking a few most obvious symptoms, and calling it a day without other attempts at differential diagnosis or- gasp- not making a diagnosis.

Yeah definitely agree with these points, and related to that, I certainly don't think that we want to make "a bad system" an excuse for not conducting thorough diagnostic assessments like you said. I can see some cases where discriminating various DSM-5 diagnoses might not make a huge difference (e.g., differentials between different depressive dxs and between some depressive/anxiety disorders), but certainly there are cases where a lazy diagnostic process just doesn't cut as you and others have pointed out (e.g., assuming mood swings or racing thoughts = bipolar).

 

[blakjak12]

The field's obsession with "mindfulness" and motivational interviewing. The latter is an important style to have in clinical interactions, but I think it gets too much play as an approach/technique. The former is useful in life in general, but just not fitting with my personality (I admit I have never truly mediated or eaten an orange slowly) or my approach to treating true pathology. I'm probably just not greatly skilled at either, and this is all counter-transference.

The Dx stuff is true too, but I think we also needs to admit that most our treatments work better on symptoms than they do on any of the "disorders" we have come up with over the decades.

If the same question were posed to an internist or pretty much any other field of clinical medicine, you might expect just as many gripes. Although, quality control within the field is probably much more of concern for us than it is for other medical fields. Its easy/easier to practice clinical psychiatry and clinical psychology poorly, and get away with it....IMHO.

Perhaps not surprisingly given my previous post, I like the point connecting treatments to symptoms versus diagnoses a lot. This seems to be true for both medication and psychotherapeutic approaches, where for example, SSRIs often are prescribed for both depressed mood/anhedonia and worry, even though these symptoms are listed within separate DSM chapters. Therapeutic approaches also seem to continue to be trending this way (e.g., the Unified Protocol and various ACT approaches).

 

[temppsych123]

2. People calling people with BPD "a borderline"
4. People thinking that my being a psychologist means I can read minds. Like asking me referral questions that I can't possibly solve.
7. Assuming that suicidal ideation is the same thing as high risk for suicide. Also conflating chronic risk with imminent risk.
8. Treating NSSI the same as suicidal behavior, risk assessment wise
13. The fact that the way we're expected to handle suicidal patients actually reinforces suicidal behavior overall
20. Assuming that eliminating suicide altogether is an entirely reasonable and attainable goal.

OMG YOU ARE MY PSYCHOLOGIST SPIRIT TWIN

I once had an attending psychiatrist refer to a pre-adolescent who had just attempted suicide as a "baby borderline." I. COULD. NOT. EVEN.

I would also add:

#8792. Clinicians who assume that their personal dislike of a client means that client has a personality disorder. OR, who argue that a client who actually meets criteria for a personality disorder should not get that diagnosis because "they're so nice" and "they're really trying." There's a reason we have diagnostic criteria and don't just go off "I'd like to have coffee with this person, so they must be fine."

 

[bcliff]

The field's obsession with "mindfulness"

I think that "mindfulness-based interventions" can be valuable when they are being implemented in the way that they were designed, like, when they're actually used to intervene upon how an individual attends to stimuli. I like Linehan's conceptualization of mindfulness as exposure ("noticing" what's happening in the present moment, even when it's aversive).

Seeing mindfulness being conflated with relaxation, or "clearing one's mind" is a big pet peeve of mine tho.

 

[temppsych123]

I think that "mindfulness-based interventions" can be valuable when they are being implemented in the way that they were designed, like, when they're actually used to intervene upon how an individual attends to stimuli. I like Linehan's conceptualization of mindfulness as exposure ("noticing" what's happening in the present moment, even when it's aversive).

Seeing mindfulness being conflated with relaxation, or "clearing one's mind" is a big pet peeve of mine tho.

Thomas Joiner wrote a pretty scathing article about mindfulness awhile back...ah, here it is:

Perspective | Mindfulness would be good for you. If it weren’t so selfish.

I don't agree with all of it, but an interesting read.

 

[futureapppsy2]

Some others:

Conflating "punishing disclosure of suicidality" with "punishing suicidality" ("punishing" in the behavior analytic sense).

Any "suicide prevention campaign" that consists solely of posting the suicide hotline number.

Conflating "emotional support animals" with "service animals" in a legal context

Assuming emotional support animals are the best or primary treatment of any mental illness

"Trauma-informed" approaches that teach or imply that traumatic stress isn't treatable

Clinicians who smugly say, "Eating disorders aren't about food"

 

[cara susanna]

Thomas Joiner wrote a pretty scathing article about mindfulness awhile back...ah, here it is:

Perspective | Mindfulness would be good for you. If it weren’t so selfish.

I don't agree with all of it, but an interesting read.

I actually agree with his initial point (the real definition of mindfulness has been warped somewhat), but then he lost me.

 

[Justanothergrad]

Assuming emotional support animals are the best or primary treatment of any mental illness

Passengers Fall in Love With Emotional Support Duck on Flight

I'll just leave this reminder here to start everyones week

 

[ExecutiveDysfunction]

28) “self medication”. Hint: there is next to no evidence to support this idea, and Europe doesn’t use this stupid idea in treating substance abuse.

SUD is not remotely my area of expertise but I’m interested in this, any citations I can check out? This is the first I’ve heard it.

Edit: I spoke too soon for my googling. Still interested but I found some stuff. I see what you mean, that drug of choice does not relate to underlying issue. I.e., patient won’t choose meth over others because they have underlying ADHD.