Diagnoses not officially in DSM

randomdoc1

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    I think we've all seen some variant of these, I'm curious to see other types of cases witnessed in your career!

    The Borderline Hug
    Diagnostically confusing. Patient is pan positive with symptoms of every disorder but does not cleanly meet any diagnosis. On medications with all receptors covered including: benzo, mood stabilizer, SSRI/SNRI, antipsychotic, antihistamine, and maybe some deplin and vitamin D3. Patient is surprisingly pleasant, not high maintenance, and otherwise clinically appears to be doing quite well on their current regimen with no apparent major side effects. But once you start trying to simplify, there's all sorts of somatic symptoms and odd symptoms reported that continue to not line up with anything that medically makes sense.

    Anxious Little Old Lady Syndrome
    Generally does not have any history of major axis II issues nor do they seem to have current presentation suggestive of Axis II. May have had some mild depression or anxiety in their remote past. Seemingly out of the blue appearing and sounding severely anxious. Often characterized by excessive rumination, pacing, saying the same types of things over and over. However, extensive medical work up has not yielded any organic findings despite the dramatic presentation. Some cases may look convincingly neurological but assessment and testing do not substantiate that. Not uncommonly it is also accompanied by depressed mood and excessive self deprecation. Generally you cannot convince this patient with any kind of reasoning or logic. Usually ends up being severe anxiety and/or depression with some cases needing and typically responding well to ECT.

    Grumpy Old Man Syndrome
    His rationale is that he's lived all his life with his symptoms and does not care to get treated. Clearly depressed +/- anxiety. Often brought in by family. Presents angry and as if he has a huge chip on his shoulder. Can be seen in the waiting room reading magazines and he will get angry if you don't have today's paper. He does not like this electronic era, preferring phone calls, phone reminders, paper bills and to write checks. He'd rather die than do a televisit despite coronavirus. Family says his typical day consists of having his 3 meals at their usual times, same food items and he watches local television. Very stuck in his ways, doesn't want to do therapy, care to engage in therapy, want to take medication or come to appointments. Reluctantly takes medication with prompting of family but with this presentation, likely medication alone will not be sufficient. Likely has comorbid personality pathology.

    Affluenza
    Adult child from affluent typically white and privileged family. Child and family members are highly intelligent and high functioning. Some cases harbor severe personality pathology. Patient has somewhat of an entitled attitude. They may technically have some degree of a mood or anxiety based disorder. However, there is over-reliance on medication or other passive forms of treatment to fix things for them. Very little is changed outside of sessions or work done on the patient part to move towards goals. In severe cases patient and parents can be masterminds at externalizing everything and surprisingly so despite their intellectual capacity. Parents can be quite enabling, pursuing confirmation of wrong diagnosis and treatment of wrong diagnosis, further entrenching the maladaptive traits of patient and family. Parents typically call quite often and there appears to be difficulty in the family as a unit with managing conflict and distress tolerance. In such cases, psychiatrist can be nervous due to lack of ownership taken by patient and family and anger being displaced on to care providers. Treatment of choice is to address the underlying pathology but often patient and family not receptive to accepting diagnosis and tend to pursue treatments that are not indicated and potentially harmful such as antipsychotics. In such cases, makes care providers eager to find way out of the case as it may be a liability waiting to happen depending on severity and you know it's a family that has a lot of money they can blow.

    Those are all the ones I can think of right now!
     
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    erg923

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      "Doc, if everyone would just do exactly what I tell them to do (referring mostly to adult children, wife and other family members, but probably most any one else too), we wouldn't have any problems here."

      Yes. That's pretty much word for word what he said, too.
       
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      PsyDr

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        GeroTurf
        Typically a referral from a referral from a referral from a crappy nursing home that says the patient is expressing homicidal or suicidal ideation. Seen in either inpatient or outpatient settings. Patient is commonly either mad as hell for reasonable causes, has made a comment about death which is misinterpreted as suicide, or hasn't been capable of speech in a decade. Why are they here? What are you supposed to do? Who knows? Presentation in inpatient settings is highly correlated with the nursing home refusing to take them back.

        The Low Function-er
        Age varies across the lifespan. Patient is almost always accompanied by a parent or adult sibling. History will reveal the patient has never been able to perform in either academic or unskilled occupational settings. There is no obvious developmental pathology. Patient and family commonly deny any mood complaints. Family member will insist the patient's lack of achievement is due to ADHD. Referral for neuropsych testing will result in the family suddenly disclosing that neuropsych assessments have been performed several times, showing low IQ, no ADHD, no ASD. Family is usually resistant to any explanation for low performance that isn't fixable.

        The Poisoner
        A variation of the classic medication diverter . Patient is typically a long married female, who presents to clinic with complaints that are nearly word for word out of the DSM5. Affect is in-congruent. Controlled substances are much less commonly sought. Confused with this presentation, the prescriber will explore why the patient's report is so different than affect over several sessions. Eventually, the patient will disclose that they believe their spouse is suffering from an affective disorder and unwilling to seek treatment. Patient will then report that they have been putting their medication in spouses' food with positive results. Patient will express dismay if the provider is unhappy about this.

        FMG Referral
        Patient is typically an educated person from the USA that was seen once by a colleague whose fluency in English is limited. Patient will express confusion as to why they are being seen. When the referral is read to the patient, he/she will provide a very reasonable explanation (e.g., "yes, I told the IM guy that my family used the "find my phone" app to learn I was in the hospital, and somehow he thought I said that my phone was tracking me everywhere I went.").
         
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        wolfvgang22

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          I think we've all seen some variant of these, I'm curious to see other types of cases witnessed in your career!

          The Borderline Hug
          Diagnostically confusing. Patient is pan positive with symptoms of every disorder but does not cleanly meet any diagnosis. On medications with all receptors covered including: benzo, mood stabilizer, SSRI/SNRI, antipsychotic, antihistamine, and maybe some deplin and vitamin D3. Patient is surprisingly pleasant, not high maintenance, and otherwise clinically appears to be doing quite well on their current regimen with no apparent major side effects. But once you start trying to simplify, there's all sorts of somatic symptoms and odd symptoms reported that continue to not line up with anything that medically makes sense.

          Anxious Little Old Lady Syndrome
          Generally does not have any history of major axis II issues nor do they seem to have current presentation suggestive of Axis II. May have had some mild depression or anxiety in their remote past. Seemingly out of the blue appearing and sounding severely anxious. Often characterized by excessive rumination, pacing, saying the same types of things over and over. However, extensive medical work up has not yielded any organic findings despite the dramatic presentation. Some cases may look convincingly neurological but assessment and testing do not substantiate that. Not uncommonly it is also accompanied by depressed mood and excessive self deprecation. Generally you cannot convince this patient with any kind of reasoning or logic. Usually ends up being severe anxiety and/or depression with some cases needing and typically responding well to ECT.

          Grumpy Old Man Syndrome
          His rationale is that he's lived all his life with his symptoms and does not care to get treated. Clearly depressed +/- anxiety. Often brought in by family. Presents angry and as if he has a huge chip on his shoulder. Can be seen in the waiting room reading magazines and he will get angry if you don't have today's paper. He does not like this electronic era, preferring phone calls, phone reminders, paper bills and to write checks. He'd rather die than do a televisit despite coronavirus. Family says his typical day consists of having his 3 meals at their usual times, same food items and he watches local television. Very stuck in his ways, doesn't want to do therapy, care to engage in therapy, want to take medication or come to appointments. Reluctantly takes medication with prompting of family but with this presentation, likely medication alone will not be sufficient. Likely has comorbid personality pathology.

          Affluenza
          Adult child from affluent typically white and privileged family. Child and family members are highly intelligent and high functioning. Some cases harbor severe personality pathology. Patient has somewhat of an entitled attitude. They may technically have some degree of a mood or anxiety based disorder. However, there is over-reliance on medication or other passive forms of treatment to fix things for them. Very little is changed outside of sessions or work done on the patient part to move towards goals. In severe cases patient and parents can be masterminds at externalizing everything and surprisingly so despite their intellectual capacity. Parents can be quite enabling, pursuing confirmation of wrong diagnosis and treatment of wrong diagnosis, further entrenching the maladaptive traits of patient and family. Parents typically call quite often and there appears to be difficulty in the family as a unit with managing conflict and distress tolerance. In such cases, psychiatrist can be nervous due to lack of ownership taken by patient and family and anger being displaced on to care providers. Treatment of choice is to address the underlying pathology but often patient and family not receptive to accepting diagnosis and tend to pursue treatments that are not indicated and potentially harmful such as antipsychotics. In such cases, makes care providers eager to find way out of the case as it may be a liability waiting to happen depending on severity and you know it's a family that has a lot of money they can blow.

          Those are all the ones I can think of right now!
          Who are and how did you get my patient notes?
          Just kidding.
          I remember learning in Anatomy lab that every vessel and nerve wasn't exactly where Netter showed it was. My professor explained to us that each human body, like all organic life, will have some variation that makes every one unique. This is also true of the psyche.
          People are often a confusing mix of a variety of cultural influences, personality (mal)adaptations, and dysfunction that the DSM only begins to explain as a starting point.
          I think a lot of the time what separates a psychiatrist from others is our ability to sift through the resultant diagnostic ambiguity.
           
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          clausewitz2

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            I think we've all seen some variant of these, I'm curious to see other types of cases witnessed in your career!

            The Borderline Hug
            Diagnostically confusing. Patient is pan positive with symptoms of every disorder but does not cleanly meet any diagnosis. On medications with all receptors covered including: benzo, mood stabilizer, SSRI/SNRI, antipsychotic, antihistamine, and maybe some deplin and vitamin D3. Patient is surprisingly pleasant, not high maintenance, and otherwise clinically appears to be doing quite well on their current regimen with no apparent major side effects. But once you start trying to simplify, there's all sorts of somatic symptoms and odd symptoms reported that continue to not line up with anything that medically makes sense.

            Anxious Little Old Lady Syndrome
            Generally does not have any history of major axis II issues nor do they seem to have current presentation suggestive of Axis II. May have had some mild depression or anxiety in their remote past. Seemingly out of the blue appearing and sounding severely anxious. Often characterized by excessive rumination, pacing, saying the same types of things over and over. However, extensive medical work up has not yielded any organic findings despite the dramatic presentation. Some cases may look convincingly neurological but assessment and testing do not substantiate that. Not uncommonly it is also accompanied by depressed mood and excessive self deprecation. Generally you cannot convince this patient with any kind of reasoning or logic. Usually ends up being severe anxiety and/or depression with some cases needing and typically responding well to ECT.

            Grumpy Old Man Syndrome
            His rationale is that he's lived all his life with his symptoms and does not care to get treated. Clearly depressed +/- anxiety. Often brought in by family. Presents angry and as if he has a huge chip on his shoulder. Can be seen in the waiting room reading magazines and he will get angry if you don't have today's paper. He does not like this electronic era, preferring phone calls, phone reminders, paper bills and to write checks. He'd rather die than do a televisit despite coronavirus. Family says his typical day consists of having his 3 meals at their usual times, same food items and he watches local television. Very stuck in his ways, doesn't want to do therapy, care to engage in therapy, want to take medication or come to appointments. Reluctantly takes medication with prompting of family but with this presentation, likely medication alone will not be sufficient. Likely has comorbid personality pathology.

            Affluenza
            Adult child from affluent typically white and privileged family. Child and family members are highly intelligent and high functioning. Some cases harbor severe personality pathology. Patient has somewhat of an entitled attitude. They may technically have some degree of a mood or anxiety based disorder. However, there is over-reliance on medication or other passive forms of treatment to fix things for them. Very little is changed outside of sessions or work done on the patient part to move towards goals. In severe cases patient and parents can be masterminds at externalizing everything and surprisingly so despite their intellectual capacity. Parents can be quite enabling, pursuing confirmation of wrong diagnosis and treatment of wrong diagnosis, further entrenching the maladaptive traits of patient and family. Parents typically call quite often and there appears to be difficulty in the family as a unit with managing conflict and distress tolerance. In such cases, psychiatrist can be nervous due to lack of ownership taken by patient and family and anger being displaced on to care providers. Treatment of choice is to address the underlying pathology but often patient and family not receptive to accepting diagnosis and tend to pursue treatments that are not indicated and potentially harmful such as antipsychotics. In such cases, makes care providers eager to find way out of the case as it may be a liability waiting to happen depending on severity and you know it's a family that has a lot of money they can blow.

            Those are all the ones I can think of right now!

            It strikes me that most of these correspond pretty well to older diagnostic categories that didn't make the DSM cut but were clearly based on clinical observations.

            The first patient is hysterical/somatoform in the classic sense, if you want to get fancy, Briquet's syndrome. Guarantee if you ask directly they dissociate a lot.

            The little old lady matches involutional melancholia to a T, right down to the needing ECT/higher test pharmacological treatment.

            And then the later two just match current ideas of personality disorders. Why is the rich family not just a festival of narcissism? Any reason to be ruling out OCPD for the elderly gentleman? I bet if you ask people who worked with him that he exercised a high degree of control over his workplace/subordinates and needed things just so.


            This is a fun game! I have one:

            The Attending and his Countertransference:

            A young man in his mid-20s who is the child of immigrants from a more traditional society in the Global South being seen because he moved to the other coast for an unpaid internship at Do-Gooders-Are-Us, dropping out of a professional graduate program to do so. Your attending happens to have immigrated from the same society and has college age us-born children of their own. The young man says he did this because he found the degree program he was in soul-crushing and wanted to do something meaningful and sprung it unexpectedly on his family because he knew they'd object. Attending insists he would only "throw his life away" if he was manic and prescribes Risperdal.
             
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            wolfvgang22

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              It strikes me that most of these correspond pretty well to older diagnostic categories that didn't make the DSM cut but were clearly based on clinical observations.

              The first patient is hysterical/somatoform in the classic sense, if you want to get fancy, Briquet's syndrome. Guarantee if you ask directly they dissociate a lot.

              The little old lady matches involutional melancholia to a T, right down to the needing ECT/higher test pharmacological treatment.

              And then the later two just match current ideas of personality disorders. Why is the rich family not just a festival of narcissism? Any reason to be ruling out OCPD for the elderly gentleman? I bet if you ask people who worked with him that he exercised a high degree of control over his workplace/subordinates and needed things just so.


              This is a fun game! I have one:

              The Attending and his Countertransference:

              A young man in his mid-20s who is the child of immigrants from a more traditional society in the Global South being seen because he moved to the other coast for an unpaid internship at Do-Gooders-Are-Us, dropping out of a professional graduate program to do so. Your attending happens to have immigrated from the same society and has college age us-born children of their own. The young man says he did this because he found the degree program he was in soul-crushing and wanted to do something meaningful and sprung it unexpectedly on his family because he knew they'd object. Attending insists he would only "throw his life away" if he was manic and prescribes Risperdal.
              A lot of the issue is that people with ego-syntonic personality disorders don't like being told they have a disorder that cannot be solved by a once daily drug that has no side effects and provides boundless happiness, energy, and sexual prowess, if they tolerate being told at all. Especially persons with cluster B pathology. These patients are the most likely to complain, impacting patient satisfaction scores that administrators revere as the most legitimate indicator of quality care. Thus, to avoid the conflict, we avoid documenting personality disorders unless it is so grossly obvious to even the most uneducated layman (administrator) who has met the patient it cannot be ignored.
               
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              randomdoc1

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                A lot of the issue is that people with ego-syntonic personality disorders don't like being told they have a disorder that cannot be solved by a once daily drug that has no side effects and provides boundless happiness, energy, and sexual prowess, if they tolerate being told at all. Especially persons with cluster B pathology. These patients are the most likely to complain, impacting patient satisfaction scores that administrators revere as the most legitimate indicator of quality care. Thus, to avoid the conflict, we avoid documenting personality disorders unless it is so grossly obvious to even the most uneducated layman (administrator) who has met the patient it cannot be ignored.
                Hmm...interesting! And agreed. I've had some success in getting people to accept the diagnosis when you package it in an attractive way. I've told patients personality pathology is not always all bad. As a matter of fact, it can prime you to be super successful in certain industries. I wonder if pointing out certain characteristics in celebrities might help?
                 
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                clausewitz2

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                  A lot of the issue is that people with ego-syntonic personality disorders don't like being told they have a disorder that cannot be solved by a once daily drug that has no side effects and provides boundless happiness, energy, and sexual prowess, if they tolerate being told at all. Especially persons with cluster B pathology. These patients are the most likely to complain, impacting patient satisfaction scores that administrators revere as the most legitimate indicator of quality care. Thus, to avoid the conflict, we avoid documenting personality disorders unless it is so grossly obvious to even the most uneducated layman (administrator) who has met the patient it cannot be ignored.

                  I would have thought in @randomdoc1 's private practice he was not beholden to patient satisfaction. Also I am glad I trained in a system that did not care very much about patient satisfaction scores.
                   
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                  futureapppsy2

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                    The Child Is The Problem
                    Family comes in for ASD or ADHD assessment for their school-aged child, often claiming every symptom in the book but downplaying the extensive and often ongoing trauma history in the family, requiring a lot of follow-up queries. Everyone in the family displays considerable psychopathology, including the parents, but that and the trauma history are continually downplayed by the parents, who just want you to give their kid an ASD diagnosis.

                    Nothing Is Wrong
                    Parents report only mild speech and language delays and normal social development. Upon assessment and report by others, it becomes clear that the child has pronounced, classic ASD.
                     
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                    randomdoc1

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                      The Awful Historian
                      Often is a young adult, especially male but can be of all demographics. Patient gives very vague, non-committal histories and statements. Per their report everything is fine. They usually have no idea what they are supposed to be taking, what they've been diagnosed with, who they've seen, or seem to know anything about their treatment history. Denies all symptoms. On mental status exam looks bored, that your office is the last place they want to be, not much of a talker really. Family often volunteers collateral and carefully skirt around the patient, for fear the patient will find out. Collateral information is drastically different from what the patient says. Often there are reports of recent serving time in jail, eviction, throwing axes, medication non-adherence, etc. Diagnoses typically associated: psychotic disorders, bipolar disorder, severe MDD, substance use disorders, high functioning borderlines.
                       
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                      clausewitz2

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                        Hmm...interesting! And agreed. I've had some success in getting people to accept the diagnosis when you package it in an attractive way. I've told patients personality pathology is not always all bad. As a matter of fact, it can prime you to be super successful in certain industries. I wonder if pointing out certain characteristics in celebrities might help?

                        "It's not an ordinary psychiatric condition and most psychiatrists can't treat it and don't know what to do. Luckily I know more than them about this and have gotten better results when we address it directly. Any questions about NPD before we talk about the treatments that work best?'
                         
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                        Trismegistus4

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                          Nocebo Effect By Proxy:

                          Adult patient brought in by his mother whom he lives with. Mother is at her wit's end because of patient's behaviors like calling the police multiple times a day to report the neighbors for bugging the house. Patient is an adult and his own guardian, and is affable and pleasantly psychotic, but too thought-disordered or otherwise low-functioning to give you a meaningful history or attest to any benefits or side effects of medicines. Mother gives you the history and it turns out patient has tried basically every psychiatric medication under the sun, and according to her, all of them have made him worse or caused intolerable side effects. Haldol? "He can't take that, it gave him muscle spasms!" Serqouel? "He gained too much weight on that!" Prolixin? "That made him worse!" Abilify? "He can't take that, it made him talk too much!" Fortunately, you realize there is a new antipsychotic he has not yet tried: Rexulti. So you prescribe Rexulti. A month later his mother brings him back: "he can't take that new medicine! I gave him two doses, and it made him worse!" Later you learn that the mother scheduled an appointment for the patient with one of your colleagues for a second opinion, because you just aren't helping him.
                           
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                          kopftonmd

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                            The Awful Historian
                            Often there are reports of recent serving time in jail, eviction, throwing axes, medication non-adherence, etc. Diagnoses typically associated: psychotic disorders, bipolar disorder, severe MDD, substance use disorders, high functioning borderlines.

                            Reports of... throwing axes? :rofl:
                             
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                            randomdoc1

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                              Reports of... throwing axes? :rofl:
                              Yup, that was a real one. Bipolar patient. xD

                              Nocebo Effect By Proxy:

                              Adult patient brought in by his mother whom he lives with. Mother is at her wit's end because of patient's behaviors like calling the police multiple times a day to report the neighbors for bugging the house. Patient is an adult and his own guardian, and is affable and pleasantly psychotic, but too thought-disordered or otherwise low-functioning to give you a meaningful history or attest to any benefits or side effects of medicines. Mother gives you the history and it turns out patient has tried basically every psychiatric medication under the sun, and according to her, all of them have made him worse or caused intolerable side effects. Haldol? "He can't take that, it give him muscle spasms!" Serqouel? "He gained too much weight on that!" Prolixin? "That made him worse!" Abilify? "He can't take that, it made him talk too much!" Fortunately, you realize there is a new antipsychotic he has not yet tried: Rexulti. So you prescribe Rexulti. A month later his mother brings him back: "he can't take that new medicine! I gave him two doses, and it made him worse!" Later you learn that the mother scheduled an appointment for the patient with one of your colleagues for a second opinion, because you just aren't helping him.

                              Ain't that the best?! Phew!
                               
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                              CalmAndCollected

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                                It strikes me that most of these correspond pretty well to older diagnostic categories that didn't make the DSM cut but were clearly based on clinical observations.

                                The little old lady matches involutional melancholia to a T, right down to the needing ECT/higher test pharmacological treatment.
                                Thank you for details on the involutional melancholia. It's crazy how it matches some severely treatment resistant patients I have seen before, down to their existantial ruminations and nihilistic delusions. I wish there was an easily accessible resource that had these "nearly included" diagnosis available. I mostly seem to get their info from older attendings who have lived through all the changes psychiatry had throughout the years.

                                I have heard of people talk about "alternatives to the DSM" in manuals like the PDM-2, but I wonder if anyone here has had any experience with them in practice...
                                 
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                                randomdoc1

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                                  Clueless First Generation (I'm ok with saying this since I'm a first generation myself)
                                  Typically brought in by a friend, family member or at requirement of employer. At this point in the clinical course, disorder is already severely advanced and glaringly obvious. Usually associated with bipolar disorder, psychotic disorders, severe MDD or panic disorder or specific phobias. But due to cultural backdrop and/or lack of knowledge, patient has not been brought to care until now. Patient despite extensive discussion and well delivered argument for reasons of pharmacotherapy is generally extremely hesitant. Likely will not bother to take the medication you prescribed or even follow up. If they do take the medication, high risk of premature discontinuation/dropping off of treatment. Patient at presentation has profound findings on MSE. In depression, psychomotor slowing, floridly depressed affect, extreme self deprecation, obvious weight changes and may be at high suicide risk. Bipolar if manic is classic, expansive affect, delusions of grandeur, hypersexual and impulsive. Cases of psychosis are quite typical in content with delusions of surveillance, persecution, calling of police, ideas of reference, etc. Heart breaking to me as a psychiatrist as the case is likely so treatable and prognosis is good but biggest limiting factor is treatment adherence.
                                   
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                                  PsyDr

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                                    The Rightfully Pissed Off Cultural Minority
                                    This patient is exclusively a member of a racial or cultural minority. Referring providers typically complain of “angry outbursts” which have often been diagnosed as bipolar ii. Because we all know anger is the sin qua non of mania. Patient is typically pretty pissed upon initial examination. When treated like a human being, and such interpretations as “it just be be infuriating to be called “boy” when you’re a successful attorney”; patient tends to be become relatively cool. Variants include practitioners of non Abrahamic religions, esl, etc.


                                    The Folie a Message Board
                                    Patient presents with a self diagnosed condition that is not accepted by the dsm5, icd10, modern science, and most people walking down the street. Self diagnosed condition will have definitive sounding qualities that almost exclusively translate into “I’m fine when I get what I want”. Symptoms remit when awesome things happen. Variants include those that insist there is nothing psychiatric about their diagnosis and furries.

                                    The Completely Normal Reaction
                                    Commonly seen in awful situations. More common in correctional, hospice, Severe TBI, homeless shelter, and other less than hopeful settings. Referrals will state that the patient’s emotional expressions are evidence of mental illness. Patient will explain that the reaction is pretty understandable. Variants include: impaired adults expressing sexual desires, etc.
                                     
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                                    clausewitz2

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                                      The Rightfully Pissed Off Cultural Minority
                                      This patient is exclusively a member of a racial or cultural minority. Referring providers typically complain of “angry outbursts” which have often been diagnosed as bipolar ii. Because we all know anger is the sin qua non of mania. Patient is typically pretty pissed upon initial examination. When treated like a human being, and such interpretations as “it just be be infuriating to be called “boy” when you’re a successful attorney”; patient tends to be become relatively cool. Variants include practitioners of non Abrahamic religions, esl, etc.


                                      The Folie Message Board
                                      Patient presents with a self diagnosed condition that is not accepted by the dsm5, icd10, modern science, and most people walking down the street. Self diagnosed condition will have definitive sounding qualities that almost exclusively translate into “I’m fine when I get what I want”. Symptoms remit when awesome things happen. Variants include those that insist there is nothing psychiatric about their diagnosis and furries.

                                      The Completely Normal Reaction
                                      Commonly seen in awful situations. More common in correctional, hospice, Severe TBI, homeless shelter, and other less than hopeful settings. Referrals will state that the patient’s emotional expressions are evidence of mental illness. Patient will explain that the reaction is pretty understandable. Variants include: impaired adults expressing sexual desires, etc.

                                      I deleted the PTSD diagnosis from someone's chart just the other day because of the last one. Got diagnosis while in jail awaiting bail hearing because he kept waking up agitated. "Yeah, I'd never been in jail before, I was afraid someone would shank me." Also was being "avoidant" towards a particular neighborhood. "These guys think I'm why their friend is locked up and they texted me to say they'd kill me if I ever went to [That Neighborhood]."

                                      Of course he was court-ordered to treatment so we'll go with "unspecified anxiety d/o", f*ck it.
                                       
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                                      PsyDr

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                                        The Obvious Sexual Problem

                                        Seen in both genders, this disorder presents in individuals who make almost no effort to attract sexual partners, yet express extreme dissatisfaction with their sexual prospects. Countertransference reactions are characterized by such ideas as “who in the hell would want to do that?!”. Extreme resistance is observed with interpretations about the discordances between what they bring to the table and what they demand. Crocs, awful t shirts, godforsaken BMIs, and a general disdain for a modicum of fashion or self care are usually evident. In partnered individuals, it is common to hear the patient express dismay as to why their partner is resistant to getting down. It is typical to hear: fantasies about ending the relationship only to be greeted by a flood of rich supermodels looking for people whose BMI exceeds their income, and hypotheses that sexual dysfunction in their partners being the result of latent homosexuality.
                                         
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                                        AcronymAllergy

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                                          "It's not an ordinary psychiatric condition and most psychiatrists can't treat it and don't know what to do. Luckily I know more than them about this and have gotten better results when we address it directly. Any questions about NPD before we talk about the treatments that work best?'
                                          The Folie Message Board
                                          Patient presents with a self diagnosed condition that is not accepted by the dsm5, icd10, modern science, and most people walking down the street. Self diagnosed condition will have definitive sounding qualities that almost exclusively translate into “I’m fine when I get what I want”. Symptoms remit when awesome things happen. Variants include those that insist there is nothing psychiatric about their diagnosis and furries.

                                          These not-infrequently go hand-in-hand in folks with h/o single, uncomplicated concussion. They and/or their spouse now report they're completely dependent for self-care ADLs, because otherwise they'd probably forget to shower, eat, void, and breathe. Odds are, they have a MH provider somewhere along the line who's validated as much; bonus points if the provider then offered crystal therapy.

                                          Also: Inadequate Personality Disorder. I sometimes wonder if this one should make a DSM comeback.
                                           
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                                          PsyDr

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                                            These not-infrequently go hand-in-hand in folks with h/o single, uncomplicated concussion. They and/or their spouse now report they're completely dependent for self-care ADLs, because otherwise they'd probably forget to shower, eat, void, and breathe. Odds are, they have a MH provider somewhere along the line who's validated as much; bonus points if the provider then offered crystal therapy.

                                            Are you referencing VA patients that say they can't remember their own name, but somehow are attending college full time, and no one is concerned about their ability to consent to sexual intercourse despite these supposed impairments? Or are you referencing the NFL settlement guys that completed MBAs while reporting severe memory impairments, and then they were caught via texting showing how they were cheating on neuropsych tests ?
                                             
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                                            AcronymAllergy

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                                              Are you referencing VA patients that say they can't remember their own name, but somehow are attending college full time, and no one is concerned about their ability to consent to sexual intercourse despite these supposed impairments? Or are you referencing the NFL settlement guys that completed MBAs while reporting severe memory impairments, and then they were caught via texting showing how they were cheating on neuropsych tests ?

                                              No comment.
                                               
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                                              Liquid8

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                                                Ah, what a great thread!

                                                Had a few ALOLS when I started out. One of them (still my patient) used to leave lots of messages between appointments while I was adjusting her medication. Then she suddenly stopped calling, and I actually wondered if she’d passed away. Fortunately it turned out that her mood picked up and her anxiety went away.

                                                Definitely have a few “affluenza” patients on my books. A common thread is that their parents tend to be controlling or overinvolved and rapport can be initially be hard to establish with the patient. Once some boundaries can be setup and they can gain some sense of independence or purpose things tend to improve, which also alleviates some of the parental anxiety too. I find most parents tend to err on the side of being medication adverse, but I think this is probably cultural.

                                                Used to get the turf referrals from geriatrics all the time on CL and Aged psych jobs. Pretty straightforward in most cases as most from that generation tend to be quite easy to deal with.

                                                Have never had a Poisoner – would not prescribe, and report them to the police as drugging someone is considered to be assault here.

                                                The Awful Historian
                                                Often is a young adult, especially male but can be of all demographics. Patient gives very vague, non-committal histories and statements. Per their report everything is fine. They usually have no idea what they are supposed to be taking, what they've been diagnosed with, who they've seen, or seem to know anything about their treatment history. Denies all symptoms. On mental status exam looks bored, that your office is the last place they want to be, not much of a talker really. Family often volunteers collateral and carefully skirt around the patient, for fear the patient will find out. Collateral information is drastically different from what the patient says. Often there are reports of recent serving time in jail, eviction, throwing axes, medication non-adherence, etc. Diagnoses typically associated: psychotic disorders, bipolar disorder, severe MDD, substance use disorders, high functioning borderlines.

                                                Have often found that these anti-social/narcissistic types will open up about their teenage forensic history. Here things that happen before 18 don’t get wiped from their criminal record after a certain age, which is why I think they let down their guard about this. Of course if you find out they lie via omission from differing collateral, it’s almost diagnostic too.

                                                Nocebo Effect By Proxy:

                                                Adult patient brought in by his mother whom he lives with. Mother is at her wit's end because of patient's behaviors like calling the police multiple times a day to report the neighbors for bugging the house. Patient is an adult and his own guardian, and is affable and pleasantly psychotic, but too thought-disordered or otherwise low-functioning to give you a meaningful history or attest to any benefits or side effects of medicines. Mother gives you the history and it turns out patient has tried basically every psychiatric medication under the sun, and according to her, all of them have made him worse or caused intolerable side effects. Haldol? "He can't take that, it gave him muscle spasms!" Serqouel? "He gained too much weight on that!" Prolixin? "That made him worse!" Abilify? "He can't take that, it made him talk too much!" Fortunately, you realize there is a new antipsychotic he has not yet tried: Rexulti. So you prescribe Rexulti. A month later his mother brings him back: "he can't take that new medicine! I gave him two doses, and it made him worse!" Later you learn that the mother scheduled an appointment for the patient with one of your colleagues for a second opinion, because you just aren't helping him.

                                                Lucky escape! Patient like this probably needs a depot injection to overcome all these carer induced inadequate medication trials.

                                                The Aurora Borealis

                                                Once saw an old guy with chronic anxiety issues who would come in with his much younger wife. Early on I remember she had been angling for a Xanax script, despite him never having had it before and having done well on SSRIs in the past - I had a thought she might have been using his medications but wasn’t sure. On what would turn out to be our last appointment she told me he was still having panic attacks and had just had one during the consultation - supposedly it lasted for a single minute with no observable symptoms. He didn’t say anything or look any different when it was supposedly happening, but apparently it was up there with the worst he’d ever had. I remember the Steamed Ham/Aurora Borealis scene from the Simpsons popped into my mind (“Aurora Borealis? At this time of year? At this time of day? Localized entirely within your kitchen?”).
                                                 
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                                                Sushirolls

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                                                  Transaction Letter

                                                  Only reason patient is in the office is for a letter of support for various transgender re-assignment surgeries. Or is only seeking an ESA letter. Had one Boomer roll in seeking an ESA letter because (s)he and spouse were traveling more and disappointed they couldn't brink their dog into hotels. All attempts to even make a single mental health diagnose with in depth symptom reviews were virtually all negative. No functional impairment anywhere. Never mind my website clearly states I don't prescribe ESA. Patient and spouse were quite disappointed that I didn't write an ESA letter.
                                                   
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                                                  michaelrack

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                                                  1. Attending Physician
                                                    What diagnosis did you use for billing?
                                                    Transaction Letter

                                                    Only reason patient is in the office is for a letter of support for various transgender re-assignment surgeries. Or is only seeking an ESA letter. Had one Boomer roll in seeking an ESA letter because (s)he and spouse were traveling more and disappointed they couldn't brink their dog into hotels. All attempts to even make a single mental health diagnose with in depth symptom reviews were virtually all negative. No functional impairment anywhere. Never mind my website clearly states I don't prescribe ESA. Patient and spouse were quite disappointed that I didn't write an ESA letter.
                                                     

                                                    myPsychAlt

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                                                      You're 28 years old and it's time to grow up disorder

                                                      Presents mostly nonspecific anxiety symptoms. Wants a stimulant to help with them after trying friend's adderall and xanax, which "worked really well". College-educated but may or may not have a degree. Has been working inconsistently at a number of bars since graduation. Thinks his band could totally get signed. Considering law school. Recently stopped long-standing cannabis habit, but only because he discovered kratom (which isn't an important detail to disclose to psychiatrist). Has social media profile of either hard right "red pill" posts or rants about how the DNC rigged the primary against Bernie (in either case was really into Ron Paul as a teenager). Speaks often of starting a podcast/youtube channel.
                                                       
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                                                      futureapppsy2

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                                                        Everything Is Wrong

                                                        Parent and/or teachers (usually teachers) rate the early childhood or young elementary school age client extremely high on every possible dimension of psychopathology, sometimes so much so as to invalidate the scale. Upon assessment, the child has untreated, fairly severe ADHD with no other noble pathology, except maybe some reactive, oppositional-defiant tendencies. Medication and PCIT are incredibly effective if it's caught relatively early.
                                                         
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                                                        futureapppsy2

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                                                          The Aurora Borealis

                                                          Once saw an old guy with chronic anxiety issues who would come in with his much younger wife. Early on I remember she had been angling for a Xanax script, despite him never having had it before and having done well on SSRIs in the past - I had a thought she might have been using his medications but wasn’t sure. On what would turn out to be our last appointment she told me he was still having panic attacks and had just had one during the consultation - supposedly it lasted for a single minute with no observable symptoms. He didn’t say anything or look any different when it was supposedly happening, but apparently it was up there with the worst he’d ever had. I remember the Steamed Ham/Aurora Borealis scene from the Simpsons popped into my mind (“Aurora Borealis? At this time of year? At this time of day? Localized entirely within your kitchen?”).
                                                          Can I see it?
                                                           
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                                                          myPsychAlt

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                                                            Fragile Masculinity Disorder (various subtypes)

                                                            1. Previously employed and functional until assigned female supervisor, now requiring disability letter subtype.
                                                            2. Relationship impairment due to wife having greater employment opportunities subtype.
                                                            3. Can't do CBT because it forces me to talk about my emotions subtype
                                                            4. Red pill forum subtype
                                                            5. Child support is feminist oppression subtype
                                                            6. Barfighter subtype
                                                            7. Former Cop subtype
                                                             
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                                                            randomdoc1

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                                                              Fragile Masculinity Disorder (various subtypes)

                                                              1. Previously employed and functional until assigned female supervisor, now requiring disability letter subtype.
                                                              2. Relationship impairment due to wife having greater employment opportunities subtype.
                                                              3. Can't do CBT because it forces me to talk about my emotions subtype
                                                              4. Red pill forum subtype
                                                              5. Child support is feminist oppression subtype
                                                              6. Barfighter subtype
                                                              7. Former Cop subtype
                                                              #2 seems to really do a number on some folks.
                                                               
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                                                              Ceke2002

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                                                              1. Other Health Professions Student
                                                                FMG Referral
                                                                Patient is typically an educated person from the USA that was seen once by a colleague whose fluency in English is limited. Patient will express confusion as to why they are being seen. When the referral is read to the patient, he/she will provide a very reasonable explanation (e.g., "yes, I told the IM guy that my family used the "find my phone" app to learn I was in the hospital, and somehow he thought I said that my phone was tracking me everywhere I went.").

                                                                This made me chuckle. I had a similar thing happen back in the 90s, albeit without the lack of English fluency on the part of the Doctor. First time appointment/assessment with a Psychiatrist at a community clinic, we were running through previous psych history/diagnoses and I used the metaphor of it feeling like some sort of horrendously disorganised filing cabinet inside my head to try and describe part of the experience of clinically diagnosed ADHD. Psych had to step out for a moment, left their notes behind, of course I couldn't resist taking a peek and they had seriously jotted down, "Patient has delusions of filing cabinet in head." LOLWUT? NO!
                                                                I never did work out how they managed to make that particular quantum leap from 'metaphor' to 'delusion'.

                                                                -------------------------------

                                                                Another one to add to the list, that sometimes appears in peer to peer support groups/networks.

                                                                Attentionitist with adjunct Denialitis on top of Axis III diagnosis.

                                                                Patient typically has some type of eating disorder, is in and out of treatment with little to no actual treatment adherence (but you know they really are trying very hard, and they absolutely promise that this latest IP/IOP will be different, cross their heart x 10 and pinkie swear), often denies the severity of their disorder, despite being on a first name basis with local hospitals/treatment centres.

                                                                Patient eventually receives a diagnosis of *insert typically chronic medical condition*. Despite remaining noncompliant with treatment patient is now miraculously cured of the aforementioned food & weight related disorder. Of course the patient continues to show little to no reduction or change in eating disorder symptoms, but don't you dare try and point out that their being clinically emaciated, with continuing weight loss and a revolving hospital door of emergency rehydration/I fainted and hit my head/my electrolytes were a bit dodgy type admissions might not exactly be related to the medical condition they can now blame everything on. Of course pointing anything out would be a moot point, because they'll point it out for you with a rousing thrice daily chorus of 'I'm sick, but not like that, and I wasn't cured because I was never sick, like *that*!'

                                                                Lather, rinse, repeat until friends and peer support persons start to wonder if whacking someone upside the head with a clue by four could be considered a legitimate form of treatment.

                                                                I'm sure I could think of some others from a peer support point of view as well.
                                                                 
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                                                                randomdoc1

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                                                                  Drugs R Us
                                                                  Typically on a regimen of 8mg of Xanax daily with 100mg of oxycontin and 80mg of Adderall IR (or some variation of that holy trifecta). The patient swears up and down "nothing else works" for their panic disorder, ADHD, and pain. Yet oddly, none of their history suggests the diagnoses they claim to have. Often times, they don't seem to be meeting any criteria for any axis I disorder. They continue to report 10/10 pain while in session. MSE findings typically also do not support their subjective history. Likely they are diverting or may actually be taking all of these medications. They are surprisingly still alive, walking, talking, and alert.

                                                                  There is a geriatric variant to this. They tend to be highly correlated with likelihood of diverting. Although a minority are actually taking all these drugs. Bonus points for also being on TCA, benadryl, seroquel and trazodone because "I just can't sleep." They will likely continue to report severe persistent insomnia.

                                                                  Prognosis, generally poor as patient is unlikely to be willing to listen to evidence based recommendations. In that sense, this becomes a large manner of risk management and carefully transitioning care to next provider who is able to accommodate the case.
                                                                   
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                                                                  Oct 13, 2008
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                                                                    FMG Referral
                                                                    Patient is typically an educated person from the USA that was seen once by a colleague whose fluency in English is limited. Patient will express confusion as to why they are being seen. When the referral is read to the patient, he/she will provide a very reasonable explanation (e.g., "yes, I told the IM guy that my family used the "find my phone" app to learn I was in the hospital, and somehow he thought I said that my phone was tracking me everywhere I went.").
                                                                    OK this is a huge necrobump was reading through this thread and had flashbacks to the place where I did my IM rotations. Was on rounds with my resident and she asked the patient what color their stools were. The patient said, clear as day and without any hint that it was abnormal or concerning, "dark brown." We get back to the workroom and the resident tells me to go guaiac the patient and was resistant to my attempts to explain that the patient said "brown" and not "black."
                                                                     
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