Evaluating for ADHD?

[Stagg737]

---

Members don't see this ad.

Finish that statement though. You're saying patients who have ADHD causing dysfunction are more likely to be open to non-stimulants. So what about the patients who have ADHD causing dysfunction who aren't willing to try non-stimulants? That's where you bring in the red flag and that's what I'm pushing back on.

Then we ask why aren't they willing to try non-stimulants. Like I said, there's a difference between patients who come in wanting to try stimulants but being willing to try alternative options vs someone coming in demanding stimulants and only stimulants when it's a new diagnosis. I'm much more comfortable letting the former try stimulants if they're indicated and would question any physician's judgment who is fine just handing stimulants to someone in that latter category without serious questioning as it is absolutely a red flag.

Stimulants are first line for a reason. Treating them with non-stimulant when standard of care dictates stimulants in absence of contraindications isn't optimal treatment, regardless of your own experience.

Why so black and white? Stimulants as the first line for legit ADHD is the guideline, it is not law. EBM and guidelines are population level evidence meant as generalizations, and individual cases often require deviation from general guidelines. If everything was just algorithmic, we wouldn't be needed to assess or treat at all. Rigidity with guidelines and standards of care in fields that are as dependent on subjective accounts of symptoms as psych is just bad practice.

 

[ObsequiousAplomb]

I want to add in here on what Stagg and Mass Effect are going back and forth on. There are several signs in any eval that make me less likely to go with controlled medications, and I'm aware that many of these are due to my own countertransferrence:
- insisting on using my first name after correction
- saying "I've earned" or "I'm entitled to" or "it's my right to get" or "you are being unprofessional for not giving me" the specific treatment
- sudden onset of dysfunction in a presentation that doesn't usually do that
- insidious onset of dysfunction in a presentation that doesn't usually do that
- insisting on using the phrase "panic attack" to refer to situations that, based on their description, are not panic attacks, even after psychoeducation
- emailing me or texting my office number instead of sending messages through the portal, even after repeated instruction. If the last text from me is "don't text me, message me on Osmind," then I'm usually prepping myself for the termination speech
- missing multiple appointments without warning

Unfortunately, all of these are rather prominent in the post- TikTok era. People presenting with fear they have BPD usually have all of these but, fascinatingly, low MSI-BPD scores. People presenting with ADHD that wasn't addressed in childhood are also commonly doing the above irksome things. I have to make an effort to set those frustrations aside to make sure I don't under-treat ADHD.

 

[Merovinge]

I want to add in here on what Stagg and Mass Effect are going back and forth on. There are several signs in any eval that make me less likely to go with controlled medications, and I'm aware that many of these are due to my own countertransferrence:
- insisting on using my first name after correction

This has never not been the reddest of red flags from my experience. r of >0.7 with NPD.

 

[clausewitz2]

This has never not been the reddest of red flags from my experience. r of >0.7 with NPD.

Or enacting really unfortunate and unsettling romantic/sexual transference as an attempt at being flirtatious.

 

[Stagg737]

This has never not been the reddest of red flags from my experience. r of >0.7 with NPD.

You can even bump that r to >0.9 when they not only use your first name, but your full first name instead of a preferred name in a condescending tone (ie, calling someone "Daniel" instead of just "Dan").

 

[Mass Effect]

Then we ask why aren't they willing to try non-stimulants.

So you're using wanting evidence-based first-line treatment as a litmus test as to whether or not they're worthy of evidence-based first-line treatment. Dude. Just stop.

Why so black and white? Stimulants as the first line for legit ADHD is the guideline, it is not law. EBM and guidelines are population level evidence meant as generalizations, and individual cases often require deviation from general guidelines. If everything was just algorithmic, we wouldn't be needed to assess or treat at all. Rigidity with guidelines and standards of care in fields that are as dependent on subjective accounts of symptoms as psych is just bad practice.

You ARE being algorithmic and black and white, no matter how much you convince yourself you're not. You're also being incredibly biased against this diagnosis if your inclination is "I won't provide first-line treatment unless they try second-line first". WTH kind of litmus test is that?

 

[clausewitz2]

Moderator note: Let's keep things civil and refrain from personal attacks.

 

[Stagg737]

So you're using wanting evidence-based first-line treatment as a litmus test as to whether or not they're worthy of evidence-based first-line treatment. Dude. Just stop

That’s not what I’m saying at all. It’s not about gauging “worthiness”. It’s about examine their perspectives.

You ARE being algorithmic and black and white, no matter how much you convince yourself you're not. You're also being incredibly biased against this diagnosis if your inclination is "I won't provide first-line treatment unless they try second-line first". WTH kind of litmus test is that?

Again, I’m not saying that and have said differently several times.

You’ve clearly made up your mind about how you believe I practice based on cherry picking from my statements and your responses. I’ve tried to clarify but you seem to be set in your opinion on me. I’m not sure how this is productive, but I hope others are able to understand the context of my statements and I’m happy to clarify further if needed.

 

[Ceke2002]

Or enacting really unfortunate and unsettling romantic/sexual transference as an attempt at being flirtatious.

Off topic, but I so don't get this, I mean I do get erotic transference in therapy is a thing, but it still makes my brain go, "Say what now?". Like I do have a functioning set of eyeballs, I can tell when the Doctor standing/sitting in front of me is an attractive person, but they're still a Doctor. Like have some decorum people.

 

[Ceke2002]

I want to add in here on what Stagg and Mass Effect are going back and forth on. There are several signs in any eval that make me less likely to go with controlled medications, and I'm aware that many of these are due to my own countertransferrence:
- insisting on using my first name after correction
- saying "I've earned" or "I'm entitled to" or "it's my right to get" or "you are being unprofessional for not giving me" the specific treatment
- sudden onset of dysfunction in a presentation that doesn't usually do that
- insidious onset of dysfunction in a presentation that doesn't usually do that
- insisting on using the phrase "panic attack" to refer to situations that, based on their description, are not panic attacks, even after psychoeducation
- emailing me or texting my office number instead of sending messages through the portal, even after repeated instruction. If the last text from me is "don't text me, message me on Osmind," then I'm usually prepping myself for the termination speech
- missing multiple appointments without warning

Unfortunately, all of these are rather prominent in the post- TikTok era. People presenting with fear they have BPD usually have all of these but, fascinatingly, low MSI-BPD scores. People presenting with ADHD that wasn't addressed in childhood are also commonly doing the above irksome things. I have to make an effort to set those frustrations aside to make sure I don't under-treat ADHD.

Honestly this gives me hope, that the majority of people in the TikTok era are clearly too stupid to know how to scam pills, or they're delusional enough to think that kind of behaviour is going to get them a legitimate script. Good, more for the rest of us (medically speaking). 🙂

 

[docloufan]

Overall....this whole thread should be an absolute embarrassment to the profession of clinical psychiatry. Vast disagreement about basic bread and butter management of the most emerging diagnosis in psychiatry in the 21st century. Personal bias. Professional bias. Training bias. Lack of training bias. Prescription liability phobia/bias. Unbelievable.

Where do we turn from here, folks? What's next?

 

[Ceke2002]

Overall....this whole thread should be an absolute embarrassment to the profession of clinical psychiatry. Vast disagreement about basic bread and butter management of the most emerging diagnosis in psychiatry in the 21st century. Personal bias. Professional bias. Training bias. Lack of training bias. Prescription liability phobia/bias. Unbelievable.

Where do we turn from here, folks? What's next?

As someone who was diagnosed in 1975 I have watched ADHD go from a legitimate diagnosis of a neurodevelopmental disorder that can seriously mess up someone's life, to a trendy fad that can be diagnosed based on how you hold your hands when you walk or how often you bump into things, and of course it's a 'super power' nowadays as well don't you know </sarcasm>. I will always speak against outright dismissal of the disorder, but I do not blame a single one of these Doctors for their biases, or concerns with proper diagnosis, or concerns with prescription liabilities, or any other legitimate concerns that may be expressed, because I am sick to the back teeth of ADHD being treated like some cool fashion accessory. It IS overdiagnosed, and conversely I think that also means it is underdiagnosed because the legitimate cases who would actually benefit from diagnosis and treatment are getting lost in the sea of tiktok-esque noise.

 

[Ironspy]

Overall....this whole thread should be an absolute embarrassment to the profession of clinical psychiatry. Vast disagreement about basic bread and butter management of the most emerging diagnosis in psychiatry in the 21st century. Personal bias. Professional bias. Training bias. Lack of training bias. Prescription liability phobia/bias. Unbelievable.

Where do we turn from here, folks? What's next?

Disagreement is not embarrassing. We all see different patient populations and willingness to start a stimulant is vastly different depending on the setting (outpatient child v correctional v eating disorders v outpatient adult v CMH).

I certainly don’t agree with every post but have appreciated the differences of opinion and the (mostly) respectful discussion.