Firing a patient you’re scared of

[Attending1985]

How do you do this? I have an aspd patient and I’m scared of him. He tells me he’s been violent with women in the past and I have a gut feeling that I should not be seeing him anymore.

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[Attending1985]

I’m almost scared firing him will be worse. Like give him more reason to fixate.

 

[LadyHalcyon]

How do you do this? I have an aspd patient and I’m scared of him. He tells me he’s been violent with women in the past and I have a gut feeling that I should not be seeing him anymore.

Are you seeing him for therapy or just medication management?

 

[Attending1985]

Are you seeing him for therapy or just medication management?

Just medication

 

[LadyHalcyon]

Just medication

Besides his history of violence toward women, are there other reasons you are scared of him? I have definitely felt scared with some patients, as I work with mainly forensic populations. It is extremely uncomfortable so I empathize with your situation. Do you have panic buttons in your office? Is there security readily available if necessary?

 

[Attending1985]

Besides his history of violence toward women, are there other reasons you are scared of him? I have definitely felt scared with some patients, as I work with mainly forensic populations. It is extremely uncomfortable so I empathize with your situation. Do you have panic buttons in your office? Is there security readily available if necessary?

No panic buttons. It’s the tone of recent conversation regarding past violence.

 

[ara96]

No panic buttons. It’s the tone of recent conversation regarding past violence.

I hear you as I've been there before. Do you have a supervisor for your clinic who you can talk to? Your safety is their responsibility.

 

[TexasPhysician]

I fire all patients the same way. They get a letter via certified mail, prescription for 30 days, referral sheet, etc.

No need to be specific on why they are being fired.

 

[deleted480308]

I hear you as I've been there before. Do you have a supervisor for your clinic who you can talk to? Your safety is their responsibility.

Your safety is your responsibility.

No one pays as dearly for you being unsafe as you do, no one has more on the line. Do what you have to do

 

[Monocles]

can you transfer to a male colleague that isn't afraid of him?

for the record on principle I am 100% behind firing pts that make you feel unsafe. I'm glad your residency actually gives you that option!

 

[birchswing]

I fire all patients the same way. They get a letter via certified mail, prescription for 30 days, referral sheet, etc.

No need to be specific on why they are being fired.

If you there is no termination process and no termination session, doesn't that suggest the psychiatrist is solely a biological medical provider and has no therapeutic relationship with the patient? This would be anathema in the field of psychology, but psychiatrists often assert that every interaction, including brief encounters for refills, include non-drug therapeutic interactions.

 

[Mass Effect]

No panic buttons. It’s the tone of recent conversation regarding past violence.

Are you still in residency? Hard to believe you guys don't have panic buttons or some mechanism for safety. Have there not been violent incidents in that clinic in the past? In this day and age for any clinic not to have panic buttons or a way to signal for help is a lawsuit waiting to happen. If you're in residency, you need to ask your attending about this. If you're out of residency, you need to talk to your employer about installing panic buttons.

Is there security on premises? If so, you can have them circle around outside your office whenever that patient comes in.

 

[WisNeuro]

Are you still in residency? Hard to believe you guys don't have panic buttons or some mechanism for safety. Have there not been violent incidents in that clinic in the past? In this day and age for any clinic not to have panic buttons or a way to signal for help is a lawsuit waiting to happen. If you're in residency, you need to ask your attending about this. If you're out of residency, you need to talk to your employer about installing panic buttons.

Is there security on premises? If so, you can have them circle around outside your office whenever that patient comes in.

Isn't this like a JHACO violation or something?

 

[FlowRate]

Are you still in residency? Hard to believe you guys don't have panic buttons or some mechanism for safety. Have there not been violent incidents in that clinic in the past? In this day and age for any clinic not to have panic buttons or a way to signal for help is a lawsuit waiting to happen. If you're in residency, you need to ask your attending about this. If you're out of residency, you need to talk to your employer about installing panic buttons.

Is there security on premises? If so, you can have them circle around outside your office whenever that patient comes in.

I'm working in a SPMI clinic right now and our panic button is a phone number...

"Excuse me sir, could you stop hitting me while I dial 3333 and ask for a rapid response?"

 

[deleted310399]

How do you do this? I have an aspd patient and I’m scared of him. He tells me he’s been violent with women in the past and I have a gut feeling that I should not be seeing him anymore.

I sympathize with you . I work in a rural outpatient clinic and we do have our share of " characters " . Anti socials , benzo/stimulant seekers , violent psychotics and what not . I would talk to your employer right away about this and institute an action plan . The way i see it , you have no obligation to keep seeing a patient that indirectly threatens you or makes you feel unsafe . I agree with an above poster that your safety is your own responsibility in the end .

 

[Attending1985]

Ok I'm mistaken I do have a panic button. That doesn't make me feel any better. This guy with "anxiety" doesn't benefit from seeing me and this is in now way worth putting myself at risk. Why does our system do this? Bring in predators with no psychiatric diagnosis and give them a label and attention which appeals to their narcissism?! I'll talk to my manager.

 

[WisNeuro]

Isn't the ASPD a psychiatric diagnosis?

 

[whopper]

If you're a resident discuss this with your attending. That's why they are there-to instruct you. (Of course not mentioning that some doctors aren't that great and maybe your attending might not be providing you with appropriate instruction-happened to me).

I'm not saying this cause I disagree with it. The same laws passed to strengthen the rights of doctors to not perform abortions are written in a manner where you can pretty much deny a patient services/treatment based on personal religious or ethical beliefs. In short this basically allows a doctor to fire a patient for anything because anything could be claimed as a religious or ethical belief. Again I'm not saying I agree with it and the way it's written several doctors could abuse this. E.g. deny services based on race, etc.

But this does give you a legal buffer in terms of deciding to continue to work with this patient. In short you could terminate people for very flippant reasons though again I don't endorse this type of practice, nor am I implying that your situation is flippant.

Despite what I mentioned above I do only try to terminate patients for solid reasons. E.g. one patient was literally smoking in the waiting room, was often times rude to me and my assistant. Another patient was clearly medication seeking getting controlled substances from several providers. Pretty much any doctor would agree such a patient should be terminated and the guidelines clearly back up this should be done in those situations. Although I'm sure some of my terminated patients will disagree with me, I've never terminated a patient for a flippant reason. And again, while I don't agree with the laws I mentioned, it did give me quite a comfortable buffer in knowing that if they legally tried to challenge me they'd not have a leg to stand on.

Also as one guy who trained me told me (and this guy was a great teacher), anytime you want to terminate a patient (or they're otherwise ticking you off) you should spend at least some time investigating how you handled it cause maybe you should keep the patient and work on that specific issue. The fact of the matter is you will most definitely encounter other patients who are upsetting in some way, shape, or form.

The program you are in also has a direct responsibility to make sure they follow appropriate safety protocols some of which were mentioned above.

 

[Attending1985]

If you're a resident discuss this with your attending. That's why they are there-to instruct you. (Of course not mentioning that some doctors aren't that great and maybe your attending might not be providing you with appropriate instruction-happened to me).

I'm not saying this cause I disagree with it. The same laws passed to strengthen the rights of doctors to not perform abortions are written in a manner where you can pretty much deny a patient services/treatment based on personal religious or ethical beliefs. In short this basically allows a doctor to fire a patient for anything because anything could be claimed as a religious or ethical belief. Again I'm not saying I agree with it and the way it's written several doctors could abuse this. E.g. deny services based on race, etc.

But this does give you a legal buffer in terms of deciding to continue to work with this patient. In short you could terminate people for very flippant reasons though again I don't endorse this type of practice, nor am I implying that your situation is flippant.

Despite what I mentioned above I do only try to terminate patients for solid reasons. E.g. one patient was literally smoking in the waiting room, was often times rude to me and my assistant. Another patient was clearly medication seeking getting controlled substances from several providers. Pretty much any doctor would agree such a patient should be terminated and the guidelines clearly back up this should be done in those situations. Although I'm sure some of my terminated patients will disagree with me, I've never terminated a patient for a flippant reason. And again, while I don't agree with the laws I mentioned, it did give me quite a comfortable buffer in knowing that if they legally tried to challenge me they'd not have a leg to stand on.

Also as one guy who trained me told me (and this guy was a great teacher), anytime you want to terminate a patient (or they're otherwise ticking you off) you should spend at least some time investigating how you handled it cause maybe you should keep the patient and work on that specific issue. The fact of the matter is you will most definitely encounter other patients who are upsetting in some way, shape, or form.

The program you are in also has a direct responsibility to make sure they follow appropriate safety protocols some of which were mentioned above.

I’m an attending. This patient is not “upsetting me” I’m scared. Talked to my manager and will not be seeing this patient. Nothing is worth putting myself at risk.

 

[Attending1985]

Isn't the ASPD a psychiatric diagnosis?

What I mean is giving untreatable axis II all these axis I labels

 

[WisNeuro]

What I mean is giving untreatable axis II all these axis I labels

I'm with you about the mislabeling. But I disagree with the untreatable. Difficult to treat, yes, but it can be done. I imagine many on this board and over on the psych board would attest to the successful treatment of Axis II disorders.

 

[Attending1985]

I'm with you about the mislabeling. But I disagree with the untreatable. Difficult to treat, yes, but it can be done. I imagine many on this board and over on the psych board would attest to the successful treatment of Axis II disorders.

I agree with you. I really like working with BPD and a few others but ASPD I believe there is no good evidence that’s it’s amendable to therapy

 

[Dharma]

I'm with you about the mislabeling. But I disagree with the untreatable. Difficult to treat, yes, but it can be done. I imagine many on this board and over on the psych board would attest to the successful treatment of Axis II disorders.

Even ASPD? I imagine success rates being pretty low vs something like BPD where remission rates can actually be quite favorable.

 

[WisNeuro]

I agree with you. I really like working with BPD and a few others but ASPD I believe there is no good evidence that’s it’s amendable to therapy

Absence of evidence is not evidence of absence. Prior to the late 80s and into the 90s, people claimed the same thing about BPD. ASPD still remains understudies, particularly with regards to treatment. There are some larger scale treatment arms in the UK, and some smaller ones in the US looking at this. Also, I wouldn't look at it in terms of "remission." Otherwise, nothing would truly be considered treatable. It's about reducing problematic behaviors and increasing QOL.

 

[Attending1985]

Absence of evidence is not evidence of absence. Prior to the late 80s and into the 90s, people claimed the same thing about BPD. ASPD still remains understudies, particularly with regards to treatment. There are some larger scale treatment arms in the UK, and some smaller ones in the US looking at this. Also, I wouldn't look at it in terms of "remission." Otherwise, nothing would truly be considered treatable. It's about reducing problematic behaviors and increasing QOL.

At this point we have no good evidence it’s treatable. Absence of empathy is a poor prognosticator. We have to be careful when there’s violent criminal behavior because when treatment fails someone besides the patient gets hurt. I believe you’re a neuropsychologist so I’m assuming you don’t work in the ED. If you worked in emergency psychiatry you could see how this presents huge problems to the system,

 

[whopper]

Absence of evidence is not evidence of absence

Agree. I see refusing to give up on things that at that time couldn't be solved as highest quality of a good clinician.

But given the dangers of ASPD you also have to be realistic. You also have to weigh your own safety, the safety of others around you, balance out that part of treatment could be that the person has to suffer the consequences of their actions. E.g. refusing a mental health defense to someone who committed a crime knowing that crime harmed others.

Reduction of problematic behaviors can also enter some questionable zones. E.g. Zonking people with meds to oversedate them in prison may reduce violence rates. Giving meds out for disorders that have little to no evidence to back their use while those meds have their own risks also brings up several problematic issues.

Which goes into the overal QOL as you rightfully mentioned. But given that ASPD's been a peggable diagnosis for decades, and given that several clinicians before us have tried already existing meds and several therapies with pretty much lack of success, trying to treat it IMHO really should only be on the table if there's something that clinician can offer that's different (and what else can be tried?) than what's been tried before or if there's reason to believe there's something going on instead of in addition of ASPD.

 

[Liquid8]

I think discussion on panic buttons and the like miss the point. The outwardly aggressive patient is easy to sack based on behaviour alone. It is generally less clear as to how you deal with one who is indirectly threatens you.

There might be some benefit in exploring it further “Some of the things you are saying might come across as threatening or frighten people…” and I’ve used this kind of approach for very angry guys usually going through an ugly divorce/separation and where I’m not quite sure if it’s actually antisocial behaviour or a normal response to a very stressful situation.

I have only had one patient who truly frightened me. When he missed his first followup appointment (which in hindsight I shouldn’t have even booked), I used it as an opportunity to sack him via receptionist. Decided to waive the no-show fee because it might have given him the thought that he could just come back after settling this, and no amount of money was worth that risk. I had nothing to offer him that he wanted except Xanax, which collateral suggested that he was probably abusing or selling. With this one I didn’t feel comfortable confronting him on things because I couldn’t predict how he’d react. I remember that the thing that bothered me most about this patient was the casual indifference and complete lack of remorse about past violent behaviour, and that after the initial consult I was looking at any excuse to get him off my books.

If he’d come back, I’d probably have been in the same dilemma as the OP.

Aside from being very firm on non-attendance/discharge rules, I had considered raising my fees substantially to provide a financial disincentive. The other out I had for this patient was drawing the line on what treatment I would provide. He’d told me he’d had chronic schizophrenia from an early age and was actively hallucinating, yet had failed on high doses of every anti-psychotic and always refused ECT. When I spoke to his community team, they couldn’t confirm compliance, thought he’d been selling his medications and that the "psychosis" was learned behaviour. I figured that if I offered him ECT, he would refuse as it would mean not using benzos, and that would be my avenue for discharge.

Since then, I’ve had a few more Anti-social PD types with various outcomes. I remember there being one who was trying to get off drugs, and arranged a detox admission at the suggestion of his family. However, it was clear he wasn’t taking it seriously and had to kick him out after he continuously refused to give urine samples for drug testing. He came back to see me a few times and stopped seeing me soon afterwards. Two years on, I receive a request for information from the local corrections facility which was sad, as his family were very supportive and well meaning, and he also had a lot going for him.

 

[whopper]

I've had dangerous patients before. It was much easier for me to deal with them because they were on a forensic unit and locked away from society.

But what do you do if they aren't locked up? This is something not generally handled in regular psych training. My last patient where this happened allegedly killed a family pet. He also only came to my office with his mother. He was young adult still living with his mother

I told the patient I wanted very extensive psychological testing in various forensic instruments. I referred him to a psychologist. I also wasn't even confident he had a treatable Axis I. Part of the reason for the testing was to root out any personality issues, weigh his future risk potential, but also help me to figure out if he had an axis I on a level more so than just clinical interview.

Well maybe lucky for me he never showed up to my office again.

 

[Merely]

Hypothetical: You’re in outpatient pp as an attending doing medication management and brief therapy, how do you protect yourself? Do you guys carry guns? Tasers? Pepper spray? Or just hope you can hold off any type of assault?

 

[deleted480308]

Hypothetical: You’re in outpatient pp as an attending doing medication management and brief therapy, how do you protect yourself? Do you guys carry guns? Tasers? Pepper spray? Or just hope you can hold off any type of assault?

I would carry

 

[clausewitz2]

At this point we have no good evidence it’s treatable. Absence of empathy is a poor prognosticator. We have to be careful when there’s violent criminal behavior because when treatment fails someone besides the patient gets hurt. I believe you’re a neuropsychologist so I’m assuming you don’t work in the ED. If you worked in emergency psychiatry you could see how this presents huge problems to the system,

Not true about no evidence base for treatment. I recommend looking into MBT. You might now be set up to do it, which is fair enough, but therapeutic nihilism is not warranted.

 

[Armadillos]

Hypothetical: You’re in outpatient pp as an attending doing medication management and brief therapy, how do you protect yourself? Do you guys carry guns? Tasers? Pepper spray? Or just hope you can hold off any type of assault?

Besides economic efficiency I imagine this is part of why many solo pp psychiatrists work in an office/building with other psychiatrists/therapists and have shared common spaces.

 

[Mass Effect]

Ok I'm mistaken I do have a panic button. That doesn't make me feel any better

I agree about discharging the patient, but the fact that you didn't know you had a panic button is a problem. Your clinic should have done a better job of highlighting that and other safety measures. What we do can be dangerous and many psychiatrists find that out at some point in their career. Basic safety protocol isn't something that should be unknown or forgotten.

I think discussion on panic buttons and the like miss the point

I don't think it misses the point at all. When discussing safety, it's important to talk about safety protocol as every clinic/healthcare system will provide something different. Working with mentally ill people (which sometimes means personality disordered people) can be dangerous. In this case, there are red flags the OP is clearly sensing, which is good and speaks to his/her ability to listen to his/her instincts. However, there are plenty of patients out there who don't carry the ASPD diagnosis, but are dangerous and you don't always figure that out until you deny the benzo script or you file the report with child safety services or you try to send them for involuntary hospitalization or they just plain have a bad day and take it out on you. Panic buttons and a plan to maintain clinician safety should be part of the conversation in any case in which there's potential for violence.

 

[LadyHalcyon]

At this point we have no good evidence it’s treatable. Absence of empathy is a poor prognosticator. We have to be careful when there’s violent criminal behavior because when treatment fails someone besides the patient gets hurt. I believe you’re a neuropsychologist so I’m assuming you don’t work in the ED. If you worked in emergency psychiatry you could see how this presents huge problems to the system,

I think you are conflating psychopathy and ASPD

 

[birchswing]

Re: treatability of ASPD

This is an older article but for some reason it was just on Twitter and read it the whole way through (it's long) on psychopathy in children and the treatment modalities. They're not actually diagnosed as psychopathic but rather conduct disorder with callous regard or something like that, but probably something that would be diagnosed as ASPD in adults:

When Your Child Is a Psychopath

One of the treatment centers had relative success with a model of reward-based systems. They theorize that people with these tendencies don't respond to punishment but do have hyperactive pleasure responses and respond to rewards.

My main takeaway from it was was a sense of a blurring in my mind between the field of criminal justice and mental health treatment. It didn't sound like something that could be done on an outpatient basis.

Afterward I looked up some of the centers mentioned in the articles, and some of them have harrowing reviews from former employees and patients that do make them sound like abusive prisons (including the employees saying the children were mistreated). On the other hand, some say they were helped a lot.

 

[LadyHalcyon]

Something is off when approximately 80% of prisoners meet criteria for a diagnosis of ASPD. Because the criteria is largely behaviorally based, people with offense histories are overidentified. I believe malignant narcissm can capture personality traits most people associate with ASPD.

 

[Stagg737]

Not true about no evidence base for treatment. I recommend looking into MBT. You might now be set up to do it, which is fair enough, but therapeutic nihilism is not warranted.

MBT?

 

[Liquid8]

I don't think it misses the point at all. When discussing safety, it's important to talk about safety protocol as every clinic/healthcare system will provide something different. Working with mentally ill people (which sometimes means personality disordered people) can be dangerous. In this case, there are red flags the OP is clearly sensing, which is good and speaks to his/her ability to listen to his/her instincts. However, there are plenty of patients out there who don't carry the ASPD diagnosis, but are dangerous and you don't always figure that out until you deny the benzo script or you file the report with child safety services or you try to send them for involuntary hospitalization or they just plain have a bad day and take it out on you. Panic buttons and a plan to maintain clinician safety should be part of the conversation in any case in which there's potential for violence.

Sure, but in the OP's case the patient has already come back multiple times so if a panic button is going to be used it means they're already in a bad situation that was predicted and could have been avoided by sacking the patient. I don't disagree that there is a major systemic issue that OP's rooms aren't fitted out properly and that is certainly something that needs to be addressed. However, I doubt that having an alarm is going to be enough to make the OP suddenly feel safer in their interactions. The patient would not know if there were alert systems in place, and the presence or lack of such safety measures may not necessarily change any inclination they have to behave violently. Thus, I see the more immediate issue as trying to assist the OP in avoiding a potentially dangerous situation with the specific patient in question.

 

[clausewitz2]

MBT?

Mentalization-based treatment - Wikipedia


That page doesn't talk about it specifically but it has been applied to ASPD with some success, as a failure to mentalize is common to BPD and ASPD.

It is probably not going to be helpful for the puppy-torturing kind of ASPD, the kind the PDDM would call sadistic personality disorder, but those folks are way less likely to be in your office in a non-forensic setting.

 

[WisNeuro]

Agree. I see refusing to give up on things that at that time couldn't be solved as highest quality of a good clinician.

But given the dangers of ASPD you also have to be realistic. You also have to weigh your own safety, the safety of others around you, balance out that part of treatment could be that the person has to suffer the consequences of their actions. E.g. refusing a mental health defense to someone who committed a crime knowing that crime harmed others.

Reduction of problematic behaviors can also enter some questionable zones. E.g. Zonking people with meds to oversedate them in prison may reduce violence rates. Giving meds out for disorders that have little to no evidence to back their use while those meds have their own risks also brings up several problematic issues.

Which goes into the overal QOL as you rightfully mentioned. But given that ASPD's been a peggable diagnosis for decades, and given that several clinicians before us have tried already existing meds and several therapies with pretty much lack of success, trying to treat it IMHO really should only be on the table if there's something that clinician can offer that's different (and what else can be tried?) than what's been tried before or if there's reason to believe there's something going on instead of in addition of ASPD.

Agree, I never questioned that. I questioned writing off an entire diagnosis of people as untreatable. Which is a terrible thing to say as a clinician. Not feeling competent or comfortable treating a certain disorder is one thing, you can simply find someone who is willing. That's part of being in a community, knowing where to refer rather than just throwing up your hands and telling patients to figure it out themselves.

At this point we have no good evidence it’s treatable. Absence of empathy is a poor prognosticator. We have to be careful when there’s violent criminal behavior because when treatment fails someone besides the patient gets hurt. I believe you’re a neuropsychologist so I’m assuming you don’t work in the ED. If you worked in emergency psychiatry you could see how this presents huge problems to the system,

We have no preponderence of evidence that it's treatable. We have lots of evidence that treatment can reduce certain problematic behaviors. As I mentioned, there are several, large scale, RCT trials currently ongoing which are looking to add to the literature. While I do not work in the ED, I am a consultant on our several involuntary inpatient units, I still see these patients on a weekly basis. Be careful with your assumptions. I'm not commenting on your decision to not see the patient, I am commenting on your quick willingness to write off an entire diagnosis as untreatable when there is evidence, and clinicians who do in fact do this treatment work.

 

[Stagg737]

Mentalization-based treatment - Wikipedia


That page doesn't talk about it specifically but it has been applied to ASPD with some success, as a failure to mentalize is common to BPD and ASPD.

It is probably not going to be helpful for the puppy-torturing kind of ASPD, the kind the PDDM would call sadistic personality disorder, but those folks are way less likely to be in your office in a non-forensic setting.

I'm aware of what MBT is, I've just never heard anyone argue that's it can be applied to ASPD patients. Any literature on that at this point or isn't it just observation of individual cases? Because I think an argument could be made that any mild personality disorder could be treated successfully with some form of therapy, but then I start questioning the validity of the diagnosis for those patients.

 

[WisNeuro]

I'm aware of what MBT is, I've just never heard anyone argue that's it can be applied to ASPD patients. Any literature on that at this point or isn't it just observation of individual cases? Because I think an argument could be made that any mild personality disorder could be treated successfully with some form of therapy, but then I start questioning the validity of the diagnosis for those patients.

I believe that there are a few RCTs out for this, and at least one recent one that looked at comorbid ASPD/BPD with MBT.

 

[clausewitz2]

I'm aware of what MBT is, I've just never heard anyone argue that's it can be applied to ASPD patients. Any literature on that at this point or isn't it just observation of individual cases? Because I think an argument could be made that any mild personality disorder could be treated successfully with some form of therapy, but then I start questioning the validity of the diagnosis for those patients.

Google Scholar

This should have plenty of hits to keep you busy.

Fonagy and Bateman's most recent MBT manual has a whole chapter dedicated to ASPD.

So, the people who came up with MBT certainly think it can be applied to these folks.

I would be very, very careful revising personality diagnoses strictly because they actually respond to structured treatment. The idea that they are necessarily trait like is clearly false for many of them (60% of people meeting BPD criteria no longer meeting them ten years on etc.)

There is a reason DSMV was going to abandon categorical PDs before losing its nerve. I think to make categorical thinking like this work you need to go full on Millon and have a thousandty different categories and even he wanted to draw a distinction between styles, traits and types.

You can't medicate away a lot of interpersonal dysfunction but that doesn't mean you can't help these people should they want help. I am skeptical of court-mandated treatment, though there has also been some work with really intense contingency management in a residential setting for ASPD showing some benefits. There was an Atlantic article talking about it a couple years ago. A major takeaway consistent with what we already knew seems to be punishment learning doesn't work that well but carefully structuring and framing rewards does.

 

[Attending1985]

Agree, I never questioned that. I questioned writing off an entire diagnosis of people as untreatable. Which is a terrible thing to say as a clinician. Not feeling competent or comfortable treating a certain disorder is one thing, you can simply find someone who is willing. That's part of being in a community, knowing where to refer rather than just throwing up your hands and telling patients to figure it out themselves.



We have no preponderence of evidence that it's treatable. We have lots of evidence that treatment can reduce certain problematic behaviors. As I mentioned, there are several, large scale, RCT trials currently ongoing which are looking to add to the literature. While I do not work in the ED, I am a consultant on our several involuntary inpatient units, I still see these patients on a weekly basis. Be careful with your assumptions. I'm not commenting on your decision to not see the patient, I am commenting on your quick willingness to write off an entire diagnosis as untreatable when there is evidence, and clinicians who do in fact do this treatment work.

I assumed you didn’t work in and ED because of your profession which is true. Not sure why you need to caution me against assuming a neuropsychologist wouldn’t be doing emergency psych.

 

[Mass Effect]

Sure, but in the OP's case the patient has already come back multiple times so if a panic button is going to be used it means they're already in a bad situation that was predicted and could have been avoided by sacking the patient.

What? This doesn't make sense to me. Just because the patient came back multiple times doesn't mean that a panic button can't be used in the future. Likewise, just because a patient has never been violent in the past doesn't mean that a "bad situation" can't happen in the future. I never commented on the OP discharging the patient. I was simply commenting on the panic button issue. The OP initially said they didn't have them, which is absurd to me considering what we do. Now that we know they do have them, I'm left questioning how it's possible the OP didn't know when it's a key safety feature in the office, especially if you're going to see these types of personality disordered patients.

The patient would not know if there were alert systems in place, and the presence or lack of such safety measures may not necessarily change any inclination they have to behave violently.

That's not the point of a panic button. If it was, they'd be visible to the patient. It's exactly the opposite.

 

[whopper]

Wisneuro,

Nothing I was stating was against your prior post. We've both been on this forum for years and I've found you to be quite adept with your knowledge. My statements were merely adding.

ASPD and other PDs.
When dealing with ASPD I could be wrong and I tell patients this, and I tell them the limitations of diagnosis. I also offer to treat any possible Axis I disorders that might be going on to be thorough but will state I don't think they have one if that is my opinion. E.g. if someone has several traits of ASPD I might try them on a psychotropic med but with the full disclosure they might not have it and we're grasping for straws.

ASPD-due to the dead end it often times puts clinicians into, and because understanding personality requires knowing the person in-depth I recommend clinicians not diagnose ASPD in someone unless they have an extensive amount of data on the person. I've found several rough people in correctional settings not have ASPD but someone raised in the Ivory Tower may think they do. Some people with extensive criminal histories may have some type of sense of honor or other ethical code they take seriously.

I've had patients where I was confident they had ASPD to the point where I was willing to state it on the record and in court but these were people where I had extensive dealings with them over the course of months.

What I've often times found is psychiatrists often times treat things like Axis II disorders without stating the limitations. E.g. a teenager bullied upon by others in school blows in in anger one day, they bring her to a psychiatrist who loads her up with Depakote. Even when I talked to that psychiatrist I asked if that person believed the child had Bipolar Disorder and he even admits he doesn't think so stating the Depakote is for behavioral control. Goddammit, I wouldn't want that kid on Depakote and if I even mentally considered it an option I'd bring up with everyone that it's not for this disorder and would only even consider it if the patient had a good grasp of the risks vs benefits.

Likewise in settings where patients have limited intelligence such as in nursing homes, group homes and forensic units I've often times seen patients pretty much just zonked out on meds. I'd walk into that setting the first day in what used to be utter shock and disgust with how the prior psychiatrist treated. E.g. a patient with ASPD diagnosed with Schizoaffective DO, and on a large amount of Olanzapine that makes him sleep about 15 hours a day, and while he's awake he's a zombie. I got that patient completely off the medication and he didn't show any signs of psychosis or mania for 2 years. When I talked to his prior psychiatrist he even admitted he didn't think the guy had an Axis I other than Pathological Gambing, substance abuse disorders, and had ASPD but he wanted to "control" his behavior.

 

[Attending1985]

What? This doesn't make sense to me. Just because the patient came back multiple times doesn't mean that a panic button can't be used in the future. Likewise, just because a patient has never been violent in the past doesn't mean that a "bad situation" can't happen in the future. I never commented on the OP discharging the patient. I was simply commenting on the panic button issue. The OP initially said they didn't have them, which is absurd to me considering what we do. Now that we know they do have them, I'm left questioning how it's possible the OP didn't know when it's a key safety feature in the office, especially if you're going to see these types of personality disordered patients.



That's not the point of a panic button. If it was, they'd be visible to the patient. It's exactly the opposite.

They were installed last week. We had been asking them for awhile but I was gone on vacation last week when they were installed and no one told me.

 

[Attending1985]

If we call all human behavior that is undesirable or problematic a psychiatric disorder and claim we can help we’re kidding ourselves. Yet this is what we continue to do and do it more despite terrible results. No wonder people don’t like us.

 

[clausewitz2]

Wisneuro,

Nothing I was stating was against your prior post. We've both been on this forum for years and I've found you to be quite adept with your knowledge. My statements were merely adding.

ASPD and other PDs.
When dealing with ASPD I could be wrong and I tell patients this, and I tell them the limitations of diagnosis. I also offer to treat any possible Axis I disorders that might be going on to be thorough but will state I don't think they have one if that is my opinion. E.g. if someone has several traits of ASPD I might try them on a psychotropic med but with the full disclosure they might not have it and we're grasping for straws.

ASPD-due to the dead end it often times puts clinicians into, and because understanding personality requires knowing the person in-depth I recommend clinicians not diagnose ASPD in someone unless they have an extensive amount of data on the person. I've found several rough people in correctional settings not have ASPD but someone raised in the Ivory Tower may think they do. Some people with extensive criminal histories may have some type of sense of honor or other ethical code they take seriously.

I've had patients where I was confident they had ASPD to the point where I was willing to state it on the record and in court but these were people where I had extensive dealings with them over the course of months.

What I've often times found is psychiatrists often times treat things like Axis II disorders without stating the limitations. E.g. a teenager bullied upon by others in school blows in in anger one day, they bring her to a psychiatrist who loads her up with Depakote. Even when I talked to that psychiatrist I asked if that person believed the child had Bipolar Disorder and he even admits he doesn't think so stating the Depakote is for behavioral control. Goddammit, I wouldn't want that kid on Depakote and if I even mentally considered it an option I'd bring up with everyone that it's not for this disorder and would only even consider it if the patient had a good grasp of the risks vs benefits.

Likewise in settings where patients have limited intelligence such as in nursing homes, group homes and forensic units I've often times seen patients pretty much just zonked out on meds. I'd walk into that setting the first day in what used to be utter shock and disgust with how the prior psychiatrist treated. E.g. a patient with ASPD diagnosed with Schizoaffective DO, and on a large amount of Olanzapine that makes him sleep about 15 hours a day, and while he's awake he's a zombie. I got that patient completely off the medication and he didn't show any signs of psychosis or mania for 2 years. When I talked to his prior psychiatrist he even admitted he didn't think the guy had an Axis I other than Pathological Gambing, substance abuse disorders, and had ASPD but he wanted to "control" his behavior.

I am surprised that you feel that having a sense of honor or some identifiable code of ethics is inconsistent with ASPD. Flying into a towering rage when disrespected and prizing rep above anything else is totally consistent with most understandings of the antisocial construct I've come across. Similarly, feeling that 95% of people don't count as real people and you can do whatever you want to them while requiring respectful and even protective interactions with a limited number of people, especially kin, is also not at all rare for ASPD.

I agree with you that assessing this in correctional settings is very fraught. Plenty of people who did not have these traits before incarceration learned quickly that they need to carry themselves that way or they will be ruthlessly victimized. It is highly adaptive to their environment.

 

[LadyHalcyon]

Think about it from this perspective: someone grows up in a poor environment. Maybe they were exposed to gang violence, maybe their parents were abusing drugs, maybe they witnessed domestic violence, and maybe they even were abused themselves. The relationship between trauma, and/or generally invalidating environments, and BPD has been clearly established. Schema therapy discusses different defense mechanisms associated with specific schemas. An individual can either surrender, avoid, or overcompensate as a way to to cope with said schema. If the schema is "People will hurt me/people can't be trusted" then a clinician may see the following:

Surrender: The individual chooses untrustworthy partners and may be overvigilant/suspicious of others

Avoidance: The individual may avoid close relationships with others

Overcompensation: The individual may mistreat or exploit others

The idea that all individuals diagnosed with ASPD lack the ability to empathize is just plain wrong. It is essential to remember their behavior was often adaptive at some point in their life.