FMLA Renewl

[nrmp]

We often get request for FMLA filled out to protect jobs for symptoms flare-ups and absence from work. Do you guys continue to renew annually? I have patients for whom I did it but then I am starting to see a trend where they will continue to request yearly when it's expiring even though they are relatively stable.

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[Ironspy]

I've never had this come up and maybe I don't fully understand the question. Are they absent from work 12 weeks/year (bc FMLA is only good for 12 weeks)? I would not fill FMLA forms out unless I believed that the patient was unable to work due to their psychiatric disorder which I was actively treating and I give an estimated timeline (6-9 weeks typically and I'll renew to 12 weeks if needed) for return to work. I would not "renew" for the following year unless I was treating them for a relapse and I believed that they could not work during treatment.

 

[nrmp]

I've never had this come up and maybe I don't fully understand the question. Are they absent from work 12 weeks/year (bc FMLA is only good for 12 weeks)? I would not fill FMLA forms out unless I believed that the patient was unable to work due to their psychiatric disorder which I was actively treating and I give an estimated timeline (6-9 weeks typically and I'll renew to 12 weeks if needed) for return to work. I would not "renew" for the following year unless I was treating them for a relapse and I believed that they could not work during treatment.

They usually have an option asking will the employee be incapacitated for a single continuous period of time- answer is "No" as they are still able to work. But there is always another question for episodic periodic flare-ups preventing them from performing job function? - if answer is "yes" you can specify like 1-2 days every 2-3 months or so. Therefore let's says he/she is feeling extremely panic at times and end up taking unpaid off for a day or two as allowed it could save the job.

 

[Candidate2017]

They usually have an option asking will the employee be incapacitated for a single continuous period of time- answer is "No" as they are still able to work. But there is always another question for episodic periodic flare-ups preventing them from performing job function? - if answer is "yes" you can specify like 1-2 days every 2-3 months or so. Therefore let's says he/she is feeling extremely panic at times and end up taking unpaid off for a day or two as allowed it could save the job.

You say they are stable, so why can't they use a sick day every 2-3 days? Or the rare BZD for panic attacks? Also, FMLA allows patients to use days for Dr's appointments, such as... therapy appointments for panic disorder.

 

[nrmp]

You say they are stable, so why can't they use a sick day every 2-3 days? Or the rare BZD for panic attacks? Also, FMLA allows patients to use days for Dr's appointments, such as... therapy appointments for panic disorder.

Yes you are right, makes complete sense. Patient wasn't stable when it was done a year ago but now when they are I agree I should just do for doctors appointments.

 

[Ironspy]

They usually have an option asking will the employee be incapacitated for a single continuous period of time- answer is "No" as they are still able to work. But there is always another question for episodic periodic flare-ups preventing them from performing job function? - if answer is "yes" you can specify like 1-2 days every 2-3 months or so. Therefore let's says he/she is feeling extremely panic at times and end up taking unpaid off for a day or two as allowed it could save the job.

Avoidance tends to worsen anxiety

 

[Mass Effect]

Avoidance tends to worsen anxiety

That's all fine and good, but telling someone in the midst of a panic attack that they must drive to work is just asking for trouble. There are a lot of people who can't work during severe anxiety and many more who should not be driving during a panic attack.

Also, avoidance worsens anxiety when the anxiety is due to the thing you're avoiding.

 

[clausewitz2]

That's all fine and good, but telling someone in the midst of a panic attack that they must drive to work is just asking for trouble. There are a lot of people who can't work during severe anxiety and many more who should not be driving during a panic attack.

Also, avoidance worsens anxiety when the anxiety is due to the thing you're avoiding.

Yeah but if having a panic attack has the consequence of escaping doing something burdensome and unpleasant, what do you think the most likely contingency do you think they are going to learn, explicitly or implicitly?

I think it's one thing if the FMLA is to allow them to attend an intensive treatment program or doing something very concrete, but in general I am not sure I would sign off on FMLA just for GAD or panic attacks. Now, if that "anxiety" is actually psychosis or incipient mania, which is often how it gets described to me until I start asking more detailed questions, that's another matter entirely...

 

[Ironspy]

Yeah but if having a panic attack has the consequence of escaping doing something burdensome and unpleasant, what do you think the most likely contingency do you think they are going to learn, explicitly or implicitly?

I think it's one thing if the FMLA is to allow them to attend an intensive treatment program or doing something very concrete, but in general I am not sure I would sign off on FMLA just for GAD or panic attacks. Now, if that "anxiety" is actually psychosis or incipient mania, which is often how it gets described to me until I start asking more detailed questions, that's another matter entirely...

You said most of what I wanted to already. Additionally, panic attacks are short lived and I don’t see a reason to take a whole work day off for something that is ~10 min as it reinforces the wrong message. I do fmla for ect/TMS, IOP etc when there is (IMO) a concrete reason to need entire days/weeks off. Mania/psychosis also as long as there is a plan to use that time for treatment

 

[Mass Effect]

Yeah but if having a panic attack has the consequence of escaping doing something burdensome and unpleasant, what do you think the most likely contingency do you think they are going to learn, explicitly or implicitly?

Do you want your surgeon having a panic attack in the operating room? Or a police officer having a panic attack? Or a pizza driver having a panic attack on the road? Putting the actual job aside, do you want a patient to be driving on the road when having a panic attack? I sure don't.

Put another way:

Patient A: "Doc, I have severe panic attacks about work. I'm so anxious that I have panic attacks at work."

Obviously, Patient A shouldn't be conditioned to miss work due to anxiety.

Patient B: "Doc, I have severe panic attacks due to ___ (insert migraines, nausea, PTSD, anything else besides work) and when I have one, I can't make the hour-long commute to work.

I'd argue that you're not reinforcing anxious tendencies in Patient B because his anxiety is not due to work or to the commute, but it does keep the rest of us safe when the patient isn't peeling out of a parking lot while having a panic attack.

 

[Mass Effect]

You said most of what I wanted to already. Additionally, panic attacks are short lived and I don’t see a reason to take a whole work day off for something that is ~10 min as it reinforces the wrong message. I do fmla for ect/TMS, IOP etc when there is (IMO) a concrete reason to need entire days/weeks off. Mania/psychosis also as long as there is a plan to use that time for treatment

There's no DSM criteria for length of panic attack. I was always taught this 10 minute rule too, but in residency, I worked with one of the experts in the field who said it was outdated and hogwash. There is nothing that magically happens in every patient after 10 minutes that calms that person down. That makes sense to me. I think time is variable depending on the patient and it can be debilitating for some.

 

[WisNeuro]

There's no DSM criteria for length of panic attack. I was always taught this 10 minute rule too, but in residency, I worked with one of the experts in the field who said it was outdated and hogwash. There is nothing that magically happens in every patient after 10 minutes that calms that person down. That makes sense to me. I think time is variable depending on the patient and it can be debilitating for some.

10-15 minutes is the very high level of physiological panic symptoms, essentially before your body will wind down from the adrenaline rush. So, the 9-10. They can still be in the 6-8 range for a while after, but the peak will be fairly time limited, which is presumably the most impairing part.

Also, for these FMLA renewals, is it contingent upon behavioral treatment? This is honestly one of the easiest things to treat with almost full symptom resolution. This and PTSD are the disorders I still conduct therapy. N of 1 as a therapist, but I have yet to have a patient who did not have at least 80% sustained resolution after a 8-12 week round of therapy.

 

[clausewitz2]

Do you want your surgeon having a panic attack in the operating room? Or a police officer having a panic attack? Or a pizza driver having a panic attack on the road? Putting the actual job aside, do you want a patient to be driving on the road when having a panic attack? I sure don't.

Put another way:

Patient A: "Doc, I have severe panic attacks about work. I'm so anxious that I have panic attacks at work."

Obviously, Patient A shouldn't be conditioned to miss work due to anxiety.

Patient B: "Doc, I have severe panic attacks due to ___ (insert migraines, nausea, PTSD, anything else besides work) and when I have one, I can't make the hour-long commute to work.

I'd argue that you're not reinforcing anxious tendencies in Patient B because his anxiety is not due to work or to the commute, but it does keep the rest of us safe when the patient isn't peeling out of a parking lot while having a panic attack.

I am curious how often you report patients with panic attacks to the state driving license authority to have their license suspended if their panic attacks are severe enough that you have concerns about them having a panic attack while driving. In my state if I genuinely thought this I would be obligated to inform the relevant state agency which would probably lead to them needing an evaluation to keep their license.

If you aren't doing this, but are providing paperwork to excuse them from work, how concerned are you really about their driving safety?

Genuinely curious, is there any evidence that panic attacks cause traffic accidents? My attempt to do a quick lit search this morning is complicated by a vast number of papers on panic attacks developing as a consequence of road accidents, so if anyone can point to literature on the reverse case, I'd be very grateful. I ask because many people I work with who are phobic about driving are pretty convinced that if they are anxious they will die in a fiery wreck, but I'd hate to reinforce their fear if that's not actually the case.

I work with a population that is very enriched for severe anxiety issues so will admit I have become something of a harda** about this in general.

 

[WisNeuro]

I am curious how often you report patients with panic attacks to the state driving license authority to have their license suspended if their panic attacks are severe enough that you have concerns about them having a panic attack while driving. In my state if I genuinely thought this I would be obligated to inform the relevant state agency which would probably lead to them needing an evaluation to keep their license.

If you aren't doing this, but are providing paperwork to excuse them from work, how concerned are you really about their driving safety?

Genuinely curious, is there any evidence that panic attacks cause traffic accidents? My attempt to do a quick lit search this morning is complicated by a vast number of papers on panic attacks developing as a consequence of road accidents, so if anyone can point to literature on the reverse case, I'd be very grateful. I ask because many people I work with who are phobic about driving are pretty convinced that if they are anxious they will die in a fiery wreck, but I'd hate to reinforce their fear if that's not actually the case.

I work with a population that is very enriched for severe anxiety issues so will admit I have become something of a harda** about this in general.

i will say that worry about a panic attack while driving is a usual fear for people with panic disorder, but also one of the easiest targets for exposure. If it's there, usually one of the first things I target as it is generally one of their biggest avoidance domains. Easy to make an exposure hierarchy for this, and by and large, very quick progress for those who engage with the exposures.

 

[clausewitz2]

10-15 minutes is the very high level of physiological panic symptoms, essentially before your body will wind down from the adrenaline rush. So, the 9-10. They can still be in the 6-8 range for a while after, but the peak will be fairly time limited, which is presumably the most impairing part.

Also, for these FMLA renewals, is it contingent upon behavioral treatment? This is honestly one of the easiest things to treat with almost full symptom resolution. This and PTSD are the disorders I still conduct therapy. N of 1 as a therapist, but I have yet to have a patient who did not have at least 80% sustained resolution after a 8-12 week round of therapy.

This is what drives me nuts. The clients I see in CMHC settings who clearly have these sorts of problems who have just been getting vaguely empathetic listening for years when they are dealing with conditions that we can almost talk about as curable. I don't necessarily blame the midlevels who get to see people at most twice a month for 30 minutes for not, y'know, implementing rigorous evidence-based protocols, but I have only once even gotten one to try something exposure-based for a mutual client. It went well, for what it's worth. I try my best to fill in the gaps sometimes and I certainly have read a lot about the theory, practice, implementation etc but a) I have not had extensive supervision about it in the past and b) without scheduling shenanigans I get 20 minutes, so this only works if I happen to have had a cancellation in the following slot or I give up my lunch break/put them in the last slot of the day. It drives me to distraction.

 

[WisNeuro]

This is what drives me nuts. The clients I see in CMHC settings who clearly have these sorts of problems who have just been getting vaguely empathetic listening for years when they are dealing with conditions that we can almost talk about as curable. I don't necessarily blame the midlevels who get to see people at most twice a month for 30 minutes for not, y'know, implementing rigorous evidence-based protocols, but I have only once even gotten one to try something exposure-based for a mutual client. It went well, for what it's worth. I try my best to fill in the gaps sometimes and I certainly have read a lot about the theory, practice, implementation etc but a) I have not had extensive supervision about it in the past and b) without scheduling shenanigans I get 20 minutes, so this only works if I happen to have had a cancellation in the following slot or I give up my lunch break/put them in the last slot of the day. It drives me to distraction.

Yeah, one of the aspects I hate about our faux "parity" laws. Exposure based therapies really do need a good setup to get people acclimated and to manage their expectations before they begin. Also usually works best when you can pair in-vivo exposures with interoceptive exposures within session. Really hard to do this kind of therapy effectively unless you have at least an hour to work with every week.

 

[watto]

"The only person here afraid of their panic is you."
I try not to send the alternate message.

 

[birchswing]

I had panic disorder (although I still think the diagnosis was questionable because whatever I had was in no way limited to 10 minute durations--and there are various other reasons I found it questionable).

Anyhow, I was a very unsafe driver due to whatever it was I had—I didn't want to drive at all, but I went to a magnet school that did not have a bus that went there so I was forced to learn to drive by my parents who couldn't/wouldn't take me. And I actually asked my psychiatrist if it was safe for me to be driving while on Ativan, and he told me it would have been unsafe for me to drive not on Ativan. In reality, I was not a safe driver on or off of it, but it boggles the mind to think I was let on the road in the states I was in. There were times I didn't know what to do and just closed my eyes. Never had an accident, but it very easily could have happened.

 

[comp1]

I don't think FMLA should be any different from other types of leave. If taken for medical purposes, it should be used for furthering recovery. In the case of psychiatry, that would generally be an IOP, PHP, ECT or partial days for TMS or intensive talk therapy. Just staying at home on an annual basis doesn't really further recovery in any studies I have seen. If on the other hand, they need to participate in these therapeutic programs annually and seem to benefit, I could see it being appropriate. Most FMLA isn't paid leave.

 

[clausewitz2]

I don't think FMLA should be any different from other types of leave. If taken for medical purposes, it should be used for furthering recovery. In the case of psychiatry, that would generally be an IOP, PHP, ECT or partial days for TMS or intensive talk therapy. Just staying at home on an annual basis doesn't really further recovery in any studies I have seen. If on the other hand, they need to participate in these therapeutic programs annually and seem to benefit, I could see it being appropriate. Most FMLA isn't paid leave.

I've filled out FMLA for one person this didn't apply to. They had narcolepsy and were going to get fired because sometimes they were an hour late to work in the morning on occasion (had a hard time waking up if they had only gotten 13 hours of sleep the night before). So I said they should be able to get two hours of FMLA twice a month. This worked out well for all involved.