how to build a practice SUPER fast (joke)

[randomdoc1]

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1. put all your PTSD patients, borderline patients, any patient with mood lability/insomnia on xanax
2. soon as someone mentions attentional complaints, give adderall IR
3. CBT is overrated, be a bleeding heart
4. offer to do long term disability paperwork for all comers
5. say you have a holistic/alternative approach and are into herbals (that seems to be the in thing these days) and tout the benefits of THC. Better yet, if you are in a state that legalizes it, sell it in your clinic.
6. we need to stop being so scared of benzos, klonopin to keep it on the even keel and xanax for breakthrough, temazepam to keep our circadian rhythm in check. we keep your yin and yang in balance, hey, use some stims if you're feeling a bit sedated

hope to hear other tips and tricks from other forum readers! yes, i thought it may be fun to poke a little fun at the frustrations some of us have in practice

 

[Trismegistus4]

1. put all your PTSD patients, borderline patients, any patient with mood lability/insomnia on xanax
2. soon as someone mentions attentional complaints, give adderall IR
3. CBT is overrated, be a bleeding heart
4. offer to do long term disability paperwork for all comers
5. say you have a holistic/alternative approach and are into herbals (that seems to be the in thing these days) and tout the benefits of THC. Better yet, if you are in a state that legalizes it, sell it in your clinic.
6. we need to stop being so scared of benzos, klonopin to keep it on the even keel and xanax for breakthrough, temazepam to keep our circadian rhythm in check. we keep your yin and yang in balance, hey, use some stims if you're feeling a bit sedated

hope to hear other tips and tricks from other forum readers! yes, i thought it may be fun to poke a little fun at the frustrations some of us have in practice

There's a private practice psychiatrist in my area who recently stopped taking Medicare, so I've been getting a steady stream of his patients, and they're ALL on benzos. Just saw one of them today--this guy has been diagnosed with NPH, for which his shunt is currently failing, he comes in walking with a walker and acting demented as all get-out... and he's on daily Xanax. A few weeks ago I saw one who seriously is on Klonopin, Xanax, and temazepam all together! Fortunately, at least she says the temazepam doesn't work and doesn't even want to take it. Now I've got to figure out how to get her off the concurrent Klonopin and Xanax. BTW, this private practice psychiatrist is a Fellow of the American Psychiatric Association. I guess that's how you become a fellow: give everybody benzos.

On the topic of disability paperwork, I have another patient on my schedule soon who's complaining that her LTD insurance carrier is cutting off her benefits, saying my notes don't justify her being on LTD. Well, no ****, lady, every time you come in you talk about how well you're doing. Look, you don't want to work, I get it; I don't want to work either. But I can't wave my magic doctor wand and declare that third-party entities have an obligation to keep giving you free money when you come in talking like your life is one long extended vacation!

 

[Fan_of_Meehl]

1. put all your PTSD patients, borderline patients, any patient with mood lability/insomnia on xanax
2. soon as someone mentions attentional complaints, give adderall IR
3. CBT is overrated, be a bleeding heart
4. offer to do long term disability paperwork for all comers
5. say you have a holistic/alternative approach and are into herbals (that seems to be the in thing these days) and tout the benefits of THC. Better yet, if you are in a state that legalizes it, sell it in your clinic.
6. we need to stop being so scared of benzos, klonopin to keep it on the even keel and xanax for breakthrough, temazepam to keep our circadian rhythm in check. we keep your yin and yang in balance, hey, use some stims if you're feeling a bit sedated

hope to hear other tips and tricks from other forum readers! yes, i thought it may be fun to poke a little fun at the frustrations some of us have in practice

Could also be a blueprint for how to rise up the ranks of the new 'Mental Health' service line at the VA all the way up to 'National Mental Health Grand Poobah over All VISN's.'

 

[randomdoc1]

7.do some integration by incorporating some other outside the box quacky stuff. Like hcg diet for weight loss, off label Lyme disease panels, hormonal testing possible subtle off balances, etc.

 

[Trismegistus4]

The comment about Adderall IR resonates with me too. I've received numerous transfers of people who were on Adderall IR and it was the first and only stimulant they've ever been given. And of course, that is the holy grail and they then don't want to try anything else. Look, I'm not advocating prescribing stimulants to anyone, but have these other docs never heard of Concerta or Vyvanse? Who exactly are these docs who think it's a good idea to dive right in off the deep end with Adderall IR?

 

[randomdoc1]

The comment about Adderall IR resonates with me too. I've received numerous transfers of people who were on Adderall IR and it was the first and only stimulant they've ever been given. And of course, that is the holy grail and they then don't want to try anything else. Look, I'm not advocating prescribing stimulants to anyone, but have these other docs never heard of Concerta or Vyvanse? Who exactly are these docs who think it's a good idea to dive right in off the deep end with Adderall IR?

Agreed. Especially in primary care. That and NPs from what I observed. I also can’t stand how benzos are the go to first line for agitation, anxiety, distress, etc. even worse when it turns out it was due to AODA or ptsd. Sheesh.

 

[michaelrack]

My approach for stimulants (for sleep disorders usually) is to start off with short acting agents and then transition to long acting formulation... I will occasionally start off with vyvanse, but this can lead to insurance issues

 

[dl2dp2]

1. put all your PTSD patients, borderline patients, any patient with mood lability/insomnia on xanax
2. soon as someone mentions attentional complaints, give adderall IR
3. CBT is overrated, be a bleeding heart
4. offer to do long term disability paperwork for all comers
5. say you have a holistic/alternative approach and are into herbals (that seems to be the in thing these days) and tout the benefits of THC. Better yet, if you are in a state that legalizes it, sell it in your clinic.
6. we need to stop being so scared of benzos, klonopin to keep it on the even keel and xanax for breakthrough, temazepam to keep our circadian rhythm in check. we keep your yin and yang in balance, hey, use some stims if you're feeling a bit sedated

hope to hear other tips and tricks from other forum readers! yes, i thought it may be fun to poke a little fun at the frustrations some of us have in practice

On a more serious note, I think the more successful practices these days market on exactly the OPPOSITE of all of these. There are way too many "holistic" practices that peddle benzos out there trying to make a quick buck off the third party payer. Think about it: who are the people who would be coming in droves for Adderall IR and get disability? People who don't have steady jobs and are low functioning. These are not ideal patients to keep in your practice, and such a practice is a headache to maintain. Insurance practices should really be structured as non-profits and apply for municipal support to get a team-based delivery model. The problems you are describing has a lot to do with mismatch of care delivery and the patient population.

If you want to fill a true private practice quickly with people who can PAY and will get better, I would take the opposite approach. For example, for people who want ADHD meds, I would tell them straight out that you are gonna pay a lot time for a very comprehensive evaluation before any prescriptions can be written. They have to follow your rules, which are dictated by good clinical care and scientific evidence. Ironically, people end up coming to me even though they could've picked someone else and pay them much less. People who are well off actually respect a confident clinician who can tell them no. You don't want to develop a reputation as a bottom feeder clinician--for one thing, they don't get paid well and in the long run won't be able to fill with anything BUT that mismatched population.

I think there's a big misconception on these boards that the most well-to-do psychiatrists are money grubbing peddlers selling controlled substances to addicts and halfway committing insurance frauds. No that's not how it works. The best paid psychiatrist provide the highest quality care that are the most expensive. There is a woefully inadequate supply of high quality private care. It's next to impossible to find a psychiatrist competent psychopharmacologist who also does evidence based psychotherapy for common conditions like ADHD and alcohol use. The quality of psychotherapists (PhD/LCSWs) who supposedly specialize in psychotherapy in X is highly variable--this is personal experience, I try to outsource therapy whenever possible, but sometimes it's just impossible. The degree of incompetence is absolutely shocking. You have NO idea how many therapists drop patients the minute they hear ANY hint of suicidal ideation, or co-morbidity, etc. People WILL pay what the market can bear if you can demonstrate your value.

 

[Merely]

On a more serious note, I think the more successful practices these days market on exactly the OPPOSITE of all of these. There are way too many "holistic" practices that peddle benzos out there trying to make a quick buck off the third party payer. Think about it: who are the people who would be coming in droves for Adderall IR and get disability? People who don't have steady jobs and are low functioning. These are not ideal patients to keep in your practice, and such a practice is a headache to maintain. Insurance practices should really be structured as non-profits and apply for municipal support to get a team-based delivery model. The problems you are describing has a lot to do with mismatch of care delivery and the patient population.

If you want to fill a true private practice quickly with people who can PAY and will get better, I would take the opposite approach. For example, for people who want ADHD meds, I would tell them straight out that you are gonna pay a lot time for a very comprehensive evaluation before any prescriptions can be written. They have to follow your rules, which are dictated by good clinical care and scientific evidence. Ironically, people end up coming to me even though they could've picked someone else and pay them much less. People who are well off actually respect a confident clinician who can tell them no. You don't want to develop a reputation as a bottom feeder clinician--for one thing, they don't get paid well and in the long run won't be able to fill with anything BUT that mismatched population.

I think there's a big misconception on these boards that the most well-to-do psychiatrists are money grubbing peddlers selling controlled substances to addicts and halfway committing insurance frauds. No that's not how it works. The best paid psychiatrist provide the highest quality care that are the most expensive. There is a woefully inadequate supply of high quality private care. It's next to impossible to find a psychiatrist competent psychopharmacologist who also does evidence based psychotherapy for common conditions like ADHD and alcohol use. The quality of psychotherapists (PhD/LCSWs) who supposedly specialize in psychotherapy is highly variable--this is personal experience, I try to outsource therapy whenever possible, but sometimes it's just impossible. The degree of incompetence is absolutely shocking. You have NO idea how many therapists drop patients the minute they hear ANY hint of suicidal ideation. People WILL pay what the market can bear if you can demonstrate your value.

With re to being paid what the market will bear, are you talking about a cash practice? Otherwise aren’t you just paid by insurance for each patient so it makes more sense to see 4+ patients per hour if you wanted to increase profitability.

 

[dl2dp2]

With re to being paid what the market will bear, are you talking about a cash practice? Otherwise aren’t you just paid by insurance for each patient so it makes more sense to see 4+ patients per hour if you wanted to provide low quality care but actually increase profitability.

Half of psychiatrists "don't take insurance". However, this does not mean that you are not partially subsidized by insurance out of network benefits. In my experience, I found that a decent number of patients come to me paying straight cash when they don't have any insurance. I think a lot of people can afford a few hundred dollars a month for quality psychiatric care, if you can demonstrate real value. The issue of OON/insurance coverage problem mainly apply to patients who need intensive psychotherapy. And if you live in a good sized metro, there are layers of options with a mix of insurance/non-insurance based care.

Of course, you can say half of America has less than 15k in savings, and will never be able to commit 5k to private mental health treatment. To this I say PP is not the right treatment model for this group. For this group, you need a medical home model with layers of wraparound support, case managers, social workers for screening, etc. etc. Just because these people are poor doesn't mean that they don't deserve the time they need--but just not with you. Trying to fill a solo private practice with that group is mistake #1--and it's not just a clinical mistake, it's a business strategy mistake--misallocation of human capital.

 

[VA Hopeful Dr]

My approach for stimulants (for sleep disorders usually) is to start off with short acting agents and then transition to long acting formulation... I will occasionally start off with vyvanse, but this can lead to insurance issues

As one of those primary care people, I always try to start with long acting but insurance coverage is getting pretty bad about it. And even the generic longer acting stuff isn't all that cheap. Cash price for generic concerta is still like $100. Ritalin LA around $80. Adderall XR $60.

Meanwhile Adderall IR is $25.

 

[whopper]

so I've been getting a steady stream of his patients, and they're ALL on benzos.

Most of you will go through the very same.

Also there's a place in town, an inpatient psych facility, that diagnoses EVERYONE with bipolar disorder, gives everyone lithium and Seroquel no matter what is going on with them.

 

[randomdoc1]

Most of you will go through the very same.

Also there's a place in town, an inpatient psych facility, that diagnoses EVERYONE with bipolar disorder, gives everyone lithium and Seroquel no matter what is going on with them.

Yea, they are totally off the ball. No comorbid panic disorder? Where's the benzos?

On a serious note, there is an inpatient facility that does that too. Except everyone leaves on abilify, 400mg lamotrigine and gets taken off all antidepressants. At least it brings in business, maybe they're on to something 😉.

 

[whopper]

The place in my area, a doc only sees the patient for a few minutes, NPs do most of the work, and the NPs don't know what they're doing. They diagnose Bipolar Disorder off of a screening tool that isn't designed to diagnose (none of them are) by simply just racking up symptoms on a checklist and if you have more than 4 you got Bipolar Disorder, but that's what they do at this place. (For you students, those screening tools are only a guide and you need to still chart the temporal patterns of mania/depression, and rule out substance-induced episodes, something these NPs don't do).

And the guy who owns the place rakes in millions despite that he's offering very substandard care.

The reason why places like this rake in cash is cause there's shortages of psychiatrists, people need treatment and then this guy gives a fast-food version of it and use of that term is insulting to fast-food. At least in fast-food you know you're getting cheap food. These patients don't know they're being given the equivalent of a factory-automated process diagnosis and treatment, something that you're not supposed to do as a practicing physician.

And the reason why people don't know they're getting crap is cause psychiatry has it's grey areas where people can't objectively and immediately tell they're getting bad treatment. I've said this before. While psych in and of itself is a valid field, it's far easier to get away with crap, and when there's a shortage of psychiatrists, the dung-servers can serve it, get away with it, and the patients don't know better will keep coming back.

 

[MedMan80]

Most of you will go through the very same.

Also there's a place in town, an inpatient psych facility, that diagnoses EVERYONE with bipolar disorder, gives everyone lithium and Seroquel no matter what is going on with them.

Honestly the inpatient child unit in our area does this as well, to be the devils advocate however..when you sit down and talk to a lot of these kids they can meet the criteria for BP2/sometimes BP1..and of course much of the time the diagnosis goes back to unspec bipolar d/o or maybe an emerging borderline PD on the outpatient, but a lot of these kids end up doing better/faster on an atypical on the inpatient unit..That being said, if the doc was just labeling BPD with a 5 min eval for the purposes of getting easy insurance auth, then I agree with you that's 100% BS

 

[MedMan80]

The place in my area, a doc only sees the patient for a few minutes, NPs do most of the work, and the NPs don't know what they're doing. They diagnose Bipolar Disorder off of a screening tool that isn't designed to diagnose (none of them are) by simply just racking up symptoms on a checklist and if you have more than 4 you got Bipolar Disorder, but that's what they do at this place. (For you students, those screening tools are only a guide and you need to still chart the temporal patterns of mania/depression, and rule out substance-induced episodes, something these NPs don't do).

And the guy who owns the place rakes in millions despite that he's offering very substandard care.

The reason why places like this rake in cash is cause there's shortages of psychiatrists, people need treatment and then this guy gives a fast-food version of it and use of that term is insulting to fast-food. At least in fast-food you know you're getting cheap food. These patients don't know they're being given the equivalent of a factory-automated process diagnosis and treatment, something that you're not supposed to do as a practicing physician.

And the reason why people don't know they're getting crap is cause psychiatry has it's grey areas where people can't objectively and immediately tell they're getting bad treatment. I've said this before. While psych in and of itself is a valid field, it's far easier to get away with crap, and when there's a shortage of psychiatrists, the dung-servers can serve it, get away with it, and the patients don't know better will keep coming back.

A lot of good points here whopper!

 

[whopper]

I'm wondering how many people liked my post above cause they want to emulate what this POS psychiatrist does.

I forgot to mention, the same POS psychiatrist is providing clinical data to various pharm companies so each patient he diagnoses with Bipolar Disorder he gets a nice little monetary gratuity for throwing another patient into their study.

Seriously, so many psychiatrists and psychologists in the area know this is going on but because we weren't the actual patients we aren't in a position where we can complain of this poor treatment. Literally, I've had over a 40 patients all report the same thing-that when in this place they were seen by the doctor only 5 minutes or less, an NP did pretty much all the work, they checked a few boxes on a screening list and they were told that in and of itself diagnoses them with Bipolar Disorder. The talk around town among many health providers (even non mental-health providers) is they know this place is BS. E.g. a friend of mine who's an IM doc went up to me and asked, "what's up with _____? They diagnosed one of my patients with Bipolar Disorder and even I know that patient doesn't have it. They just have a drinking problem."

It's sad. It's happening right under our noses and nothing's being done to stop this BS practice.

 

[splik]

It's sad. It's happening right under our noses and nothing's being done to stop this BS practice.

you could report it to the medical board for negligent supervision of NPs and fraud. While it is unlikely they will do anything, you will have discharged your duty to call out a rogue practitioner, and the board has to put any complaints on file, even if they don't act on it. If there are further complaints in the future, then they will have more of a basis to act on them.

 

[ridethecliche]

Thread had potential.

Forgot to mention mindfulness. So close yet so far.

 

[TexasPhysician]

Thread had potential.

Forgot to mention mindfulness. So close yet so far.

That must be the key for my counselors!

 

[ridethecliche]

That must be the key for my counselors!

But if you do that everyone will get fixed and there goes your practice!

 

[TexasPhysician]

But if you do that everyone will get fixed and there goes your practice!

If I could command that cure rate, I’d be a multi-millionaire fast!

 

[psyguru]

The place in my area, a doc only sees the patient for a few minutes, NPs do most of the work, and the NPs don't know what they're doing. They diagnose Bipolar Disorder off of a screening tool that isn't designed to diagnose (none of them are) by simply just racking up symptoms on a checklist and if you have more than 4 you got Bipolar Disorder, but that's what they do at this place. (For you students, those screening tools are only a guide and you need to still chart the temporal patterns of mania/depression, and rule out substance-induced episodes, something these NPs don't do).

And the guy who owns the place rakes in millions despite that he's offering very substandard care.

The reason why places like this rake in cash is cause there's shortages of psychiatrists, people need treatment and then this guy gives a fast-food version of it and use of that term is insulting to fast-food. At least in fast-food you know you're getting cheap food. These patients don't know they're being given the equivalent of a factory-automated process diagnosis and treatment, something that you're not supposed to do as a practicing physician.

And the reason why people don't know they're getting crap is cause psychiatry has it's grey areas where people can't objectively and immediately tell they're getting bad treatment. I've said this before. While psych in and of itself is a valid field, it's far easier to get away with crap, and when there's a shortage of psychiatrists, the dung-servers can serve it, get away with it, and the patients don't know better will keep coming back.

I also see nps misdiagnosing/mistreating bipolar II as mdd with ssris. They will be wondering why one would stop elavil or trazodone in a manic patient who is complaining of insomnia.

Sent from my SM-G965U using Tapatalk

 

[nexus73]

Most of you will go through the very same.

Also there's a place in town, an inpatient psych facility, that diagnoses EVERYONE with bipolar disorder, gives everyone lithium and Seroquel no matter what is going on with them.

Don't they know you're supposed to put everyone on Depakote and Risperdal.

 

[randomdoc1]

Don't they know you're supposed to put everyone on Depakote and Risperdal.

You all got it wrong. Seroquel AND depakote with mirtazapine max dose for insomnia. How’s that for some metabolic syndrome? Or maybe it should be zyprexa instead of seroquel?

 

[ridethecliche]

I thought the plan was to give Keppra to every patient with mood issues. I've heard that works awesome!

 

[randomdoc1]

Ugh, just got a new patient with schizoaffective disorder. Of course, previous provider puts her on Adderall for concentration complaints. I started abilify and she complains about the Abilify and says now she REALLY needs to continue that Adderall because of the fatigue she gets on the Abilify....wtf. Maybe that amphetamine is what is contributing to the psychosis in the first place >.>

 

[clausewitz2]

Ugh, just got a new patient with schizoaffective disorder. Of course, previous provider puts her on Adderall for concentration complaints. I started abilify and she complains about the Abilify and says now she REALLY needs to continue that Adderall because of the fatigue she gets on the Abilify....wtf. Maybe that amphetamine is what is contributing to the psychosis in the first place >.>

Not actually insane:

"
A systematic review of psychostimulant treatment of negative symptoms of schizophrenia: Challenges and therapeutic opportunities"

https://www.sciencedirect.com/science/article/pii/S0920996413001655

 

[randomdoc1]

A systematic review of psychostimulant treatment of negative symptoms of schizophrenia: Challenges and therapeutic opportunities

RESULTS:
Improvement of NSS after psychostimulant administration is reviewed both in challenge and treatment paradigms with various agents such as methylphenidate, amphetamine, and modafinil or armodafinil. The literature points to evidence that, used adjunctively, DA agonists may improve NSS without worsening of positive symptoms in selected patients who are stable and treated with effective antipsychotic medications. Several areas of inadequate study and limitations are identified including small study samples, single-site trials, varying rigor of bias control, the dose and the duration of adjunctive psychostimulant administration, and the potential for development of tolerance.

CONCLUSION:
Large, controlled clinical trials to further characterize effects of psychostimulants on NSS in carefully selected patients are warranted.

I'd like to get her psychosis under control first. She's still delusional by the way. I'd still prefer nuvigil over adderall.

 

[clausewitz2]

RESULTS:
Improvement of NSS after psychostimulant administration is reviewed both in challenge and treatment paradigms with various agents such as methylphenidate, amphetamine, and modafinil or armodafinil. The literature points to evidence that, used adjunctively, DA agonists may improve NSS without worsening of positive symptoms in selected patients who are stable and treated with effective antipsychotic medications. Several areas of inadequate study and limitations are identified including small study samples, single-site trials, varying rigor of bias control, the dose and the duration of adjunctive psychostimulant administration, and the potential for development of tolerance.

CONCLUSION:
Large, controlled clinical trials to further characterize effects of psychostimulants on NSS in carefully selected patients are warranted.

I'd like to get her psychosis under control first. She's still delusional by the way. I'd still prefer nuvigil over adderall.

Modafinil/armodafinil work by inhibiting dopamine re-uptake and appears to be DAT-dependent based on knockout studies, although it is not quite pharmacologically identical to stimulants.

Also Abilify is less sedating than many neuroleptics but it certainly can sedate people. It is also possible that the fatigue she is complaining about is the kind of cognitive slowing/working memory impairment that we know is associated with neuroleptics. Obviously a tricky case. I am curious about whether her delusions or positive sx interfere with her life significantly, but that is way off topic for this thread.

 

[MedMan80]

Mo


Modafinil/armodafinil work by inhibiting dopamine re-uptake and appears to be DAT-dependent based on knockout studies, although it is not quite pharmacologically identical to stimulants.

Also Abilify is less sedating than many neuroleptics but it certainly can sedate people. It is also possible that the fatigue she is complaining about is the kind of cognitive slowing/working memory impairment that we know is associated with neuroleptics. Obviously a tricky case. I am curious about whether her delusions or positive sx interfere with her life significantly, but that is way off topic for this thread.

Good luck getting insurance to pay for the modafinil for this indication, although worth mentioning that Costco sells it as a cash price of 30ish dollars if the patient can afford it..

 

[randomdoc1]

Good luck getting insurance to pay for the modafinil for this indication, although worth mentioning that Costco sells it as a cash price of 30ish dollars if the patient can afford it..

Costco is exactly what I do, and you do not need a membership to use the pharmacy. I also have the patient buy the largest tab and break it in half, so the price is more like, $15/month.

I am curious about whether her delusions or positive sx interfere with her life significantly, but that is way off topic for this thread.

she's pretty delusional. she self isolates from most and she's bordering on paranoid about other medications (starting to wonder if some are poisonous or not), all but adderall (yet?).

 

[ridethecliche]

That's like weirdly specific lol.

 

[randomdoc1]

That's like weirdly specific lol.

well...it is a pretty self reinforcing drug given the potent effects on the nucleus accumbens =/. That and the amphetamines do more than simple dopamine reuptake inhibition, there is also a lot of dopamine release from the neurons which imho is a lot of dopamine sitting around for a psychotic patient or one prone to psychosis.

 

[Crayola227]

Modafinil/armodafinil work by inhibiting dopamine re-uptake and appears to be DAT-dependent based on knockout studies, although it is not quite pharmacologically identical to stimulants.

Also Abilify is less sedating than many neuroleptics but it certainly can sedate people. It is also possible that the fatigue she is complaining about is the kind of cognitive slowing/working memory impairment that we know is associated with neuroleptics. Obviously a tricky case. I am curious about whether her delusions or positive sx interfere with her life significantly, but that is way off topic for this thread.

I've seen bradykinesia Parkinsonian effects with Ablify, that the patient sort of felt like was a profound fatigue despite having more "motivation" and "oomph," and was having to take afternoon naps on it. My parent with ADD used to drink two pots of coffee before bed, it truly seemed to put him to sleep. I never rule out that anything can be sedating for whatever reason.

 

[randomdoc1]

I don’t doubt antipsychotics can cause fatigue. Although the stim was started well before any antipsychotic was in this case.

 

[cara susanna]

You forgot emotional support animals! The MH administration at my last job used to joke about opening a practice when they retire where they just give out marijuana and dogs. They'd call it "Pot and Puppies."

 

[Fan_of_Meehl]

You forgot emotional support animals! The MH administration at my last job used to joke about opening a practice when they retire where they just give out marijuana and dogs. They'd call it "Pot and Puppies."

Pot, Puppies, and Paychecks (for PTSD) sounds like a dream...until it's not.

 

[nexus73]

You forgot emotional support animals! The MH administration at my last job used to joke about opening a practice when they retire where they just give out marijuana and dogs. They'd call it "Pot and Puppies."

You could round this out by focusing on adult adhd and suboxone prescriptions.

 

[Trismegistus4]

Pot, Puppies, and Paychecks (for PTSD) sounds like a dream...until it's not.

And don't forget, the PTSD doesn't actually satisfy criterion A (firsthand exposure to actual or threatened death, serious bodily injury, or sexual violence.) There are so many people out there with woefully undiagnosed PTSD from having people say mean things to them, or hearing that their friend's house got burglarized when they weren't home, and it's tragic that our society asks them to keep getting up and going to work every day instead of collecting free money from the government.

 

[uname943]

And don't forget, the PTSD doesn't actually satisfy criterion A (firsthand exposure to actual or threatened death, serious bodily injury, or sexual violence.) There are so many people out there with woefully undiagnosed PTSD from having people say mean things to them, or hearing that their friend's house got burglarized when they weren't home, and it's tragic that our society asks them to keep getting up and going to work every day instead of collecting free money from the government.

The DSM5 does not mandate first hand exposure to get PTSD.

Criterion A trauma exposure can be through:
"• Direct exposure
• Witnessing trauma
• Learning of a trauma
• Repeat or extreme indirect exposure to aversive details"

Table 1: DSM-5 criteria for PTSD

 

[Fan_of_Meehl]

The DSM5 does not mandate first hand exposure to get PTSD.

Criterion A trauma exposure can be through:
"• Direct exposure
• Witnessing trauma
• Learning of a trauma
• Repeat or extreme indirect exposure to aversive details"

Table 1: DSM-5 criteria for PTSD

Richard McNally made perhaps the most significant observation on the 'bracket creep' (i.e., the expanding definition of what counts as a traumatic stressor to satisfy Criterion A):

(paraphrased): As the number and types of incidents to be considered 'traumatic' increases (to the point that they become nearly universally experienced by people in the population and perhaps even very frequently experienced), the etiological significance of the 'traumatic events' in causing the 'symptoms of PTSD' decreases, and vice versa.

Stated differently, as 'bracket creep' for Criterion A increases, the traumatic stressor itself recedes into the causal background and personologic/predisposing variables within the individual advance into the causal foreground (in explaining the 'symptoms of PTSD) which, if you think about it, is a direct assault on the integrity of the construct/taxon of 'Posttraumatic Stress Disorder' itself. Quite a problem, conceptually.

 

[Trismegistus4]

Richard McNally made perhaps the most significant observation on the 'bracket creep' (i.e., the expanding definition of what counts as a traumatic stressor to satisfy Criterion A):

(paraphrased): As the number and types of incidents to be considered 'traumatic' increases (to the point that they become nearly universally experienced by people in the population and perhaps even very frequently experienced), the etiological significance of the 'traumatic events' in causing the 'symptoms of PTSD' decreases, and vice versa.

Stated differently, as 'bracket creep' for Criterion A increases, the traumatic stressor itself recedes into the causal background and personologic/predisposing variables within the individual advance into the causal foreground (in explaining the 'symptoms of PTSD) which, if you think about it, is a direct assault on the integrity of the construct/taxon of 'Posttraumatic Stress Disorder' itself. Quite a problem, conceptually.

Exactly. "Learning of a trauma?" Give me a break. The idea that someone heard from a friend that they got mugged, and thereafter is constantly diving under the nearest table every time they hear a sudden noise, dissociating, having suicidal thoughts, and can't leave their house is totally bogus.

 

[Fan_of_Meehl]

Exactly. "Learning of a trauma?" Give me a break. The idea that someone heard from a friend that they got mugged, and thereafter is constantly diving under the nearest table every time they hear a sudden noise, dissociating, having suicidal thoughts, and can't leave their house is totally bogus.

Yes. There's an almost infinite number of particulars that could fall under the broad conceptual umbrella of 'learning of a trauma.'

I would consider being shown a video of your three-year-old child being mercilessly tortured to death and raped in the next room to be sufficiently disturbing to count as a Criterion A stressor.

On the other end of things, reading about someone being slapped in the face would not be a Criterion A stressor.

And there's an ocean of possibilities in between.

We have a fundamental problem when we try to make the DSM definitions all about 'objective facts' (the operational definition angle) and not interpretation of facts through theoretical constructs (and life experiences, for example). A good example is the DSM criteria for Antisocial Personality Disorder vs. the construct of Type 1 psychopathy. Operationalism is a useful tool in science, even in behavioral science. But you'll never fully get away from theory and interpretation as glue that knits observational 'facts' together.

 

[calvnandhobbs68]

The DSM5 does not mandate first hand exposure to get PTSD.

Criterion A trauma exposure can be through:
"• Direct exposure
• Witnessing trauma
• Learning of a trauma
• Repeat or extreme indirect exposure to aversive details"

Table 1: DSM-5 criteria for PTSD

Criteria are overly inclusive.

“Repeat or extreme indirect exposure to aversive details”...oh so when a kid gets straight Fs on his tests all semester he can now claim that he has PTSD? Getting bad grades can be traumatic right? Gtfo.

 

[Trismegistus4]

Criteria are overly inclusive.

“Repeat or extreme indirect exposure to aversive details”...oh so when a kid gets straight Fs on his tests all semester he can now claim that he has PTSD? Getting bad grades can be traumatic right? Gtfo.

I'm seeing this kind of thing a lot in patients' charts. The masters-level therapists are diagnosing people with PTSD solely on the basis of their expressing general emotional distress over some experience which, while negative, was hardly life-destroying. One of the first patients I saw in my current job was a woman who probably had characterological problems, but who was extremely invested in having a diagnosis of PTSD. Her trauma? Getting fired from her job.

 

[uname943]

Criteria are overly inclusive.

“Repeat or extreme indirect exposure to aversive details”...oh so when a kid gets straight Fs on his tests all semester he can now claim that he has PTSD? Getting bad grades can be traumatic right? Gtfo.

Strawman. No one here is making that argument. The DSM notes that trauma has to be about death, threatened death, serious injury, or sexual violence.

 

[Fan_of_Meehl]

I'm seeing this kind of thing a lot in patients' charts. The masters-level therapists are diagnosing people with PTSD solely on the basis of their expressing general emotional distress over some experience which, while negative, was hardly life-destroying. One of the first patients I saw in my current job was a woman who probably had characterological problems, but who was extremely invested in having a diagnosis of PTSD. Her trauma? Getting fired from her job.

It's an interesting phenomenon. PTSD seems to be the only psychiatric disorder that most patients will get PISSED at you for NOT diagnosing in them. I have to tell people 'no' all the time.

 

[randomdoc1]

It's an interesting phenomenon. PTSD seems to be the only psychiatric disorder that most patients will get PISSED at you for NOT diagnosing in them. I have to tell people 'no' all the time.

I get plenty of peopled pissed at me for saying that they actually don't have ADHD and feeling alert on stimulants is not diagnostic. Some people have also carved out identities as being "bipolar" when they are clearly not. Fortunately one patient was receptive to being treated as unipolar treatment resistant depression and he got so much better after decades of him barking up the wrong tree.

 

[randomdoc1]

People who are well off actually respect a confident clinician who can tell them no. You don't want to develop a reputation as a bottom feeder clinician--for one thing, they don't get paid well and in the long run won't be able to fill with anything BUT that mismatched population.

I may have to create a friendly argument against this. There's a guy who runs an adult ADHD clinic that only takes cash. His model is you pay a few hundred a month for a "subscription" for his services. I'd think that only people who are better off can afford this. He's extremely busy and running a super lucrative practice. He doesn't know a darn thing about ADHD and rumor has it, he believes he has ADHD himself. If he truly does, who knows. imho, from experience, benzos certainly keep people coming back, well off or not. There are many private practices in my community that are extremely busy with privately insured people who are middle to upper class, unfortunately it is not uncommon to see some wild benzodiazepine regimens. I've learned of this after some psychiatrists retired and I had to turn some people away saying "sorry, I'm not comfortable with continuing your 8mg of ativan while you are also chronically on fentanyl and oxycodone (that and 8mg is a lot)." A good number of my current patients who work for reputable companies have also tried to broach the topic of "why can't you just increase the klonopin, that klonopin seems to work really well" but i just explain them the evidence and some of the pharmacology. Most have been receptive to my explanations though. The thing is, I think even well educated patients, unless you work in medicine, it is hard to tell what is good medicine and what is not (e.g. most don't know how appraise the medical literature or have great knowledge of the pharmacology). Patients primarily know and have to work off, their own personal experiences with the medications.

While psych in and of itself is a valid field, it's far easier to get away with crap, and when there's a shortage of psychiatrists, the dung-servers can serve it, get away with it, and the patients don't know better will keep coming back.