most difficult psych patients

[OldPsychDoc]

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Only seen 1 psychiatrist as a psych patient, and one pediatrician but never was directly in charge of treatment. I managed lotsa nurses though.... i think it really depends on the diagnosis. So far nurses have proven to me to be the most NON-COMPLIANT human beings on earth.. I can't convince them of anything.

Nothing like an opiate addicted nurse with a bit of histrionic PD...throw in a touch of fibromyalgia, and

 

[billypilgrim37]

Nothing like an opiate addicted nurse with a bit of histrionic PD...throw in a touch of fibromyalgia, and

If your archetype pt is also a lesbian, I think I know about three of her.

 

[whopper]

I managed lotsa nurses though.... i think it really depends on the diagnosis. So far nurses have proven to me to be the most NON-COMPLIANT human beings on earth.. I can't convince them of anything.

Do you mean the nurses that you work with, or nurses that are your patients?

 

[Regnvejr]

....What gets me with DID patients is how some of them continually test you. It can be like borderline PD to the nth degree and it gets scary at times.

Essentially, DID is a more extreme reaction to trauma than BPD is. So it is not surprising that these patients have strong BPD features as well. In fact, out of the relatively significant number of DID patients I have had, all have PTSD and most also have BPD.

 

[ClinPsycMasters]

Dissociation is a continuum actually. It goes from the common stuff that everyone does (like getting really absorbed in a good book) all the way up to the fragmentation with amnesia barriers that is DID. The alters in DID aren't really separate people or personalities, but they can act like it to a large degree. I think the process of dissociaton can play a large role in BPD, PTSD, etc, but that DID is a valid, if very extreme, manifestation.

Yes, I am aware that dissociation can be conceptualized as a continuum. I think DID is being diagnosed more and more often these days, hence my negative view of it. But it's quite likely that there are valid cases of DID out there. And must be hell to diagnose and manage/treat, specially when numerous alters involved. I'd be really interested in psychoanalytic views of DID and its development.

 

[billypilgrim37]

Any time a med student mentions something about dissociation (why is this so high on every MS's differential?), I usually tell them "*this institution* doesn't believe in dissociation." Because I'm pretty sure it is requisite to not believe in DID to work in my department. There's one guy at the VA who does, and when we rotate with him he spends quite a while educating/convincing us about DID.

 

[sunlioness]

Yes, I am aware that dissociation can be conceptualized as a continuum. I think DID is being diagnosed more and more often these days, hence my negative view of it.

Why would something being diagnosed more often make you think of it more negatively? Does the fact that bipolar disorder and ADHD seem to be being diagnosed more often recently also make you doubt that these are valid diagnoses?

Having said that, it isn't my experience that DID is being diagnosed more frequently recently. That could be just because of the community I live in. The overall tenor of the mental health community around here is fairly "anti", with some exceptions scattered around.

From what I understand, there was a pretty hysterical DID craze back in the early '90s in which a lot of boundary impaired "trauma therapists" who likely had their own survivor issues were diagnosing DID and publishing all over the place, with frequent mention of Satanic daycares and dead babies. Kind of glad I missed that one. 🙂

 

[whopper]

From what I understand, there was a pretty hysterical DID craze back in the early '90s in which a lot of boundary impaired "trauma therapists" who likely had their own survivor issues were diagnosing DID and publishing all over the place, with frequent mention of Satanic daycares and dead babies. Kind of glad I missed that one.

This is true. Several psychologists used to testify as expert witnesses on it in major trials. They used recovered memories which have been found to be unreliable.

Since sexual abuse is a type of memory that was theorized to be submerged as a type of ego-defense, and because it is associated with DID, some tried to use it as a legal defense. Several therapists tried to diagnose people with DID that mental health professionals with years of experience today tell me were on the order of ridiculous.

 

[Therapist4Chnge]

Since sexual abuse is a type of memory that was theorized to be submerged as a type of ego-defense, and because it is associated with DID, some tried to use it as a legal defense. Several therapists tried to diagnose people with DID that mental health professionals with years of experience today tell me were on the order of ridiculous.

It definitely received (and deserved) the beaten it took in the courts. Any clinician that does unproven fringe work in regard to trauma needs to be formally reprimanded. A true DID case is the zebra amongst horses. I don't think there are more zebras than say 50 years ago, though I think we have some better insight as to what makes a zebra and what is actually a horse with painted on stripes.

 

[ClinPsycMasters]

it isn't my experience that DID is being diagnosed more frequently recently.

Oops, I was referring to depersonalization disorder not DID. Got my facts mixed up.

 

[whopper]

Any time a med student mentions something about dissociation (why is this so high on every MS's differential?), I usually tell them "*this institution* doesn't believe in dissociation." Because I'm pretty sure it is requisite to not believe in DID to work in my department. There's one guy at the VA who does, and when we rotate with him he spends quite a while educating/convincing us about DID.

I've had a few, not many, cases of people with a dissociative disorder who were misdiagnosed as being psychotic.

It's hard to differentiate between someone who is severely dissociating and psychotic, but I think it needs to be on someone's radar.

One example, I had a young female patient who's husband left her, he provided her with a good life, and she couldn't take care of herself. She ended up in the homeless shelter. While there, she started staring off into space and mumbling to herself. She was brought to the hospital and diagnosed as being psychotic. She was like that for about 5 days while on high doses of an antypical and Depakote.

Then her husband tells the treatment team he's going to take her back--she's immediately better. In fact she's not even taking the medication anymore and she's doing fine for 2 days.

Then 2 days later, he changes his mind. She's back to staring off into space and mumbling when asked questions.

This IMHO was not psychosis. It was IMHO dissociation in the face of a major stressor--the loss of her husband, her children (because he will get custody--she was a former stripper, he was a white collar guy), a severe drop in the quality of her life that she saw no hope in getting back.

I bet if he came back and told he he changed his mind again, she'd be fine. That clearly is not psychosis by our understanding of it.

To medicate someone like this is actually causing harm because it's going to start a fast trip to nowhere---a patient who is not psychotic being put on several antipsychotics, and eventually Clozaril because they don't show improvement.

Another case, didn't happen to me but one of my teachers, a guy wanted out on his marriage and preplanned it without letting his wife know. Then one day she comes home and the locks on the doors are changed. He actually had her sign documents that she did not know what they were that were post nuptial papers (the guy had money). He also arranged with his lawyer to have a restraining order put on her even though she did nothing dangerous.

She could not get into her home and she had no means to take care of herself. Just 1 month prior, her husband threw a large party for her in her honor proclaiming what a great wife she was. All her credit cards were also in his name and he cut her off from them.

She went into a state of acute emotional despair and ended up in the hospital. She was never psychotic and said something to the effect of "I can't believe my husband did this. It's as if he's been replaced by an evil double." She was also showing signs of dissociation such as staring off into space.

Well that was enough for the psychiatrist to have her placed on mega doses of an antipsychotic which then heavily sedated her to the point where she couldn't even stand up. She was then deemed not able to care for herself in the community and brought to the inpatient unit where she was then continued on this dosage. Her idiot treatment team never considered that this was an old lady, she was dependent on her husband, and she was in a state of emotional despair, and she really wasn't even psychotic, and 20 mg of Zyprexa could knock out this person of old age who was of low weight. Her treatment team described her as "confused", "disorganized" and unable to care for herself.

She didn't improve from her mega doses of Zyprexa, and actually took the medication thinking that if a doctor recommended it, there might actually be something to it that she should believe would help her. She was then transferred to a long term facility where she stayed for several months.

Finally, the doctor I mentioned was put on her case, he reviewed it, and talked to the psychiatrist about it (the doc I'm talking about is a psychologist). The patient was taken off of medication, and when taken off, she showed no signs of psychosis. She readily admitted she said that she said something to the effect that her husband may have been replaced and said it was a figure of speech.

I hate saying this, but I see this type of case happen from time to time, perhaps on the order of at least 3 per year. Someone misdiagnosed, put on the wrong treatment, then put on a fast trip to nowhere where they'll stay trapped for a long long long long time until someone took the time to actually truly read the case and try to understand what was going on, not just throw a pill at the most obvious symptom.

 

[Faebinder]

Do you mean the nurses that you work with, or nurses that are your patients?

heh, a joke i hope... No I ment nurses that are patients... X-nurses in many cases.

 

[Regnvejr]

It definitely received (and deserved) the beaten it took in the courts. Any clinician that does unproven fringe work in regard to trauma needs to be formally reprimanded. A true DID case is the zebra amongst horses. I don't think there are more zebras than say 50 years ago, though I think we have some better insight as to what makes a zebra and what is actually a horse with painted on stripes.

Indeed. I treat a significant number of trauma patients, as the local community otherwise barely accept the existence even of PTSD (and because we now have the State's first DBT team, which can take over therapy), and I have seen two cases in 3 years. Not everyday stuff.

 

[Regnvejr]

...I hate saying this, but I see this type of case happen from time to time, perhaps on the order of at least 3 per year. Someone misdiagnosed, put on the wrong treatment, then put on a fast trip to nowhere where they'll stay trapped for a long long long long time until someone took the time to actually truly read the case and try to understand what was going on, not just throw a pill at the most obvious symptom.

I have seen lots of crappy diagnoses. One always MUST review the criteria used for every diagnosis for a new patient in your care. I have seen more than a handful of patients diagnosed with schizophrenia for hypnogogal hallucinations and not an unclear thought anywhere. And quite a few bipolar patients diagnosed as borderline because they were "difficult."