Psychiatry Rant

[mehc012]

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No.

An Advanced Directive is different than a psychiatric hold.

An Advanced Directive, like the MDHHS, allows for the patients wishes and choices be known regarding advocates, choice of hospital, choice of provider, medications, and procedures. That form deals with voluntary patients: "My admission as a formal voluntary patient...," "I still have the right to give three days notice of my intent to leave a hospital if I am a formal voluntary patient."

A psychiatric hold, on the other hand, is involuntary. If a patient presented as described, and meets the legal criteria for involuntary hospitalization, the procedure is initiated allowing for confinement, observation, evaluation, and treatment. If the patient does not meet criteria, he/she cannot be held involuntarily, but may consent to voluntary hospitalization. Despite being on a hold, a patient can refuse medications and treatment, unless it is an emergency.



Sometimes an acute drug induced psychosis will clear in a few days without the need for meds.

Studies have shown that prolonged psychosis is a toxic state. Not treating it is like deciding not to put out a fire, resulting in more injury and disability.

I understand the difference. That was literally what I was pointing out. It's the why that bugs me.
I was more treating the hold itself as an acute treatment, of sorts, preventing death right now for an illness that may or may not resolve moving forward.
If someone expressed that they would not want life-preserving measures in the case of severe future mental illness, in my mind that would include a hold, as the entire purpose of a hold in the case of someone with SI is to prevent a suicide attempt/completion. The person, while they weren't suicidal, basically said that they would prefer to die of the complication of their illness.

Now, I'm not advocating that we should allow this, mind you. I'm just pointing out that we treat mental illness differently than physical illness. It's funny how often the hardest part of a discussion is even getting anyone to agree with the basic premise. I kind of thought the interesting part would come afterwards in discussing whether or not we think we should continue to treat them differently (I'd say yes, most likely) but we're still stuck in mental gymnastics trying to pretend that our policies are consistent across the board, when it's really no big deal that they aren't (policies rarely are).

I think an issue in the case where you want to hurt yourself AND you don't have capacity or competency or whatever, you're not in your right mind, if you've lost some touch with reality as you are psychotic, or are not able to articulate understanding of what might be the reasonable outcomes of refusing treatment (quick and dirty definition of capacity for making decisions), is to what extent are you a danger to others.

If you're totally with it to the point that you can get yourself d/c'd and kill yourself, great, I think you might manage that and not injure others. OTOH, perhaps you decide to go out "suicide by cop", jumping off a bridge into traffic, gun kill spree, murder suicide, even swallowing your gun a bullet could pass through. That's all suicide choices that hurt others that even "with it" people can make.

So I would argue that it's one thing for you to want to commit suicide when you're with it enough to arrange your own discharge. To some extent people who are going to practice self-murder, I would argue might be more of a concern about possibly hurting others compared to those who are mentally well, or stable, or don't need inpt tx, and don't express any SI/HI.

OTOH, while the proportion of mentally ill people who become violent is less than the gen pop, a psychiatrist is always considering to what extent are you a danger to others. If you're being held against your will because of the danger you are to yourself, often you're also a danger to others.

I think it's one thing to refuse a transfusion, and another to think that you should be able to ask that you not be institutionalized if you become psychotic to the point of being a danger to yourself or others. Which I would argue many are just by virtue of being a danger to oneself in many (not all) cases. No man is an island.

Now this is an interesting point. I'm not sure I fully agree with the idea that actively suicidal people are necessarily high risk for homicidal intent. I think it's far more nuanced than that. I only have personal experience with a small number of people, thankfully, but I tended to see more of "I don't want to be a burden and I can't even think of a way to die that wouldn't burden other people". Obviously that's not true all of the time.

However, I can understand how it would seem that way from a provider front, and your point about being 'with it' enough to pretend is really interesting.

more on this idea, it seemed to me whenever I was interviewing someone, I would ask about SI/HI, and it just made sense to me that when someone is getting so desperate and mentally ill that they are thinking about violence as a solution (towards themself), to consider if they are also thinking about hurting others.....

I'm not sure why you wouldn't think about this. Especially since it seems like a lot of crises involve some degree of issues with interpersonal relating.... like, are they suicidal because their SO broke up with them? wouldn't you consider if they are thinking about murder-suicide? I've frequently been surprised how much that comes up

I agree that reactive suicidality, where there's an aspect of "I'll show [person]" makes my spidey-sense tingle a bit more on the HI front than a chronic low self esteem issue, for example. But I feel as if more often, the interpersonal aspects come from the depression/low self esteem, rather than the other way around.

Fair enough. We're talking clinical decision-making vs. the theoretical issues surrounding involuntary holds/institutionalizing patients for the greater good. Since we were talking abstract notions about the "dehumanization" and "dignity" of patients it seemed fitting to point out protecting the safety of a patient often is also protecting the safety of others, one reason that justifies doing so.

Absolutely! Thanks both of you for the more interesting discussion here.

To more clearly express what I meant by dehumanizing, because I feel that it has become a distractor here: I think that any form of involuntary confinement is dehumanizing by its very nature. That's not the fault of psychiatry, it's an unfortunate side effect of the best intervention they have for these sorts of issues. I don't have an issue with a hold properly used; yeah it's awful and it sucks, but it's better than the alternative (even if you were allowed to opt out of holds, for example, few people would bother to know they could and even fewer would do it.) But I refuse to ignore the downsides of it, and it really bothered me in Psych block when our classmates would respond to every hypothetical with "hold" as a default reflex answer, because 'better safe than sorry'. Many people had the attitude that it's no big deal, and that I cannot accept. It is always a big deal to take away another person's freedom, even temporarily, and even for their own eventual good.

But none of that had anything to do with the discussion on how we treat mental and physical illness differently on the 'opting out' front, and I thank all of you for having a pretty interesting discussion of the ins and outs of that, seriously. Far better, imo, than continuing to legitimize the bullcrap spewed in the OP.

 

[Crayola227]

I understand the difference. That was literally what I was pointing out. It's the why that bugs me.
I was more treating the hold itself as an acute treatment, of sorts, preventing death right now for an illness that may or may not resolve moving forward.
If someone expressed that they would not want life-preserving measures in the case of severe future mental illness, in my mind that would include a hold, as the entire purpose of a hold in the case of someone with SI is to prevent a suicide attempt/completion. The person, while they weren't suicidal, basically said that they would prefer to die of the complication of their illness.

Now, I'm not advocating that we should allow this, mind you. I'm just pointing out that we treat mental illness differently than physical illness. It's funny how often the hardest part of a discussion is even getting anyone to agree with the basic premise. I kind of thought the interesting part would come afterwards in discussing whether or not we think we should continue to treat them differently (I'd say yes, most likely) but we're still stuck in mental gymnastics trying to pretend that our policies are consistent across the board, when it's really no big deal that they aren't (policies rarely are).

However, I can understand how it would seem that way from a provider front, and your point about being 'with it' enough to pretend is really interesting.

To more clearly express what I meant by dehumanizing, because I feel that it has become a distractor here: I think that any form of involuntary confinement is dehumanizing by its very nature. That's not the fault of psychiatry, it's an unfortunate side effect of the best intervention they have for these sorts of issues. I don't have an issue with a hold properly used; yeah it's awful and it sucks, but it's better than the alternative (even if you were allowed to opt out of holds, for example, few people would bother to know they could and even fewer would do it.) But I refuse to ignore the downsides of it, and it really bothered me in Psych block when our classmates would respond to every hypothetical with "hold" as a default reflex answer, because 'better safe than sorry'. Many people had the attitude that it's no big deal, and that I cannot accept. It is always a big deal to take away another person's freedom, even temporarily, and even for their own eventual good.

I agree that taking away someone's choice is a big deal.

I wouldn't say that the whole purpose of a hold is to prevent suicide. I think a hold allows a provider to more closely assess a patient to uncover why someone wants to hurt themselves. Is it because of the voices in their head? Honestly, sometimes catching someone who seems to be attending to internal stimuli, for example, might not happen in a clinic visit. Psychotic depression, where someone *literally* believes they are in a hell nightmare-scape and think that death might be the only way to stop the pain... why not intervene? We do with the delirious patient that is refusing abx for their UTI.

Because we believe that we should try to restore people to what we might call enough sanity, and I think this makes sense, because a lot of people would tell you that they don't want to be psychotic (except when they are) and they are dismayed by the choices they made while they were. This also applies to severe depression a lot of the time.

Keep in mind, that in the ED, plenty of interventions happen without patient consent. I've seen it happen even when there is an advanced directive in place (not that that should happen). In fact, I've been told that the young and healthy should not have an advanced directive, or should not have one that prohibits certain interventions (CPAP, bagging, intubation, for example). Physicians have to sign those forms. You can always have a POA that can speak up to prevent some interventions, but in the emergency scenario it's not a given that they are there in time to intervene.

Many people are also not aware that the POA has more power than the advanced directive. This is based on the idea that medicine is too complicated to let those simplistic documents rule all. That a POA is better able to take in the whole situation and deal with scenarios where the directive really might not represent what the patient would want in a very specific scenario

(I could get into a rant (which I have elsewhere) on code discussions and advanced directives and how physicians can have discussions that do a better job of eliciting what a patients really wants, and reasonable measures that have a higher likelihood of doing so).

The wishes of a POA aren't binding on what physicians do, actually. For the most part physicians don't stand against the advanced directive or POA, but actually, they can! Most don't for a lot of reasons. When these things go to court, however, often physicians win. Most of the time an ethical committee and attorney are consulted when this happens, which is likely why - they're in place to ensure that this is appropriate.

Right or wrong, we tend towards the side of protecting life. Someone has to be alive and mentally with it at some point to tell you they want intervention removed/not to happen so they can die as a result of their illness If that doesn't happen... If we just let the natural course of illness take place where it leads to death, that can't really be undone. (Nevermind how often this leads to a life that can't be undone by the patient). Doing so, I argue, actually affords the patient a chance to make an informed decision moving forward in many cases. To stabilize in the ED or with a hold, I argue, actually does more to respect patient autonomy and their ability to make an informed decision to move themselves to the goal of care that they want (or their POA).

And, interestingly, there's that those truly set on suicide, and well enough to think this far, and don't want anyone to interfere with that process, just don't tell others. Sure, we teach people to watch for the "signs" and if someone is "dropping hints", but a fair number of completed suicides don't have that particular warning sign. In fact, I would take that as evidence of a greater degree of informed choice. The patient is showing that they understand the consequences of their actions - that certain actions lead to a hold and interference with suicide plans, and that silence will help them move forward.

So essentially, I'm arguing that the person who makes their suicidal intent, either is asking for help, or is not thinking clearly enough to avoid being stopped. To my mind, that justifies the intervention. Because the patient does have autonomy, and can act to preserve it and kill themselves.

Going further with what you're saying, the person who isn't suicidal asking to be left to complete suicide as a consequence of their illness. I guess that's just where we as a society choose to take away someone's right. I think that's motivated by the idea that mental illness, which is treatable, shouldn't be the COD. If you get well and carry out your suicide, maybe that's just the limit of what we can do to treat people.

I guess I don't know that what we do with "forcing" treatment on the mentally ill is so different than other examples in other areas in medicine. In fact, I think the other examples are far more disturbing in so many ways.

TLDR:
Ultimately, I think my argument is that what you describe isn't unique to psych. That's why the ethics of medicine is such an interesting topic for its complexity and broad application 🙂

 

[mehc012]

I agree that taking away someone's choice is a big deal.

I wouldn't say that the whole purpose of a hold is to prevent suicide. I think a hold allows a provider to more closely assess a patient to uncover why someone wants to hurt themselves. Is it because of the voices in their head? Honestly, sometimes catching someone who seems to be attending to internal stimuli, for example, might not happen in a clinic visit. Psychotic depression, where someone *literally* believes they are in a hell nightmare-scape and think that death might be the only way to stop the pain... why not intervene? We do with the delirious patient that is refusing abx for their UTI.

Because we believe that we should try to restore people to what we might call enough sanity, and I think this makes sense, because a lot of people would tell you that they don't want to be psychotic (except when they are) and they are dismayed by the choices they made while they were. This also applies to severe depression a lot of the time.

Keep in mind, that in the ED, plenty of interventions happen without patient consent. I've seen it happen even when there is an advanced directive in place (not that that should happen). In fact, I've been told that the young and healthy should not have an advanced directive, or should not have one that prohibits certain interventions (CPAP, bagging, intubation, for example). Physicians have to sign those forms. You can always have a POA that can speak up to prevent some interventions, but in the emergency scenario it's not a given that they are there in time to intervene.
TLDR:
Ultimately, I think my argument is that what you describe isn't unique to psych. That's why the ethics of medicine is such an interesting topic for its complexity and broad application 🙂

Ah sure...a good doc will take advantage of the chance to observe/speak to someone while on hold and use that information to guide future treatment, but the purpose of a hold, and the only reason it is allowable, is to prevent acute death or injury (to pt or others). You'd be surprised at how often people manage to make it through their entire involuntary stay after a suicide attempt without actually having any therapy, or speaking to their psychiatrist about anything other than whether or not they will sign the voluntary form and extend the stay (which can be a strangely antagonistic/manipulative conversation on both ends). Of course, that's bad medicine no matter how you shake it out, so it's not really worth discussing here, other than to reiterate that it is 'acceptable' and allowed to happen because the end goal which permits the loss of autonomy is to prevent the acute risk of suicide. Which is also, as I believe you pointed out somewhere above, why the whole thing can quickly get pretty hairy when it comes to medications and other interventions that the patient may or may not want (in either their altered or baseline state).

As for your TL;DR...your example takes us back to a psych problem, though, or at least something similar (dementia, delirium, psychosis...various forms of altered mental status with an awake, active, talking person vs an unconscious one). In general, we seem more willing to ignore "Jimmy wouldn't want a blood transfusion" than "Jimmy wouldn't want antipsychotics." That's probably largely because Jimmy-about-to-die is less likely to be in your face and making your job hard, but also probably because of the contextual cues and feelings that differentiate the two, as well as the ongoing nature of deciding not to treat someone for something that will continue to come up indefinitely until the problem is addressed (vs letting someone pass away, where once the decision plays out, you can't backtrack). And so on.

Does remind me of a fun time in the ED, however, where a patient came in with some kind of injury (think they shot their finger off cleaning their gun at 2 in the morning, or something weird like that) and was perfectly fine until they suddenly became incredibly agitated, flailing injured hand around so hard that the dressing came off, the splint came off, and the previously-somewhat-stablized finger was flopping around bonelessly, getting everything messy and continually decreasing this guy's chances of recovering normal hand use. Anyway, they of course went in to give some haloperidol, only to have the wife start freaking out because he HATED antipsychotics, didn't we read the chart? They're on his adverse drug reactions list!!

Sure enough, there it was in the chart: Haloperidol, adverse drug reaction: "It makes me feel sleepy and like I can't do anything." Of course, the doctor rolled their eyes and gave the dose, but cue much debate about whether we were required to avoid 'adverse drug effects' if the effect described...was the desired effect.

 

[NickNaylor]

Fair enough, what are your thoughts on this paper publish in NEJM:

Selective Publication of Antidepressant Trials and Its Influence on Apparent Efficacy




Sent from my iPhone using SDN mobile

Didn’t look at the paper, but based on the title I’m going to assume that the main thrust of the article is essentially that pharma influences psychiatric drug trials and many results that we have are biased. So what? Obviously that’s not ideal and is something the field should be aware of and, if possible, try to correct, but what’s your point?

 

[michaelrack]

In the real world, at least in the state of Mississippi, one of the purposes of a hold (72 hold) is to observe/assess the patient and find out what is going on. Often a person will take a few pills, somehow end up in the ER, and then deny it was a suicide attempt. Family members will say the patient has been making suicidal statements. As an inpatient psychiatrist, I take the patient from the ER on a hold (or will sometimes place it myself over the phone if it my own hospital's ER) and then admit the patient for further evaluation. IN rural areas, patients are typically admitted to psych wards under a 72 hour hold without being personally evaluated by a psychiatrist prior to the hold being placed.
An in the state of mississippi, anyone can pay a few hundred dollars at the county court house and apply to have a person committed.

 

[thepoopologist]

Fair enough, what are your thoughts on this paper publish in NEJM:

Selective Publication of Antidepressant Trials and Its Influence on Apparent Efficacy

Sent from my iPhone using SDN mobile

Did you have your own thoughts about the article, other than the suggestive title that seems to confirm your idea that psych is a pseudoscience

This is their conclusion: "We cannot determine whether the bias observed resulted from a failure to submit manuscripts on the part of authors and sponsors, from decisions by journal editors and reviewers not to publish, or both. Selective reporting of clinical trial results may have adverse consequences for researchers, study participants, health care professionals, and patients."
Translation: We know there's a bias, we can't pinpoint where it's from, but withholding information is bad for everyone.

Then in the same article

"Our findings have several limitations: they are restricted to antidepressants, to industry-sponsored trials registered with the FDA, and to issues of efficacy (as opposed to “real-world” effectiveness"

So for example, if I were to read a study funded by Sunovion about the efficacy of Latuda in major depressive disorder (a paper I ran across in residency), it would be no surprise to find a comparison to placebo rather than with an existing treatment. It would be no surprise that the population would lean more toward the treatment naive than treatment refractory. It would be no surprise to find the duration of the study to be just enough to elicit the most positive results. It would be no surprise because industry sponsored trials are there to push their drug to market; at the same time, this shouldn't discount the merits of a good study. And here's another question to ask, how many positive studies are needed to move forward in the FDA approval process. Does the conspiracy that this title suggests apply only to psychiatric medications or to all drugs going through the approval process.

Obviously this article can be more fully dissected. Here are some questions I learned to ask when I was a resident in journal club
1. Who are the authors and what are their motivations?
2. Who is funding them?
3. Where are they sourcing the data from?
4. What type of study is it? You can glean a lot based on sample size, retrospective vs prospective, randomized double blind vs naturalistic, etc. I recently came across a "randomized double blind" study consisting of 11 patients and I laughed and I laughed
5. How much can I extrapolate the results to real world practice?
6. What journal is it published in?

 

[WingedOx]

So for example, if I were to read a study funded by Sunovion about the efficacy of Latuda in major depressive disorder (a paper I ran across in residency), it would be no surprise to find a comparison to placebo rather than with an existing treatment. It would be no surprise that the population would lean more toward the treatment naive than treatment refractory. It would be no surprise to find the duration of the study to be just enough to elicit the most positive results. It would be no surprise because industry sponsored trials are there to push their drug to market;

Yeah, LOL if the OP thinks this is limited to psychiatry. Studies like this are what you're going to see cited at every drug dinner you go to.

 

[NghtSky04]

I have several orders more faith in Buddhist monks than I do in most psychiatrists. Most people practicing in the field have a minimal understanding/awareness of their own minds or their own interpretations of "reality" around them, let alone what the mind actually is. With that being said, psychiatry is still a valuable field that can offer life saving remedies to patients. It has a lot of room to grow and I do see it moving in the right direction.

 

[mehc012]

I have several orders more faith in Buddhist monks than I do in most psychiatrists. Most people practicing in the field have a minimal understanding/awareness of their own minds or their own interpretations of "reality" around them, let alone what the mind actually is. With that being said, psychiatry is still a valuable field that can offer life saving remedies to patients. It has a lot of room to grow and I do see it moving in the right direction.

Honestly, these statements make me wonder if you actually know what psychiatry is, or if you just have it confused with philosophy class.

 

[calvnandhobbs68]

Not that I don't think psychiatry is not important, but as it is right not, its inefficient and even harmful in some cases.
We still do not understand the brain, we still don't know the mechanisms for almost all cognitive functions, nor the areas involved. And while psychiatrists and are attempting to help with the knowledge we have, their efforts seem like a hit or miss.
I mean something as simple as chronic sleep deprivation can result in serious cognitive impairments and mood instability, which would lead a psychiatrist to falsely diagnose them with depression/anxiety based of arbitrary metrics that are subjective and relative to each individual. Then the patient is prescribed a medication which is not likely to work and can even cause bad side effects, only to come back to the psychiatrist again and get prescription for a different medication and so on. See what I mean?

I just feel like its a broken field, and the patients are suffering because if it.

Sounds like a lot of your objections could be solved by, you know, doing a HISTORY and physical. Guess that’s why they have the history part of it.

 

[Waldeinsamkeit]

DO NOT QUOTE

I'm not sure if I'm the only one who feels this way, but does anyone else feel like psychiatry is a pseudoscientific field?

I've seen how psychiatrists diagnose patients, based on a collection of symptoms and are very subjective not only to the patient themselves, but also to the physician, particularly in depression.
I rarely see psychiatrists factor in the patients' environment, how much of their illness, like depression, is because of just certain personality traits (that are fiercely resistant to change)?
There is absolutely no objective way to tell if anyone is depressed, have anxiety, OCD, depersonalization, and so on. There is no biomarker to confirm the illness, or if the patient was cured.

They throw all these terms at you like they know what they’re talking about, they prescribe meds that supposedly cover a very broad range of symptoms but work only like 40% of the time and often result in much more side effects, and from there psychiatrists play a guessing game and suggest trying a different med. This goes on and on, and the poor patients get their hopes up with every new attempt and soon get those hopes crushed again, leaving them feeling helpless and in distraught.

I feel for the patients, mental illnesses are stressful and can be very isolating. I do not undermine their suffering, I question the efficiency of psychiatry as a field.

I get what you are saying when you talk about pseudoscience, but I am unclear when you say psychiatrist don't consider other environmental causes or the treatments aren't effective.

Psychiatrists are some of the most non-committal diagnosticians I have ever met, noting all potential variables. And personality traits are kinda under the umbrella of personality disorders.

Off the top of my head, Lithium decreases incidence of suicide substantially and ECT is extraordinarily effective for depression. SSRIs and atypicals have also been found effective.

I understand your frustration with the field, but I think some of your other grievances are unfounded.

 

[Blackdogue]

Not that I don't think psychiatry is not important, but as it is right not, its inefficient and even harmful in some cases.
We still do not understand the brain, we still don't know the mechanisms for almost all cognitive functions, nor the areas involved. And while psychiatrists and are attempting to help with the knowledge we have, their efforts seem like a hit or miss.
I mean something as simple as chronic sleep deprivation can result in serious cognitive impairments and mood instability, which would lead a psychiatrist to falsely diagnose them with depression/anxiety based of arbitrary metrics that are subjective and relative to each individual. Then the patient is prescribed a medication which is not likely to work and can even cause bad side effects, only to come back to the psychiatrist again and get prescription for a different medication and so on. See what I mean?

I just feel like its a broken field, and the patients are suffering because if it.

I think broken is the wrong choice of word. Psychiatric illnesses are the most difficult puzzles in medicine and that's the main reason they haven't been solved to a satisfying degree. Progress is happening, albeit slowly. The brain is just too complicated.

 

[Drrrrrr. Celty]

I think broken is the wrong choice of word. Psychiatric illnesses are the most difficult puzzles in medicine and that's the main reason they haven't been solved to a satisfying degree. Progress is happening, albeit slowly. The brain is just too complicated.

Yah, we don't know everything, shut medicine down entirely.

 

[Drrrrrr. Celty]

Honestly, these statements make me wonder if you actually know what psychiatry is, or if you just have it confused with philosophy class.

I think the person is just hardcore dumb. No need to sugarcoat it.

 

[Blackdogue]

Yah, we don't know everything, shut medicine down entirely.

That being said, I cannot deal with the lack of objective findings. I will have to complete a full year of psychiatry to become a neurologist in Germany (total overkill) and I'm having nightmares just thinking about it. I can't live like this. I hope the good hours will partly compensate. By the way, both neurology and psychiatry are 5 years in Germany, including one year in each others specialty. what do American neurologists/psychiatrists think about the one year training in each others specialty? I personally don't see the point, as the overlap isn't THAT great and neurologists could spend this time better in internal medicine, where there is more overlap. In fact, in Germany you aren't required to spend a single day in internal to become a neurologist, but I plan to do an elective year, cause I don't see how I could be a good neurologist without it. Maybe they know something I don't...

 

[Drrrrrr. Celty]

That being said, I cannot deal with the lack of objective findings. I will have to complete a full year of psychiatry to become a neurologist in Germany (total overkill) and I'm having nightmares just thinking about it. I can't live like this. I hope the good hours will partly compensate. By the way, both neurology and psychiatry are 5 years in Germany, including one year in each others specialty. what do American neurologists/psychiatrists think about the one year training in each others specialty? I personally don't see the point, as the overlap isn't THAT great and neurologists could spend this time better in internal medicine, where there is more overlap. In fact, in Germany you aren't required to spend a single day in internal to become a neurologist, but I plan to do an elective year, cause I don't see how I could be a good neurologist without it. Maybe they know something I don't...

A person with an arm torn up by cutting, injecting drugs, etc probably has more objective findings than someone who comes into your clinic for migraine headache.

I think there is overlap and there is management of most patients by the other at some point. Ex. someone with MS is probably going to get depressed or potentially may come in due to psychiatric symptoms before being diagnosed with MS formally after referral.

Likewise pseudo neurological conditions are psychiatric in origin. Ex. Pseudo seizures.

 

[Blackdogue]

A person with an arm torn up by cutting, injecting drugs, etc probably has more objective findings than someone who comes into your clinic for migraine headache.

I think there is overlap and there is management of most patients by the other at some point. Ex. someone with MS is probably going to get depressed or potentially may come in due to psychiatric symptoms before being diagnosed with MS formally after referral.

Likewise pseudo neurological conditions are psychiatric in origin. Ex. Pseudo seizures.

You're right about that, but I think on average my point still stands. Also, according to latest research plasma cgrp and pentraxin 3 are potential biomarkers at least for a big subset of chronic migraine sufferers, which leads me to believe we will have biomarkers for many neurological diseases earlier than psychiatric ones, but I could be wrong, of course. Of course there is overlap with psychiatry, maybe I didn't express myself well, my question was really if you think one year of psychiatry is too much while zero years of internal is too little for a neurology residency. Thank you for your reply.

 

[NickNaylor]

You're right about that, but I think on average my point still stands. Also, according to latest research plasma cgrp and pentraxin 3 are potential biomarkers at least for a big subset of chronic migraine sufferers, which leads me to believe we will have biomarkers for many neurological diseases earlier than psychiatric ones, but I could be wrong, of course. Of course there is overlap with psychiatry, maybe I didn't express myself well, my question was really if you think one year of psychiatry is too much while zero years of internal is too little for a neurology residency. Thank you for your reply.

As a psychiatry resident, I do wish we got more neurology exposure. I’m not sure that it would be all that useful clinically, but I like neurology and enjoyed the two months that we had to do. I would agree with you that a full year of psychiatry is a bit overkill. Our neurology residents get a single month of psychiatry exposure over the course of four years.

 

[Blackdogue]

As a psychiatry resident, I do wish we got more neurology exposure. I’m not sure that it would be all that useful clinically, but I like neurology and enjoyed the two months that we had to do. I would agree with you that a full year of psychiatry is a bit overkill. Our neurology residents get a single month of psychiatry exposure over the course of four years.

I think the young neurologists association in Germany are filing an online petition to be able to include other electives in the year reserved for psychiatry. I hope things change before I start in about a year from now. I also like some psychiatry experience, but maybe 6 months instead of 12.

 

[MSTPlease]

I've seen some miraculous things as far as positive side effect of SSRIs on IBS sx... and that totally makes sense from a physiological standpoint

same with chronic pain

the improvements don't just seems to be a question of an overall improved sense of well-being from treating depression

the nervous systems involved in the gut and the transmission of pain, also rely on serotonin

I speak from some personal experience on this one, but I'm hardly the only one whose had benefit on that front

IBS can be much more limiting than one might think from a condition where you don't have any tissue damage to speak of, I tell patients when they scope clean that the good news is that they don't have lesions that are going to pop and bleed or such, they don't have increased risk of cancer, they're not going to get blood loss anemia, the bad news is that their symptoms are still just as real in the presence of a normal appearing gut

this is somewhat similar to mental health
life isn't just about lesions you can point to in the addressing of symptomotology

For your female patients, I'd consider a referral to an ob/gyn for endometriosis. So many women with endo get misdiagnosed as IBS.

Also, with regard to psych, pseudoscience, and biomarkers, remember that MS use to be considered a psychogenic disease until the MRI came into practice. The validity of fibromyalgia used to be fiercely debated but the pressure point test is really a remarkable site to see. I just mentioned endometriosis which also used to be considered a psychogenic disease and yet there is very obvious, objective pathology in these women. Chronic fatigue syndrome is another one about to topple as exercise tolerance tests gain validation.

And have you (OP) been in a rheum clinic? So many of the symptoms and antibodies overlap - it's often a guessing game as to which one it actually is and which drugs to use.

 

[noMoreMDPhDapplicant]

How many of these anti-psych people are actually med students or physicians? If you are, I would love for you to encounter in the ED or on the med floors a patient with increasing CPK and lactate being restrained by 5 security officers, kicking, spitting and screaming about killing the devil. I would love for you to tell your attending and RNs, "Eh, let it self-resolve." Active psychosis is a medical emergency.

Get outta here with the quick fix nonsense and ADHD rant. That's a PCP issue.

Which is exactly the reason why psychiatry is a bogus fake field that doesn't need to exist. It is a MEDICAL emergency, which you will subdue with a haldol.
What can psychiatrists even do in that case that other doctors can't do due to the lack of training?

 

[noMoreMDPhDapplicant]

While there are valid psychopathologies out there, some of them are just variations of personal characteristics that are labelled as a psychiatric disease so psychiatrists can bill and earn cash.

1. ADD - while I understand there are meds out there to treat this "disease," giving extra time and accommodations for testing for this disease is way overboard. Does a coding patient get 2x time and a quiet room, too?

2. I still can't fathom how some fetishes are labeled as a pathology while homosexuality is not a disease anymore, even though gay sex clearly has a higher STD transmission rate than, say, necrophilia, and therefore is a more serious public health threat. This is an extreme example for sure and I by no means approve of necrophilia. I just can't understand the double standards here.

 

[noMoreMDPhDapplicant]

Neurology is a real medical field.

Psychiatry is a bogus field that has been created for the incompetent docs to cater to the weak and actually bill for their practice. While I'm sure other people would've emerged to care for the same patient population, you really don't need an MD for that, which is why psychologists are basically doing all the therapy stuff and MD psychiatrists are just prescribing meds.

 

[Oso]

Which is exactly the reason why psychiatry is a bogus fake field that doesn't need to exist.

Psychiatry is a bogus field that has been created for the incompetent docs to cater to the weak and actually bill for their practice.

Goddamnit, not this **** again

It's Memorial day, go enjoy a hot dog or something

 

[zanzizic]

I personally feel for psychiatrists. Having imperfect tools and only rudimentary lnowledge of human mind, psychiatrists are tasked with solving problems that may require much better understanding of neuroscience than what we have, but also much broader range of solutions. It’s not like a psychiatrist can prescribe someone a new life in Bhutan.

This.

The human psyche is the most mysterious and inpenetrable system that physicians are called on to treat. It’s way easier to set a broken bone or open an occluded coronary artery (sorry ortho and cardiology) than it is to understand mental dysfunction.

Physicians aren’t scientists. We apply scientific knowledge to help alleviate human problems. Unfortunately, as others have stated, our knowledge in the field of psychiatry lags behind other field because of how complex our brains and minds (those aren’t the same thing) really are. That doesn’t make the field pseudoscientific.

 

[noMoreMDPhDapplicant]

For your female patients, I'd consider a referral to an ob/gyn for endometriosis. So many women with endo get misdiagnosed as IBS.

Also, with regard to psych, pseudoscience, and biomarkers, remember that MS use to be considered a psychogenic disease until the MRI came into practice. The validity of fibromyalgia used to be fiercely debated but the pressure point test is really a remarkable site to see. I just mentioned endometriosis which also used to be considered a psychogenic disease and yet there is very obvious, objective pathology in these women. Chronic fatigue syndrome is another one about to topple as exercise tolerance tests gain validation.

And have you (OP) been in a rheum clinic? So many of the symptoms and antibodies overlap - it's often a guessing game as to which one it actually is and which drugs to use.

The fact that MS is now a disease under neurology's practice scope clearly validates my point that psychiatry is all about "I think there's something wrong here but I have no freaking clue what it is so we will see if this works"

I know other specialties have diseases like this, but psychiatry is ENTIRELY like that, which is probably why the OP was frustrated in the first place. Once you figure the disease out, it belongs to neurology, or rheum potentially I guess.

I'm not denying that these people need help. I even appreciate the psychiatrists' attempt to fix those problems. However, I hate how psychiatry influences the legit medical practice, as seen in their completely arbitrary ruling of what's a disease and what's not and accommodations they make for what shouldn't be a disease. (See my opinions of ADD and homosexuality above)

 

[zanzizic]

Neurology is a real medical field.

Psychiatry is a bogus field that has been created for the incompetent docs to cater to the weak and actually bill for their practice. While I'm sure other people would've emerged to care for the same patient population, you really don't need an MD for that, which is why psychologists are basically doing all the therapy stuff and MD psychiatrists are just prescribing meds.

Mental issues can be caused or worsened by physical and medical problems. Lots of times that requires a medical doctor to sort that out. Psychiatrists have medical experience that psychologists do not.

 

[noMoreMDPhDapplicant]

Mental issues can be caused or worsened by physical and medical problems. Lots of times that requires a medical doctor to sort that out. Psychiatrists have medical experience that psychologists do not.

That's fair. I back off on my claim that psychiatry doesn't need to exist or is a fake field.

It seems to be understood among the proponents of psychiatry that even the most experienced psychiatrists do not even have a remote understanding of the human psyche, however. Then why are they even entitled to rule ADD as a disease and accommodate certain folks with meds? On which basis are they ruling certain conditions a disease and certain not? DSM is full of bull****. Even the psychiatrists themselves know they don't have the whole picture, but the impact they are making on medical practice is huge and WRONG from my perspective.

Probably doesn't help that psychiatry is full of liberals and I am not.

 

[Akali]

Probably doesn't help that psychiatry is full of liberals and I am not.

lol. Did Breitbart or Fox News just run some anti-psych piece and rile you up or something?

 

[noMoreMDPhDapplicant]

lol. Did Breitbart or Fox News just run some anti-psych piece and rile you up or something?

Lol I don't have TV so I don't watch them.
Do they put up an anti-psych piece sometimes though? Because if so they are obviously doing their job.

 

[VA Hopeful Dr]

:troll:

 

[Oso]

That's fair. I back off on my claim that psychiatry doesn't need to exist or is a fake field.

You didnt know the difference between psychiatry and psychology? Or that medical illnesses can contribute to/exacerbate psychiatric disease?

Have you ever actually done a rotation in psychiatry? Or were your stream of consciousness ramblings based on pure conjecture?

 

[noMoreMDPhDapplicant]

You didnt know the difference between psychiatry and psychology? Or that medical illnesses can contribute to/exacerbate psychiatric disease?

Have you ever actually done a rotation in psychiatry? Or were your stream of consciousness ramblings based on pure conjecture?

In an ideal world, all the "psychiatric illnesses" would be under neurology's practice.

Why does it matter medical illnesses can exacerbate psychiatric illnesses to my (now retracted) claim that psychiatry shouldn't even exist under the practice scope of an MD?
Osteogenesis imperfecta causes dentinogenesis imperfecta. Does this mean dentists need to be MD's?
Eating disorder patients get dietician consults. Do the dieticians need to be MD's?

And yes I have done a rotation in psychiatry. Thanks for asking 🙂

 

[noMoreMDPhDapplicant]

You didnt know the difference between psychiatry and psychology? Or that medical illnesses can contribute to/exacerbate psychiatric disease?

Have you ever actually done a rotation in psychiatry? Or were your stream of consciousness ramblings based on pure conjecture?

You seem to be the one not knowing the scope of psychology. You should know that the certified clinical psychologists are allowed to practice CBT on psych patients, right? They just can't prescribe meds.

 

[Oso]

Deleted because ran out of fuqs

Gonna go play with my dog instead

 

[noMoreMDPhDapplicant]

Deleted because ran out of ****s

Gonna go play with my dog instead

For someone with an opinion that a therapy dog does a better job than an average psychiatrist, I gladly support your decision 🙂

 

[Drrrrrr. Celty]

In an ideal world, all the "psychiatric illnesses" would be under neurology's practice.

Why does it matter medical illnesses can exacerbate psychiatric illnesses to my (now retracted) claim that psychiatry shouldn't even exist under the practice scope of an MD?
Osteogenesis imperfecta causes dentinogenesis imperfecta. Does this mean dentists need to be MD's?
Eating disorder patients get dietician consults. Do the dieticians need to be MD's?

And yes I have done a rotation in psychiatry. Thanks for asking 🙂

Because psychiatric illnesses directly impacts quality of life, treatment plans, adherence, morbidity/mortality. Psychiatry is not a sub-field of neurology, they're not the same at all. Neurology deals with the physical brain, the neurological findings and deficits associated. Psychiatry deals with the functional well being of patients, it provides individual's capacity to preform and function in their daily life. Just because psychiatry is influenced by neurology does not mean it is neurology any less than PM&R is neurology despite being even more so neurology based.

I think the notion that psychiatry is not a medical practice is really just myopic and really fails to recognize that the psychiatry is not just a consult service. It is a direct follow up and long term specialty that manages a variety of conditions that patients present with. I mean by this logic why not just have diabetic therapists and get rid of endocrinology too since subspecialties which manage disorders also largely managed by others have no specialized validity.

 

[sloop]

While there are valid psychopathologies out there, some of them are just variations of personal characteristics that are labelled as a psychiatric disease so psychiatrists can bill and earn cash.

1. ADD - while I understand there are meds out there to treat this "disease," giving extra time and accommodations for testing for this disease is way overboard. Does a coding patient get 2x time and a quiet room, too?

2. I still can't fathom how some fetishes are labeled as a pathology while homosexuality is not a disease anymore, even though gay sex clearly has a higher STD transmission rate than, say, necrophilia, and therefore is a more serious public health threat. This is an extreme example for sure and I by no means approve of necrophilia. I just can't understand the double standards here.

The fact that you don't understand how necrophilia is more problematic than homosexuality is insane. For one, necrophilia tends to be associated with a whole bunch of violent tendencies and, even when it's not predatory, it is far less tolerated culturally.

Just as the rest of medicine attempts to pay attention to environmental context during diagnosis and treatment, social and cultural context is important with psychiatric disease. Underlying psychiatry is the pragmatic assumption that it's not reasonable to expect society to conform to every variety of extreme temperaments and behaviors, so the best we can do is try to identify those people at risk for all of the negative psychological consequences of being at odds with the surrounding society. Necrophilia would cause many such problems whereas homosexuality does not. Most people accept that people can agree to take the risks of increased transmission of STDs in a consensual sexual relationship. Most people would also find the idea of performing sex acts on a dead body somehow violating and impermissible.

 

[noMoreMDPhDapplicant]

Because of my mistake of emotionally saying that psychiatry should not exist, which I retract because that's not my point, is derailing this thread.

My main critique of psychiatry is that (let me just quote my own posts so I don't have to repeat):

1. ADD - while I understand there are meds out there to treat this "disease," giving extra time and accommodations for testing for this disease is way overboard. Does a coding patient get 2x time and a quiet room, too?

2. I still can't fathom how some fetishes are labeled as a pathology while homosexuality is not a disease anymore, even though gay sex clearly has a higher STD transmission rate than, say, necrophilia, and therefore is a more serious public health threat. This is an extreme example for sure and I by no means approve of necrophilia. I just can't understand the double standards here.

I'm not denying that these people need help. I even appreciate the psychiatrists' attempt to fix those problems. However, I hate how psychiatry influences the legit medical practice, as seen in their completely arbitrary ruling of what's a disease and what's not and accommodations they make for what shouldn't be a disease. (See my opinions of ADD and homosexuality above)

It seems to be understood among the proponents of psychiatry that even the most experienced psychiatrists do not even have a remote understanding of the human psyche, however. Then why are they even entitled to rule ADD as a disease and accommodate certain folks with meds? On which basis are they ruling certain conditions a disease and certain not? DSM is full of bull****. Even the psychiatrists themselves know they don't have the whole picture, but the impact they are making on medical practice is huge and WRONG from my perspective.

 

[noMoreMDPhDapplicant]

The fact that you don't understand how necrophilia is more problematic than homosexuality is insane. For one, necrophilia tends to be associated with a whole bunch of violent tendencies and, even when it's not predatory, it is far less tolerated culturally.

Just as the rest of medicine attempts to pay attention to environmental context during diagnosis and treatment, social and cultural context is important with psychiatric disease. Underlying psychiatry is the pragmatic assumption that it's not reasonable to expect society to conform to every variety of extreme temperaments and behaviors, so the best we can do is try to identify those people at risk for all of the negative psychological consequences of being at odds with the surrounding society. Necrophilia would cause many such problems whereas homosexuality does not. Most people accept that people can agree to take the risks of increased transmission of STDs in a consensual sexual relationship. Most people would also find the idea of performing sex acts on a dead body somehow violating and impermissible.

Wow. Culture. Very contextual for a disease to be defined, isn't it? I also clearly said I never condone necrophilia.

Maybe only in the liberal hivemind is gay sex tolerated culturally, which I guess psychiatry. I'm pretty sure the whole issue of gay marriage was hot just a couple years ago...?

 

[noMoreMDPhDapplicant]

The fact that you don't understand how necrophilia is more problematic than homosexuality is insane. For one, necrophilia tends to be associated with a whole bunch of violent tendencies and, even when it's not predatory, it is far less tolerated culturally.

Just as the rest of medicine attempts to pay attention to environmental context during diagnosis and treatment, social and cultural context is important with psychiatric disease. Underlying psychiatry is the pragmatic assumption that it's not reasonable to expect society to conform to every variety of extreme temperaments and behaviors, so the best we can do is try to identify those people at risk for all of the negative psychological consequences of being at odds with the surrounding society. Necrophilia would cause many such problems whereas homosexuality does not. Most people accept that people can agree to take the risks of increased transmission of STDs in a consensual sexual relationship. Most people would also find the idea of performing sex acts on a dead body somehow violating and impermissible.

Is there any other field of medicine that lets the "culture" influence the definition of a disease, by the way? Just curious.

So if a homosexual person were to travel to a country where it is culturally unacceptable to be gay (which there are many), does that person suddenly become a "patient"? Just curious.

I think DSM is used actually around the globe (correct me if I'm wrong), but then it sounds like the "culture" component of defining a disease seems to follow the US, or at the very least a developed western country's culture, given that homosexuality tends to be CULTURALLY accepted in those places. Isn't that a little pedantic and overbearing to countries with different cultures? Just curious.

 

[sloop]

Is there any other field of medicine that lets the "culture" influence the definition of a disease, by the way? Just curious.

So if a homosexual person were to travel to a country where it is culturally unacceptable to be gay (which there are many), does that person suddenly become a "patient"? Just curious.

I think DSM is used actually around the globe (correct me if I'm wrong), but then it sounds like the "culture" component of defining a disease seems to follow the US, or at the very least a developed western country's culture, given that homosexuality tends to be CULTURALLY accepted in those places. Isn't that a little pedantic and overbearing to countries with different cultures? Just curious.

Is there any other field of medicine where the patient’s suffering is very profoundly related to a problem of social function within the broader society? The point is that we treat maladaptive patterns of thought and behavior that cause suffering.

There are people who are gay and live in environments that oppress them. These people often have problems in their mental life as a result. I think that this suffering is worth addressing. This is not an indictment of being a homosexual but an understanding that behaviors that are at odds with the feelings and beliefs of those around often generates suffering.

The DSM is mainly used in America as it is the brainchild of the APA, however it is used elsewhere. It has some problems and, for what it’s worth, I train at a place that relatively deemphasizes the DSM. Regardless, the basic belief of psychiatry is that mental suffering is worth treating and that we should do our best to diagnose and treat this suffering while accepting our limitations. Surely you don’t disagree with this.

 

[noMoreMDPhDapplicant]

Is there any other field of medicine where the patient’s suffering is very profoundly related to a problem of social function within the broader society? The point is that we treat maladaptive patterns of thought and behavior that cause suffering.

There are people who are gay and live in environments that oppress them. These people often have problems in their mental life as a result. I think that this suffering is worth addressing. This is not an indictment of being a homosexual but an understanding that behaviors that are at odds with the feelings and beliefs of those around often generates suffering.

The DSM is mainly used in America as it is the brainchild of the APA, however it is used elsewhere. It has some problems and, for what it’s worth, I train at a place that relatively deemphasizes the DSM. Regardless, the basic belief of psychiatry is that mental suffering is worth treating and that we should do our best to diagnose and treat this suffering while accepting our limitations. Surely you don’t disagree with this.

I definitely agree that the suffering is worth addressing. However, what if the suffering is a result of the homosexuality itself? Why wouldn't you define this as a disease? My point is any kind of paraphilia should be ruled as a disease, and if one of them is not, it loses consistency in ruling any paraphilia as a disease, because now you are considering other factors and making a very subjective judgment call.

But obviously my perspective is too conservative in this society at the current time.

Thank you, also, for educating me on the DSM. I do agree mental suffering is worth treating.
I just don't agree with the DSM's ruling of certain conditions, and its impact of advocating for certain groups.

 

[Mass Effect]

However, what if the suffering is a result of the homosexuality itself?

Because a disease is literally a disorder, which homosexuality is not. For someone trying so hard to sound smart, you're really missing the point on the most basic of concepts. It's called common sense and logical thinking.

 

[noMoreMDPhDapplicant]

Because a disease is literally a disorder, which homosexuality is not. For someone trying so hard to sound smart, you're really missing the point on the most basic of concepts. It's called common sense and logical thinking.

For someone trying so hard to argue a point, you're really missing a point on the most basic of concepts. Please educate me on why it's common sense and logical thinking. ELI5.

Are you saying the psychiatrists prior to the 60's, let alone many people around the world, lacked common sense and logical thinking? That's very pretentious of you.

 

[Mass Effect]

Have you ever actually done a rotation in psychiatry? Or were your stream of consciousness ramblings based on pure conjecture?

OP is likely a pre-med. He doesn't even know what a disease is.

 

[noMoreMDPhDapplicant]

OP is likely a pre-med. He doesn't even know what a disease is.

And you are likely a DO who couldn't get into an MD school and struggled to match into an ACGME residency. And also likely has a mental disorder so making a list of the states with licensing boards that ask for history of mental illnesses.

You know, just making conjectures like you did, except that I'm not incorrect like you.

 

[Goro]

The summer troll season is fully underway.

 

[WingedOx]

In an ideal world, all the "psychiatric illnesses" would be under neurology's practice.

Oh, I'm sure the neurologists would just love that.

 

[Mass Effect]

Oh good, it's about time he was banned. Now please, let's make sure this is a lifetime ban?