Relationship with psychologists

[hamstergang]

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I'm not sure what I'm looking for here but after an interaction today I just want to get this out there. First, 2 cases to illustrate the issue:

1) A patient came to me on an SSRI and antipsychotic for diagnoses of OCD and psychosis (I actually don't know what psychotic disorder was diagnosed). However, by my assessment, he was never psychotic. His psychologist and previous psychiatrist said he had AH and delusions, but the description given to me sounds more like obsessive thoughts from OCD, albeit very odd obsessive thoughts. I'd like to try tapering the antipsychotic, and the patient's mother agrees. But, the patient is giving e resistance because the psychologist has him really convinced that he was psychotic and may be psychotic again without proper treatment.

2) I was asked to consult on a kid in an inpatient unit due to irritability. I see ODD with probably one or more of the following: ADHD, a learning disorder, a mixed receptive/expressive language disorder, and mild cognitive impairment. The psychologist that saw the patient and referred him for the consult feels his has DMDD. He was really trying to convince me that I was wrong and it is DMDD so that I can treat for that so his irritability can be more under control so he can do better in the hospital (and while I agree that less irritability would be good for his overall health, I'm not quite sure how to treat for that anyway).

So here's my issue. I'm the psychiatrist seeing these kids and evaluating them for the appropriateness of their medications. I'm the expert in that area, so my judgment there should be trusted. Pushing me or the kid towards a certain medication feels inappropriate. On the other hand, these psychologists clearly care about their patients. They feel, in their professional judgment, that I am making the wrong diagnosis and therefore wrong treatment plan. If they're right, then my choices would lead to a poor outcome for their patients. So I can understand their behaviors to some degree.

When I see patients referred from other fields of medicine, I don't see this same dynamic happening as we recognize each other to be experts in our own domains. But here, there's a lot of overlap in the expertise of psychologists and psychiatrists. I generally trust psychologists to make accurate diagnoses of my patients, but I don't really know how to navigate these cases.

 

[DD214_DOC]

I think the core problem is that each of you assumes your diagnosis is, "correct" and, "accurate". It's impossible to really know something like that because a lot of the information we elicit for such purposes is horribly inaccurate and filtered so many times, details change depending on what day questions are asked, some things are left out when interviewed by person A but not by person B.

Really, who cares what the label is? Identify what sxs are the primary concern, how they negatively affect the person experiencing them, then go from there.

 

[heartsink]

Arm wrestle.

 

[hamstergang]

Really, who cares what the label is? Identify what sxs are the primary concern, how they negatively affect the person experiencing them, then go from there.

Normally I'd fully agree with this sentiment, but in both these cases the diagnosis changes the treatment. If the first kid was psychotic or not would determine if an antipsychotic could be beneficial on top of the SSRI. In the second case, irritability from a primary mood disorder gets treated differently than irritability from ODD.

This isn't even about any of us not recognizing the diagnostic ambiguities of psych. It's that in some cases, you have to at least temporarily commit to a side if you plan to initiate some treatment.

 

[wolfvgang22]

Welcome to professional disagreement. Diagnose and treat what you feel is appropriate. Prescribe what you think is best. It's your medical license, not the psychologist's. Document why you prescribe what you prescribe. If they want a different opinion, they can get one from a different psychiatrist. You can even offer that option, nicely. It's OK to disagree without being disagreeable. If you are open minded, pleasant, and professional, it will work out. Let everybody know you appreciate their input.

 

[smalltownpsych]

I typically won't argue much with psychiatrists I work with. If we have a difference of opinion on diagnosis I hear their reasons and give my own. Since I have some experience working with families I know that trying to convince someone to see things your way doesn't work well. When I refer, I expect them to use their own clinical judgement and expertise. Of course I have had different diagnoses from a psychiatrist before. At times I was mistaken and other times it was the psychiatrist. How I work with the patient despite the disagreement is what really matters. Modeling that people can disagree and still work together is helpful for most of my patients.

As far as the psychotic vs OCD patient, that makes me think that this psychologist did not get enough experience working with more severe mental illness. Keep in mind that many of my colleagues have had limited exposure to more severe cases. I intentionally sought those experiences because I could see how it would make me a better clinician, but I could have avoided that population which I think is an area of weakness for many psychologists' training.

 

[MacDonaldTriad]

Second generation antipsychotics can worsen OCD. They can help too, but there is a literature about OCD appearing in the context of starting antipsychotics with 5HT2 antagonism.

 

[WingedOx]

A patient came to me on an SSRI and antipsychotic for diagnoses of OCD and psychosis (I actually don't know what psychotic disorder was diagnosed). However, by my assessment, he was never psychotic. His psychologist and previous psychiatrist said he had AH and delusions, but the description given to me sounds more like obsessive thoughts from OCD, albeit very odd obsessive thoughts. I'd like to try tapering the antipsychotic, and the patient's mother agrees. But, the patient is giving e resistance because the psychologist has him really convinced that he was psychotic and may be psychotic again without proper treatment.

I've said this many times... A DSM in the hands of a concrete thinker is the most dangerous thing in psychiatry.

 

[WisNeuro]

As a Neuropsychologist, I'd agree with the "it's your license" sentiment and do what you think is right. Lazy and inaccurate diagnoses happen with both disciplines. If I had a dollar for every "Bipolar" diagnosis I've seen from psychiatry, when there is no history of a hypo/manic episode. Or "adult-onset" ADHD. Bottom line, there are poor professionals abound in the healthcare system. Form good relationships with the good ones, come up with strategies to deal with the bad ones.

 

[PsyDr]

I have several psychiatrists who refer patient like these for testing. The therapist thinks one thing, the psychiatrist thinks another. Testing gives data.

 

[DD214_DOC]

I've said this many times... A DSM in the hands of a concrete thinker is the most dangerous thing in psychiatry.

This is getting added to my favorite quotes list

 

[nitemagi]

Here's my general experience and approach:
I receive a phone call -- I'm referring A to you for help with B condition. I think they have B after treating them for 6 months and think maybe they should be on C med. [and many will say they aren't sure because it's outside their scope].
I say OK, let me meet them, then we'll talk again.

I meet A, and think really it's D and E. I call back the therapist and say -- "Here's what I saw. This and That, which makes me think it might be D and E rather than C. What do you think?" In doing that I have put the data I have on the table and the differential I'm drawing from the data I have. I've now invited them to contribute their data in a collaborative process. In general they seem to respond well to this because I'm respecting the work they've put in. Usually they're reaching out because what they've been doing hasn't been working, and they're looking for help (in diagnosis, treatment, etc). I have had ZERO experiences of it being oppositional when I take this approach.

I may then explain the rationale for using one med over another (which may go against their recommendations) and sometimes give a lot of detail, which they usually like because I'm showing respect for them as professionals with some expertise.

We agree to a collective strategy of seeing if treating D and E works out.

 

[MacDonaldTriad]

Don’t you hate check list psychiatry? It is the false refuge of green horns.

 

[smalltownpsych]

1) A patient came to me on an SSRI and antipsychotic for diagnoses of OCD and psychosis (I actually don't know what psychotic disorder was diagnosed). However, by my assessment, he was never psychotic. His psychologist and previous psychiatrist said he had AH and delusions, but the description given to me sounds more like obsessive thoughts from OCD, albeit very odd obsessive thoughts. I'd like to try tapering the antipsychotic, and the patient's mother agrees. But, the patient is giving e resistance because the psychologist has him really convinced that he was psychotic and may be psychotic again without proper treatment.

As I read this again, it sounds like a conversation with the psychologist might be warranted, especially if they are still meeting with the patient. Perhaps there was a time when the psychotic symptoms were worse and you would want that info or perhaps the patient is misconstruing the message that he may become psychotic again. There is a significant proportion of individuals who have one psychotic episode and don't have another, don't recall the stat off the top of my head. There is always the possibility that the psychologist and the previous psychiatrist were way off on this, but you can't really know without checking.

 

[DD214_DOC]

Don’t you hate check list psychiatry? It is the false refuge of green horns.

The worst thing about this field, and I have zero respect for people who obsess over DSM criteria.

I just saw a pt with about 10 different dx from other providers. In 20 minutes I got her in tears and talking about how her anger is displaced anger towards a close family member who traumatized her and the guilt she experiences for harboring this anger, how she pushes people away due to a fear that she'll be hurt or exploited if someone gets too close, etc etc. She left smiling that someone finally gets it and actually had hope that she could get better.

Not a bad day.

 

[F0nzie]

Rule #1 staff are always sicker than the patient.

 

[smalltownpsych]

The worst thing about this field, and I have zero respect for people who obsess over DSM criteria.

I just saw a pt with about 10 different dx from other providers. In 20 minutes I got her in tears and talking about how her anger is displaced anger towards a close family member who traumatized her and the guilt she experiences for harboring this anger, how she pushes people away due to a fear that she'll be hurt or exploited if someone gets too close, etc etc. She left smiling that someone finally gets it and actually had hope that she could get better.

Not a bad day.

Hey, sounds like you're trying to do my job! 😱 Trying to say that longstanding conflictual relationships and unexpressed emotions could affect current mood? How old-fashioned of you. The drug reps aren't going to give out anymore free pens and face-valid diagnostic checklists if we keep promoting this outdated heretical concept. 😉