Treatment Resistant Anxiety

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Clearly most psychiatrists, evidenced by the rigidity of ideas on this board cannot diagnosis subtle bipolar spectrum disease let alone PCP's. You can have your own opinions but watch them change all of a sudden when dsm 5 and then 6 is out and voila-no more specific rigid checkboxes. "internal restlessness" is what someone wants it to be. The guy who made the GAD checklist describs that as part of GAD which is can be. It doesnt mean that is the only thing it happens in.

Also mania and depression is not clear whoever said that. It masquarades as anxiety and all sorts of things

but to each is own. Keep trying the 6th SSRI and then SNRI then remeron etc and see wehre that gets you.


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love it. different STROKES for REAL! when you hear affective lability and tatooes you think bipolar disorder. when I hear affective lability and tatooes I think identity personality issues.

who's right? You think the dsm will vindicate you. I think treatment approach will vidicate me. No WAY is a mood stabilizer by itself is going to integrate this dude's personality. and he may very well benefit from the decreased rejection sensitivity that an adequate trial of a high dose SSRI may provide (of course, I wouldn't hold my breath). this is a therapy case, or I'll eat my hat.

and I'm ok with that. I've eaten a few hats in my time.

but RIGID? I love it. Keep it coming wallstreet. I'm starting to dig the Wallstreet show.

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Although we disagree and can argue about it in a professional respectful fashion (I hope as I dont mean anything but a professional arguement here with respect to all)-this is the essence of why most of us really enjoy psychiatry. Its the least cookie-cutter speciality left IMO.

Although there are accepted algorithms, it is still very gray as far as diagnosing and treatment.

If we did nto have this disagree of arguements then some of us would not be here as it would lose the essence of what makes psychiatry really interesting as a physician.
 
Although we disagree and can argue about it in a professional respectful fashion (I hope as I dont mean anything but a professional arguement here with respect to all)-this is the essence of why most of us really enjoy psychiatry. Its the least cookie-cutter speciality left IMO.

Although there are accepted algorithms, it is still very gray as far as diagnosing and treatment.

If we did nto have this disagree of arguements then some of us would not be here as it would lose the essence of what makes psychiatry really interesting as a physician.

roger THAT! well said.
 
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subtle bipolar spectrum disease let alone PCP's.

Well there is the diagnosis of cyclothymia, that is what I would call a subtle bipolar disorder.

I've rarely encountered it. My opinion is that many people who have it won't seek treatment, and when it's encountered, because it's not a more glaringly obvious diagnosis such as full blown bipolar disorder, other doctors will miss it.

Another problem is that residents in general are trained to see the more obvious disorders because they work in a hospital setting. Most people with cyclothymia will not end up going to the hospital over it. If they ever did, they're condition is pretty much bipolar disorder in every instance.

I haven't started to see cyclothymia much until private practice. In that setting I have patients that are generally working full-time, have good insight, and their disorders are not to the point where they can't function in society. Makes sense because with cyclothymia, a person's symptoms aren't often of a strong intensity where they cannot work, but their quality of life is worsened.

With differing scenarios, you're going to see very different patients. I can't think of any instances where I ever diagnosed ADHD in an ER. Most of my PP cases are depression or anxiety disorders, almost all of my forensic unit cases are psychosis, mania, MR, malingering, and/or substance abuse.

Depending on where you train, you may completely miss out on treating a particular type of disorder because in that scenario, you may only see a patient of a certain type.
 
I think the issue with the DSM and clinical diagnosis is desgning a clinical trial.

Clinical trials are often rigid and need to be that way. Thats where the checklists can be (somewhat) helpful. Most physicians know that these things aren't supposed to be used in the real world and the DSM etc is a guide. Its evidence based, not evidence only medicine because the evidence is never enough to cover all the bases. Clinical judgment for one psychiatrist may make them believe one person is bipolar while another psychiatrist may think they are mostly personality driven, yet another might think its severe treatment resistant anxiety.

Hopefully, the treatment converges and symptom resolution leads to functional improvement. We need to learn to be wide in our differentials and judicious in our approach. The DSM, no matter what number, will never be flexible like a psychiatrist. However, the DSM is needed and the checklists are needed. Just as long as the researchers are put in charge of actual real world assessment or policy making...thats when the problems start.
 
And in the end all our drugs are approved for almost everything now and they all kinda suck!:soexcited: So take that shotgun out and fireaway-in the end it probably wont matter!
 
Clearly most psychiatrists, evidenced by the rigidity of ideas on this board cannot diagnosis subtle bipolar spectrum disease let alone PCP's.

Just because someone challenges your statements doesn't mean that they are rigid. Nor does it mean that they're personally attacking you or that they even necessarily disagree. Personally speaking, I like to argue here (in the diplomatic sense) in order to understand different viewpoints and to learn, as I believe most here do as well.

You can have your own opinions but watch them change all of a sudden when dsm 5 and then 6 is out and voila-no more specific rigid checkboxes.

So far this doesn't seem to be the case. In fact so far as I can tell there won't be any changes to the criteria for a manic or hypomanic episode:

http://www.dsm5.org/ProposedRevisions/Pages/proposedrevision.aspx?rid=425

http://www.dsm5.org/ProposedRevisions/Pages/proposedrevision.aspx?rid=426

The biggest shift in mood disorders will likely be elimination of the "mixed episode" (which will simply be termed "manic episode, with mixed features") and the addition of a "with mixed features" specifier. This does not, however, represent a paradigmn shift towards an expanded "mixed-hypomanic" type of bipolar conceptualization. As in DSM-IV, restlessness, inner tension and the like will not be included as criteria for bipolar disorder in DSM-5 to my understanding:

http://www.dsm5.org/ProposedRevisions/Pages/proposedrevision.aspx?rid=483

Predominant depressive symptoms with anxiety will be coded as MDD with a "with anxiety, mild to severe" specifier:

http://www.dsm5.org/ProposedRevisions/Pages/proposedrevision.aspx?rid=483

"internal restlessness" is what someone wants it to be.

Actually it's a specific symptom, though like most symptoms it has a variety of presentations.

The guy who made the GAD checklist describs that as part of GAD which is can be. It doesnt mean that is the only thing it happens in.

Despite its many shortcomings, the DSM was created by a specialized task force who based diagnostic criteria on professional research, not some "guy's" personal opinion.

Also mania and depression is not clear whoever said that. It masquarades as anxiety and all sorts of things

I don't deny the possibility, but the onus is on you to expound on and support this statement. Sincerely, I would like to know upon what evidence you base this assertion. I think we could make this topic into a very interesting and productive thread of its own.

but to each is own. Keep trying the 6th SSRI and then SNRI then remeron etc and see wehre that gets you.

Or how about a single ADEQUATE trial of a SSRI to treat depressive and anxiety symptoms, perhaps reduce rejection sensitivity and to facilitate psychotherapy as Suedehead had suggested?
 
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And in the end all our drugs are approved for almost everything now and they all kinda suck!:soexcited: So take that shotgun out and fireaway-in the end it probably wont matter!

Yep, but I try to use buckshot instead of birdshot.:D
 
And in the end all our drugs are approved for almost everything now and they all kinda suck!:soexcited: So take that shotgun out and fireaway-in the end it probably wont matter!

NOW you're making sense.
 
I now laugh when I see psychiatrists give out Neurontin for bipolar disorder because I can no longer get angry over it.

No good evidence it works for bipolar disorder, yet it's given out like candy for it.

There is some data showing it can help prevent an alcoholic relapse, can reduce anxiety, can be used for antidepressant augmentation in those with treatment resistant depression, but all of the data mentioned above, IMHO, only points out to it being used in a manner where it should be considered 2nd line treatment at best if even that.
 
Why are you so concerned with what medication to hand out next? This guy has clearly had a rough life and is going through situational depression and suffers constant anxiety. For God's sake, get to know him...uncover every detail of his life. Discover his fears, hopes and dreams. Familiarize yourself with his everyday life. Treat him as a friend, not a number. Work with him through CBT and psycotherapy. Help him fix what's wrong in his life and what's holding him back. Stop trying to diagnose him and instead be patient until the diagnosis shows itself in time.
 
Of course you could also allow the patient to command how fast and structured the diagnosis and treatment should go based on the pros and cons presented by the doctor.

Several patients want medication treatment to start earlier rather than spend several sessions where the doctor just listens, not to mention they may not have the money to afford many sessions.
 
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