Why do so many CAPS docs..

[DD214_DOC]

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Seem to have absolutely no clue what actual psychosis is? It really baffles me.

 

[PikminOC]

Parents don't want to hear their kid is psychotic

 

[wolfvgang22]

Every CAPS doc I've met knows. Maybe a local phenomenon?
Got a story to share?

Funny thing, I had a mother scream at me in fellowship because we diagnosed her 6 year old daughter as having had a large benadryl overdose, not schizophrenia. She threatened to sue for misdiagnosis, even though the sweet little girl was back to normal within 24 hours of supportive care.

 

[DD214_DOC]

Every CAPS doc I've met knows. Maybe a local phenomenon?
Got a story to share?

Funny thing, I had a mother scream at me in fellowship because we diagnosed her 6 year old daughter as having had a large benadryl overdose, not schizophrenia. She threatened to sue for misdiagnosis, even though the sweet little girl was back to normal within 24 hours of supportive care.

Oh do I have stories ....


Most recently: 11yo female dx with a psychotic disorder and put on Abilify, leading to about 15 lbs of weight gain in 1-2 months. "Psychosis" was based upon her report of randomly-occurring "command auditory hallucinations" last only seconds and not associated with any mood symptoms, or any other symptoms really. Patient described the voices as, "two voices, genderless [ed. though she can't actually describe what they "sound" like], can't recognize, that tell her to, 'slit my throat'. Literally no other symptoms. I decided to be an actual psychiatrist and explore other possibilities, particularly is there is a hidden, "function" for these, "hallucinations". Turns out mom treats these, "psychotic episodes" by taking her shopping, buying her ice cream, or driving her over an hour to visit grandma, whose house is apparently much more fun than her own.

Oh, she also has more concerning problems related to poor self-esteem, body image, and a generally negative opionion of her physical appearance and weight. She was already overweight prior to any of the inpatient shenanigans. Anxiety related more to a general apprehension of getting bullied about her appearance or weight in social situations. So, naturally, let's treat her with a completely unnecessary medication guaranteed to cause her to gain EVEN MORE WEIGHT. Brilliant!!!

Here's the general timeline: Kid claims to be hearing voices, gets coddled by mom, then admitted to be diagnosed with a psychotic disorder and put on abilify. Abilify makes her gain more weight, so anxiety gets worse and she actually starts to get depressed. I get her, call bull**** on the psychosis, get her off abilify and into therapy. Things start to improve. She pulls the random, "voices telling me to set myself on fire" crap again to sucker mom into taking her shopping with grandma, gets admitted a day and a half later (when her 30 seconds of psychosis had ended almost a day and a half earlier), called psychotic again, put back on abilify.

There really should be some sort of unwritten rule in psychiatry that if an inpatient doc -- assuming they also have an outpatient practice, which most seem to have around here -- gives an established outpatient a new diagnosis and treatment regimen that is so far removed from what the outpatient doc is doing and can't even rationally support it, the inpatient doc now inherits them as an outpatient.

 

[st2205]

Got a story to share?

I've got hundreds. Most of my second year rotation was spent picking up patients after discharge from a local facility with silly diagnoses and on Zyprexa. Another facility I used to moonlight at, seeing half a unit on a weekend of kids who had some kind of psychotic diagnosis and receiving treatment for such. Of course, a more 'nuanced' physician, and not a lowly resident like myself, could argue that I'm not seeing it because they've done a bang-up job treating it.

 

[Merovinge]

Interesting, because I see folks coming from probably a dozen CAP inpatient facilities and basically no one carries a diagnosis of psychosis. It seems like even when psychosis is present it is under diagnosed here since no one wants to have to explain that your child has schizophrenia.

 

[smalltownpsych]

If I had a dollar for every anxious parent who had a kid who hears voices. In my mind if the kid is interacting with reality appropriately then I really don't worry too much about reports of voices. The problem is that inpatient treatment for kids is usually focused on medication for symptoms. If they don't get a new medication then people feel like there was no point. The bulk of what is going on with kids is behavioral and if we conceptualized from that perspective first, then we would avoid a lot of the irrational medicating.

 

[TexasPhysician]

I find this thread to be largely an unfair generalization. As a CAP, I don't think that I currently have a single child or adolescent in my outpatient practice that is truly psychotic. It is extremely rare and usually a function of something else.

Inpatient psychiatry is currently in a sad state of affairs whether child or adult. The insurance industry and government has resulted in care that requires frequent medication adjustments and certain diagnoses labeled to receive reimbursement. Don't even get me started on the average length of stay being incredibly low to borderline useless. Instead of inpatient care for less severe diagnoses, adolescents and adults are shunted to the prison system. Many parents do not recognize mental health to be more important than an ipad, so they wait until a crisis situation actually occurs before recognizing the problem.

There is plenty of blame to be spilled.

This is largely why I started my own cash private practice. The results are significantly better than I obtained in other settings, because I actually get to practice appropriately.

 

[thoffen]

Reason number 73 that I don't treat kids. 🙂

 

[Jules A]

The CAPs in my area are fairly solid thankfully although I have seen more than a fair share of NPs and psyDs who have diagnosed young children with a psychotic disorder and even more common is an erroneous pediatric dx of Bipolar due to aggression, trauma and unstable homes. I have worked inpatient acute, RTC and juvenile detention. I personally have never seen a child under the age of 12 with what I felt was actually psychosis especially the neuropsych crowd who unfortunately seem to get it in disproportionate numbers. My guess is this is an attempt to medicate in the name of treating a diagnosis rather than being forthcoming with risks vs benefits and documenting considerate off label prescribing for that complicated population. I have however seen a handful of adolescents, almost always with a heavy family hx of schizophrenia, who absolutely were psychotic but again a very small number as compared to the total number of adolescents I have encountered.

 

[PistolPete]

I find this thread to be largely an unfair generalization. As a CAP, I don't think that I currently have a single child or adolescent in my outpatient practice that is truly psychotic. It is extremely rare and usually a function of something else.

Inpatient psychiatry is currently in a sad state of affairs whether child or adult. The insurance industry and government has resulted in care that requires frequent medication adjustments and certain diagnoses labeled to receive reimbursement. Don't even get me started on the average length of stay being incredibly low to borderline useless. Instead of inpatient care for less severe diagnoses, adolescents and adults are shunted to the prison system. Many parents do not recognize mental health to be more important than an ipad, so they wait until a crisis situation actually occurs before recognizing the problem.

There is plenty of blame to be spilled.

This is largely why I started my own cash private practice. The results are significantly better than I obtained in other settings, because I actually get to practice appropriately.

This is the main reason why I want to someday have my own practice. I feel that the problem is systemic. This probably isn't the politically correct thing to say, but it's probably true: there's way more crappy psychiatrists than there are good ones. Why? Because psychiatry is easy to do poorly, and hard do well. You end up with sloppy residents and then sloppy attendings who don't treat children and adults correctly.

 

[DD214_DOC]

By its nature a psychotic kid is a very ill kid. One of the only three psychotic kids I've ever seen was not, "now and then I hear a voice for a few seconds but otherwise I'm totally fine" ill. He was, "writes rap songs using only numbers, drowns puppies with garden hoses, ties grandma to her bed while she sleeps, and compulsively copulates with the floor whenever an alarm clock goes off" ill.

In case you're wondering (I know you are) his explanation was because every time an alarm clock goes off, it meant Jesus was in heaven having sex.

And suddenly my workday mornings would never be the same...


Sent from my iPhone using SDN mobile

 

[smalltownpsych]

In a somewhat related tangent. Parents need to have better emotional,regulation skills than their kids. Sitting in an airport watching obnoxious kid push frazzled moms buttons. Looks like half my day from yesterday. At least now I can just ignore it. Yesterday I was almost the frazzled psychologist yelling at oppositional parents. Thank god I have a week off!
😎

 

[Ceke2002]

In a somewhat related tangent. Parents need to have better emotional,regulation skills than their kids. Sitting in an airport watching obnoxious kid push frazzled moms buttons. Looks like half my day from yesterday. At least now I can just ignore it. Yesterday I was almost the frazzled psychologist yelling at oppositional parents. Thank god I have a week off!
😎

Yep, and they also need to stop playing Oppression Olympics with their 'Mommy' blogger groups too. There's a definite hierarchy of disease in certain communities, 'My 6 year old has ADHD' doesn't have nearly as much of a sympathy gathering punch to it as 'My 6 year old has Schizophrenia'. 🙄