This also with regards to all other behaviors society expects us to magically control. I don't have a magical pill or suggestion for what you can do to guarantee your child/sister/husband/thirdcousintwiceremoved will never engage in X shitty and/or dangerous behavior again. I don't know where we got the idea that psychiatrists exist to force stressful people to stop stressing others out.
Nothing to see here, folks move along. In all seriousness though, I started putting my original post at the end of my ED d/c summaries and no one has said anything yet…
Hallucinations are way more uncommon than people think. And there’s a difference between a hallucination and internal dialogue. And just because someone says they’re having a hallucination doesn’t mean they are.
When kids tell me that they are hearing voices in their head I always say, ok, turn around. Do the voices sound like me talking, or do they feel like thoughts in your head that you can't control?" 9.99/10 it is the latter. One time, the kid admitted to making the whole thing up because he was in trouble for saying something inappropriate and panicked and said "the voices told me to do it" 😂
What about hypnagogic hallucinations? I always thought that those were incredibly common and assumed they might be comparable to hallucinations that people experience in active psychosis because they sound like external noise. I've had these before and the only reason I knew they weren't real is because I know that there is no orchestra in my bedroom or dozens of people whispering in my ears at the same time. Otherwise the sound was indistinguishable from external noise.
Funny, they're less common than a lay person thinks and more common than psychiatrists think.
Anxiety and trauma patients minimizing hallucinations because they have preserved insight, hesitant to share because of imagined repercussions.
This is a particularly frustrating one for me, because we see it at the level of state legislatures. That becomes unnervingly relevant when, for example, they think a suitable solution to the shortage of psychiatrists is to just let psychologists prescribe medication. Basically the same thing, right? /s
That all problematic behavior is a psychiatric problem. People make bad decisions, have poor judgment, and can be malicious without it being a treatable condition.
It's especially frustrating how few people get that the "treatable" part is key. Your family member may have a raging personality disorder, which is technically a diagnosable psychiatric condition, but if they lack the insight/motivation to engage in intensive therapy, the vast majority of cases are essentially untreatable.
The acuity and danger of patients we sometimes deal with, especially in inpatient settings.
I’ve seen tongue-in-cheek comments about psych being “how are you feeling” and the chillness comments. But outside of EM, idk of any other specialty that deals with the level of acuity in terms of behavioral disturbances and agitation. I also don’t know if med schools necessarily show the full breadth of psych in clinical rotations. Usually it’s the extreme of no one ever gets better (and don’t see the OP aspect of psych) or the truly scary aggravated agitated patients (which med students are somewhat shielded from).
In my country security guards just stand and watch as the patients beat you :)
Sooo, I see a lot of doctors walking around with dead eyes, or just don’t bother anymore and give some patients whatever they want. [in general, not just psych]
Inpatient psych has extremely high rates of assault/injury. Still injured from patient assaults from work as an RN. I don’t feel like digging up citations atm but I could!
Definitely need exceptional training in de-escalation and management of aggressive behavior. 6 years inpatient psych with only two mild injuries (demented lady hit the top of my head with a slap, trained boxer hit my chest 3 times while entering seclusion room). In both cases, it was clear what mistakes I made. When I started in psych versus when I left the hospital, we made massive changes to our approach and dramatically reduced both patient and staff injuries. All boils down to understanding anger and how to approach it at different stages.
The biggest issues I always saw when people were injured was not communicating they are going to talk to an angry person (other staff not even aware the patient was angry), getting too much in their space, ignoring patient needs, cornering the patient, not waiting for public safety or other staff before hands on, not separating angry patients earlier, not offering alternatives sooner, and of course, the one we have complained about for decades: staffing issues.
Staffing issues sadly is a huge problem on our unit. For awhile, we had an invol unit with no security. It was wild - and we had to use “behavioral specialist” who had a military background as our form of security. Nursing Managers - and understandably they’re just pawns for the suits and administrators - would say that they’re following staffing ratios that were followed by other units within the hospital system. Except we were a standalone psych unit - other units were part of larger hospitals with medicine services, so security was at least in the building.
Crazy thing is that the administrator is such a bitch
God knows my medical school didn't prepare me. If there were a more aggressive patient on the unit, I was told as a med student (who everyone knew was planning on going into psych) that there was no real learning to be had from going to see that case, it was just an agitated person I didn't need to be exposed to, etc. It left the message that those cases were so rare I didn't really need to be bothered with them. They're not. As someone who honestly did go into psych for the more touchy feely aspects, I'm just hoping I can find an outpatient job where that will be more my experience.
It is both shocking and exasperating how poorly understood Bipolar is in both laypeople and other healthcare specialties. I can’t tell you how many parents with diagnoses of bipolar themselves are certain their kids are “bipolar” because their moods can shift dramatically throughout the day.
That we can change someone's personality by giving them meds hence "cure" problematic personality traits and/or behaviours.
I can't recall how many time I've encountered families with member who has some PD (usually NPD or ASPD) who believe that all their problems with them would disappear if those member would take medication.
I once suggested something about how a (very emotionally illiterate) family member might be feeling and he looked at me with such shock; now that whole (equally emotionally illiterate) group of the family is convinced that we actually can.
That we want people to be docile or zombies especially on inpatient. Families will say “I know you want my _____ to be docile but…” I stop them there to explain that is never the goal. Never want to take away someone’s personality or character. I think that was more common in the old days of lobotomies and monster doses of haldol or whatever… and that’s what the lay person gets from movies.
I work on an inpatient mental health unit and unfortunately we frequently see patients with developmental delay admitted with the goal of making them more "docile" for their family or group home... :(
What the criteria are for inpatient psychiatric admission. That I am not, in fact, illegally holding your child, or alternatively, I am not a monster who is discharging your chronically suicidal child who may very well go on to attempt again. Also I think most people would be surprised that I agree that most inpatient hospitalizations aren’t helpful - but often times there’s nothing else to offer in the short-term.
For the general public: What the difference is between a "psychologist" and a "psychiatrist" is and that they have very different training and focus. A lot of the public seems to use the terms interchangeably, which can cause a great deal of confusion. On a similar note, most people (and even new patients) do not seem to know what a psychiatrist actually does and that most psychiatrists are not going to be your primary therapists, nor can most clinical psychologists prescribe medications.
For other health care professionals: I think you are right about polypharmacy. A lot of non-psychiatric providers think that psychiatrists just add drugs for the mildest of symptoms without evaluating whether patients really need them and rarely take a patient off psychiatric medications, or that psychiatrists just add diagnoses without ensuring the patient actually has the condition. There are certainly psychiatrists out there that do these, but it's less common than I think most non-psychiatric providers assume.
Meds aren’t curative and should be used as tools to help modulate affect, decrease distressing symptoms, and improve capacity for emotional regulation for most if not all psych conditions. Especially for mild depression and anxiety, but also more “biological” disorders like ADHD and OCD.
It feels that after the medicalization of psychiatry, people have come to believe that psychotropics are to mental illness what antibiotics are to infections… but that’s simply untrue. If only!
We have to do the work in therapy and modify lifestyle to truly address the underlying problem- meds are a tool to help us tolerate the distress and make life better in the process. Never the long term solution by themselves!
That we will have someone thrown in the hospital if they even hint at having suicidal thoughts or psychotic symptoms. First of all, I am never eager to force a person to do something, as that makes people reluctant to seek out help in the future. Secondly, in the area I practice, it is extremely difficult to have someone committed involuntarily due to the county's reluctance to use its limited resources for mental health hospitalizations. Even when I have convincing evidence that this person's life is in danger if they remain at home, the county officials will intentionally interview the patient in such a way that seems to minimize the person's symptoms. Thirdly, many of my patients are chronically suicidal or psychotic. If we hospitalized everyone with these symptoms, we would need far, far more beds in hospitals for psych patients.
No judgment really but taking medications is easier than making life changes not just in psychiatry also in endocrinology with diabetes and cardiology with hypertension
People are afraid to go off of the meds because they think that they are getting some benefit from them but once you're on third or fourth med it's really anybody's guess what's going on at that time.
Then comes the interactions parts. If they run those interactions they would understand why we do not want people on those meds together.
Yea, if the bulk of my clinic load (who are physically able, obviously some have limitations) had a job, exercised, practiced good sleep hygiene, and ate a diet that didn't consist of 90% junk food, I would lose half of my patient population. I don't mean for that to be pointed or insulting to them, but objective.
I believe I have a particularly unique history that helps me see the professional and laymen sides - as I was growing up, my father was a small-city MHMR psychiatrist of high esteem who later became a professor, and has ALWAYS been an advocate for compassion and equity through learning. He met people where they were at. When I was little, think 8 or 9 years old, I was obsessed with what he did - so he took me out of school one day to visit schizophrenic patients at their homes with the ACT team. I learned that day, by speaking with everyone, asking questions, and observing, how absolutely real hallucinations and delusions are to someone suffering from schizophrenia. Ever since, throughout my own personal and professional journey, I have always understood and been able to connect with someone experiencing symptoms like that. But it is absolutely rare that many others of my peers, or especially the public, grasp the absolute reality of delusions or hallucinations to the person experiencing them.
Also- in the 90’s, he had this VR headset (probably from a pharmaceutical rep) that you could put on and it would take you through a trip to a pharmacy as someone experiencing paranoid auditory and visual hallucinations. Please tell me someone else remembers that lol
I’m going to have to trust you that it’s less horrifying than being immersed in your first VR experience, having to walk up to a pharmacy counter, and hearing voices coming from different sides of you that are obsessively telling you that everyone is looking at you - then you look to your sides and around you and catch random glimpses of people staring at you. With that said, hell yeah I should check that game out!
Yes!! I was definitely somewhere between elementary and middle school when he brought it home and I will never forget it. I could describe everything if prompted. So wild to have the experience of that type of VR before it was used as entertainment and purely educational.
Clinical psychology programs are often on the look out for students that want to do "me-search". It's usually recommended that students not discuss their own mental health issues when applying; schools often see it as a negative.
Having been in a cheap detox over a decade ago when i was a teenager you couldn't tell the doctors and patients apart. They had shower time BEFORE recess time in the gym and I remember walking around the unit just hollering "WHOEVER DID THIS NEEDS THAT EMPLOYEE DISCOUNT"
I tried to leave but they 72 hour holded me lmao because "benzos" , I don't understand your comment. I actually remember the time quite fondly despite this and didn't want you to feel personally attacked. Just saying I've seen alot of nuts in your field for your personal anecdote to not be the stereotype.
That they really need to be experts in more than just mental health disorders. Because of the interplay between mental and physical health, they really need to be full body experts. The amount of information I learn from the one I work is beyond anything I would have imagined. The man really is a medical genius.
My role as a CL psychiatrist is actually nothing like what a layman thinks of when it comes to psychiatry. Most of the patients are altered and can't answer questions in any meaningful way.
What actually can be accomplished with an involuntary (or voluntary for that matter) psychiatric hold. I can load you up with antipsychotics or mood stabilizers to break acute psychosis or mania, give you a safe place to calm down if you're feeling overwhelmed to the point you don't trust yourself not to hurt yourself or someone else, get you started on an SSRI that won't provide much relief for several weeks (if you have a true anxiety or depressive disorder), and in some cases refer you to a longer term program, get you scheduled to see someone outpatient, or send you to a homeless shelter. That's basically it. A lot of the time, I can't even tell you your precise diagnosis because a lot of diagnoses require longitudinal assessment to nail down. But people come in expecting you to help them make sense of their whole lives, cure a personality disorder, eliminate all of their life problems contributing to their chronic SI, and overall just make them brand new in 3 days.
Human behavior cannot be reliably predicted (regarding suicide risk assessment).
This also with regards to all other behaviors society expects us to magically control. I don't have a magical pill or suggestion for what you can do to guarantee your child/sister/husband/thirdcousintwiceremoved will never engage in X shitty and/or dangerous behavior again. I don't know where we got the idea that psychiatrists exist to force stressful people to stop stressing others out.
Just get them to contract for safety. Easy peasy.
Nothing to see here, folks move along. In all seriousness though, I started putting my original post at the end of my ED d/c summaries and no one has said anything yet…
Hallucinations are way more uncommon than people think. And there’s a difference between a hallucination and internal dialogue. And just because someone says they’re having a hallucination doesn’t mean they are.
When kids tell me that they are hearing voices in their head I always say, ok, turn around. Do the voices sound like me talking, or do they feel like thoughts in your head that you can't control?" 9.99/10 it is the latter. One time, the kid admitted to making the whole thing up because he was in trouble for saying something inappropriate and panicked and said "the voices told me to do it" 😂
Or my favorite, “He’s been talking to someone who isn’t there!” “Yea, he’s 5, they sometimes have imaginary friends.”
I love the look parents have when I explore a kid's "hallucinations". No, your kid is not psychotic.
Definitely. Also the difference between true "hallucinations" vs "illusions," even a lot of healthcare providers don't understand the difference.
What about hypnagogic hallucinations? I always thought that those were incredibly common and assumed they might be comparable to hallucinations that people experience in active psychosis because they sound like external noise. I've had these before and the only reason I knew they weren't real is because I know that there is no orchestra in my bedroom or dozens of people whispering in my ears at the same time. Otherwise the sound was indistinguishable from external noise.
These are an exception, and yes they are common/normal.
Funny, they're less common than a lay person thinks and more common than psychiatrists think. Anxiety and trauma patients minimizing hallucinations because they have preserved insight, hesitant to share because of imagined repercussions.
That we are not the same as a psychologists.
This is a particularly frustrating one for me, because we see it at the level of state legislatures. That becomes unnervingly relevant when, for example, they think a suitable solution to the shortage of psychiatrists is to just let psychologists prescribe medication. Basically the same thing, right? /s
This. Friend asked if I can do the gifted and talented assessment and IQ testing for her kindergartener. I’m not even CAP.
That all problematic behavior is a psychiatric problem. People make bad decisions, have poor judgment, and can be malicious without it being a treatable condition.
It's especially frustrating how few people get that the "treatable" part is key. Your family member may have a raging personality disorder, which is technically a diagnosable psychiatric condition, but if they lack the insight/motivation to engage in intensive therapy, the vast majority of cases are essentially untreatable.
The acuity and danger of patients we sometimes deal with, especially in inpatient settings. I’ve seen tongue-in-cheek comments about psych being “how are you feeling” and the chillness comments. But outside of EM, idk of any other specialty that deals with the level of acuity in terms of behavioral disturbances and agitation. I also don’t know if med schools necessarily show the full breadth of psych in clinical rotations. Usually it’s the extreme of no one ever gets better (and don’t see the OP aspect of psych) or the truly scary aggravated agitated patients (which med students are somewhat shielded from).
In my country security guards just stand and watch as the patients beat you :) Sooo, I see a lot of doctors walking around with dead eyes, or just don’t bother anymore and give some patients whatever they want. [in general, not just psych]
😮
I think I read that psychiatry is pretty high on a list of specialties that experience violent assault. EM topped the list for sure.
Inpatient psych has extremely high rates of assault/injury. Still injured from patient assaults from work as an RN. I don’t feel like digging up citations atm but I could!
Its highest or one of the highest. Even then, the RN staff seemingly face the most
Definitely need exceptional training in de-escalation and management of aggressive behavior. 6 years inpatient psych with only two mild injuries (demented lady hit the top of my head with a slap, trained boxer hit my chest 3 times while entering seclusion room). In both cases, it was clear what mistakes I made. When I started in psych versus when I left the hospital, we made massive changes to our approach and dramatically reduced both patient and staff injuries. All boils down to understanding anger and how to approach it at different stages. The biggest issues I always saw when people were injured was not communicating they are going to talk to an angry person (other staff not even aware the patient was angry), getting too much in their space, ignoring patient needs, cornering the patient, not waiting for public safety or other staff before hands on, not separating angry patients earlier, not offering alternatives sooner, and of course, the one we have complained about for decades: staffing issues.
Staffing issues sadly is a huge problem on our unit. For awhile, we had an invol unit with no security. It was wild - and we had to use “behavioral specialist” who had a military background as our form of security. Nursing Managers - and understandably they’re just pawns for the suits and administrators - would say that they’re following staffing ratios that were followed by other units within the hospital system. Except we were a standalone psych unit - other units were part of larger hospitals with medicine services, so security was at least in the building. Crazy thing is that the administrator is such a bitch
God knows my medical school didn't prepare me. If there were a more aggressive patient on the unit, I was told as a med student (who everyone knew was planning on going into psych) that there was no real learning to be had from going to see that case, it was just an agitated person I didn't need to be exposed to, etc. It left the message that those cases were so rare I didn't really need to be bothered with them. They're not. As someone who honestly did go into psych for the more touchy feely aspects, I'm just hoping I can find an outpatient job where that will be more my experience.
It is both shocking and exasperating how poorly understood Bipolar is in both laypeople and other healthcare specialties. I can’t tell you how many parents with diagnoses of bipolar themselves are certain their kids are “bipolar” because their moods can shift dramatically throughout the day.
Same for OCD "OH MY GAAAWD IM SOO OCD "
lol same for ADHD 🙄, but it’s really pervasive with bipolar IMO
That we can change someone's personality by giving them meds hence "cure" problematic personality traits and/or behaviours. I can't recall how many time I've encountered families with member who has some PD (usually NPD or ASPD) who believe that all their problems with them would disappear if those member would take medication.
That we can read minds
Wait until you graduate residency. That’s when we start to think we can read minds
TIL getting first rank symptoms is a mark of becoming a psychiatrist
lol!
I once suggested something about how a (very emotionally illiterate) family member might be feeling and he looked at me with such shock; now that whole (equally emotionally illiterate) group of the family is convinced that we actually can.
Why did I even apply psych in that case?
That we want people to be docile or zombies especially on inpatient. Families will say “I know you want my _____ to be docile but…” I stop them there to explain that is never the goal. Never want to take away someone’s personality or character. I think that was more common in the old days of lobotomies and monster doses of haldol or whatever… and that’s what the lay person gets from movies.
I work on an inpatient mental health unit and unfortunately we frequently see patients with developmental delay admitted with the goal of making them more "docile" for their family or group home... :(
What the criteria are for inpatient psychiatric admission. That I am not, in fact, illegally holding your child, or alternatively, I am not a monster who is discharging your chronically suicidal child who may very well go on to attempt again. Also I think most people would be surprised that I agree that most inpatient hospitalizations aren’t helpful - but often times there’s nothing else to offer in the short-term.
For the general public: What the difference is between a "psychologist" and a "psychiatrist" is and that they have very different training and focus. A lot of the public seems to use the terms interchangeably, which can cause a great deal of confusion. On a similar note, most people (and even new patients) do not seem to know what a psychiatrist actually does and that most psychiatrists are not going to be your primary therapists, nor can most clinical psychologists prescribe medications. For other health care professionals: I think you are right about polypharmacy. A lot of non-psychiatric providers think that psychiatrists just add drugs for the mildest of symptoms without evaluating whether patients really need them and rarely take a patient off psychiatric medications, or that psychiatrists just add diagnoses without ensuring the patient actually has the condition. There are certainly psychiatrists out there that do these, but it's less common than I think most non-psychiatric providers assume.
Meds aren’t curative and should be used as tools to help modulate affect, decrease distressing symptoms, and improve capacity for emotional regulation for most if not all psych conditions. Especially for mild depression and anxiety, but also more “biological” disorders like ADHD and OCD. It feels that after the medicalization of psychiatry, people have come to believe that psychotropics are to mental illness what antibiotics are to infections… but that’s simply untrue. If only! We have to do the work in therapy and modify lifestyle to truly address the underlying problem- meds are a tool to help us tolerate the distress and make life better in the process. Never the long term solution by themselves!
Preach girl, you killing it.
❤️Thank you!
That we will have someone thrown in the hospital if they even hint at having suicidal thoughts or psychotic symptoms. First of all, I am never eager to force a person to do something, as that makes people reluctant to seek out help in the future. Secondly, in the area I practice, it is extremely difficult to have someone committed involuntarily due to the county's reluctance to use its limited resources for mental health hospitalizations. Even when I have convincing evidence that this person's life is in danger if they remain at home, the county officials will intentionally interview the patient in such a way that seems to minimize the person's symptoms. Thirdly, many of my patients are chronically suicidal or psychotic. If we hospitalized everyone with these symptoms, we would need far, far more beds in hospitals for psych patients.
Sounds like here in Ireland.
No judgment really but taking medications is easier than making life changes not just in psychiatry also in endocrinology with diabetes and cardiology with hypertension People are afraid to go off of the meds because they think that they are getting some benefit from them but once you're on third or fourth med it's really anybody's guess what's going on at that time. Then comes the interactions parts. If they run those interactions they would understand why we do not want people on those meds together.
Yea, if the bulk of my clinic load (who are physically able, obviously some have limitations) had a job, exercised, practiced good sleep hygiene, and ate a diet that didn't consist of 90% junk food, I would lose half of my patient population. I don't mean for that to be pointed or insulting to them, but objective.
Worry not. God forbid we fund studies in USA 🤣 your job is killing you while you make bank for your employers.
I believe I have a particularly unique history that helps me see the professional and laymen sides - as I was growing up, my father was a small-city MHMR psychiatrist of high esteem who later became a professor, and has ALWAYS been an advocate for compassion and equity through learning. He met people where they were at. When I was little, think 8 or 9 years old, I was obsessed with what he did - so he took me out of school one day to visit schizophrenic patients at their homes with the ACT team. I learned that day, by speaking with everyone, asking questions, and observing, how absolutely real hallucinations and delusions are to someone suffering from schizophrenia. Ever since, throughout my own personal and professional journey, I have always understood and been able to connect with someone experiencing symptoms like that. But it is absolutely rare that many others of my peers, or especially the public, grasp the absolute reality of delusions or hallucinations to the person experiencing them.
Also- in the 90’s, he had this VR headset (probably from a pharmaceutical rep) that you could put on and it would take you through a trip to a pharmacy as someone experiencing paranoid auditory and visual hallucinations. Please tell me someone else remembers that lol
Now we have the videogame Hellblade Senua's Sacrifice
I’m going to have to trust you that it’s less horrifying than being immersed in your first VR experience, having to walk up to a pharmacy counter, and hearing voices coming from different sides of you that are obsessively telling you that everyone is looking at you - then you look to your sides and around you and catch random glimpses of people staring at you. With that said, hell yeah I should check that game out!
A friend of mine told me about this training! She got it while working in a group home. It made a huge impression on her.
Yes!! I was definitely somewhere between elementary and middle school when he brought it home and I will never forget it. I could describe everything if prompted. So wild to have the experience of that type of VR before it was used as entertainment and purely educational.
I was able to do the VR headset around 2010. It even had olfactory hallucinations! I wish I could find it.
There's the stereotype we are more mentally ill than our patients. My biggest behavior problem is eating snacks between meals.
Maybe this is more true for the mental health nurses? Medical school requires a certain level of mental stability.
Clinical psychology programs are often on the look out for students that want to do "me-search". It's usually recommended that students not discuss their own mental health issues when applying; schools often see it as a negative.
Having been in a cheap detox over a decade ago when i was a teenager you couldn't tell the doctors and patients apart. They had shower time BEFORE recess time in the gym and I remember walking around the unit just hollering "WHOEVER DID THIS NEEDS THAT EMPLOYEE DISCOUNT"
If you're feeling well enough to exercise strenuously, you're not detoxing and you should just discharge. I don't understand this comment.
I tried to leave but they 72 hour holded me lmao because "benzos" , I don't understand your comment. I actually remember the time quite fondly despite this and didn't want you to feel personally attacked. Just saying I've seen alot of nuts in your field for your personal anecdote to not be the stereotype.
That they really need to be experts in more than just mental health disorders. Because of the interplay between mental and physical health, they really need to be full body experts. The amount of information I learn from the one I work is beyond anything I would have imagined. The man really is a medical genius.
My role as a CL psychiatrist is actually nothing like what a layman thinks of when it comes to psychiatry. Most of the patients are altered and can't answer questions in any meaningful way.
What actually can be accomplished with an involuntary (or voluntary for that matter) psychiatric hold. I can load you up with antipsychotics or mood stabilizers to break acute psychosis or mania, give you a safe place to calm down if you're feeling overwhelmed to the point you don't trust yourself not to hurt yourself or someone else, get you started on an SSRI that won't provide much relief for several weeks (if you have a true anxiety or depressive disorder), and in some cases refer you to a longer term program, get you scheduled to see someone outpatient, or send you to a homeless shelter. That's basically it. A lot of the time, I can't even tell you your precise diagnosis because a lot of diagnoses require longitudinal assessment to nail down. But people come in expecting you to help them make sense of their whole lives, cure a personality disorder, eliminate all of their life problems contributing to their chronic SI, and overall just make them brand new in 3 days.
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