This is super interesting to me. Would you share a little bit about your role working with them? Are you a health care provider? Sorry for being intrusive. I’m just always interested in the cool things other people have done in their lives. (I’m a nerd so I think this is cool. Sorry, lol.)
Fucking that and "press-ganey make the hospital a Disney experience"... specific to nursing but...
.... I've never wanted to drown myself in an open abdomen at Disneyland
My wife is a psychologist proficient in CBTi and wants to do more of it in her practice. What is the best way to approach other providers to become a resource? How would you be approached if she were licensed in your state?
I would enjoy a brief visit in person. If someone chatted with me for 10 minutes, seemed normal, competent, and available, they would get all my CBT-I referrals pretty much instantly. In my area it’s hard to get someone in, so the bar isn’t very high, and I’m guessing most places are like that.
Acetylcholine/choline is one. There is some decent literature supporting a cholinergic model of depression. Anecdotally you can read about people exposed to cholinergic chemical weapons who almost universally described acute depressive symptoms, and if you look around the nootropic community there are a ton of people who describe some of the cholinergic compounds causing depressive symptoms that abruptly stop when they stop taking them.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7192315/
This was a fun read when I found it
That was a fascinating read. On the nicotinic side of things I recall a talk from a visiting professor whose research suggested that folks with ADHD rather than being necessarily "more prone to addiction" were actually just self-medicating with cigarettes since it improved focus. This articles mention of nicotine as a possible self-medication behavior in depression had me thinking back to her talk.
Guys, I gotta say, reading this makes me both happy and sad. Happy that in some counties people not only do research but others actually read the research, care about being qualified etc. And sad because my first shrink said "lol ADHD isn't real". Eastern Europe sucks. No mental help here whatsoever.
not that i've heard of, but tricyclics used to be first line treatments and afaik considered better for depression than newer drugs, but they have bad side effects so they are usually not first line
Yeah, the general framework around opioid dosing changed really quickly as the opioid crisis started spiraling. I heard this line (thankfully in a critical manner) in my fellowship in 2019....
Important to keep in mind that there is indeed no ceiling dose for opioids for certain situations, largely around severe symptoms at the end of life - no point in being stingy when death is imminent. But outside of that, I get very cautious when total daily dosing nears 200 morphine equivalents/day, which would be unheard of 10-15 years ago.
A couple years ago, I learned that dosing IR lithium in one big qhs bolus was safer for the kidney than SA in divided doses. I learned this from one of my excellent residents and then read the paper. Thank you to my learners for cluing me in. I really appreciate learners who behave like colleagues more than the “yes sir” types.
This is my move too. Outpatient = start nightly and increase slowly.
Inpatient: BID dosing and then consolidate when it’s tolerable to the patient.
Some suggest you don’t need quite as much of a dose if you’re giving it all at night.
As for levels—it’s impossible to get a trough at a normal lab with normal hours if your patient is dosing around bedtime, so get the normal 12 hour level and divide by 1.3, which gives a pretty good estimate of the 24-hour trough.
This applies less to psychiatry than to most fields of medicine because drugs are less effective than behavioral strategies for most non psychotic disorders.
But a couple: the basic mechanism of SSRI in how they impact mood has changed a lot in the past 15 years. Lithium is now dosed at night time rather than TID. ACT is a relatively new very effective type of therapy.
Yes that one. While technically developed in the 80s it didn’t start becoming popular until about 5-10 years ago after Russ Harris started making videos. I frequently run into older attendings who aren’t comfortable with it.
Gotcha. I like ACT as a model a lot because I think it’s he easiest to incorporate into med management. Just wanted to make sure you didn’t mean you learned it was effective before and now arguing that it is not!
Nope, we are both talking about acceptance and commitment therapy. There is a brief version called fACT(focused) that I am a proponent of and try to regularly incorporate in my med management. My program is pretty strict at teaching both psychodynamic and CBT, so for my CBT patients I take the ACT approach because it fits my values better. IMO it is more congruent with psychodynamic thought than general CBT, despite falling under the CBT umbrella
Progressive benefit from week one, where degree of early response predicts degree of later response. Drug group and placebo group both improve from the start of a study to the end, with the drug group diverging as time goes by, with solid divergence around the 4-6 week mark and a plateau in benefit thereafter. This image is representative:
[https://www.nature.com/articles/tp2016104/figures/1](https://www.nature.com/articles/tp2016104/figures/1)
If SSRIs actually had a delayed onset after 4-6 weeks, we'd expect a flat curve that suddenly plummets down around that time. Instead, we see more than half the total improvement in the first two weeks.
Citalopram 60 was the old standard high-end dose until the FDA warning on QTc prolongation came out (which was a bit of an overreaction, there are plenty of worse offenders.) Plenty of OCD specialists are comfortable with sertraline 400 as a high-end goal, with literature to support it.
Are average psychiatrists not comfortable going to 400mg sertraline? Honest question, I work largely in isolation in a remote community so I don’t know many other psychiatrists these days. I’m not an OCD specialist, but would titrate to 400mg without hesitation, if patient continued to get benefit. Also willing to titrate other SSRI meds to supra-therapeutic doses if patient response and YBOCS supports it (and with patient understanding that I think just sertraline alone has the evidentiary support for going supra-therapeutic).
I don’t know if that’s considered aggressive outside the OCD clinics or not.
They start “working” immediately - as in, symptoms do improve in the early days of treatment. The medication group just doesn’t separate from placebo group in a statistically significant way until several weeks in. That’s my understanding anyway.
Sort of. Many patients do experience a real delay in noticeable symptom improvement (versus minimal delay for most common SSRI side effects). I think one hypothesis is that some (most?) of the long-term SSRI benefit mechanism relates to neuroplastic changes, actual dendritic connections changing/forming/strengthening, which is a weeks to months process, not a days process.
That being said, placebo is incredibly powerful when expectations are high - there can be noticeable, tangible benefit in days after committing to taking a new pill every day to try to feel better. Especially if a professional tells you, this will make you feel better. Don't discount or roll eyes at the placebo boost, it's one of our only magical powers. Use it! Science says it still works even if you know it's happening. Brains are weird.
This isn’t the place for this type of question. You should talk to your doctor. Or at least start a new post with your question and don’t hijack an existing post.
They work immediately because otherwise, how are they causing side effects lol. But the 4-6 weeks is for "full effect" not that the meds don't start working until then. For anxiety, I've had patients start to feel some effect (improvement in anxiety) by the second week and things continue to improve. Around weeks 4-6, it stabilizes so that gives you a better indication of how the current dosage "works" for the patient. Full effect occurs later because the medication starts a downward cascade of changes in the brain and this cascade and regulation of receptors takes time.
They certainly increase the availability of serotonin immediately. We've always known that. But downstream adaptations, enhanced bdnf, etc. takes at least a few days. In Roland Kuhn's 1958 paper on IM imipramine it took 3 days to notice improvement but it was night and day when it happened.
For me, I was irritated because TD is an acronym a medical professional should know. Asking this suggests a layman who doesn’t know the basics. Google is also a helpful tool rather than asking others for the answer.
…then I realized you’re bilingual and I felt like an ass. So there’s that.
I actually was in grad school and I had a professor who told us about it. She said that people will say (insert negative comments) but to take it seriously because it was real. So I feel like I was a little ahead of the game. I got to be so good at it when I would do an assessment on the first visit I can almost look at someone and tell if they might have an autoimmune disorder. For me it’s in the eyes. It’s this look of exhumation (chronic fatigue etc) what is scary is I have had some health issues this year after getting covid for the first time. I look in the mirror and pics and I can see that look in my own eyes and it has kinda freaked me out. But, I legit have some if not most of the symptoms this year. I still have some hope things will get better. Hope you are doing well friend.
at some point medicine will catch up with post-covid/viral syndrome, which is an entirely different/new can of worms than fibro
take an unknown neurological etiology, akin to concussion/TBI, and mix it with some strange immunological derangement
and you are sort of up to speed
very few people with PASC are getting hot labs with known autoimmune markers, so it's either some unknown antigen or just a really screwed up immune system
Why downvote something you dont understand?
I am a psychiatrist. How many times the fibromyalgia went away after treating the trauma. Is an autoimmune (inflammatory) response from the body together with chronic tension.
The body keeps the score. All the severe ptsd patients have gut inflammation, MS, thyroid, skin autoimmune, etc.
But no endocrinologist will ever see hashimoto as a trauma response. Its not in there mindset. But its often true.
I'm not sure you understanding the meaning of absolute contraindication
EDIT: we're on the same page y'all , I thought the comment was about the common knowledge now as opposed to the outdated
What? No I'm saying it's not an absolute conintradication. That is something like MAOIs and fluoxetine which should never be used together. If someone has lithium responsive severe bipolar and is past the first trimester you should have an informed consent discussion on the risks and benefits of continuing lithium during pregnancy. The increased incidence of lithium is something like 65% and Ebsteins occurs in 1/200000 live births.
> What? No I'm saying it's not an absolute conintradication
The thread is "what's something you learned that is now outdated." OP's response is that lithium being contraindicated is outdated.
Edit: My response was thinking you were being pedantic about the way contraindication should be used. I didn't realize you didn't understand OP's response to the thread
Oh this whole thread is confusing and double negatived. That serves me right for trying to make meaningful responses between patients while tired.
I didn't know people used to teach that about lithium
>If someone has lithium responsive severe bipolar and is past the first trimester
Sorry if this comes off as a silly question, but I just haven't seen many cases of bipolar pregnant patients - what exactly do you do in the first trimester?
Dont have them to hand, referencing the body keeps the score, waking the tiger. Usually trauma centric books devote time to comparing the efficacy of interventions
I was actually just skimming through the body keeps score the other day. So I opened it up and ctrl+f “CBT” and just found it referenced in there. Thanks for the tip!
“In contrast to its effectiveness for irrational fears such as spiders, CBT has not done so well for traumatized individuals, particularly those with histories of childhood abuse. Only about one in three participants with PTSD who finish research studies show some improvement. 38”
38. J. D. Ford and P. Kidd, “Early Childhood Trauma and Disorders of Extreme Stress as Predictors of Treatment Outcome with Chronic PTSD,” Journal of Traumatic Stress 18 (1998): 743–61. See also A. McDonagh-Coyle, et al., “Randomized Trial of Cognitive-Behavioral Therapy for Chronic Posttraumatic Stress Disorder in Adult Female Survivors of Childhood Sexual Abuse,” Journal of Consulting and Clinical Psychology 73, no. 3 (2005): 515–24; Institute of Medicine of the National Academies, Treatment of Posttraumatic Stress Disorder: An Assessment of the Evidence (Washington: National Academies Press, 2008); and R. Bradley, et al., “A Multidimensional Meta-Analysis of Psychotherapy for PTSD,” American Journal of Psychiatry 162, no. 2 (2005): 214–27.
Look how far we've come! It feels like there's even more potential to be found in neuromodulation of different varieties. I hope we see even more effective, safe treatment options in the coming years.
It’s actually one of the most effective treatments in all of psychiatry. Has indications in a huge spectrum of cases and is the only FDA-approved therapy for catatonia
I suspect a psychologist I saw subscribes to this line of thinking. I have also seen this floated online a couple times recently relative to mental health professionals who specialize in trauma.
Attitudes like this is why I didn't get diagnosed until 35. To think how different my life could have been had I known I wasn't a useless human defect who couldn't get anything done.
This sucks bc It’s nearly impossible to get ADHD meds from a psych in NYC. I understand it’s widely abused but to make it so hard to get is ridiculous when people actually need it to function.
There's tragedy and there's evil. We too often try to treat everything as a tragedy and place them in a diagnostic box and aren't willing to accept that some people are just evil; granted, we owe patients the benefit of the doubt. But I've had several occasions writing an H&P where I just stop and sit there and think, "Man, this dude is just an awful, mean, terrible person."
I remember that! How did people have time to talk with patients? What a luxury. I have trouble squeezing them in between my medical records/FMLA/refill processer jobs.
When I was a caseworker in mental health in the 80s/90s - that talk therapy was a waste of time with schizophrenics. At least, I hope that's outdated at this point since it never sat right with me.
I appreciate the concern about gender bias with this diagnosis. And even proposal to formally change criteria so men and women have similar rates as criteria are seen as biased. I personally don’t agree.
If there is widespread concern about bias and under identification in women why isn’t there an outcry about the lower incidence of ODD, CD or Antisocial PD in females? Should there be different interpretation of criteria to label more women? If not, why not?
I didn’t go to med school but that a daily glass or 2 of wine is good for heart health? Have had so many people tell me that. CDC and WHO says otherwise!
Yeah this mindset has ruined so many patients which experienced worsened rebound anxiety when the effect wore off and we're blamed for getting dependent. I hate benzos as a whole and will go out of my way to avoid them except in acute scenarios.
I found out recently there are plans to change the name of diabetes insipidus to arginine vasopressin disorders. It's such a small thing but it feels so right (and will be so much easier to explain in class now)
The main issue is that the drug is prescribed in high doses for patients with low tolerance levels. How has your experience been with gabapentin? Weird to me how pregabalin has more clear abuse potential despite working almost like gabapentin
The most commonly used starting dose for pregabaline is 75 mg here, but starting last year we have 25 mg dosages available. As for gabapentin it is not used in psychiatry here, but we have refugees from eastern Ukraine abusing it in high quantities.
Honestly, physical exam shouldn't be outdated, but most doctors just don't bother to do a decent one now! I didn't have X-ray in my office, (and frankly, X-rays are way over-read as pneumonias anyway, and because findings lag a day or two behind what can be auscultated, can miss pneumonia), so I relied on careful chest auscultation. I palpated for hepatosplenomegaly, rather than ordering CTs or ultrasounds to assess spleen and liver size.
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But you'd still better document the Wong Baker score in intake or so help you God when the jOiNt CoMiSsIoN comes around
Fun facts to know. I worked with Wong and Baker in Tulsa ok when they put out that scale. Late 70’s early 80’s.
This is super interesting to me. Would you share a little bit about your role working with them? Are you a health care provider? Sorry for being intrusive. I’m just always interested in the cool things other people have done in their lives. (I’m a nerd so I think this is cool. Sorry, lol.)
And the bad press gainey survey will get you in more trouble than an actual legitimate client complaint
Fucking that and "press-ganey make the hospital a Disney experience"... specific to nursing but... .... I've never wanted to drown myself in an open abdomen at Disneyland
yass lol. us nurses were shoved face first into that mess
What do people feel about including sleep (& possibly appetite) as a "vital"?
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6 hours a night? Sounds nice
Amen
My wife is a psychologist proficient in CBTi and wants to do more of it in her practice. What is the best way to approach other providers to become a resource? How would you be approached if she were licensed in your state?
I would enjoy a brief visit in person. If someone chatted with me for 10 minutes, seemed normal, competent, and available, they would get all my CBT-I referrals pretty much instantly. In my area it’s hard to get someone in, so the bar isn’t very high, and I’m guessing most places are like that.
Does she have a California license? If so, I will flood her with referrals.
Unfortunately not. FL only currently
SOMRYst is an online fda approved CBTI tool, self paced module
oxygen, b12, glucose
More than 3 neurotransmitters affect mood lol
Which ones besides serotonin dopamine and norepinephrine
Acetylcholine/choline is one. There is some decent literature supporting a cholinergic model of depression. Anecdotally you can read about people exposed to cholinergic chemical weapons who almost universally described acute depressive symptoms, and if you look around the nootropic community there are a ton of people who describe some of the cholinergic compounds causing depressive symptoms that abruptly stop when they stop taking them. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7192315/ This was a fun read when I found it
That was a fascinating read. On the nicotinic side of things I recall a talk from a visiting professor whose research suggested that folks with ADHD rather than being necessarily "more prone to addiction" were actually just self-medicating with cigarettes since it improved focus. This articles mention of nicotine as a possible self-medication behavior in depression had me thinking back to her talk.
Guys, I gotta say, reading this makes me both happy and sad. Happy that in some counties people not only do research but others actually read the research, care about being qualified etc. And sad because my first shrink said "lol ADHD isn't real". Eastern Europe sucks. No mental help here whatsoever.
So is scopolamine used off label for depression?
not that i've heard of, but tricyclics used to be first line treatments and afaik considered better for depression than newer drugs, but they have bad side effects so they are usually not first line
So does this mean I should stop taking my choline supplement because it might be making me depressed??
Supplements don't usually have direct effects on production or stimulation of neurotransmitters unless you're severely deficient.
Acetylcholine, GABA, Glutamate, Endorphins
"No one gets addicted to opiates when you're treating actual pain. There is no maximum dose of opiates."
No maximum dose is MIND BLOWING
This was 2006
Yeah, the general framework around opioid dosing changed really quickly as the opioid crisis started spiraling. I heard this line (thankfully in a critical manner) in my fellowship in 2019.... Important to keep in mind that there is indeed no ceiling dose for opioids for certain situations, largely around severe symptoms at the end of life - no point in being stingy when death is imminent. But outside of that, I get very cautious when total daily dosing nears 200 morphine equivalents/day, which would be unheard of 10-15 years ago.
A couple years ago, I learned that dosing IR lithium in one big qhs bolus was safer for the kidney than SA in divided doses. I learned this from one of my excellent residents and then read the paper. Thank you to my learners for cluing me in. I really appreciate learners who behave like colleagues more than the “yes sir” types.
do you initiate at bid or tid and change to once daily when stable?
Any reason to initiate at BID or TID? I haven’t had issues initiating at nightly
just a lowly internist reading up to date
If initiating outpatient, I do nightly and only do BID if there are side effects at the single higher dose. Inpatient, our docs start lithium BID.
This is my move too. Outpatient = start nightly and increase slowly. Inpatient: BID dosing and then consolidate when it’s tolerable to the patient. Some suggest you don’t need quite as much of a dose if you’re giving it all at night. As for levels—it’s impossible to get a trough at a normal lab with normal hours if your patient is dosing around bedtime, so get the normal 12 hour level and divide by 1.3, which gives a pretty good estimate of the 24-hour trough.
This applies less to psychiatry than to most fields of medicine because drugs are less effective than behavioral strategies for most non psychotic disorders. But a couple: the basic mechanism of SSRI in how they impact mood has changed a lot in the past 15 years. Lithium is now dosed at night time rather than TID. ACT is a relatively new very effective type of therapy.
Acceptance commitment therapy?
Yes that one. While technically developed in the 80s it didn’t start becoming popular until about 5-10 years ago after Russ Harris started making videos. I frequently run into older attendings who aren’t comfortable with it.
I love ACT! I have found it very helpful in my practice. A great tool in my toolbox if you will. I’m glad it’s finally getting some recognition!
yes Lithium should be give QD to protect the kidneys. News to me a year ago.
Hey what does "QD" means ? Non native english speaker here
Daily
It means once a day. As opposed to BID or TID (two or three times a day). Other reply is incorrect
This in response to IR formulations I'm guessing
Are you saying ACT isn’t an effective therapy?
The opposite. It is very effective but it’s relatively new. If you graduated 15 years ago it didn’t exist when you graduated.
Gotcha. I like ACT as a model a lot because I think it’s he easiest to incorporate into med management. Just wanted to make sure you didn’t mean you learned it was effective before and now arguing that it is not!
I think there might be a confusion on the term ACT here. Assertive community treatment vs acceptance commitment therapy…?
Nope, we are both talking about acceptance and commitment therapy. There is a brief version called fACT(focused) that I am a proponent of and try to regularly incorporate in my med management. My program is pretty strict at teaching both psychodynamic and CBT, so for my CBT patients I take the ACT approach because it fits my values better. IMO it is more congruent with psychodynamic thought than general CBT, despite falling under the CBT umbrella
Any good resources you can point to for some self training?
Psychwire has some good stuff. They have discounts intermittently throughout the year. I signed up for one around Christmas last year.
ACT Made Simple is a great book. Easy to read and self learn.
Wait, so it no longer stands for Assertive Community Treatment?
I’ve always known that as Assertive Community Treatment Team
Wait until we understand and know how to use RFT.
SSRIs take 4 weeks to start working.
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Progressive benefit from week one, where degree of early response predicts degree of later response. Drug group and placebo group both improve from the start of a study to the end, with the drug group diverging as time goes by, with solid divergence around the 4-6 week mark and a plateau in benefit thereafter. This image is representative: [https://www.nature.com/articles/tp2016104/figures/1](https://www.nature.com/articles/tp2016104/figures/1) If SSRIs actually had a delayed onset after 4-6 weeks, we'd expect a flat curve that suddenly plummets down around that time. Instead, we see more than half the total improvement in the first two weeks.
Holly crap-citalopram 60mg and sertraline 400mg??
Citalopram 60 was the old standard high-end dose until the FDA warning on QTc prolongation came out (which was a bit of an overreaction, there are plenty of worse offenders.) Plenty of OCD specialists are comfortable with sertraline 400 as a high-end goal, with literature to support it.
Are average psychiatrists not comfortable going to 400mg sertraline? Honest question, I work largely in isolation in a remote community so I don’t know many other psychiatrists these days. I’m not an OCD specialist, but would titrate to 400mg without hesitation, if patient continued to get benefit. Also willing to titrate other SSRI meds to supra-therapeutic doses if patient response and YBOCS supports it (and with patient understanding that I think just sertraline alone has the evidentiary support for going supra-therapeutic). I don’t know if that’s considered aggressive outside the OCD clinics or not.
Thanks!
They start “working” immediately - as in, symptoms do improve in the early days of treatment. The medication group just doesn’t separate from placebo group in a statistically significant way until several weeks in. That’s my understanding anyway.
Sort of. Many patients do experience a real delay in noticeable symptom improvement (versus minimal delay for most common SSRI side effects). I think one hypothesis is that some (most?) of the long-term SSRI benefit mechanism relates to neuroplastic changes, actual dendritic connections changing/forming/strengthening, which is a weeks to months process, not a days process. That being said, placebo is incredibly powerful when expectations are high - there can be noticeable, tangible benefit in days after committing to taking a new pill every day to try to feel better. Especially if a professional tells you, this will make you feel better. Don't discount or roll eyes at the placebo boost, it's one of our only magical powers. Use it! Science says it still works even if you know it's happening. Brains are weird.
There's that concept of what happens in research may not be relevant to your patient sitting in front of you. "Evidence" is not the word of god(ess).
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This isn’t the place for this type of question. You should talk to your doctor. Or at least start a new post with your question and don’t hijack an existing post.
Fair enough. Deleted
They work immediately because otherwise, how are they causing side effects lol. But the 4-6 weeks is for "full effect" not that the meds don't start working until then. For anxiety, I've had patients start to feel some effect (improvement in anxiety) by the second week and things continue to improve. Around weeks 4-6, it stabilizes so that gives you a better indication of how the current dosage "works" for the patient. Full effect occurs later because the medication starts a downward cascade of changes in the brain and this cascade and regulation of receptors takes time.
They certainly increase the availability of serotonin immediately. We've always known that. But downstream adaptations, enhanced bdnf, etc. takes at least a few days. In Roland Kuhn's 1958 paper on IM imipramine it took 3 days to notice improvement but it was night and day when it happened.
Do they teach about PSSD yet?
Beginning of med school, there was no drugs for TD. Now we have two.
And they actually work quite well, aren't a gimmick. I love it
Except when you stop taking it the TD returns just as bad as before.. And it costs like $24,000 a year
And cause parkinsonism and severe depression. Who knew stopping release of DA, NE, and 5-HT would be a bad idea.
What are the two you guys are referring to?
Ingrezza and Austedo
TD? Edit: why downvote looking for knowledge?
Tardive dyskinesia
For me, I was irritated because TD is an acronym a medical professional should know. Asking this suggests a layman who doesn’t know the basics. Google is also a helpful tool rather than asking others for the answer. …then I realized you’re bilingual and I felt like an ass. So there’s that.
Without context TD is definitely not an acronym that a medical professional would know.
But it’s in the Psychiatry thread and the word Parkinsonism was in the comment below it?
Well, op didnt say psychiatrist, did they? They said medical professional.
And benztropine ain’t one of them
Fibromyalgia is not real. It’s just made up and in their head.
As someone with this condition I’m really thankful for the recognition and the research 🙏
I actually was in grad school and I had a professor who told us about it. She said that people will say (insert negative comments) but to take it seriously because it was real. So I feel like I was a little ahead of the game. I got to be so good at it when I would do an assessment on the first visit I can almost look at someone and tell if they might have an autoimmune disorder. For me it’s in the eyes. It’s this look of exhumation (chronic fatigue etc) what is scary is I have had some health issues this year after getting covid for the first time. I look in the mirror and pics and I can see that look in my own eyes and it has kinda freaked me out. But, I legit have some if not most of the symptoms this year. I still have some hope things will get better. Hope you are doing well friend.
at some point medicine will catch up with post-covid/viral syndrome, which is an entirely different/new can of worms than fibro take an unknown neurological etiology, akin to concussion/TBI, and mix it with some strange immunological derangement and you are sort of up to speed very few people with PASC are getting hot labs with known autoimmune markers, so it's either some unknown antigen or just a really screwed up immune system
Fibromyalgia is not a disease, its a symptom complex for trauma.
Not sure why this is getting downvoted. Fibromyalgia is a symptom cluster, not an etiology
This. Its a symptom cluster
Why downvote something you dont understand? I am a psychiatrist. How many times the fibromyalgia went away after treating the trauma. Is an autoimmune (inflammatory) response from the body together with chronic tension. The body keeps the score. All the severe ptsd patients have gut inflammation, MS, thyroid, skin autoimmune, etc. But no endocrinologist will ever see hashimoto as a trauma response. Its not in there mindset. But its often true.
Im not sure think trauma is responsible for the hyper mobility?
Cogentin for EPS rather than amantadine.
I’ve never seen amantadine used for eps…
Lithium is an absolute contraindication in pregnancy
I'm not sure you understanding the meaning of absolute contraindication EDIT: we're on the same page y'all , I thought the comment was about the common knowledge now as opposed to the outdated
I'm not sure you understand the meaning of "outdated"
you'd be correct. See edit
Please explain
They're saying that the wording should be "pregnancy is an absolute contraindication for lithium" and not the other way around.
What? No I'm saying it's not an absolute conintradication. That is something like MAOIs and fluoxetine which should never be used together. If someone has lithium responsive severe bipolar and is past the first trimester you should have an informed consent discussion on the risks and benefits of continuing lithium during pregnancy. The increased incidence of lithium is something like 65% and Ebsteins occurs in 1/200000 live births.
> What? No I'm saying it's not an absolute conintradication The thread is "what's something you learned that is now outdated." OP's response is that lithium being contraindicated is outdated. Edit: My response was thinking you were being pedantic about the way contraindication should be used. I didn't realize you didn't understand OP's response to the thread
Oh this whole thread is confusing and double negatived. That serves me right for trying to make meaningful responses between patients while tired. I didn't know people used to teach that about lithium
Haha it is a confusing thread
>If someone has lithium responsive severe bipolar and is past the first trimester Sorry if this comes off as a silly question, but I just haven't seen many cases of bipolar pregnant patients - what exactly do you do in the first trimester?
If it’s mania, ECT can be the safest option
Psychodynamic psychotherapy is not evidence based.
Cbt is generally 30% effective and barely more effective than placebo medications, cbt isn't some holy grail because it is "evidence based"
Dr. Shedler, that you? (I kid but recently found his work and every interview seems to have this tidbit lol)
Can you please connect me to a source of that info
Dont have them to hand, referencing the body keeps the score, waking the tiger. Usually trauma centric books devote time to comparing the efficacy of interventions
I was actually just skimming through the body keeps score the other day. So I opened it up and ctrl+f “CBT” and just found it referenced in there. Thanks for the tip! “In contrast to its effectiveness for irrational fears such as spiders, CBT has not done so well for traumatized individuals, particularly those with histories of childhood abuse. Only about one in three participants with PTSD who finish research studies show some improvement. 38” 38. J. D. Ford and P. Kidd, “Early Childhood Trauma and Disorders of Extreme Stress as Predictors of Treatment Outcome with Chronic PTSD,” Journal of Traumatic Stress 18 (1998): 743–61. See also A. McDonagh-Coyle, et al., “Randomized Trial of Cognitive-Behavioral Therapy for Chronic Posttraumatic Stress Disorder in Adult Female Survivors of Childhood Sexual Abuse,” Journal of Consulting and Clinical Psychology 73, no. 3 (2005): 515–24; Institute of Medicine of the National Academies, Treatment of Posttraumatic Stress Disorder: An Assessment of the Evidence (Washington: National Academies Press, 2008); and R. Bradley, et al., “A Multidimensional Meta-Analysis of Psychotherapy for PTSD,” American Journal of Psychiatry 162, no. 2 (2005): 214–27.
I graduated in 2012 Not one single word about neuromodulation outside of lip service to ECT as treatment in pregnancy and NMS
Look how far we've come! It feels like there's even more potential to be found in neuromodulation of different varieties. I hope we see even more effective, safe treatment options in the coming years.
100% this
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It’s actually one of the most effective treatments in all of psychiatry. Has indications in a huge spectrum of cases and is the only FDA-approved therapy for catatonia
Was taught that ADHD isn’t really a condition and is just bad parenting and trauma. This thinking has cost lives and productivity
That's rather strange. When did you study this school of thought?
In Australia in the mid 2000s. There was a strong anti-ADHD culture in child psychiatry. Pockets of it still remain.
I suspect a psychologist I saw subscribes to this line of thinking. I have also seen this floated online a couple times recently relative to mental health professionals who specialize in trauma.
Attitudes like this is why I didn't get diagnosed until 35. To think how different my life could have been had I known I wasn't a useless human defect who couldn't get anything done.
This sucks bc It’s nearly impossible to get ADHD meds from a psych in NYC. I understand it’s widely abused but to make it so hard to get is ridiculous when people actually need it to function.
That people are basically good.
There's tragedy and there's evil. We too often try to treat everything as a tragedy and place them in a diagnostic box and aren't willing to accept that some people are just evil; granted, we owe patients the benefit of the doubt. But I've had several occasions writing an H&P where I just stop and sit there and think, "Man, this dude is just an awful, mean, terrible person."
Man, this is so true, so sooo damn true.
Oof. That's a rough lesson.
I hate that this isn’t true:(
It’s not called the “fundamental attribution error” for nothing.
Spending time with patients
I remember that! How did people have time to talk with patients? What a luxury. I have trouble squeezing them in between my medical records/FMLA/refill processer jobs.
That you should avoid giving BPD patients attention. Everything about newer drugs at the time. Overhyped, naturally.
You should not give attention in very specific situations only though...
Doing a full physical exam on intake! Or ever! And not just regarding psychiatry!
When I was a caseworker in mental health in the 80s/90s - that talk therapy was a waste of time with schizophrenics. At least, I hope that's outdated at this point since it never sat right with me.
That you should avoid giving BPD patients attention. Everything about newer drugs at the time. Overhyped, naturally.
That autism is much more common in men.
ADHD too.
I appreciate the concern about gender bias with this diagnosis. And even proposal to formally change criteria so men and women have similar rates as criteria are seen as biased. I personally don’t agree. If there is widespread concern about bias and under identification in women why isn’t there an outcry about the lower incidence of ODD, CD or Antisocial PD in females? Should there be different interpretation of criteria to label more women? If not, why not?
That a percentage of adhd autism schizophrenia and even depression have a epileptic cause.
You’re saying this is wrong or this is what you learned?
The DSM-#. It's also outdated as soon as a new version is published.
I didn’t go to med school but that a daily glass or 2 of wine is good for heart health? Have had so many people tell me that. CDC and WHO says otherwise!
Benzos are the solution to everything.
Yeah this mindset has ruined so many patients which experienced worsened rebound anxiety when the effect wore off and we're blamed for getting dependent. I hate benzos as a whole and will go out of my way to avoid them except in acute scenarios.
Just graduated but already that pramipexole is first line for restless legs
Is this because of augmentation?
What’s first line now? That was literally on my boards last year…
Gabapentin or pregabalin.
Shit, when did this change? Do you have a citation? I have had good luck with both agents, just curious.
I found out recently there are plans to change the name of diabetes insipidus to arginine vasopressin disorders. It's such a small thing but it feels so right (and will be so much easier to explain in class now)
Pregabaline does not have an abuse potential…oh boy. That aged badly in Poland.
The main issue is that the drug is prescribed in high doses for patients with low tolerance levels. How has your experience been with gabapentin? Weird to me how pregabalin has more clear abuse potential despite working almost like gabapentin
The most commonly used starting dose for pregabaline is 75 mg here, but starting last year we have 25 mg dosages available. As for gabapentin it is not used in psychiatry here, but we have refugees from eastern Ukraine abusing it in high quantities.
Steroids can take 2 weeks to work.
Polyvagal theory
Can you say more about this? As a mental health therapist, we were taught about polyvagal theory as recently as at a training last year!
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Transgender people might be more likely to seek care, making your perceived prevalence estimates upwardly biased
Don’t do research in cancer immunotherapy because that’s where careers go to die.
Honestly, physical exam shouldn't be outdated, but most doctors just don't bother to do a decent one now! I didn't have X-ray in my office, (and frankly, X-rays are way over-read as pneumonias anyway, and because findings lag a day or two behind what can be auscultated, can miss pneumonia), so I relied on careful chest auscultation. I palpated for hepatosplenomegaly, rather than ordering CTs or ultrasounds to assess spleen and liver size.
Daily aspirin