Throwaway05
2hr ago
We require people to get car insurance because we know they will make the wrong decision (not getting insurance) if left to their own devices. Some people try this anyway.
We know that people will make the wrong decision with medicine also. Some of this is objective - people would prescribe themselves substances that are controlled (for a reason, for instance opiates), people will ask for treatments where the benefits are clearly outweighed by the risks. Consider all the people who use marijuana when they clearly are not supposed to,* or try and get Addy as a performance enhancing drug, or use illegal substances. What do you think would happen if you could just Dilaudid at the pharmacy? It would be a catastrophe.
The classic non drugs of abuse example is antibiotics. People will ask for antibiotics every time they get sick. Even when it's clearly viral and therefore the abx won't help. They will demand abx, they will write reviews complaining about it and bully the prescriber into giving them abx - even though they won't do anything helpful. Zero benefit.
And the costs can be high to the individual (side effects can be very bad), and to society (antibiotic resistance is increasing greatly). If someone becomes disabled because they took an abx of their own recognize society will pay the cost. This is not theoretical, people kill their kidneys with NSAIDs for example (that's OTC).
If left to their own devices patients will make objectively shitty decisions. The regulatory state exists to prevent this, you don't want people on the road without insurance.
When it comes to the more subjective stuff it does get a bit fuzzier but the fundamental problem remains, no layman has the knowledge and experience to make these judgements, just googling a pubmed article is not enough, smart and educated people think they can figure it out but this requires training and experience. The average person has no chance and society needs to be organized around protecting average and below average people.
The regulatory state has its problems but we require building codes because people will elect to live in a poorly built slum if given the choice because it's cheap. We have to protect people from themselves.
People will take a gamble on "it's fine I have a 1% change of a bad side effect from this antibiotic but society will pay the cost and even though this infection is viral maybe its not."
This is stupid.
People do not like being told what they can do and put in their bodies, but little in the world is as important to get correct as human lives. I remember what it was like before I was a doctor, I thought I knew what I was doing I did not.
*I'm not saying nobody is allowed marijuana, it's complicated.
Throwaway05
2hr ago
It's important to understand that medical stuff is more complicated than a layman is likely to understand, you see a lot of minimizing and belittling of the knowledge base of doctors these days and it leads to people not respecting the depth of complexity here. We do ourselves no favors in the process.
Consider a Statin. The benefits are pretty big...sometimes. But there isn't a lot of consensus as to who to give it and when. you have complex questions like "what number of rare debilitating side effects are appropriate for a moderate decrease in population risk. If you prevent 10 MIs is that worth one 30 year old getting an autoimmune issue and being unable to walk? What about 20? What about 50? What about 100? What do you do if the Family Med and Cardiology organizations disagree over what to do?
Medicine is both an art and a science and often lacks consensus. Standard of care is fuzzy and constantly being revised. We have to do ongoing education throughout our entire careers because a recommendation that was present from day one of my medical school is suddenly known to be wrong. Or maybe not, I have to read the paper and check.
Patients are not equipped to handle these considerations and don't realize how REAL they can be. We know patients will injure themselves or get themselves killed with poor decisions if left to their own devices so it's our job not to. Sketchy hormone replacement (testosterone), overprescription of stimulants and benzos, poor antibiotic stewardship...patients will do their best to do what feel is right with zero information and this can be extremely harmful to others or society (in the form of unnecessary medical costs and care).
Throwaway05
3hr ago
Our role is to identify the correct medication, tell you what you need to know about it (which is later reinforced by the pharmacist), check in with you to make sure you are still doing as instructed, and so on.
Many medications are very dangerous if taken incautiously - TB drugs require a lot of instructions and very careful compliance for instance. Low dose Lithium is extremely safe but can easily interact with other medications, cause significant side effects, or cause problems in response to athletic activity and dehydration.
Some medications have side effects that will very rapidly kill you that are rare enough patients wouldn't think of them....the list goes on.
Throwaway05
3hr ago
I'm shocked that you thought even for a second that Bluesky would be better than Twitter - it's purpose is to be a new home for people who are upset that moderates and conservatives are being given a voice, any early adoption is going to be centered around that. Yes some of the media are trying to take mostly apolitical stuff over (like football) but its purpose is still "fuck Musk for platforming people we hate."
Throwaway05
23hr ago
If you have the insight to post this here you are not fucked.
A few things to keep in mind.
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Your ability to tell what is real and true is going to be compromised at times. Involve your family and your doctor in your care. Get a therapist. Outsource some things to them. Don't make certain types of decisions (like stopping medication) without involving them. Others may be able to tell you when you are declining better than you can self-assess because losing that is part of the illness. Establish safe guards and personality structure that allows you to get help while you are doing well so you can be protected when you aren't.
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Negative symptoms are harder to treat, but they can be treated. Let those caring for you know about the negative symptoms. Don't bottle it up.
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Many illnesses (not just mental illness) involve stepwise decline. Further episodes, longer episodes can compound. So do whatever you can to decrease the frequency of episodes and their duration.
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You have met people in your life with serious mental illness and not known about it. Many people do well, and then you never know unless you catch them in an episode. There is hope.
Throwaway05
2d ago
Basically there's a lot of evidence and belief it does nothing at all so that the dose doesn't matter. This is countered by people who believe it works great in at least certain settings (ex: "well for general outpatient management no, but for acute crisis in mental hospital/inpatient ward..."). Some people will also argue that you need spaced dosing for efficacy and that that is more important for dosing.
Fundamentally it is extremely hard to do insomnia research because getting the right population slice is challenging. Pursuant to that, it may also be culturally dependent and a million other annoying things.
Stick with what the research YOU find and YOUR attendings say (with the later being important to wellness lol).
If you look at say Trazodone we have a lot of papers and guidelines in the U.S. saying it doesn't do shit.....but then some newer papers saying it's doing some weird stuff and thats the cause of the subjective improvement in symptoms. It is a mess and you'll see a variety of strong and seemingly evidence based opinions.
Saw your PM will reply when I get a chance, I think that needs more attention.
Throwaway05
2d ago
I only vaguely remember, this opinion formed back when I first discovered Scott which would have been during Trump's original run when most reputable sources of information died.
Probably anything to do with Insomnia, hypnotics, and especially melatonin. That line of research and guidelines is hideously complicated and in the U.S. at least has no clear consensus.
Any stance is wrong lol.
Throwaway05
2d ago
Emergency Department, that's often where the absolute worst psychiatric crisis happen - people who are high as fuck (and eventually calm down before they get to Psych) or incredibly decompensated (and get snowed with medication before they get to psych).
Outpatient Psych types in particular often forget just how bad things can get because the kind of patients who really need inpatient management end up being too disorganized to be seen outpatient and get disposed first to the ED, prison, or state level hospitals. .
Throwaway05
2d ago
The two things that stick out to me the most are his whole distaste for the FDA and his intense dislike of inpatient psychiatric stays.
The FDA does a lot of good and a lot of bad but the ratio is aligned with what we mostly value.
IP is important, I feel like he probably doesn't have enough ED experience and must have worked with shitty hospitals.
Granted the last time I looked at either of these opinions from him was in like 2017? So not sure if he has updated or I'm misremembering.
Also some boring Pharm stuff I remember reading back in the day but I'm guessing his views have changed a bunch and I haven't read much on the new site, dont want to hold that against him lol.
Throwaway05
2d ago
Will message you.
And yeah no doubt the media fucking sucks.
My fear is that people will engage in HER style stuff and this example is a bleeding edge version of that.
McWilliams is useful even if you are just skimming the personality disorder chapters because you will have colleagues with those. It's also interesting enough to make you go through it at pace haha.
I think things like your therapist looking at you like you are an idiot and you going "yeah I know" are underrated parts of therapy and the chatbot isn't going to do those things for now.
Throwaway05
2d ago
Haha I am a physician but I am not Scott and disagree with him on a large amount of his medical opinions.
I think you make a very fair point about access, and I don't have a good counterargument but it is worth noting that people excessively overweight their ability to manage their own health (including health care professionals who have lots of training in knowing better).
I guess the best argument I have is that these days a lot of mental health problems are caused by socialization adjacent issues and solving that with an advanced form of the problem is unlikely to be an elegant solution.
Throwaway05
2d ago
Oh hey!
When you get a chance I would love to hear how things are going for you!
On to the matter at hand -
Please update my understanding of that particular suicide if it's incorrect, but what I'd heard is that the person was substituting human contact with the chatbot and his parents didn't catch the worsening social withdrawal because he was telling them he was talking to someone. My fear is not that chatbots will encourage people to do things, but that they won't catch and report warning signs, and serve as an inferior substitute for actual social contact. Not sure what the media presentation is since I'm relying on professional translation.
Moving beyond that however, I think you underweight the value of therapy. DBT and CBT have excellent quality evidence at this point. The reason for those two specifically is likely two fold - they are "simpler" to perform, and because they are more standardized they are easier to research.
Also, good psychodynamics is not Freudian nonsense, it's mostly CBT with different language and some extra underlying terminology that is very helpful for managing less severe pathology. Again I tell you to read Nancy McWilliams haha.
At its absolute worse therapy is stuff like forcing social interaction, forcing introspection and so on. Some people can function well off of a manual, and some people can study medicine on their own. But nearly everyone does better with a tutor, and that's what therapy is.
A tutor is also more likely to catch warning signs because of (at this time) superior human heuristic generation and the ability to perform a physical and mental status exam.
Throwaway05
2d ago
Tremendously poor idea, general purpose chatbots have already led to suicides (example- https://amp.theguardian.com/technology/2024/oct/23/character-ai-chatbot-sewell-setzer-death).
Purpose built ones will have more safeguards but the problem remains that they are hard to control and can easily go off book.
Even if they work perfectly some of the incentives are poor - people may overuse the product and avoid actual socialization, leaning on fake people instead.
And that even if is doing a ton of work, good therapy is rare and extremely challenging, most people get bad therapy and assume that's all that is available.
Services like this can also be infinitely cheaper than real therapists which may cause a supply crisis.
Throwaway05
3d ago
Medications and management of medical issues is more complicated than most realize. Medical education emphasizes teaching doctors about our knowledge deficiencies for a reason, and it's very common for people in the field to grossly overestimate their understanding and knowledge. We complain about nurses, midlevels, and even other doctors having no fucking clue what they are doing at times.
It is extremely challenging for a layman, even one who is intelligent and informed, to bridge the training gap.
"Ok but who cares" is a reasonable question, but it is important to understand that errors don't just hurt you. A big example right now is antibiotics. Left to their own devices people will ask for and use antibiotics even when it's dangerous or simply not even a bacterial infection. This has a downstream effect on others, like an increase in antibiotic resistance.
It's also easy to hurt yourself and we find it unacceptable to allow society to not pick up the bill.
Let's say you have some mild chronic pain like arthritis, you read and are smart enough to know that ibuprofen can be good for this. But then you don't know the right dose, or the right frequency and then don't realize it is not a good idea with your diabetes. After a reasonable amount of time your kidneys are dead and you end up on dialysis - and society is paying for that. Even if you have good insurance or a lot of wealth that's a spot that could be given to someone else.
And that's a medication you can already buy over the counter.
Throwaway05
3d ago
For reading purposes I'd recommend just looking at DSM criteria or searching pubmed and finding what seems to be a reasonable review article.
Correctly making these diagnosis can be hard, and many cases seem obvious but aren't. While Borderline (BPD) is more common in women we find that Antisocial (ASPD) is over-diagnosed in men (not all criminals have it but...) and under-diagnosed in women. Borderline is the opposite (just because this dude murdered someone doesn't mean he isn't borderline). People with disordered personality who hurt people almost always get an ASPD diagnosis but people with severe BPD often hurt others. Impulsivity is a cardinal symptom in both (contra organized serial killer stereotypes). Often the dx just gets thrown out on gender lines, which is sometimes accurate but not always.
ASPD can be thought of us being a fucking asshole in mild to moderate cases and evil in moderate to severe cases (as demonstrated by disregard for the rights of others).
People with BPD in contrast care too much about others to some extent. There's been an attempt to rebrand it as "Emotional Dysregulation Disorder" which is instructive. Impulsive, passionate, lots of relationships that end abruptly, things like "I LOVE YOU, I HATE YOU" (splitting). For most they'll pattern match to a moody teenager, but in an adult body.
This is also a core part of what Cluster-B disorders often are, over expression of immature coping mechanisms aka acting like a kid. Also one of the reasons why they often burn off with age.
Severe borderline looks like psychosis (inability to determine what's real) and that's what the border in borderline is named for. There's an attendant identity instability which sometimes leads to being trans. Severe antisocial is lizard people types.
Histrionic is less interesting, you can call it stereotypical energetic Italian disorder if you like and wouldn't be too far off.
Narcissistic is simple at a basic level - Trump often gets accused of this (although I'm not sure I buy that). It gets pretty complicated if you look deeper though, most mass shooters are a subtype of this and not ASPD.
People often overweight anger in antisocials, it is often present but the lack of emotion is frequently more startling - lack of remorse, lack of respect for others, lack of love for partners). Often violence, anger, and intimidation happen because they are cheat codes towards getting whatever utility they are seeking, not because of investment leading to anger.
Most mental health conditions have heritable elements and we suspect that ASPD and BPD are two-hit situations (lived experience and genetic predisposition). Raisedby types may have it themselves, and failing that some shit happens with mothers and daughters - boys will just leave or pushback physically and be able to protect themselves, would be my guess.
In contrast crazy bitch exes are of interest to men because a lot of borderline traits are desirable (most stereotypical: abundant, quality sexual activity) and unlike mothers, exes can be more easily a legal or financial threat.
Uhhh that rambling went on longer than I thought it would, sorry. Everything I said is shortcuts/oversimplification.
Throwaway05
7d ago
The boyfriend died shortly after he showed up unannounced at Thiel and his husband’s Christmas party and apparently made a big scene. (Classic case of a mistress with unwarranted confidence).
Do you know anything about the personality this guy had? Stories like this almost always pattern match to certain kinds of mental illness (in this case maybe Borderline Personality Disorder).
Unstable relationships, attractive and likely to get in a superficial relationship, aggressive and maybe suicidal when spurned, possibly paranoid...
Likely someone who knows the people involved would be like "oh yeah that checks out he was crazy."
But outside looking in it isn't as obvious and these other explanations pop up.
Throwaway05
11d ago
Man you must have been around in the "shit I can't double click, I might as well just retire" days.
Throwaway05
11d ago
I thank god every day that I mostly use Epic (like at this point most damn doctors in the U.S.).
It sucks but it sucks way less than all the other options.
I don't know if you've run into any of this yet but AI assist tools are getting quite good. Should people be using them? Likely no, but they are hugely helpful.
Throwaway05
11d ago
That being said, there are lots of reasons why people don't take their medication
Putting side effects and related problems aside (and they are severe, antipsychotics increase all cause mortality for example), many patients don't think they have a problem.
https://en.wikipedia.org/wiki/Anosognosia
It's a core symptom for many with psychotic illnesses and but many mood disorders or personality disorders involve people thinking nothing is wrong or blaming unrelated things.
Many of those with awareness of illness want to be free anyway, even if it means being miserable. Sometimes it is so they can do drugs. Sometimes it's because inpatient facilities suck.
Valuing autonomy is good but it leads to some grossness at times.
Throwaway05
11d ago
I'm going to admit that I mostly skimmed looking for clinical pearls, but you may find this article interesting.
https://www.politico.com/agenda/story/2017/03/vista-computer-history-va-conspiracy-000367/
Anything about your end of things that you think a doctor should know?
Throwaway05
12d ago
I think the perception is more important than the reality here. The lefts wants to paper over all of her faults right now, but if she had won give it 5, 10, 20 years and their is going to be a big old asterisk on the first female president.
That Scarlett Letter would be tough to manage in the long term.
Throwaway05
12d ago
I can't endorse this enough. I've been more positive than you on Trump for a long time, but even with that (as well as an outright hatred of the woke) I still bought some of the propaganda, and I never really had an interest in hearing his speeches.
Now he sits down with Rogan, they both sound reasonable despite the spin, and their personalities make sense and match to others I have encountered in my life. I don't think Trump meets the criteria for narcissism after that interview, and Vance is clearly one of us regardless of any flip-flopping.
Even with all the practice in avoiding the democratic propaganda machine I still fell for it.
Throwaway05
13d ago
Wokeness is widely popular with women and necessarily involves holding together a lot of contradictory opinions, so the training is out there. Consider the modern dating market - women still want a man who is masculine, pays, etc. but they also want feminist girl bosses at the same time. These things don't work together, but they manage.
Cultural acceptability is what is normal. Lots of culturally acceptable believes are unwise or harmful, however.
Throwaway05
13d ago
Yeah I mean their are variations in personality and certainly some men are like this, but a large portion of my social group is going off right now and yeah that includes people from "histrionic" backgrounds but also lots Asians and so on who are all freaking out because they are deep in the woke bubble and panicking and huffing propaganda. This is people with graduate degrees mind you.
Most of them will calm down.
I'm not saying this is normal in the sense that is healthy, but it is reasonably common in certain social groups (yikes).
Antibiotic stewardship is something that impacts others, but the bigger problem is that people will ignore their own health as much as possible and then society pays the costs by caring for them after their mistakes. With obesity and some other lifestyle things accept this because you do need to limit how much you impact people's rights, but throttling of medical care is almost universally considered reasonable due the complexity in making informed decisions.
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