r/Psychiatry

I don't do ASD assessments specifically but for the purpose of general assessment I do note when there are ASD traits I can see in front of me that may be contributing to the presentation.

I have had a few people (mostly male but some female) who clearly present as autistic to me on MSE / cross-sectionally, e.g.

• Sitting upright in formal-looking unmoving postures
• Fleeting poor eye contact that evidently causes them some discomfort
• Non-spontaneous speech of short length which only directly answers your question with little to no tonal variation or bizarre ways of using it, e.g. using mid-sentence tonality when ending a sentence which leads to confusion as I wait for further elaboration that does not arrive
• Generally impaired turn taking in conversation, a lot of "no sorry, you go"
• Very restricted affect which they will report is long-standing (and collateral will agree) in contrast to a newly restricted affect you may see in depression
• Difficulty getting ideas across that are not already part of their explanatory framework due to what I feel is concrete thinking, e.g. I had a patient who had excellent insight into the fact that their non-compliance with medication had led to previous relapses into psychosis, but was also extremely insistent that 2 standards of alcohol every weekend since the age of 18 (non-American) was binge-drinking of extremely early onset and had also been a large driver of their relapses - and could not be convinced otherwise

And yet when I take a more targeted history about autism, nothing of note shows up. At most they seem a little introverted, but they deny all the main things including stereotyped interests, sensory issues, social difficulties, fascinations that others might consider odd (e.g. dates, number plates), rigid routines etc.. And the developmental history might show a mild delay, but otherwise very normal there as well and certainly these people are reasonably functional now and have completed tertiary education.

I get that if I am asking these questions bluntly e.g. "do you have troubles with routines" I may not get the best answers as they may only be able to reference their own experience and tell me no, unaware that compared to someone else they in fact are quite rigid. I am also aware that they may also sniff out that I am screening them for ASD and try to obfuscate, but I am aware of that risk from many BPD screenings and do try and ask the questions discreetly and open-endedly. I do feel like my actual process of taking the history is reasonable.

Essentially - the MSE and my entire conversation with them shows strong ASD traits, and yet what they tell me on history does not show this at all.

What am I missing here?

Honestly with the rise of more and more medical psychiatry units I genuinely feel like this could become a really strong new normal. Admitting patients with a primary psychiatric issue to the psychiatry ward makes the most sense to me even if they have medical comorbidities and having a psychiatrist manage both the medical issues and the psychiatric issues in one place seems like it could really streamline patient care and reduce duration of admission.

Over the last few weeks I've been playing around with Doximity's AI scribe to help with my clinic note taking. I want to share my experience, get feed back, and hopefully be of use to yall.

I use a custom prompt I created to write the subjective and assessment portion of my clinic notes. I only turn it on after the visit and provide all the information myself. I am not comfortable with an ambient listening software capturing my patient's direct words. I do use gender specific pronouns at times but never names, age, or specific locations. These things are in my note, but I type them directly into the EMR. I do include specific medications, labs, symptoms, and pertinent medical history.

I would say overall it has been moderately helpful. Reading the created note every time slows things down a little, but lately I have only had to correct and edit something in about 10-20% of notes. My note writing time has dropped by about 5 mins per note. I think the biggest benefit and why I plan to keep using it for now is the psychological relief of being able to talk about the visit in a non-linear way and have a concise logical subjective/assessment come out of that.

I would like to share the prompt I've been using, but it will likely get auto-blocked because it looks like personal advice/experience. If anyone is interested, let me know and I can DM it to you.

Have some personal reasons where it is seeming like a good option to defer going straight into child fellowship after finishing residency.

What are people's perspectives on how this may look on my application? Could it be perceived as bad or not being serious about CAP in any way?? I'm passionate about child psych and would feel comfortable explaining the personal reasons on my application/ in interviews.

Has anyone done this and if so, what were your reasons for a year or two of attendinghood before child fellowship?

Hi everyone! Has anybody used Acamprosate off label for insomnia or anxiety? If so please share your experience.

I have a patient a 72M (very nice gentleman) with severe anxiety and insomnia that developed after 2 strokes, he fortunately has no other neuromuscular deficits, we tried all classical approaches including melatonin, ssri, benzos/hypnotics, SGA, doxepin, mirtazapine, trazodone, Seroquel, low dose lithium (300mg qhs), gabapentin etc. None of these worked well ir he had SEnso we had to stop (Ambien helped but caused high daytime anxiety and dyspnea). Quviviq and similar things are not an option due to financial factors.

He currently can sleep (most of the time) only with Zyprexa 15mg that he tolerates well but due to his age and metabolic factors it is not the best option for the long term.

Im thinking of trying QHS depakote or lithium, but also looking for other options.

Sleep study scheduled for next week.

Any helpful information/ideas would be greatly appreciated. Thank you!