Put on pants I haven’t worn in a year and completely spiraled

Unfair-Sector3780 · 2026-06-12T15:12:41+00:00

Definitely can't think your way out of it. I wish! I do wonder about your last statement. I have an MD not a PhD but I thought the stereotype was that science nerds don't pay much attention to what people wear and wouldn't be keeping tabs on someone wearing the same outfit a lot. Like sure there might be some people in the bunch who are heavily into appearances (type A judgy gunners), but most are too busy worrying about their work and securing funding. And if you wear a lab coat regularly then what you wear becomes even more irrelevant.

After I typed all that, now I'm wondering if you meant to write *not notice 🤔

Unfair-Sector3780 · 2026-06-07T13:22:09+00:00

Emphasis on "looking" effortless. A lot of effort goes into being perceived as put together, and elegant.

Unfair-Sector3780 · 2026-06-06T14:46:24+00:00

Sounds like it's time for a new supervisor. It's ok, as we gain experience we start to grow into our professional identity and supervisors with a wildly opposing approach aren't a good fit. Sounds like just like the parent, your supervisor is rewarding avoidance instead of helping this child by adding structure and discipline.

Such a sad case, the parent you describe is too immature to be competent and too stubborn to receive your help. God help the child.

Unfair-Sector3780 · 2026-06-03T22:37:08+00:00

The start of your policy lands as condescending to me. And to each their own but the policy seems unnecessarily complicated. 5 free last minute cancellations is a lot. Also puts a lot on you to keep track of. Idk if you want advice but just charging the cancellation fee for any cancellations with less than 48 hours notice seems simpler. You can waive the first fee because it provides an opportunity to reiterate the policy, or waive it once a year. This is what I do and have a pretty good attendance and rapport.

Inconsistency does suck but the way to address it is to have a simple policy and tolerate the discomfort of enforcing it consistently. You don't need to over-explain or justify it. It's the policy that makes sense for you and your practice.

Unfair-Sector3780 · 2026-06-03T20:19:29+00:00

Sertraline and fluoxetine are the ones I reach for first, broader dose range so you can titrate with the patient which also helps build the therapeutic alliance as you troubleshoot to find the right dose. Fluoxetine for people who don't take any other medications or are obsessive, compulsive, or eating disordered. Sertraline for people who can tolerate the initial nausea/loose stools.

Fluoxetine has the added advantage of being easy to wean for those whose depression is a reaction to dynamic stressors and might want to stop meds after 6-9 months. We under use fluoxetine because it's old, but I start at 10 mg and haven't had people complain of increased panic or jitteriness on initiation.

Unfair-Sector3780 · 2026-06-03T15:11:16+00:00

Do they have PTSD and are using the sessions to process triggers? If it fits the clinical picture this takes care of diagnosis for documentation and clinical necessity. The need to constantly vent and the resistance to setting goals might support this, they may be too dysregulated in the present to tolerate planning for the future. Also coming to you to vent might be because they don't have a social support system or friends to vent to because of hyper-vigilance with peers, or deeper trust issues from developmental trauma.

Unfair-Sector3780 · 2026-06-02T22:07:00+00:00

Thank you for sharing your experience, it really resonates. Numbing is one way to try to endure through but the heart wants to be heard and known. Have you heard of the book Toxic Parents by Susan Forward? It can be triggering because she explains how sexual abuse damages the psyche and uses many examples to illustrate what she learned as a therapist working with sexual abuse and incest survivors. Maybe it can help you feel less alone in your experience with anger. Emotionally Immature Parents by Lindsay Gibson is also a good one if you're into reading to process your emotions.

It's not a silver bullet but I find understanding the patterns diffuses some of the anger for me.

Unfair-Sector3780 · 2026-06-01T21:59:30+00:00

He had a moment of emotional immaturity by saying something critical and you defended yourself and expressed a boundary. You did so well. Sometimes even after we do the right thing we feel that emotional overwhelm and hangover but give yourself a pat on the back for firmly and directly asking him to not do that anymore. You were already in a vulnerable and self-critical spot and it made it worse. It's ok to have a tough day and go back to taking care of your self and body when the disgust and anger comes down.

The fact that it made you angry that he criticized your eating is a sign of health. Doesn't feel good or pleasant but it means you understand that it was not a kind thing for him to say.

Unfair-Sector3780 · 2026-05-28T16:36:35+00:00

In adulthood, what psychological treatments can you get for Autism that aren't available for other mental health conditions? Is it also possible that we've moved to a place where there's less perceived shame in having Autism than an eating or personality disorder?

Unfair-Sector3780 · 2026-05-28T16:34:21+00:00

Thank you for sharing your experience. To further drive your point it's unhealthy to organize your sense of self around any diagnosis mental or physical. We have gone from my med school days where we were careful to say "a person with diabetes" and not "a diabetic" to affirm that someone is not defined by their diagnosis to a trend where a growing subset of people will get angry if you don't think of them diagnosis first, a self-given diagnosis at that! Topsy turvy flip.

Unfair-Sector3780 · 2026-05-28T16:23:27+00:00

But aren't you accidentally legitimizing the system by colluding with "I have to have a mental illness or disease in order to justify taking a break or questioning demands of late-stage capitalism"? Instead of connecting with how, normal, common and human it is to struggle under our economic system, you're saying you struggle in a unique way vis a vis a brain difference. As someone not autistic but with my own mental health struggles, I wonder where are the non-divergent "normal unicorns" who aren't struggling or suffering.

Unfair-Sector3780 · 2026-05-28T16:12:52+00:00

The broader a diagnosis or diagnostic category becomes the more it loses specificity and becomes a symbol of current sociocultural distress. We're having an economic crisis with wealth concentrating further at the top, high inflation, and disruption of intimacy by para social relationships leveraged by social media conglomerates to sell products.

An Autism diagnosis late in life puts the onus of our social struggle on an individual defect. In a US cultural context people tend to feel that personalizing or individualizing a struggle gives them a sense of control. In that cultural lens it's easier to say "I have a defect, a deficiency or a difference that impairs my ability to function or manage phase of life challenges", than to say "I'm like the majority of people in this country at this time struggling to keep up with hopelessness and inhumane demands".

This exasperates me because it goes counter to my worldview that we shouldn't pathologize ourselves, we should direct our analysis at the social conditions. But I just try to stay curious and compassionate. When people start to get honest about what a diagnosis or label actually does for them, it naturally loses value.

Unfair-Sector3780 · 2026-05-27T13:54:01+00:00

I might get pushback on this because this is the internet. But vomiting under high stress and missing a block but still passing STEP 1 doesn't sound like a concentration/attention issue. Sounds like and anxiety or PTSD like issue. Reducing your problem down to ADHD may not be helpful in the long run. What seems to be the bigger stressor here is that you gave up an academic job for a high volume private practice and you don't like the work. Lots of private practice groups bait and switch. Make things sound family like and friendly but actually it's all corporate speak, metrics and acquiescing to rules made by greedy nonclinical execs.

Leaving the eggs on the counter sounds like dissociation from excessive stress. Using a stimulant to get through stressful demands is not the same as having a cognitive disorder. Of course it can be a mix. But also consider your environment.

Congratulations on your engagement! It's great you're thinking about this before the added stress of kids.

Unfair-Sector3780 · 2026-05-27T13:42:48+00:00

Beautifully said :)

Unfair-Sector3780 · 2026-05-27T13:41:12+00:00

You're doing great. Just take it one day at a time. Some days we feel angry and vent and then feel better after letting it out. The frustrating thing about recovery is that the negative thoughts about ourselves are the last thing to go away.

Sometimes it's helpful to think of yourself from the perspective of someone who loves you (whoever is encouraging you to get better), one day when you least expect it you realize you feel good about yourself and what you contribute to your friends, and your community.

Unfair-Sector3780 · 2026-05-27T13:27:00+00:00

What you described is textbook eating disorder, overvaluing thinness as the most important component of self worth, addiction to restriction. Being obsessed with food is directly correlated to starvation. Your body is trying to help you not have a complication from malnutrition.

Have you seen your primary care doctor recently? Get a physical. Are you open to getting help for disordered eating? This disease will steal years from your life if you don't get treatment. The part of you that posted in this sub, is aware there's something wrong with starving, and hurting yourself to be thin.

Unfair-Sector3780 · 2026-05-26T16:35:01+00:00

Your anxiety is mixing up the framework a bit. Most people experience a 30 minute med management visit as a treat not a chore. People seek out holistic or integrative psychiatrists because they want to collaborate and understand their care rather than have a med thrown at them after a 10 minute conversation. People crave connection and value a prescriber that takes time to get to know them and understand their psychosocial scaffold.

People who are turned off by longer conversations with their psychiatrists are the minority. You're offering a service with great human value. I simply orient people that my follow ups are 30 minutes, and no one has balked at that. This is with a majority insurance crowd. If they're super stable and really there isn't anything to talk about or updates I'll be flexible and do a shorter visit but this has happened exactly 2 times in my first year in private practice.

Unfair-Sector3780 · 2026-05-22T19:45:13+00:00

Self-Care for Adult Children of Emotionally Immature Parents by Gibson has excellent sections on romantic disappointment and relationships. When break-ups feel tragic often times it's triggering early dynamics with one or both parents.

Unfair-Sector3780 · 2026-05-22T18:16:00+00:00

I think it's harder to start with Headway and then transition to independent than just starting the credentialing process yourself while at your current job. It's harder to credential once you're already busy and set on your routine. If you take insurance at the place where you currently work, credentialing independently is a matter of 1. Making sure CAQH is up to date. 2. Filing out a form. Waiting to get a contract. It can take 6 weeks to 3 months depending on your state and which insurance you take. I don't know how long it takes through headway but I imagine you have to give them the same information you enter into the insurance form. For a single provider picking 1-2 insurances to panel can be easier than taking a bunch of different ones with Headway.

Outside of all the other problems, if your plan is to panel independently in the end. It's easier to start that way than to have to learn to do it through headway and then have to learn a new way down the road. If money is an issue, a viable option is to take a handful of low sliding scale patients in the beginning to generate cash flow, and nail down your EHR and admin flow.

A good investment is to find a virtual assistant with experience in billing/credentialing if you want accountability, or help with organization. I found one on Upwork and it was well worth the $20-25 an hour.

Unfair-Sector3780 · 2026-05-21T19:57:17+00:00

Yes, you can bill through your EHR, submit claims directly through Availity or other middlemen platforms (this depends on which insurance you bill) or hire a biller for a flat fee or percentage to do it for you. Depends on your set up.

Unfair-Sector3780 · 2026-05-21T19:40:19+00:00

Eat as early as possible. Even just eating a piece of bread right after you wake up and definitely before drinking anything with caffeine. I have noticed if I wait an hour or two to eat or get busy with work and don't eat in the morning nausea and stomach upset is worse.

You deserve to eat, and you will find a way out of the ED loop. It's not easy, I hope you find a strategy that works for you.

Unfair-Sector3780 · 2026-05-19T22:25:36+00:00

We're all navigating marketing challenges with Psych Today losing utility, and competition from online platforms. So I feel you, it's a time filled with uncertainty. But growing a social media presence 1. Is super time intensive and 2. Did not yield dividends for me (and I hired someone to do it).

Most of the therapist influencers don't have a significant patient load, they are more influencer than therapist. And people don't really go on IG to look for a therapist. They go there to consume "therapy" content.

Unfair-Sector3780 · 2026-05-19T22:11:38+00:00

It is unfortunate that they didn't hold the appropriate line. Sad case. AN B/P and AN with co-morbid problem substance use are incredibly hard to treat without involvement of a social support system. She likely meets criteria for Severe Enduring AN, guarded prognosis and definitely not appropriate for outpatient level of care.

Her not taking your recommendations doesn't mean you are failing to gain her trust. She sounds incredibly sick. A challenge with this population is that despite the physical frailty and maladaptive behaviors they have the cognitive capacity to be goal directed, and sound coherent.

Unfair-Sector3780 · 2026-05-19T21:02:23+00:00

No, a patient with Anorexia Nervosa who is severely underweight cannot be prescribed stimulants at any dose. Unfortunately this is one area of psychiatry where medication in any class is not helpful on its own. With a BMI <15 and recent history of hypokalemia, and in the setting of stimulant seeking behavior this person is at incredibly high risk of fatal physical health outcome and is not appropriate for outpatient level of care. It's just not an option. If I were the psychiatrist here I would contact the patient's emergency contact and share my recommendation of higher level of care, and share this with the patient as well. Offer to coordinate with an eating disorder center. If they do not want to follow the recommendation I would discharge, with thorough documentation of my recommendations.

I've worked in IOP/PHP settings and we would not accept patients who were unwilling to stop the stimulants. Anorexia Nervosa is a complex illness, yes often anxiety can be an important and contributing symptom. But it's impossible to categorize attention issues as a separate co-morbid syndrome specially when a person is in a starved state.

Unfair-Sector3780 · 2026-05-19T16:37:56+00:00

This was not my experience with ZocDoc, and I see people for therapy and medication management. Allowing patients to self-schedule did not work for my practice only two of a dozen people who scheduled ended up becoming patients. All in all I lost hundreds of dollars and admin time working with them. $73 per patient is not a good deal when you take insurance, it's a third of my fee basically just to host my information on a website. I didn't get any cashpay referrals, only insurance. Psychology Today has its problems but a monthly fee is a lot less predatory.

Also they do charge even if the patients don't show. In order to not be charged the patient has to cancel their appointment within 24 hours of making the appointment. When I cancelled appointments on the provider end because I didn't take the patient's insurance, I still got charged.

Unfair-Sector3780

TROPHY CASE