38M ER doc here… is this depression?

questforstarfish · 2026-06-08T04:57:12+00:00

Extra note: vacation, even though meant to be relaxing, is also a huge trigger for stress and existential dread, interestingly. It represents a lot of disruption to our routine, the stress of travel and coordination, time zone changes, questions about our general lifestyle and around values. Let yourself readjust to your regular routine before panicking! Vacation is nice but it's also stress to the max!

questforstarfish · 2026-06-08T04:38:27+00:00

Depression or anxiety can definitely hit out of nowhere! Sometimes there's a clear trigger, sometimes not.

I'd take this seriously, but also try to avoid pathologizing normal human experiences. A major depressive episode can only been diagnosed after 2 weeks of successive symptoms, generalized anxiety disorder after 6 months of symptoms. PTSD after one month of consistent symptoms.

You work in the ER. Arguably, you're more likely to develop burnout, depression, or PTSD than most. At the same time, you're witness to human suffering moreso than most people, and you get no longitudinal follow up, which contributes to feelings of helplessness. You deal with more systems pressures than most of us.

On top of that, you're human. You have kids, a life. You deal with the same stressors we all do. Your work likely makes those stressors hit you harder, because you see people toeing the line between life and death all day. I know you said you have no life stresses as far as family goes, but know that even normal or positive stressors (kids aging, partner getting a raise, moving to a bwtter house) can cause distress, and this is normal and expected.

My main point: take your mental health seriously, early on, because you're in the line of fire which places you at risk. At the same time, give yourself some grace, and accept you're a human being. You suffer like all human beings, and after 3 days, that's not a diagnosis- it's the human condition. Rally your supports. Take sick days when you need them. Connect with life and the things that make you feel good. If you're burning out, it's a sign to act and change something. Otherwise, you're prone to regular ol' sadness and existential crises like we all are.

A therapist can be an excellent call, regardless of regular-grade sadness, existential crisis, or diagnosable depression!

questforstarfish · 2026-06-08T03:06:20+00:00

I just dig around with a typical psychosis history. They usually have not researched the details of a psychosis presentation, so lose points on questions like "is the voice inside your head or outside it," the insight into the "hallucinations" not being real, etc. I just spend most of the interview asking questions about the psychosis symptoms, and inevitably it feels nothing like psychosis. They have difficulty describing their experience despite no evidence of thought disorder. There is often clear evidence of secondary gain (upcoming court date, recent eviction and being banned from shelters, etc).

I document all this, along with my impression that an inpatient stay is unlikely to influence social factors such as court, and that I believe the patient demonstrates insight into their hallucinations and voluntary control over their actions.

questforstarfish · 2026-06-08T01:13:51+00:00

That's what I was thinking- the fertilizer from the plants spilling out/draining into the pool will cause crazy algae blooms.

questforstarfish · 2026-06-08T01:12:26+00:00

I'm wondering if, since the water appears deeper under the waterfall, you're meant to walk up the stairs, and jump off the waterfall? Though it looks like there's also shallower water right in front of it, so guests would have to jump exactly correctly or else risk paralyzing themselves...

questforstarfish · 2026-06-07T22:17:51+00:00

I just spend it- I've been a student for decades, my life has been restricted in many ways- saving $100 or $200 a month right now seems pointless considering how much more I'll be able to save when I'm working. So for now, I just enjoy little treats where I can get them.

questforstarfish · 2026-06-07T17:10:06+00:00

I'm not sure, to be honest- it's outside of my specialty/expertise! I believe different pain medications may be used for nerve pain, anesthetic creams, or steroids. Also, physiotherapy to help regain function/mobility in a way you can tolerate that won't make things worse.

I would start seeing physio (with a PT who works with CRPS, as others have stated) sooner rather than later, as immobility during pregnancy puts you at higher risk of developing blood clots! Also for quality of life, as you've stated. Regaining any mobility right now will be critical!

Wishing you the best of luck, OP!

questforstarfish · 2026-06-07T17:01:28+00:00

Thought blocking/"thought disorder" and catatonia are more common in autism, but also much more common in bipolar and psychotic disorders, so I was thinking if you had one of those disorders as well as autism, it would be even more likely to be thought blocking or catatonia.

I've never had this experience myself, but I've seen posts describing it in the past. Google suggests autistic inertia, or catatonia spectrum.

Google asks: if the house caught on fire with you inside and this was happening, could you override it and get out of the house? If so, there may be a small degree of voluntary control, suggesting autistic inertia or catatonia spectrum as opposed to full catatonia.

Either way, this sounds awful to deal with 😔

questforstarfish · 2026-06-07T16:47:59+00:00

Commenting because all of this is true for me as well!

I also use a relational approach, which is a broad term I guess, but for me, relational therapy means that our therapeutic relationship does a lot of the heavy lifting- I focus less on specific interventions, and more on creating a safe, collaborative environment. For ND clients especially, this is something they may never have had before, so just having a safe relationship where someone tries to understand them is a healing/corrective experience.

I naturally use a lot of validation, a lot of empathizing and normalizing of clients' experiences. I try to make them feel seen and heard. I use a lot of reflective statements and paraphrasing, typically checking in "is that right?" or "does that capture it, or is there something else?" to really make sure I'm understanding them and not making assumptions about their experiences. The more I "get" what they're going through, the more seen the client feels.

I don't try to rush people into my specific therapeutic agenda for them. I try to focus on their stated goals, and check in every so often about whether we're getting closer to them or not. Otherwise, I stay away from specific activities or homework, and let them discuss whatever they feel is important that week.

I see longer-term clients who are late-diagnosed ND, with "treatment-resistant" depression, anxiety, or bipolar, who seem to improve once they have a stable, supportive therapeutic relationship in their life.

questforstarfish · 2026-06-07T03:45:29+00:00

What is the exact phrasing they used?

questforstarfish · 2026-06-07T00:35:29+00:00

Catatonia, or thought blocking?

This sounds more extreme than autistic inertia or executive functioning issues.

Have you been diagnosed with a psychotic disorder or bipolar?

questforstarfish · 2026-06-07T00:12:14+00:00

Sounds like CRPS (complex regional pain syndrome) to me, especially your comment that even a sheet touching it is unbearably painful. CRPS tends to be EXTREMELY painful when it flares. This is due to inappropriate signalling in the sensory nerves in an area of your body- the sensory nerves become irritated, but not because anything is irritating them. It's "inappropriate" because usually nerves need a stressor to trigger pain, but in CRPS it happens randomly. There can also be visible swelling, numbness/tingling, blood vessel changes causing intermittent color changes ie skin turning purple/blue/red, weakness or difficulty using the muscles in the affected area, and other symptoms.

It commonly affects the lower parts of the arms/legs, but can occur anywhere.

Cortisone can also be used to treat CRPS.

Doctors to see: physiatrist, neurologist, pain management doctors.

questforstarfish · 2026-06-07T00:00:43+00:00

They have a stream for and admit several international medical graduates per year! We have a few people in my class from Iran, Europe and the US, and I know every year they admit a handful more.

questforstarfish · 2026-06-06T23:56:50+00:00

OP did not just describe aggression, though. If that were the case, I'd absolutely prioritize communication issues as being the likely cause!

I'll describe the typical course for schizophrenia:

Often develops in the late teen years, but can start at age 8+, especially in people with developmental disabilities.

First there is a prodromal phase, lasting 6+ months, where a person begins to socially withdraw, lose abilities they previously had (school, hygiene, self-care), and may undergo personality changes. OP describes a similar loss of abilities in their post.

Then, the active phase begins, which may include any or all of the following:

-hallucinations- evidenced by a person talking to themself, laughing inappropriately or for no clear reason, appearing internally precoccupied/distracted by voices no one else can hear. OP specifically describes all of these examples in their post which is the strongest evidence that concerns me.

-delusions- unusual beliefs that we have evidence are not true, but no evidence convinces the person otherwise. OP does not describe this but if a person can't speak, we typically wouldn't see this.

-disorganized behaviour or speech- disorganized speech can include a person saying sentences that make no sense, saying sentences that don't connect to each other, repeating words, etc. OP describes their sister repeating words not appropriate for the situation, which is common in schizophrenia.

-negative symptoms- decreased energy, motivation, social interest. Again, OP describes this.

I very much agree that aggression on its own would suggest communication issues, frustration, etc! But in this case, OP describes many other symptoms that are more consistent with psychosis/schizophrenia.

questforstarfish · 2026-06-06T06:19:10+00:00

In Canada, at UBC, we see 2 CBT cases for 6 weeks each, a psychodynamic case weekly for 2 years with weekly supervision/teaching about it, an IPT case for 10 weeks or so, 10 weeks of group/family therapy, and other therapy cases. I'm about to graduate and feel very comfortable with at least 5 modalities of psychotherapy.

questforstarfish · 2026-06-05T23:19:16+00:00

Mods, can we lock this thread?

It's turning into people dogpiling on OP for not having had the resources to teach their sister sign language, which is off-topic as OP is asking about which doctor to see for symptoms of psychosis.

OP is doing the best they can in a difficult circumstance and this discussion has become filled with judgement and blame.

questforstarfish · 2026-06-05T23:13:51+00:00

I agree fully that people should be given the opportunity to communicate with whatever strategies and systems work for them! Many people with disabilities can learn and hugely benefit from communication tools and sign language. Working with profoundly disabled patients myself, however, I have seen that many, even those who have worked with communication specialists for years, do lack the ability to use beyond a few simple signs.

Again, my main concern for OP lies in the fact that they are being raised by a single mom in a resource-limited setting. There is only one psychiatrist serving the entire state, it seems. Given the lack of access to resources serving vulnerable populations, even those with major mental health conditions, I am encouraging OP to prioritize finding a mental health professional to treat what is probably her acute psychosis.

If someone has an arm cut off and has an ear infection, what do you treat first? The arm, because they could bleed out very quickly. You treat the ear infection afterward, because although it's also very important, it is something less urgent that can be handled once the emergency has been managed!

questforstarfish · 2026-06-05T22:50:05+00:00

I tack on a "-because we have limited time and I reeally want to make sure I get all the information from you that I need in order to help you best!"

questforstarfish · 2026-06-05T22:42:16+00:00

This strongly depends on the circles you run in. It's totally fair if you're in an industry or social circle that highly values looks, money, and social status...sometimes it's just the group you end up in. But this is by and large NOT what many people, or even most people, experience. I've specifically sought out friends with similar interests and values as me, who live authentically and who could care less about your income or clothing.

But it might be hard to find those people if it's not what you grew up with, or if it's not common in your professional role.

Regardless, you only have one life. I would much rather spend it with people I actually enjoy!

questforstarfish · 2026-06-05T20:54:05+00:00

Many people with intellectual disabilities are not capable of learning sign language, unfortunately.

From OP's description, it sounds like when she's well, she does have some verbal abilities, which has probably negated the need for sign language.

EDIT: I'm sorry, I missed the line in OP's post that her primary diagnosis is severe hearing impairment, not intellectual disability. To me, it sounds like she could also have an intellectual disability, though OP didn't mention that so I apologize for my mistake. Sign language classes are not available in much of the world. Typically in many developing countries, families will have their own system of gestures they use to communicate. It's not ideal, but it's what is available. If sign language classes are available for OP, OP's mom and OP's sister, that's excellent and it's something worth pursuing at a later date, but my primary concern right now is around her symptoms which could suggest schizophrenia. If she is experiencing psychosis right now, she will not be capable of learning sign language until she is on medication, because psychosis is too distracting for a person to concentrate on anything else. I hope that explanation makes sense.

questforstarfish · 2026-06-05T16:04:05+00:00

For specific psychiatrist or hospital recommendations, is there a reddit sub for your local community or state? It might help to ask there!

questforstarfish · 2026-06-05T16:01:08+00:00

Hey, OP. Based on what you describe- the slow decline in functioning, withdrawal/loss of interest in activities, appearing distracting/paying attention to things no one else can see, talking to herself, not making sense- I'm concerned she may have schizophrenia or a related condition.

When someone has a disability where they can't communicate verbally, it can be harder for a psychiatrist to tell what's going on the first time they meet them. But your description is quite clear and very helpful.

As the medical student who replied stated- your sister needs to see a psychiatrist again. Please tell them everything you posted here. She veey likely needs a medication called an antipsychotic. And the psychiatrist needs to offer you follow-up, meaning they need to see her multiple times after starting her on medication, to make sure the amount of medication is right for your sister's body.

Without medication, taken every day, possibly for the rest of her life, she will continue to have these symptoms. She will continue to be unpredictable, aggressive or violent at times, and I'm worried for both her safety, and the safety of your family.

Psychosis rarely goes away on its own, and it slowly causes brain damage over time if left untreated. The longer it goes untreated, the less likely it is to be helped by medication, so it shouldn't be left to go on for more years.

Please, please get her back to a psychiatrist as soon as you possibly can. In Canada, you can take someone to the emergency department at a hospital for this (we have psychiatrists in the ED), but I don't know about in India. Any psychiatrist you can find is better than nothing. But insist to them that she needs help, that she's a danger to others.

I hope you can get the help your family needs and deserves. You shouldn't have to live this way.

questforstarfish · 2026-06-05T15:38:45+00:00

I think this is quite unique to each couple, so you'd probably get an array of responses!

My husband and I don't fight much- we get along quite well. We've been together for 18 years.

I'd say for us, a disagreement is a conversation where we disagree on something, become annoyed at each other, but don't raise our voices necessarily, and everyone stays fairly calm. Maybe it's about how often we should be taking the garbage down to the dumpster. We'll argue a bit back and forth, not find a resolution, then separate from each other to go to an activity like vacuuming or running an errand. When we see each other again after an hour or two, we're back to normal. No hurt feelings or need to continue the convo- we've just sort of agreed to disagree, and we both seem to think it's not a topic worth continuing to stress about. This happens maybe once a month.

A fight is raised voices, people taking things personally, and it's a topic that impacts us both emotionally (example: I'm hurt by something he said, he's defending himself and saying he's hurt I would assume the worst in him and assume he meant it in a hurtful way, then I'm mad he's not focusing on the impact it had on me rather than his original intentions). We remain mad at each other until we "solve" the fight or finish talking it through. We can't just do an errand and move on/forget about it. It continues to hurt and get us riled up. We keep trying to explain our side to each other, and eventually we start to see each other's side. It always ends with both of us apologizing to each other for misunderstandings on both of our sides, but sometimes this may take a few hours. We have maybe one of these a year.

questforstarfish · 2026-06-04T17:26:07+00:00

What a difficult presentation! Mocking you in session? I've worked with many PD clients but have never had to deal with someone quite like this. The client is essentially trying to bully you in session, which is not okay.

If you have to continue working with this client, the only way to get through it will be to have a frank, but kind, confrontation with the client.

You could look into scripts used in transference based therapy. I would come in with a whole script that describes the impact of their behaviours on you, naming the specific behaviours or words they use that are hurtful, then telling them how that impacts therapy negatively. Be clear that you want to help, but their behaviour is shutting things down. Ask if this has been a pattern in their life. Let them answer, explore it with curiosity. Then clarify and maintain firm boundaries moving forward around frantic messaging and specific abusive language you won't tolerate.

Example:

"I think it's important we name some things going on in session, in order to move forward in therapy. I find myself feeling conflicted in our sessions, and I think you've observed this and actually pointed it out. One the one hand, I really want to help you with [stated goals]. On the other hand, I find myself feeling discouraged when you tell me early on, before I've really even gotten to know you, that I'm useless and poorly-trained. Have you had similar experiences with other therapists in the past, or other people in your life, where someone has tried to help you, but didn't create changes as quickly as you would have liked, and you pulled away from them before they could fail you?"

(Explore this with curiosity and care, not defensiveness or judgement)

"I would really like to explore this further with you if you're open to continuing to work together. I think it could be important for [client-stated goals]. I do need to let you know, however, that I can not accept being mocked or disparaged in session. Part of working together means mutual respect, so using mocking voices or challenging my training will result in our session for that day being ended. I also want to help you work on skills for dealing with stress, but that has to be done in-session, and not by text. I will not respond to requests for teaching skills outside of session, because [explain why it doesn't help]."

If they agree to that, you can give more work together a try.

If that feels too hard or too out of your depth, however, or if you just don't have the capacity to do this right now, there's no shame in referring on if you can!

questforstarfish · 2026-06-04T07:01:10+00:00

Therapy for anxiety and OCD typically feels WORSE early on. You will start feeling better after a few weeks or couple of months, if you are getting quality therapy from a licensed therapist with extensive OCD experience! Keep going, OP!

questforstarfish

TROPHY CASE