Effectively seeking a psychiatric diagnosis?

February 26, 2008 1:27 PM

In a few weeks I'm going in for a physical. I would also like to take this opportunity to talk to my GP about anxiety, mood and other mental health issues, with the goal of getting a referral to a psychiatrist for further evaluation. I'm unsure how best to proceed.

Here are the things I am interested in working on and getting a diagnosis for:

1) Pretty severe social anxiety. I don't currently have any real world friends, and my basic assumption is that I'm annoying and/or offensive to most people and it is kinder to leave them alone.

2) Part and parcel of this is a paranoid feeling that every minute spent with me is a trial for anyone and they are saints who are just too polite to say anything. This keeps the anxiety ramped up when I am dealing with another human being, and does a great job of getting me to avoid human contact.

3) And just to keep things interesting, an intellectual awareness that the first two points are delusional, which leads to more self-loathing and feelings of shame because "I'm just trying to make myself feel tortured and crazy so I can wallow in self-pity and how dare I insult the people who care about me like that." Is there a name for this particular type of overthinking?

There's also frequent feelings of hopelessness/depression and enervation because of these things. Very occasionally I have manic-ish phases but nothing particularly severe.

I don't like being this way. I don't want to be this introverted. I don't like the effect it has on my personal relationships (family, spouse, workmates). It's a frequent distraction that makes it hard for me to concentrate on anything for a long period of time, which in turn leads to a lack of motivation and productivity, which exacerbates all the issues more.

So, how to make a case for a referral to my GP? And once that's done, how do I best make sure I get a clinical evaluation/diagnosis of some kind from the psychiatrist? What should I ask for? What kind of tests (written, bloodwork, etc.)? I'm okay with trying meds and/or talk therapy, but I'd like to have a thorough evaluation first. How do I get myself prepared to push for this if necessary?

posted by anonymous to Health & Fitness (20 answers total)

(I am in the U.S. -- other health care systems may differ).

Oh man, I am so glad you asked this question. First and foremost, "complete physical" does not equal "let's just take care of every single possible medical problem you might be having." For the most part, your doctor and your insurance company expect that the "complete physical" consists of a basic screening examination and some preventative services such as vaccination, cholesterol screening, etc. Most doctors would be sensitive to any other acute issues going on but when you try and squeeze two visits into the space of one, either one (or both) issues get short-shrift or all of the rest of the patients in the waiting room will be seen late.

Second, if all you want is a referral, just say so. (Again this is the U.S.) Some insurances even have a separate referral system that doesn't go through a primary care doctor. Call them. Most primary care doctors have no financial interest (or personal interest) in being a gatekeeper. You might be expected to say a little bit about the problem so the doctor knows he or she isn't sending you to one of his or her colleagues for something totally inappropriate, but that should be quick. If you don't come out and say you want the referral, the doctor is going to take a much more detailed history in order to have a crack at it. If it's a quick piece of paperwork and nothing more, you might be able to squeeze this in with your physical.

Third, if this is run of the mill anxiety (I can't tell from your description), and the doctor is good and you are comfortable with them, they would most likely be able to provide the usual first line treatments. Again, this should not be done during your "physical," which is an important part of your health care. You would want to schedule a separate visit to delve into it further. You might be able to schedule this on the same day, depending on the office's policies.
posted by Slarty Bartfast at 1:45 PM on February 26, 2008

Talk to your GP, and say pretty much what you said in your first paragraph:

"Hey, doctor, I'm feeling anxiety, mood and other mental health issues, and I'd like to get a referral to a psychiatrist for further evaluation. I'm unsure how best to proceed."

I don't think you need to get into any more detail than that with your GP.

Maybe ask for two referrals, and see both doctors to see how you like them. It sounds like you have this well thought out. Good luck, and follow through with this.
posted by jeff-o-matic at 1:47 PM on February 26, 2008

Some insurance even have a separate referral system that doesn't go through a primary care doctor. I meant to specify "for psychiatric care."
posted by Slarty Bartfast at 1:48 PM on February 26, 2008

Jeff-o-matic has it right; that's the perfect way to handle it. Then, when you go to the psychiatrist, print up your question and take it with you. They can help with this! Oh, and you aren't alone. There are a lot of us who feel this way, at least some of the time! Good luck.
posted by misha at 1:50 PM on February 26, 2008

You've made the case quite well here I think; I appreciate that it is easier to write down these feelings anonymously than it is to say to your GP "every minute spent with me is a trial for anyone" and "I'm annoying and/or offensive to most people" but to the extent you can convey even a fraction of the sentiments detailed here should win you at once a nice referral.

Also, on further reflection, it seems like you should just be able to ask for a referral ("I think I could benefit from seeing a psychiatrist...") without going into details unless you want to; you shouldn't really need to make a "case" at all to the GP. The whole point of mental health professionals is that they help you manage things, in a safe and confidential forum, that other professionals and the laity can't. GP will appreciate this.

I don't know too much about the tests, exactly -- something your new psychiatrist probably would, though. Can't think of any bloodwork off hand that would explain the symptoms you are describing.

Best of luck -- I know this seems hard, but you really are going down the good road by talking to your doc about this and you will be grateful later.
posted by bluenausea at 1:51 PM on February 26, 2008

I'm sorry you are feeling this way. I'm also in the U.S. - and here - if you mention these things to your GP - s/he will refer you to a psychiatrist AND/or probably prescribe and antidepressant/anxiolytic (anti-anxiety med).

S.B. covered it really well up there, so I'm just hopping in to mention, if this helps, that I've been told that shame is an unproductive emotion - it doesn't produce change. Try not to focus on shame, but focus on what you can do to change, if possible.

Good luck, and I hope you feel better soon. I'm glad you know that those distorted thoughts are just that and untrue.
posted by frumious bandersnatch at 1:52 PM on February 26, 2008

I agree with jeff-o-matic. You're being very clear and earnest with mefi, so just do the same with your GP. Or if you'd rather not wait or if the GP isn't any help, you can go to your health insurance's website and they'll have a database of insurance-compatible psychologists and psychiatrists that you can make an appointment with. You might have to jump through a few hoops to get 'authorization' for the visits, but you can deal with that with a call to your insurance or at your first meeting. That's what I did.
posted by cowbellemoo at 2:02 PM on February 26, 2008 [1 favorite]

I agree with the folks above. At least if you're in the US, most GP's don't really serve as a barrier or gatekeeper for mental health care. In fact, generally the minute this sort of thing comes up in a primary care visit, after the history is taken, asking the patient if he or she is interested in counseling or psychiatric referral should pretty much be automatic. It's not stigmatized at all in practice and even the most inexperienced doctor runs into this several times a week if not daily. All you need to do is outline exactly what you did above and make sure to say you'd like a referral if you're not asked directly.

There are a few medical tests that sometimes might be worth doing in this scenario, but they are generally low yield and should be left up to your doctor. Sometimes screening for anemia or thyroid issues comes up but there are no standard tests and I'm not so sure you would need any of that stuff.

One useful tip is that if this is really your primary health care concern, emphasize it. Don't show up with a laundry list of problems to go over from that upset stomach you had two weeks ago to the headache you had six months ago. I know there's an urge to be complete but filling up a brief visit with issues that can probably wait until follow-up appointments aren't ultimately going to be in your best interest.
posted by drpynchon at 2:20 PM on February 26, 2008

Man, I wish I could give you a hug.

I pretty much agree with what everyone has said so far. Just wanted to say a lot can change. Little internal changes or realizations can change the world you live in dramatically. You might look back in a year and not identify with the person who wrote this at all. Just keep that in mind if you begin to feel hopeless.

I hope you find the treatment that helps you.
posted by milarepa at 2:26 PM on February 26, 2008 [1 favorite]

Been there. It sucks. Sorry.

I started seeing a shrink strictly to get my meds refilled, but decided I could work on my anxiety, depression, etc. via talk therapy. It's making a world of difference. But it depends on the shrink----and seriously: if you don't click with the first shrink you see (usually takes a couple visits to get a good judgement), find another one. If you want to get anything valuable out of your relationship with him/her, you need to feel comfortable. Don't be ashamed to shop around for a doctor that feels right for you; it's especially important with psychiatrists. The shrink may put you on meds to get your symptoms under control and then suggest talk therapy to address the issues that cause you so much anxiety. Then you decide together whether or not to keep taking the meds. That's my experience anyway. Good luck! It will get better!
posted by hulahulagirl at 2:50 PM on February 26, 2008

in a more bureucratic healthcare system, the GP may be loath to refer you if you sound as together as you do in this post. Sorry to sound a bum note, considering all the experience above.

My experience is in the UK and Ireland with GP referrals for the mental health services.

If there is no suggestion of suicidal ideation or harm to yourself and/or others, you are more likley to be told to sleep well, give up alcohol, excercise and maybe, just maybe, you'll get a referral for counselling. The waiting lists are a few months.

So if you feel you need more urgent attention my advice would be to go through an A&E unit with clear phrases suggesting suicidal ideation. Sorry to sound so manipulative if you honestly don't feel that way, then don't do this.
But if your aim is to get help fast, you may have to tick some boxes.

If you're in Europe or the UK, please feel free to MefiMail me and I can talk you through the process.

Good luck.
posted by Wilder at 3:29 PM on February 26, 2008

/bureaucratic/ aargh!¬
posted by Wilder at 3:30 PM on February 26, 2008

some good advice here.

But just one thing: do be careful about putting mental health stuff on your insurance. it can make it very hard to ever get coverage again in the future. I know it's unfair, but sadly that's how it is in the U.S.

There are a lot of threads here on this topic that you find by searching- but I would advise paying cash if you can at all afford it.
posted by drjimmy11 at 3:38 PM on February 26, 2008

Seconding drjimmy11 re: putting mental health stuff on your insurance. I copped to having undertaken therapy and the fact that I'd been on prescription meds (antidepressants) in the process of seeking private health insurance; I was subsequently told that they'd cover me for everything...save for psychological/psychiatric help and/or meds related to same. (Which, of course, was really the only reason I was seeking insurance.)

I took a deep breath and as calmly as possible said, "...So, um, you're telling me that I'd have been better off lying to you? Why shouldn't I just cancel applying for your health insurance plan, call someone else and do exactly that?"

His response was something along the lines of, "Well, unfortunately, insurers share a lot of this information, so any other insurer you might apply to for coverage in the immediate future would be aware of this and would extend similar coverage."

Don't know if what he said is really, really true or not. But the good drjimmy11's comment reminded me of it, so I thought I'd toss in my nickel's worth. YMMV.
posted by t2urner at 3:59 PM on February 26, 2008

I'd like to second hulahulagirl's suggestion for talk therapy. Ask your GP or your psychiatrist for a recommendation, if that's something you'd like to pursue. Or at least discuss the possibility with your new psychiatrist. And best of luck to you - it sounds like things are tough, and you're doing a good thing by seeking help.
posted by bassjump at 4:06 PM on February 26, 2008

If you are nervous, write down your symptoms and questions beforehand. That way you won't forget anything.
posted by radioamy at 4:12 PM on February 26, 2008

I disagree about the mental health being a problem on your insurance (at least in the US, where I am). I was diagnosed with bipolar 6 years and 3 jobs ago, and I've never had trouble changing insurance and being covered. I suppose it might be an issue if you're getting individual insurance, but if you get it through an employer's group plan (or even through COBRA between jobs, as I have done), it won't be a problem. That said, I understand about doing things to minimize anxiety, so do not report it on your insurance if it makes you nervous to think about.

Tell the GP all of your symptoms, and that you thought it important to check with a GP before seeing a psychiatrist. Don't let them blow you off. The referral for a psychiatrist that they'll be able to give you will be someone they're affiliated with, however that person might not be covered under your insurance, so be sure to check that (if you go with insurance).

If you don't get what you need from the first GP or psychiatrist or therapist, keep trying. There are a lot of them out there, and I know it can be frustrating if you don't find a good fit right away when you really want the help, but it is so very important to find the right person. Especially for anxiety and depression, it has been shown in many studies that talk therapy is more effective in the long run than meds (and as effective in the short term), so being able to find the right person to work with is very important for your long term health.

Good luck. I am very happy at no longer being in major bipolar episodes, and I am sure you will be happy as you begin to heal.
posted by veronitron at 4:15 PM on February 26, 2008 [2 favorites]

You might want to start with talk therapy first. With anxiety, the goal is usually to learn to manage it and then reduce it and this is hard to do if your medication is masking the anxiety so you don't feel it. On the other hand, medication is faster and if this is really interfering with your life, you should be able to coordinate the two.

By the way, in California most psychiatrists focus on medication management because they are they charge so much, people go with more affordable options for the talk therapy. ($wise, I've seen 20 minutes with a psychiatrist = 60 minutes with other forms of licensed therapists like a psychologist, or marriage and family therapist (mft's also do individual therapy for depression, anxiety etc).

Also be wary if your GP wants to just prescribe some anti-anxiety meds. There are many options, each with its own advantages and side effects - psychiatrists are specialists on this. Also, with many of the anti-anxiety meds you build up tolerance so when you want to guit, you need to taper down very slowly or you will get unpleasant side effects.
posted by metahawk at 6:16 PM on February 26, 2008

Don't manipulate with fake suicide implications! There is no good that come from it. Unless you are feeling that way, then by all means mention it.

Anyway, just tell the doc what you said here, and that you would like them to refer you to a good psychiatrist who specializes in those sorts of things. If the doc tries to insist upon treating it themselves, just insist right back that you would really feel more comfortable talking to a specialist. And I think it's best to have a psychiatrist manage mental health care. That's what they do.

HIPAA has changed what insurance companies can and can't do in regards to preexisting conditions, and generally for the better. Regardless, you have the desire to work on the problem now and you have insurance now. Use the insurance you are paying for anyway.
posted by gjc at 7:48 PM on February 26, 2008

CBT is very effective for your kind of thinking. I highly recommend you request that specifically.
posted by loiseau at 8:00 PM on February 26, 2008