What is pathological demand avoidance – and how is it different to ‘acting out’?

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“Charlie” is an eight-year-old child with autism. Her parents are worried because she often responds to requests with insults, aggression and refusal. Simple demands, such as being asked to get dressed, can trigger an intense need to control the situation, fights and meltdowns.

Charlie’s parents find themselves in a constant cycle of conflict, trying to manage her and their own reactions, often unsuccessfully. Their attempts to provide structure and consequences are met with more resistance.

What’s going on? What makes Charlie’s behaviour – that some are calling “pathological demand avoidance” – different to the defiance most children show their parents or carers from time-to-time?

What is pathological demand avoidance?

British developmental psychologist Elizabeth Newson coined the term “pathological demand avoidance” (commonly shortened to PDA) in the 1980s after studying groups of children in her practice.

A 2021 systematic review noted features of PDA include resistance to everyday requests and strong emotional and behavioural reactions.

Children with PDA might show obsessive behaviour, struggle with persistence, and seek to control situations. They may struggle with attention and impulsivity, alongside motor and coordination difficulties, language delay and a tendency to retreat into role play or fantasy worlds.

PDA is also known as “extreme demand avoidance” and is often described as a subtype of autism. Some people prefer the term persistent drive for autonomy or pervasive drive for autonomy.

What does the evidence say?

Every clinician working with children and families recognises the behavioural profile described by PDA. The challenging question is why these behaviours emerge.

PDA is not currently listed in the two diagnostic manuals used in psychiatry and psychology to diagnose mental health and developmental conditions, the current Diagnostic and Statistical Manual of Mental Disorders (DSM-5) and the World Health Organization’s International Classification of Diseases (ICD-11).

Researchers have reported concerns about the science behind PDA. There are no clear theories or explanations of why or how the profile of symptoms develop, and little inclusion of children or adults with lived experience of PDA symptoms in the studies. Environmental, family or other contextual factors that may contribute to behaviour have not been systematically studied.

A major limitation of existing PDA research and case studies is a lack of consideration of overlapping symptoms with other conditions, such as autism, attention deficit hyperactivity disorder (ADHD), oppositional defiant disorder, anxiety disorder, selective mutism and other developmental disorders. Diagnostic labels can have positive and negative consequences and so need to be thoroughly investigated before they are used in practice.

Classifying a “new” condition requires consistency across seven clinical and research aspects: epidemiological data, long-term patient follow-up, family inheritance, laboratory findings, exclusion from other conditions, response to treatment, and distinct predictors of outcome. At this stage, these domains have not been established for PDA. It is not clear whether PDA is different from other formal diagnoses or developmental differences.

girl sits on couch with arms crossed, mother or carer is nearby looking concerned
When a child is stressed, demands or requests might tip them into fight, flight or freeze mode. Shutterstock

Finding the why

Debates over classification don’t relieve distress for a child or those close to them. If a child is “intentionally” engaged in antisocial behaviour, the question is then “why?”

Beneath the behaviour is almost always developmental difference, genuine distress and difficulty coping. A broad and deep understanding of developmental processes is required.

Interestingly, while girls are “under-represented” in autism research, they are equally represented in studies characterising PDA. But if a child’s behaviour is only understood through a “pathologising” or diagnostic lens, there is a risk their agency may be reduced. Underlying experiences of distress, sensory overload, social confusion and feelings of isolation may be missed.

So, what can be done to help?

There are no empirical studies to date regarding PDA treatment strategies or their effectiveness. Clinical advice and case studies suggest strategies that may help include:

  • reducing demands
  • giving multiple options
  • minimising expectations to avoid triggering avoidance
  • engaging with interests to support regulation.

Early intervention in the preschool and primary years benefits children with complex developmental differences. Clinical care that involves a range of medical and allied health clinicians and considers the whole person is needed to ensure children and families get the support they need.

It is important to recognise these children often feel as frustrated and helpless as their caregivers. Both find themselves stuck in a repetitive cycle of distress, frustration and lack of progress. A personalised approach can take into account the child’s unique social, sensory and cognitive sensitivities.

In the preschool and early primary years, children have limited ability to manage their impulses or learn techniques for managing their emotions, relationships or environments. Careful watching for potential triggers and then working on timetables and routines, sleep, environments, tasks, and relationships can help.

As children move into later primary school and adolescence, they are more likely to want to influence others and be able to have more self control. As their autonomy and ability to collaborate increases, the problematic behaviours tend to reduce.

Strategies that build self-determination are crucial. They include opportunities for developing confidence, communication and more options to choose from when facing challenges. This therapeutic work with children and families takes time and needs to be revisited at different developmental stages. Support to engage in school and community activities is also needed. Each small step brings more capacity and more effective ways for a child to understand and manage themselves and their worlds.

What about Charlie?

The current scope to explain and manage PDA is limited. Future research must include the voices and views of children and adults with PDA symptoms.

Such emotional and behavioural difficulties are distressing and difficult for children and families. They need compassion and practical help.

For a child like Charlie, this could look like a series of sessions where she and her parents meet with clinicians to explore Charlie’s perspective, experiences and triggers. The family might come to understand that, in addition to autism, Charlie has complex developmental strengths and challenges, anxiety, and some difficulties with adjustment related to stress at home and school. This means Charlie experiences a fight, flight, freeze response that looks like aggression, avoidance or shutting down.

With carefully planned supports at home and school, Charlie’s options can broaden and her distress and avoidance can soften. Outside the clinic room, Charlie and her family can be supported to join an inclusive local community sporting or creative activity. Gradually she can spend more time engaged at home, school and in the community.

Nicole Rinehart, Professor, Child and Adolescent Psychology, Director, Krongold Clinic (Research), Monash University; David Moseley, Senior Research Fellow, Deputy Director (Clinical), Monash Krongold Clinic, Monash University, and Michael Gordon, Associate Professor, Psychiatry, Monash University

This article is republished from The Conversation under a Creative Commons license. Read the original article.

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  • The “Yes I Can” Salad

    10almonds is reader-supported. We may, at no cost to you, receive a portion of sales if you purchase a product through a link in this article.

    Sometimes, we are given to ask ourselves: “Can I produce a healthy and tasty salad out of what I have in?” and today we show how, with a well-stocked pantry, the answer is “yes I can”, regardless of what is (or isn’t) in the fridge.

    You will need

    • 1 can cannellini beans, drained
    • 1 can sardines (if vegetarian/vegan, substitute ½ can chickpeas, drained)
    • 1 can mandarin segments
    • 1 handful pitted black olives, from a jar (or from a can, if you want to keep the “yes I can” theme going)
    • ½ red onion, thinly sliced (this can be from frozen, defrosted—sliced/chopped onion is always a good thing to have in your freezer, by the way; your writer here always has 1–6 lbs of chopped onions in hers, divided into 1lb bags)
    • 1 oz lemon juice
    • 1 tbsp chopped parsley (this can be freeze-dried, but fresh is good if you have it)
    • 1 tbsp extra virgin olive oil
    • 1 tbsp chia seeds
    • 1 tsp miso paste
    • 1 tsp honey (omit if you don’t care for sweetness; substitute with agave nectar if you do like sweetness but don’t want to use honey specifically)
    • 1 tsp red chili flakes

    Method

    (we suggest you read everything at least once before doing anything)

    1) Combine the onion and the lemon juice in a small bowl, massaging gently

    2) Mix (in another bowl) the miso paste with the chili flakes, chia seeds, honey, olive oil, and the spare juice from the can of mandarin segments, and whisk it to make a dressing.

    3) Add the cannellini beans, sardines (break them into bite-size chunks), mandarin segments, olives, and parsley, tossing them thoroughly (but gently) in the dressing.

    4) Top with the sliced onion, discarding the excess lemon juice, and serve:

    Enjoy!

    Want to learn more?

    For those interested in some of the science of what we have going on today:

    Take care!

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  • The Miracle of Flexibility – by Miranda Esmonde-White

    10almonds is reader-supported. We may, at no cost to you, receive a portion of sales if you purchase a product through a link in this article.

    We’ve reviewed books about stretching before, so what makes this one different?

    Mostly, it’s that this one takes a holistic approach, making the argument for looking after all parts of flexibility (even parts that might seem useless) because if one bit of us isn’t flexible, the others will start to suffer in compensation because of how that affects our posture, or movement, or in many cases our lack of movement.

    Esmonde-White’s “flexibility, from your toes to your shoulders” approach is very consistent with her background as a professional ballet dancer, and now she brings it into her profession as a coach.

    The book’s not just about stretching, though. It looks at problems and what can go wrong with posture and the body’s “musculoskeletal trifecta”, and also shares daily training routines that are tailored for specific sporting interests, and/or for those with specific chronic conditions and/or chronic pain. Working around what needs to be worked around, but also looking at strengthening what can be strengthened and fixing what can be fixed along the way.

    Bottom line: if your flexibility needs an overhaul, this book is a very good “one-stop shop” for that.

    Click here to check out The Miracle Of Flexibility, and discover what you can do!

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  • Peaches vs Plums – Which is Healthier?

    10almonds is reader-supported. We may, at no cost to you, receive a portion of sales if you purchase a product through a link in this article.

    Our Verdict

    When comparing peaches to plums, we picked the peaches.

    Why?

    Both are great! But there is a clear winner out of these two botanically-similar fruits:

    In terms of macronutrients they are very similar. Peaches have slightly more protein and plums have slightly more carbs, but the numbers are close enough to make no meaningful difference; they’re both mostly water.

    They’re also not too far from each other in the category of vitamins; peaches have more of vitamins B2, B3, B5, E, and choline, while plums have more of vitamins B1, B6, B9, C, and K. They’re equal on vitamin A, by the way, and the vitamins they do differ in, differ by around the same margins, so this category is a clear tie.

    When it comes to minerals, however, peaches win easily with more copper, iron, magnesium, manganese, phosphorus, potassium, selenium, and zinc. The two fruits are equal on calcium, and plum is not higher in any minerals.

    While they already won easily because of the mineral situation, it should be noted that peaches also have the lower glycemic index. But honestly, plums are fine too; peaches are just even lower.

    So: enjoy both, but if you’re going to pick one, peaches boast the most!

    Want to learn more?

    You might like to read:

    Take care!

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    10almonds is reader-supported. We may, at no cost to you, receive a portion of sales if you purchase a product through a link in this article.

    It’s often said that our skin is our largest organ. Our brain or liver are the largest solid organs by mass (which one comes out on top will vary from person to person), our gut is the longest, and our lungs are the largest by surface area. But our skin is large, noticeable, and has a big impact on the rest of our health.

    The sun is one of the main damaging factors for our skin; assorted toxins are also a major threat for many people, and once the skin barrier gets broken, it’s a field-day for bacteria.

    So, what can we do about it?

    Tretinoin: the skin’s rejuvenator

    Tretinoin is also called retinoic acid, not to be mistaken for retinol, although they are both retinoids. Tretinoin is much stronger.

    As for what it’s stronger at:

    It’s usually prescribed for the treatment of sun-damage, acne, and wrinkles. Paradoxically, it works by inflaming the skin (and then making it better, and having done so, keeping it better).

    In few words: it encourages your skin to speed up its life cycle, which means that cells die and are replaced sooner, which means the average age of skin cells will be considerably younger at any given time.

    This is the same principle as we see at work when it comes to cellular apoptosis and autophagy in general, and specifically the same idea as we discussed when talking about senolytics, compounds that kill aging cells:

    Fisetin: The Anti-Aging Assassin

    About that paradoxical inflammation…

    ❝The topical use of tretinoin as an antiacne agent began almost a half century ago. Since that time it has been successfully used to treat comedonal and inflammatory acne.

    Over the intervening years, the beneficial effects of tretinoin have grown from an understanding of its potent cornedolytie-related properties to an evolving appreciation of its antiinflammatory actions.

    The topical use of clindamycin and tretinoin as a combination treatment modality that includes antibacterial, comedolytic, and antiinflammatoiy properties has proven to be a very effective therapy for treating the various stages of acne

    It is now becoming increasingly clear that there may be good reasons for these observations.❞

    ~ Drs. Schmidt & Gans, lightly edited here for brevity

    Read in full: Tretinoin: A Review of Its Anti-inflammatory Properties in the Treatment of Acne

    Against damage by the sun

    The older we get, the more likely sun damage is a problem than acne. And in the case of tretinoin,

    ❝In several well-controlled clinical trials, the proportion of patients showing improvement was significantly higher with 0.01 or 0.05% tretinoin cream than with placebo for criteria such as global assessment, fine and coarse wrinkling, pigmentation and roughness.

    Improvements in the overall severity of photodamage were also significantly greater with tretinoin than with placebo.

    Several placebo-controlled clinical studies have demonstrated that topical tretinoin has significant efficacy in the treatment of photodamaged skin. Improvements in subjective global assessment scores were recorded in:

    49–100% of patients using once-daily 0.01% tretinoin,

    68–100% of patients using 0.05% tretinoin, and

    0–44% of patients using placebo.❞

    ~ Drs. Wagstaff & Noble

    …which is quite compelling.

    Read in full: Tretinoin: A Review of its Pharmacological Properties and Clinical Efficacy in the Topical Treatment of Photodamaged Skin

    This is very well-established by now; here’s an old paper from when the mechanism of action was unknown (here in the current day, 17 mechanisms of action have been identified; beyond the scope of this article as we only have so much room, but it’s nice to see science building on science):

    ❝Tretinoin cream has been used extensively to reverse the changes of photoaging. It is the first topical therapy to undergo controlled clinical testing and proved to be efficacious. These results have been substantiated with photography, histopathologie examination, and skin surface replicas.

    Tretinoin cream has an excellent safety record; a local cutaneous hypervitaminosis A reaction is the only common problem.❞

    ~ Dr. Goldfarb et al.

    Read in full: Topical tretinoin therapy: Its use in photoaged skin

    Is it safe?

    For most people, when used as directed*, yes. However, it’s likely to irritate your skin at first, and that’s normal. If this persists more than a few weeks, or seems unduly severe, then you might want to stop and talk to your doctor again.

    *See also: Scarring following inappropriate use of 0.05% tretinoin gel

    (in the case of a young woman who used it 4x daily instead of 1x daily)

    Want to try some?

    Tretinoin is prescription-only, so speak with your doctor/pharmacist about that. Alternatively, retinal (not retinol) is the strongest natural alternative that works on the same principles; here’s an example product on Amazon 😎

    Take care!

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  • Her Mental Health Treatment Was Helping. That’s Why Insurance Cut Off Her Coverage.

    10almonds is reader-supported. We may, at no cost to you, receive a portion of sales if you purchase a product through a link in this article.

    Reporting Highlights

    • Progress Denials: Insurers use a patient’s improvement to justify denying mental health coverage.
    • Providers Disagree: Therapists argue with insurers and the doctors they employ to continue covering treatment for their patients.
    • Patient Harm: Some patients backslid when insurers cut off coverage for treatment at key moments.

    These highlights were written by the reporters and editors who worked on this story.

    Geneva Moore’s therapist pulled out her spiral notebook. At the top of the page, she jotted down the date, Jan. 30, 2024, Moore’s initials and the name of the doctor from the insurance company to whom she’d be making her case.

    She had only one chance to persuade him, and by extension Blue Cross and Blue Shield of Texas, to continue covering intensive outpatient care for Moore, a patient she had come to know well over the past few months.

    The therapist, who spoke on the condition of anonymity out of fear of retaliation from insurers, spent the next three hours cramming, as if she were studying for a big exam. She combed through Moore’s weekly suicide and depression assessments, group therapy notes and write-ups from their past few sessions together.

    She filled two pages with her notes: Moore had suicidal thoughts almost every day and a plan for how she would take her own life. Even though she expressed a desire to stop cutting her wrists, she still did as often as three times a week to feel the release of pain. She only had a small group of family and friends to offer support. And she was just beginning to deal with her grief and trauma over sexual and emotional abuse, but she had no healthy coping skills.

    Less than two weeks earlier, the therapist’s supervisor had struck out with another BCBS doctor. During that call, the insurance company psychiatrist concluded Moore had shown enough improvement that she no longer needed intensive treatment. “You have made progress,” the denial letter from BCBS Texas read.

    When the therapist finally got on the phone with a second insurance company doctor, she spoke as fast as she could to get across as many of her points as possible.

    “The biggest concern was the abnormal thoughts — the suicidal ideation, self-harm urges — and extensive trauma history,” the therapist recalled in an interview with ProPublica. “I was really trying to emphasize that those urges were present, and they were consistent.”

    She told the company doctor that if Moore could continue on her treatment plan, she would likely be able to leave the program in 10 weeks. If not, her recovery could be derailed.

    The doctor wasn’t convinced. He told the therapist that he would be upholding the initial denial. Internal notes from the BCBS Texas doctors say that Moore exhibited “an absence of suicidal thoughts,” her symptoms had “stabilized” and she could “participate in a lower level of care.”

    The call lasted just seven minutes.

    Moore was sitting in her car during her lunch break when her therapist called to give her the news. She was shocked and had to pull herself together to resume her shift as a technician at a veterinary clinic.

    “The fact that it was effective immediately,” Moore said later, “I think that was the hardest blow of it all.”

    Many Americans must rely on insurers when they or family members are in need of higher-touch mental health treatment, such as intensive outpatient programs or round-the-clock care in a residential facility. The costs are high, and the stakes for patients often are, too. In 2019 alone, the U.S. spent more than $106.5 billion treating adults with mental illness, of which private insurance paid about a third. One 2024 study found that the average quoted cost for a month at a residential addiction treatment facility for adolescents was more than $26,000.

    Health insurers frequently review patients’ progress to see if they can be moved down to a lower — and almost always cheaper — level of care. That can cut both ways. They sometimes cite a lack of progress as a reason to deny coverage, labeling patients’ conditions as chronic and asserting that they have reached their baseline level of functioning. And if they make progress, which would normally be celebrated, insurers have used that against patients to argue they no longer need the care being provided.

    Their doctors are left to walk a tightrope trying to convince insurers that patients are making enough progress to stay in treatment as long as they actually need it, but not so much that the companies prematurely cut them off from care. And when insurers demand that providers spend their time justifying care, it takes them away from their patients.

    “The issues that we grapple with are in the real world,” said Dr. Robert Trestman, the chair of psychiatry and behavioral medicine at the Virginia Tech Carilion School of Medicine and chair of the American Psychiatric Association’s Council on Healthcare Systems and Financing. “People are sicker with more complex conditions.”

    Mental health care can be particularly prone to these progress-based denials. While certain tests reveal when cancer cells are no longer present and X-rays show when bones have healed, psychiatrists say they have to determine whether someone has returned to a certain level of functioning before they can end or change their treatment. That can be particularly tricky when dealing with mental illness, which can be fluid, with a patient improving slightly one day only to worsen the next.

    Though there is no way to know how often coverage gets cut off mid-treatment, ProPublica has found scores of lawsuits over the past decade in which judges have sharply criticized insurance companies for citing a patient’s improvement to deny mental health coverage. In a number of those cases, federal courts ruled that the insurance companies had broken a federal law designed to provide protections for people who get health insurance through their jobs.

    Reporters reviewed thousands of pages of court documents and interviewed more than 50 insiders, lawyers, patients and providers. Over and over, people said these denials can lead to real — sometimes devastating — harm. An official at an Illinois facility with intensive mental health programs said that this past year, two patients who left before their clinicians felt they were ready due to insurance denials had attempted suicide.

    Dr. Eric Plakun, a Massachusetts psychiatrist with more than 40 years of experience in residential and intensive outpatient programs, and a former board member of the American Psychiatric Association, said the “proprietary standards” insurers use as a basis for denying coverage often simply stabilize patients in crisis and “shortcut real treatment.”

    Plakun offered an analogy: If someone’s house is on fire, he said, putting out the fire doesn’t restore the house. “I got a hole in the roof, and the windows have been smashed in, and all the furniture is charred, and nothing’s working electrically,” he said. “How do we achieve recovery? How do we get back to living in that home?”

    Unable to pay the $350-a-day out-of-pocket cost for additional intensive outpatient treatment, Moore left her program within a week of BCBS Texas’ denial. The insurer would only cover outpatient talk therapy.

    During her final day at the program, records show, Moore’s suicidal thoughts and intent to carry them out had escalated from a 7 to a 10 on a 1-to-10 scale. She was barely eating or sleeping.

    A few hours after the session, Moore drove herself to a hospital and was admitted to the emergency room, accelerating a downward spiral that would eventually cost the insurer tens of thousands of dollars, more than the cost of the treatment she initially requested.

    How Insurers Justify Denials

    Buried in the denial letters that insurance companies send patients are a variety of expressions that convey the same idea: Improvement is a reason to deny coverage.

    “You are better.” “Your child has made progress.” “You have improved.”

    In one instance, a doctor working for Regence Blue Cross and Blue Shield of Oregon wrote that a patient who had been diagnosed with major depression was “sufficiently stable,” even as her own doctors wrote that she “continued to display a pattern of severe impairment” and needed round-the-clock care. A judge ruled that “a preponderance of the evidence” demonstrated that the teen’s continued residential treatment was medically necessary. The insurer said it can’t comment on the case because it ended with a confidential settlement.

    In another, a doctor working for UnitedHealth Group wrote in 2019 that a teenage girl with a history of major depression who had been hospitalized after trying to take her own life by overdosing “was doing better.” The insurer denied ongoing coverage at a residential treatment facility. A judge ruled that the insurer’s determination “lacked any reasoning or citations” from the girl’s medical records and found that the insurer violated federal law. United did not comment on this case but previously argued that the girl no longer had “concerning medical issues” and didn’t need treatment in a 24-hour monitored setting.

    To justify denials, the insurers cite guidelines that they use to determine how well a patient is doing and, ultimately, whether to continue paying for care. Companies, including United, have said these guidelines are independent, widely accepted and evidence-based.

    Insurers most often turn to two sets: MCG (formerly known as Milliman Care Guidelines), developed by a division of the multibillion-dollar media and information company Hearst, and InterQual, produced by a unit of UnitedHealth’s mental health division, Optum. Insurers have also used guidelines they have developed themselves.

    MCG Health did not respond to multiple requests for comment. A spokesperson for the Optum division that works on the InterQual guidelines said that the criteria “is a collection of established scientific evidence and medical practice intended for use as a first level screening tool” and “helps to move patients safely and efficiently through the continuum of care.”

    A separate spokesperson for Optum also said the company’s “priority is ensuring the people we serve receive safe and effective care for their individual needs.” A Regence spokesperson said that the company does “not make coverage decisions based on cost or length of stay,” and that its “number one priority is to ensure our members have access to the care they need when they need it.”

    In interviews, several current and former insurance employees from multiple companies said that they were required to prioritize the proprietary guidelines their company used, even if their own clinical judgment pointed in the opposite direction.

    “It’s very hard when you come up against all these rules that are kind of setting you up to fail the patient,” said Brittainy Lindsey, a licensed mental health counselor who worked at the Anthem subsidiary Beacon and at Humana for a total of six years before leaving the industry in 2022. In her role, Lindsey said, she would suggest approving or denying coverage, which — for the latter — required a staff doctor’s sign-off. She is now a mental health consultant for behavioral health businesses and clinicians.

    A spokesperson for Elevance Health, formerly known as Anthem, said Lindsey’s “recollection is inaccurate, both in terms of the processes that were in place when she was a Beacon employee, and how we operate today.” The spokesperson said “clinical judgment by a physician — which Ms. Lindsey was not — always takes precedence over guidelines.”

    In an emailed statement, a Humana spokesperson said the company’s clinician reviewers “are essential to evaluating the facts and circumstances of each case.” But, the spokesperson said, “having objective criteria is also important to provide checks and balances and consistently comply with” federal requirements.

    The guidelines are a pillar of the health insurance system known as utilization management, which paves the way for coverage denials. The process involves reviewing patients’ cases against relevant criteria every handful of days or so to assess if the company will continue paying for treatment, requiring providers and patients to repeatedly defend the need for ongoing care.

    Federal judges have criticized insurance company doctors for using such guidelines in cases where they were not actually relevant to the treatment being requested or for “solely” basing their decisions on them.

    Wit v. United Behavioral Health, a class-action lawsuit involving a subsidiary of UnitedHealth, has become one of the most consequential mental health cases of this century. In that case, a federal judge in California concluded that a number of United’s in-house guidelines did not adhere to generally accepted standards of care. The judge found that the guidelines allowed the company to wrongly deny coverage for certain mental health and substance use services the moment patients’ immediate problems improved. He ruled that the insurer would need to change its practices. United appealed the ruling on grounds other than the court’s findings about the defects in its guidelines, and a panel of judges partially upheld the decision. The case has been sent back to the district court for further proceedings.

    Largely in response to the Wit case, nine states have passed laws requiring health insurers to use guidelines that align with the leading standards of mental health care, like those developed by nonprofit professional organizations.

    Cigna has said that it “has chosen not to adopt private, proprietary medical necessity criteria” like MCG. But, according to a review of lawsuits, denial letters have continued to reference MCG. One federal judge in Utah called out the company, writing that Cigna doctors “reviewed the claims under medical necessity guidelines it had disavowed.” Cigna did not respond to specific questions about this.

    Timothy Stock, one of the BCBS doctors who denied Moore’s request to cover ongoing care, had cited MCG guidelines when determining she had improved enough — something judges noted he had done before. In 2016, Stock upheld a decision on appeal to deny continued coverage for a teenage girl who was in residential treatment for major depression, post-traumatic stress disorder and anxiety. Pointing to the guidelines, Stock concluded she had shown enough improvement.

    The patient’s family sued the insurer, alleging it had wrongly denied coverage. Blue Cross and Blue Shield of Illinois argued that there was evidence that showed the patient had been improving. But, a federal judge found the insurer misstated its significance. The judge partially ruled in the family’s favor, zeroing in on Stock and another BCBS doctor’s use of improvement to recommend denying additional care.

    “The mere incidence of some improvement does not mean treatment was no longer medically necessary,” the Illinois judge wrote.

    In another case, BCBS Illinois denied coverage for a girl with a long history of mental illness just a few weeks into her stay at a residential treatment facility, noting that she was “making progressive improvements.” Stock upheld the denial after an appeal.

    Less than two weeks after Stock’s decision, court records show, she cut herself on the arm and leg with a broken light bulb. The insurer defended the company’s reasoning by noting that the girl “consistently denied suicidal ideation,” but a judge wrote that medical records show the girl was “not forthcoming” with her doctors about her behaviors. The judge ruled against the insurer, writing that Stock and another BCBS doctor “unreasonably ignored the weight of the medical evidence” showing that the girl required residential treatment.

    Stock declined to comment. A spokesperson for BCBS said the company’s doctors who review requests for mental health coverage are board certified psychiatrists with multiple years of practice experience. The spokesperson added that the psychiatrists review all information received “from the provider, program and members to ensure members are receiving benefits for the right care, at the right place and at the right time.”

    The BCBS spokesperson did not address specific questions related to Moore or Stock. The spokesperson said that the examples ProPublica asked about “are not indicative of the experience of the vast majority of our members,” and that it is committed to providing “access to quality, cost-effective physical and behavioral health care.”

    A Lifelong Struggle

    A former contemporary dancer with a bright smile and infectious laugh, Moore’s love of animals is eclipsed only by her affinity for plants. She moved from Indiana to Austin, Texas, about six years ago and started as a receptionist at a clinic before working her way up to technician.

    Moore’s depression has been a constant in her life. It began as a child, when, she said, she was sexually and emotionally abused. She was able to manage as she grew up, getting through high school and attending Indiana University. But, she said, she fell back into a deep sadness after she learned in 2022 that the church she found comfort in as a college student turned out to be what she and others deemed a cult. In September of last year, she began an intensive outpatient program, which included multiple group and individual therapy sessions every week.

    Moore, 32, had spent much of the past eight months in treatment for severe depression, post-traumatic stress disorder and anxiety when BCBS said it would no longer pay for the program in January.

    The denial had come to her without warning.

    “I was starting to get to the point where I did have some hope, and I was like, maybe I can see an actual end to this,” Moore said. “And it was just cut off prematurely.”

    At the Austin emergency room where she drove herself after her treatment stopped, her heart raced. She was given medication as a sedative for her anxiety. According to hospital records she provided to ProPublica, Moore’s symptoms were brought on after “insurance said they would no longer pay.”

    A hospital social worker frantically tried to get her back into the intensive outpatient program.

    “That’s the sad thing,” said Kandyce Walker, the program’s director of nursing and chief operating officer, who initially argued Moore’s case with BCBS Texas. “To have her go from doing a little bit better to ‘I’m going to kill myself.’ It is so frustrating, and it’s heartbreaking.”

    After the denial and her brief admission to the hospital emergency department in January, Moore began slicing her wrists more frequently, sometimes twice a day. She began to down six to seven glasses of wine a night.

    “I really had thought and hoped that with the amount of work I’d put in, that I at least would have had some fumes to run on,” she said.

    She felt embarrassed when she realized she had nothing to show for months of treatment. The skills she’d just begun to practice seemed to disappear under the weight of her despair. She considered going into debt to cover the cost of ongoing treatment but began to think that she’d rather end her life.

    “In my mind,” she said, “that was the most practical thing to do.”

    Whenever the thought crossed her mind — and it usually did multiple times a day — she remembered that she had promised her therapist that she wouldn’t.

    Moore’s therapist encouraged her to continue calling BCBS Texas to try to restore coverage for more intensive treatment. In late February, about five weeks after Stock’s denial, records show that the company approved a request that sent her back to the same facility and at the same level of care as before.

    But by that time, her condition had deteriorated so severely that it wasn’t enough.

    Eight days later, Moore was admitted to a psychiatric hospital about half an hour from Austin. Medical records paint a harrowing picture of her condition. She had a plan to overdose and the medicine to do it. The doctor wrote that she required monitoring and had “substantial ongoing suicidality.” The denial continued to torment her. She told her doctor that her condition worsened after “insurance stopped covering” her treatment.

    Her few weeks stay at the psychiatric hospital cost $38,945.06. The remaining 10 weeks of treatment at the intensive outpatient program — the treatment BCBS denied — would have cost about $10,000.

    Moore was discharged from the hospital in March and went back into the program Stock had initially said she no longer needed.

    It marked the third time she was admitted to the intensive outpatient program.

    A few months later, as Moore picked at her lunch, her oversized glasses sliding down the bridge of her nose every so often, she wrestled with another painful realization. Had the BCBS doctors not issued the denial, she probably would have completed her treatment by now.

    “I was really looking forward to that,” Moore said softly. As she spoke, she played with the thick stack of bracelets hiding the scars on her wrists.

    A few weeks later, that small facility closed in part because of delays and denials from insurance companies, according to staff and billing records. Moore found herself calling around to treatment facilities to see which ones would accept her insurance. She finally found one, but in October, her depression had become so severe that she needed to be stepped up to a higher level of care.

    Moore was able to get a leave of absence from work to attend treatment, which she worried would affect the promotion she had been working toward. To tide her over until she could go back to work, she used up the money her mother sent for her 30th birthday.

    She smiles less than she did even a few months ago. When her roommates ask her to hang out downstairs, she usually declines. She has taken some steps forward, though. She stopped drinking and cutting her wrists, allowing scar tissue to cover her wounds.

    But she’s still grieving what the denial took from her.

    “I believed I could get better,” she said recently, her voice shaking. “With just a little more time, I could discharge, and I could live life finally.”

    Kirsten Berg contributed research.

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    We’re glad you’re enjoying them! Your request prompted us to do our recent Research Review Monday main feature on collagen supplementation—we hope it helped, and if you’ve any more specific (or other) question, go ahead and let us know! We love questions and requests

    Q: Great article about the health risks of salt to organs other than the heart! Is pink Himalayan sea salt, the pink kind, healthier?

    Thank you! And, no, sorry. Any salt that is sodium chloride has the exact same effect because it’s chemically the same substance, even if impurities (however pretty) make it look different.

    If you want a lower-sodium salt, we recommend the kind that says “low sodium” or “reduced sodium” or similar. Check the ingredients, it’ll probably be sodium chloride cut with potassium chloride. Potassium chloride is not only not a source of sodium, but also, it’s a source of potassium, which (unlike sodium) most of us could stand to get a little more of.

    For your convenience: here’s an example on Amazon!

    Bonus: you can get a reduced sodium version of pink Himalayan salt too!

    Q: Can you let us know about more studies that have been done on statins? Are they really worth taking?

    That is a great question! We imagine it might have been our recent book recommendation that prompted it? It’s quite a broad question though, so we’ll do that as a main feature in the near future!

    Q: Is MSG healthier than salt in terms of sodium content or is it the same or worse?

    Great question, and for that matter, MSG itself is a great topic for another day. But your actual question, we can readily answer here and now:

    • Firstly, by “salt” we’re assuming from context that you mean sodium chloride.
    • Both salt and MSG do contain sodium. However…
    • MSG contains only about a third of the sodium that salt does, gram-for-gram.
    • It’s still wise to be mindful of it, though. Same with sodium in other ingredients!
    • Baking soda contains about twice as much sodium, gram for gram, as MSG.

    Wondering why this happens?

    Salt (sodium chloride, NaCl) is equal parts sodium and chlorine, by atom count, but sodium’s atomic mass is lower than chlorine’s, so 100g of salt contains only 39.34g of sodium.

    Baking soda (sodium bicarbonate, NaHCO₃) is one part sodium for one part hydrogen, one part carbon, and three parts oxygen. Taking each of their diverse atomic masses into account, we see that 100g of baking soda contains 27.4g sodium.

    MSG (monosodium glutamate, C₅H₈NO₄Na) is only one part sodium for 5 parts carbon, 8 parts hydrogen, 1 part nitrogen, and 4 parts oxygen… And all those other atoms put together weigh a lot (comparatively), so 100g of MSG contains only 12.28g sodium.

    Q: Thanks for the info about dairy. As a vegan, I look forward to a future comment about milk alternatives

    Thanks for bringing it up! What we research and write about is heavily driven by subscriber feedback, so notes like this really help us know there’s an audience for a given topic!

    We’ll do a main feature on it, to do it justice. Watch out for Research Review Monday!

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