Category: Anamnesis

Include secondary gain in your differential when you have patients asking for controlled substances. These drugs include opioid pain killers, benzodiazepines, or stimulants.

Thus secondary gain needs to be part of the differential diagnosis for patients with chief complaints that can be classified as pain, anxiety or attention deficits.

The waiting room examination is an essential part of the general examination for these patients.  Think about the patient complaining of unbearable pain comfortably texting away while relaxing in the lounge chair, the calm and cool looking young fellow who “can’t seat still becasuse of my anxiety” or the patient who leaves his book with a sigh when his name is called only to tell you later about his ADHD. That is good information to have when will start your assessment.

In the same spirit, begin your examination with open-ended questions such as what’s a typical day like, what do you do for a living, how do you spend your free time, what do you enjoy doing, what are your strengthens etc. i.e. focus your interview away from (rather than on) the chief complaint. These somewhat counter intuitive strategy is a necessary ingredient for drawing a big picture that will place the patient’s chief complaint in a contextual perspective and will thus likely increase the validity of your assessment.

At the end of this process you might find out that:

1. The context does not support the text. Will rule in secondary gain and rule out a controlled substance prescription. By proceeding this way and walking the patient through the details of your decision-making you are also increasing the chances that the patient might actually agree (or at least understand where you are coming from) when you announce your final decision.

2. The context validates the text. While a controlled substance is indicated what you accomplished is to paint a picture of not only the deficits but also of the strengths that the patient has – an informative and at the same time a therapeutic result.

Gain – gain situation out of a potentially explosive situation.

In psychiatry we like to think along bio-psycho-social dimensions. Our current axial diagnosis is a reflection of this.

The reasons for our interest in things beyond the “biological” are straight forward. First, as it’s hard to draw a line in the sand separating where the brain ends and the mind begins and this mind that doesn’t separate clearly from the brain cares about our psychosocial environments. In other words, psychosocial events are, more times than not, an important cause for our thoughts, emotions, and behaviors. This does not mean biology does not matter. But it does mean that any examination of mind/brain continuum needs to include a psychosocial assessment to ensure that the collected data is non-biased and thus valid.

One of the unintended consequences of the DSM descriptive approach has been a shift in the focus of the mental health interview: from the broader themes of nature AND nurture and the implicit goal of attempting to establish cause and effect type of relationships between the different layers of one’s history, to a symptoms-focused, descriptive only approach. The gains in precision came at the price of slashing the context, which, as it turns out, is essential in understanding the deeper levels of pathology. And by “deeper level” I am not referring to the psycho-dynamic foundation of that out-of-consciousness conflict, but only to the fact the there are different levels of description. And chance is that the most superficial layer is, well, the most superficial one. Meaning, subject to much deformation and bias; as such, not nearly as accurate as the deeper levels.

Case and point: A case of chronic exhaustion

Mr. Tiredalot is a middle age gentleman complaining of no longer been able to enjoy things (including sex), feeling exhausted all the time, amotivated, dragging his feet, unable to concentrate, not sleeping for the last few weeks. There are no medical or substance abuse issues. Mr. Tiredalot denies any recent stressors. As he meets DSM criteria for depression he is started on an SSRI.

It turns out that Mr. Tiredalot’s sleep disturbance started after changing his mattress a few weeks back. A softer mattress was bought by his wife as she did not like the prior mattress that she found too hard.  Not only that Mr. Tiredalot does not find the new mattress as comfortable, but going to bed each night brings a lot of resentment about the fact that his wife decided to switch mattress without consulting  him. Going to bed turned into a “nightly” reminder of the fact that she rarely engages him in any decision making. Since the mattress switching conflict began Mr. Tiredalot wakes up in the morning with a slightly sore back and a terrible mood. Each time when he tried to breach the subject of the mattress the wife dismissed it as a “waste of time talking about it as it is a done deal”. Which only further escalated Mr. Tiredalot’s frustration. His troubles/stressors don’t reach the required threshold for an “adjustment disorder” and the patient himself does not identify any of the above as stressors.

This is an example of how an interview focusing exclusively on a description could actually miss the point.

Appearances are misleading and an antidepressant is clearly NOT recommended in this case. To see a couple’s therapist would be the best intervention for this patient at this time.

Understanding the psychosocial context – in this case the primary relationship issues with secondary sleep issues and tertiary mood issues – would not only save this patient from an antidepressant but likely many years of grief in a tense marriage.

That is were details matter.

Before making up your mind you need to have a good understanding of what the patient’s intent was.

Consider these two scenarios:

Young man in distress after breaking up with his first love tells you he took 3 Tylenol pills as he “wanted to die”. Heard Tylenol could be lethal and though that was a good way to take himself out. He comes in after mom finds good bye note and is cleary disappointed when told that 3 Tylemols are unlikely to result in any significant damage.  The patient is medically clear, however he should be hospitalized for close observation for danger to self.


Young women self referred to the ED with complaints of nausea and vomiting. You are called to consult as it turns out patient took almost 50 Tylenol Extra Strength for a “terrible headache that would not go away no matter what”.  She took way over the the recommended total daily dose of acetaminophen (4 grams per day) and is in acute liver failure. The patient is not depressed, anxious, psychotic, etc.  or in other words is, from a psychiatric perspective, “clear”.  She might need to be admitted to ICU, but if that is the whole history the psych consult can sign off.

And the point is? that…

Intent matters much more than any other component of the suicidality assessment.

Of course one needs to pay attention to the whole, which includes other data: important demographics (with divorced, older, Caucasian male having a higher risk), past history of mental illness (with major Axis I disorders and substance abuse increasing the risk), past history of suicide, or specific psychiatric symptoms (with hopelessness, command auditory hallucinations increasing risk); however, when all the above are considered and added, the intent still comes at the top.

The intent is in fact so important that it can trump a clinical picture of  otherwise minimal risk. If a young married African American woman with a non-contributory past psychiatric and medical history (in other words with a minimal risk profile) presents with clear intent, the intent should trump the otherwise minimal risk, and close monitoring should be initiated.

Usually major psychiatric pathology (what in older classification systems would fall under psychosis, as in a severe mental illness with poor reality testing) is characterized by poor or impaired insight.

As a result, patients with such pathology routinely refuse help as they tend to believe that either they don’t have a problem (patients with schizophrenia or mania) or are that they are beyond help.  In practice,  such patients tend to routinely refuse hospitalization even when (or precisely when) there is abundant evidence that hospitalization is highly recommended.

On the other hand, patients who come to the ED requesting admission fall in one of the following categories: secondary gain, personality disorders, Axis I with enough insight to appropriately ask for help (not necessarily in this order).  For obvious reasons hospitalization is not recommended for malingering and is rarely recommended for Axis II – as most personality disorders tend to flare up when excessive attention is poured over lingering character pathology,  or Axis I with good insight – as insight tends to correlate with one’s ability to stay safe, ie, inversely correlates with need for hospitalization to preserve safety.

In other words, when a patient was brought to the ED by relatives, friends or police and states that nothing is wrong and there is no need for hospitalization, more times than not hospitalization is recommended.  At the same time, when the patient brings himself to the ER requesting hospitalization, more times than not hospitalization is not recommended.

How do you cut this Gordian knot of in or out (of the hospital) when the patient is on the opposite side of your recommendation? Use your expertise to differentiate between false positive and false negative data.  And, of essence, do not make up your mind before collecting as much collateral data as you can.

Anxiety is a common complaint in a psychiatrist’s office.

When that is the case one needs to first rule out medical causes, drugs of all kinds (illegal and prescribed all together), and of course Axis I culprits such as generalized anxiety disorder, panic disorder, OCD, etc. Cluster C comes next as avoidant, OCPD and dependent people tend to be quite anxious.

And then there is the special kind of anxiety, concern, worrying about real issues: external (finances, work or relationship related etc) or INTERNAL (not liking oneself because of laziness, a bad temper, impulsivity, etc.). This is perhaps a good kind of anxiety – as long as it doesn’t reach an overwhelming intensity – and as such it should be supported.

In fact, invariably, therapeutic interventions, when successful, come with a good deal of anxiety. Nothing wrong with it as such ego dystonic states of discomfort are great motivators for completing the work.

When “good” anxiety presents itself for evaluation it should be seen as a good prognostic sign and an ally that one should value and co-opt when designing an intervention strategy.

Avoid the common mistake of labeling all anxiety as “bad”. The result is an universal goal of zapping anxiety off whenever, wherever you see it.

Not good. When it comes to anxiety nuances matter.

1. Course: ADHD is chronic versus bipolar: episodic. Which also means that you should see ADHD signs during exam, while we might or might not see signs of bipolar on presentation.

2. Long time prognosis: ADHD might get better with time while bipolar tends to get worse with time.

3. Drugs of abuse: ADHD: “cocaine (in general uppers) slow me down”. Bipolar: “I use uppers when I am down, downers when I am hyper”.

4. Family history: bipolar patients have more of a loaded fam hx in terms of affective and psychotic disorders.

5. When in doubt, safety comes first: assume and treat as bipolar (i.e. mood stabilizer) as while this will help a bipolar patient; at the same time, it might not help it would also not harm an ADHD patient. Stimulant first when in doubt is a risky choice: while it would help an ADHD patient, it will also hurt a bipolar patient who will escalade straight into severe mania.

Dual diagnosis technically means that the patient has two independent, i.e.  a primary psych and a substance misuse diagnoses. Which implies that a substance induced diagnosis has been ruled out. Easier said than done.

Case scenario: Patient reports a long history of polysubstance abuse and an equally long history of major symptoms (e.g., psychotic sxs, affective sxs, severe anxiety etc.)

How do you tease out what came first and what causes what? Ask:

1. Is there any history of sobriety?

‘No”. Then, you should assume that’s likely substance induced until proven otherwise (SIUPO).

“Yes”, then ask:

2. What’s the longest time that you’ve been sober?

If longest sobriety is less than a month, again likely SIUPO.

“More than a month”, ask:

3. During that time did you continue to have sxs?

“No”, SIUPO for sure.

“Yes”. Ask: What sort of sxs, etc.?

You see how the balance starts tilting towards dual diagnosis.

How does it affect you?

Most trainees do at least a fair job in gathering a long list of past and present symptoms and signs of psychiatric and other medical syndromes.

Most trainees also almost always forget to ask this ONE question:

“And how does this affect you?” Where “this” can be depression, anxiety, you fill in the blanks…

What do you get for this one question?

1. Improvement of rapport. As this question is not only a data gathering tool but also shows being concerned and caring about the patient’s experience.

2. A preliminary estimate of the patient’s insight.

“It affects me in a good way. I kind of like it actually.” A manic response.

 “Well, it affects me all right. I would like to have them stop following me.” A psychotic response.

“It drives me nuts. I would like to stop it.” An ego-dystonic response of an OCD patient.

3. When the level of insight is good: An estimate of the level of dysfunction.

“I can still work but I really feel like I am dragging my feet every day.” For a depressed patient this is probably more than mild but less than severe depression.

“It’s more of a nuisance. I am noticing it,  maybe my wife, but no one else”. For a patient complaining of short term memory loss this is probably more than just plain age related memory loss, but less than full blown Alzheimer’s Dementia. Mild cognitive impairment is likely.

Look for:

1. Independent psychotic symptoms

2. Historical and quantitative predominance of affective symptoms: e.g. “for most of my life I’ve been depressed/hyper”; “yes, I do hear voices but my major problem is not the voices but my depression. That’s what always gets me hospitalized”.

3. Rapid decompensations and rapid response to meds. Schizophrenia tends to be fairly chronic. Even when it presents with more of an episodic course it is still typically slow to take off and then get under control.

Past Psychiatric History

There are many things you can ask but here is a minimalistic list of informative data:

1. How many visits to a psychiatric ER?

Too many to count“: usually indicates a severe Axis  I disorder (psychotic or affective), personality disorder, moderate (or more) panic disorder, somatization disorder, or secondary gain (which can also be part of a personality disorder). Very few or none (esp. in an older patient) usually rule out Axis II.

2. How many of the above (ER visits) were followed by hospitalization?

Most of them“. Balance tilts toward Axis I. Most of them were not: balance tilts toward Axis II.

3. How many psychiatric hospitalizations total?

Too many to count: reserved prognosis (due to chronicity, dual diagnosis or Axis II comorbidity). Consider non-compliance and dual diagnosis. Just a few/none: good prognosis.

4. What was the chief complaint/reason for most of the hospitalizations/ER visits?

Great screening question. Voices or paranoia versus depression with suicidal ideation will greatly focus further inquiry.

5. What was the longest hospitalization?

I started to appreciate this question after one patient told me his been hospitalized only twice before. I was puzzled and had a difficult time understanding the mismatch between his level of dysfunction (which was pretty significant) and the very low number of hospitalizations. It turned out that his second hospitalization was 12 years long, in one of the state forensic facilities. So, while the total number of hospitalizations is informative, what really matters (when it comes to prognosis and understanding dysfunction is the total duration of the time one spend inpatient).

6. What medication(s) worked the best/was the worst?

Good question to further narrow the differential. Also, it will save you time to cross off the list ineffective/poorly tolerated medications. Futher, usually there is no need to reinvent the wheel: if a specific intervention worked once, change is that it will work again (the exceptions here is a medication tachyphylaxis reaction, more commonly known as “poop out” phenomenon, where a medication that is effective stops working)

7. Is there a history of noncompliance? Why?

Two benefits: 1. Gives a good measure of the patient’s insight. 2. Places the patient on the stages of change continuum and thus allows you to tailor your intervention accordingly.

8. Were you using drugs around the times when you got hospitalized?

If the answer is”yes, time and again” you should re-asses what’s primary versus secondary.

9. Tell me what’s the most violent you’d ever been.

Open ended increases the chance to get a valid answer.

10.  Did you ever find yourself wishing to be dead?

Suicidality is a sensitive topic. Go straight for a past history of attempts you might put the patient off. Also, your range is too narrow. Start with a broad question and follow up with more specific questions (use a concentric approach) and you will get more honest and comprehensive (thus also more valid) answers.

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