Category: Anxiety



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.


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.

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