Category: Assessment

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.

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.

If you find yourself prescribing neuroleptics for a mood disorder, mood stabilizers for a psychotic disorder and antidepressants left and right for all sort of NOS diagnoses it’s not a bad idea to take a deep breath and a hard look at your diagnoses.

Not that we never prescribe mood stabilizers for schizophrenia, or (in this brave new age of second generation everything) atypicals for mood disorders. We do.

However, even during these times of a relaxed psycho-pharmacology, an understanding of first versus second line, switching and augmenting is still a sine qua non of good doctoring.  Which implies that when your psychotropic does not closely match your patient’s diagnosis you’d better have a good explanation of why that is.

And it wouldn’t hurt either to document it accurately so that the next doctor in line or yourself looking at your old notes will understand your rationale for prescribing outside the standard of care.

You should consider also reviewing and/or appropriately documenting your drug dispensing habits for your patients on major poly-pharmacy type of cocktails. Remember that the evidence base for most poly-pharmacy type of strategies is rather flimsy, while the evidence base for compounded toxicity is gaining momentum.Bottom line: prescribing more than one medication for an indication is not the best charted territory, which by the way includes the unclear evidence-based realm of augmentation strategies.

Red flag combinations? Two or more similar agents prescribed together. This includes , going from rather non-nonsensical to somewhat explainable combinations (and I list here only combinations that I’ve actually seen): two SSRIs, tow SNRIs, SSRI + SNRI, two stimulants, two TCAs, two typical neuroleptics, two atypical neuroleptics, typical + atypical neuroleptic, two mood stabilizers (other than lithium).

Make sure that your medications match your diagnosis and that you have a good rationale for each medication you dispense to a patient.

Consider the following:

Decreased sleep: as in I “can’t sleep” versus “don’t need to sleep”.

Ruminative thinking versus racing thoughts.  “Can’t turn off my thinking” versus “thinking too fast to put it in words”.  Remember: the speed of thought is essential.

Distractibility versus tangentiality.  “Mind going blank, cant remember what I was thinking/talking about” versus “thoughts just pop up, one after another”.

Psychomotor agitation: the patient reports feeling exhausted but restless as in “I can’t stop worrying” versus hyperenergetic.

Impulsivity: as in “I wanted to kill myself as I can no longer stand feeling this way” or “I don’t think much about what to do next.”

Same or different?

Details matter.

When it comes to psychiatric history and review of systems the context is what makes or brakes your diagnosis.

Which, in the cases above, should be depression versus mania.

Don’t differentiate too broadly

It is important to be as informative (i.e. as specific) as you can.

If your diagnosis actuallty fits diagnostic criteria is there a reason to NOT call it as it is?

Sure, you wouldn’t want to be wrong.

But caution considered, wouldn’t you also want to be right?

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