Category: Dual Diagnosis



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.

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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.

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