Category: Psychiatric Emergencies

What you see – descriptive psychopathology vs. what the patient tells you – phenomenology.

At first look you might say: objective vs. subjective. E.g.: appearance, behavior, speech, affect –  all accessible to an external (objective) observer vs. thought content and mood as (subjectively) reported by the subject. Now, these distinctions are not always as neatly clear-cut as one would like. As one can observe (as opposed to experience) his own process, i.e. one’s own thought content or process are the object of examination, an objective process. Or one can note someone’s else report of his internal experience, a report inherently filtered thorough the examiner’s preconceptions and predisposition, i.e. a subjective process. When it comes to a mental status examination the boundaries between objective:subjective are often times blurred.

The take home point: a comprehensive mental state exam necessarily includes an objective and a subjective examination of the external and internal attributes of one’s mental state.

For the objective component the examiner will aim to describe one’s mental state external manifestations (speech, behavior, affect) and ask the patient to describe his mental state internal manifestations (sensations, emotions, thoughts). Examples of questions aimed at internal experiences descriptions: “Please describe what you are feeling at this time.” “Describe your anxiety in terms of severity: mild, moderate, severe. Also frequency: you experience it once in a blue moon, weekly, a few times a week, daily, multiple times a day, all the time.” In other words the goal of the objective component of the examination is to quantitatively describe its objects regardless of their internal:external mental allegiance.

For the subjective component the examiner will aim to put himself in the patient shoes i.e. attempt to feel what the patient experiences. With regards to external manifestations of one’s mental state the examiner should carefully note his own feelings. E.g. an unaccounted for but palpable sadness in the room warrants a search for depressive symptoms even when the patient emphatically denies feeling depressed. With regards to internal manifestations the examiner should ask about the qualities of emotions, sensory experiences, or thoughts, “Describe your depression.” “What does hearing the voices feel like?” are good examples of how to inquire about the phenomenology of one’s internal experiences.

In summary:

A thorough mental status examination uses objective and subjective complementary approaches to assess external as well as internal attributes of one’s mental status exam.

The objective approach strives to produce quantitative data while the subjective approach aims to produce subjective data, regardless of the data’s provenance (external vs. internal).

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.

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