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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).

On this day in 1904 Pavlov made his acceptance Nobel prize speech.

In his own words:

“Essentially only one thing in life interests us: our psychical constitution, the mechanism of which was and is wrapped in darkness. All human resources, art, religion, literature, philosophy and historical sciences, all of them join in bringing light in this darkness. But man has still another powerful resource: natural science with its strictly objective methods. This science, as we all know, is making huge progress every day.”

From Nobel Lectures, Physiology or Medicine 1901-1921, Elsevier Publishing Company, Amsterdam, 1967

107 years later we are still finding our way out of darkness. Pavlov’s theory remains as solid today as back then and over time came to ciment the foundation of experimental behaviorism. While no longer popular with philosophers, behaviorism remains strong in modern counseling, as seen in the evidence about the efficacy of cognitive-behavioral therapy in a variety of mind-brain conditions.

Using a CBT framework, you might think of symptoms, including Axis I symptoms or personality traits, as habits or, in pavlovian terms, conditioned reflexes. The treatment needs to extinguish undesirable behaviors, while creating “better” conditioned behaviors.

How do you do it?

Lack of practice results in extinction.

Lots of practice results in new habits.

Certainly true but easier said than done.

The essential ingredient that is missing in the above picture is will. Which the behavioralist can think of just another behavior that needs to be modified. However, how can this be done in a world that banishes behavior modification based on the preeminence of free will?

Solution: you need to find a way to convince your patient to go on your hand, i.e. abandon free will till recovery. Which is a risky proposal. Strong handed approaches or advice giving are unlikely to work. Alternatively, you need to find a way to engage, motivate, or persuade your patient about the right course of action.

In other words, if you are to be an effective behavioral therapist you need to first master the skills of motivational enhancement.

An interesting instance where practice has not been particularly supported by evidence.
Hopefully this new paper by Essock et al. is just a beginning. When it comes to polypharmacy, Essock et al concludes that there is “some evidence support[ing] a combination of antipsychotics and antidepressants for negative symptoms and comorbid major depressive episodes”. And that is pretty much all there is.

In other words:

No clear evidence for piling antipsychotics on the top of each other, which is common practice, or even for mood stabilizer augmentation.

Now, the problem with schizophrenia is that for most of the cases that end up in our clinics or hospitals, more often than not, we are looking at some degree of partial response. In clinical parlor these are the so called “treatment-refractory cases”.

And labels do matter: as one might need to carefully re-think their whole treatment plan when the problem is partial response, while “creative approaches” (i.e. not evidence based) are acceptable if the problem is defined as treatment residence. In other words, when the treatment refractory/resistance territory is seen as the medical equivalent of the Far West, with uncontrolled pathology looming darkly over the patient’s and doctor’s heads, shooting from the hip might be seen as actually the right thing to do. However, in medicine cowboyish approaches are never the right thing to do.

Essock et al. take home point? Think twice about combining medications.  The benefits are unclear, while the compounded toxicity is certain!

Just another reminder that conservative medicine is better medicine.

A few nursing students followed me for rounds today.

It turned out that, as part of their rotation requirements, they are supposed to complete a psychiatric interview. As they never talked to a psychiatric patient before they wanted to know about the do’s and dont’s… After talking further it became clear that their image of a psychiatric patient was the too common stereotype of a highly volatile, potentially dangerous, explosive, out of control, unpredictable person.

Instead of answering their question I asked them what was the most striking and unexpected aspect of the rounds they just saw. “It was very casual”, they said. “The way you interacted  – it was all very “normal”.” “The patients knew about their symptoms and treatments.”

Yes, most of them do.

There are always “normal” and “healthy” parts of the self that survive even the most damaging mental and emotional storms. Your expertise is to find these islands, terra firma amidst on ocean of otherwise overwhelming feelings and thoughts. That is where you want to meet your patient. As that will be the safe harbor, the heaven from where you’ll journey together to chart and explore and bring “back to civilisation” the unruly oceans of raw experience.

When terra firma is where you will meet you only need to remember that you are nowtwo equally good beings: terra firma to terra firma, human being to human being. The only difference is that you are there to offer (not force) help, out of caring for the other.

Remember this: respectful offering of help – and you will have no troubles approaching any psychiatric patient. Or, even more, approaching anyone, anywhere, for that matter.

Common scenario:

Patient has been doing well on meds. All of a sudden no longer doing well.

What’s happening?

Hypothesis: The medication(s) stopped working.

Possible explanations:

1. Medication(s) all of a sudden became ineffective. What’s the chance of that? Small.

2. Patient stopped taking the medication(s) as prescribed. What’s the chance of that? High.

Solution: Make sure compliance is optimal BEFORE considering medication changes.

Stages of Change

I find Prochaska and Di Clemente’s model of change a very useful guide for my first encounter with a new patient.

We see people who have issues.

The important question is: on the change continuum, where does your patient place himself regarding his ability to engage in change work? A practical question as the answer will inform your intervention as much as current Axis I symptoms and personality dimensions.

Case and point:

Approaching an already committed to change patient with an educational agenda is poorly timed at best, and, at worst, unproductive and even irritating to the patient. It is an equal waste of time to approach a precontemplator with a list of change promoting interventions (which would be much better suited for patients already are in a preparation or action stage).

Pathologize and Normalize

Common mistake: to take whatever you see at face value.

Most times, most things are more than it meets the eye. Not always (and that is where psychoanalysis went wrong) but most times. A degree of natural shyness compounded by basic socialization rules (including common courtesy) precludes one from washing one’s dirty laundry in public. You don’t need sophisticated psychological theories to accept that people don’t always mean what they say (or viceversa), or that, when it comes to self-disclosure, appearances might be deceiving.

In the specific case of a psychiatric patient this common problem is further compounded by the fact that the hidden issues are very private and, more times than not, either embarrassing or deeply troubling. Would the patient fear being judged? Yes. All reassurances to the contrary will be of little help when this is the case. Is the patient afraid of stigma or consequences following from his decision to disclose? Yes, and unfortunately, this perception is often times, troublingly accurate. Then there are the times when the hidden might lay outside the patient’s sphere of awareness. And then there are the times when the patient chooses to deceive.

A good psychiatrist needs to combine theoretical knowledge about patterns of manifestation of the mind/brain continuum with flair – the experience, “gut feeling” that tell him that there is more to the story.

But flair is neither easy to quantify nor model, and the novice is left with the problem of knowing there is a good chance he might be fooled, yet without a clear solution about how to spot the ‘dig further’ sign posts.

Let me illustrate:
Case scenario #1:

You see a man in his mid 20s, with no prior psychiatric history, with a chief complaint of “paranoia” x4 days, committed for involuntary hospitalization on a 72 hrs hold. You note that the patient spends a long time reviewing the commitment paper. The patient states that the commitment paper provisions are too limiting to the point of being legally abusive. You conclude that the patient’s behavior is consistent with the patient’s ongoing paranoid delusions and think the hold is justified.

Case scenario #2:

You see a man in his mid 20s, with no prior psychiatric history, with a chief complaint of paranoia x4 days, committed for involuntary hospitalization on a 72 hrs hold. You note that the patient spends a long time reviewing the commitment paper. The patient states that the commitment paper provisions are too limiting to the point of being legally abusive. You ask how so. The patient explains that he just took his bar exam, and while he realizes that his view of commitment is a minority view, his take on it is in sync with his libertarian moral and ethical choices. He further explains that the “so called paranoia” is based on his belief that his safety might be at risk following some strong anti-establishment statements that he’d chosen to host on his blog about a week prior to the evaluation. He has since received “a ton of hate mail”. You conclude that the patient’s behavior is normal and break the hold.

Before reading futher, please cast your vote for case 1 or 2.

Now that you made your mind please go on reading:

Case scenario #1:
You contact the patient’s family and find out that the patient is a lawyer who just took his bar exam. You also learn from the family that the patient’s view on mental illness commitment has always been a minority view, in sync with his libertarian moral and ethical choices. The family further explains that the “so called paranoia” is based on his belief that his safety might be at risk following some strong anti-establishment statements that he’d chosen to host on his fairly popular blog about a week prior to the evaluation. He has since received “a ton of hate mail”. The patient, with his family support, self referred for evaluation after experiencing ruminative thoughts and troubles sleeping. They were shocked when informed the patient was placed on a hold.

Case scenario #2:

You contact the patient’s family and find out that the patient used to be a law student, but never graduated from law school, as he became increasingly preoccupied with conspiracy theories. The family further reports a course significant for gradually increased social isolation from family and friends, and overall marginal meaningful functioning. The patient did not have a blog; even if he wanted to, he couldn’t, as his computer skills were not adequate. The family decided to bring the patient in following his repeatedly calling them and stating that the “Feds are out to get me” over the last few days prior to the evalution. They were relieved when informed the patient was placed on a hold.

I hope that by now it is clear that there are dangers in both normalizing and pathologizing. That is, of course, why collateral information matters.

At the same time normalizing and pathologizing can be some of your most helpful guides toward improved data validity. How so?
Examine the patient alternatively though “normalizing” and “pathologizing” lenses.

“This is normal” and “this is clinically significant” are your working hypotheses, equally weighted until proven otherwise.

Your mission is to gather as much data as you can for and against the cases of normal and pathological.

You will weight the evidence at the end. More times than not you will be surprised. When you do a good job, the balance tilts so sharply you might not even need collateral info. When you do get the collateral it will only confirm what you already know.
One last note:

Are you a normalizer or a pathologizer? This is yet another instance when it helps to know who you are. Find out and make an effort to consciously err in the opposite direction. It’s well worth it – think of it as the effort of balancing an uneven coin by adding extra weight to the lighter side.

On the lighter side: balance is the name, and building is the game.

Personality Dimensions

Categorical clarifications have the advantage of clarity. No shades of gray; it’s either black or white. Of course,  this is a quite efficient approach when things are strictly black and white. No ambiguity, no confusion. But these very advantages become weaknesses when the reality actually presents the observer with shades of gray. As there is no in-between, the nuances will be stripped of their defining characteristics and rigidly forced in one of the existing categories.

Such approach remains simple but it is also simplistic in the worst sense. Reality is butchered with gray turned into white or black depending on observer preference or bias. Furthermore, there is a risk that the gray will simply be missed by someone whose conceptual foundation, when it comes to colors, includes only black and white. It’s been shown that our perception of realty is concept based, i.e. no concepts equals no perception. When this is the case the gray will no longer be misclassified (that’s the positive) as black or white as it will no longer be perceived at all (a negative that I believe outweighs the positive with several orders of magnitude).

Case and point: my residents see Cluster A or B or C personality disorders. The better ones even see traits. But not even the best see in-between. When someone does not conform to the DSM typology they could get a “the patient does not have any Cluster A or B or C personality traits” formulation of sorts. In other words, there is black, and there is white, but there is no gray.

My suggestion: think (and look) for dimensions instead of categories. We all have personality dimensions (tones of grey).

The model I use is Costa and McCrae’s Five-Factor Model where the dimensions are:

O – Openness to experience (novelty seeking) versus Closeness

C – Conscientiousness versus Laissez-faire

EExtraversion versus Introversion

AAgreeableness versus Dis…

N – Neuroticism versus Emotional Stability

There are a few advantages of using a dimensional trait (rather than categorical) approach:

1. The factors are based on laborious statistics (factor analysis) and not opinion based constructs.

2. There is evidence about the factors genetic (albeit complex) genetic transmission. Which also helps to nicely bridge traditionally separated domains of assessment/inquiry such as Axis 1 (biological in origin, i.e. amendable through drug treatment) versus Axis 2 (psychological in origin, therefore amendable through psychotherapy).

3. The factors are measurable by testing (also public domain, free of charge online testing is available at a click of a button).

4. The factors have been shown to be universal, culturally independent construct (i.e. can be measured in China as they can be measured in Germany) (McCrae & Costa, 1997).

5. Understanding the dimensions is useful for insight and improvement through therapy (and these personality “observations’ can be shared with the patient right away) (Costa & McCrae, 1992).

6. The factors are stable over decades (average 45 years) (Soldz & Vaillant, 1999).

But even without former testing, keeping the traits in mind while sitting down with your patient, is a more straightforward model that you can use to learn about important aspects of their persona. Rather than basing your learning about the patient on complicated (and only partially proven) models about how the persona and the mind work, it’s just so much more straightforward and easier to have a trait-informed assessment.


Costa, P. T., Jr., & McCrae, R. R. (1992). Normal personality assessment in clinical practice: The NEO Personality Inventory. Psychological Assessment, 4, 5-13.

McCrae, R. R., & Costa, P. T., Jr. (1997). Personality trait structure as a human universal. American Psychologist, 52, 509-516.

Soldz, S., & Vaillant, G. E. (1999). The Big Five personality traits and the life course: A 45-year longitudinal study. Journal of Research in Personality, 33, 208-232.

Here is a rather common scenario. The inexperienced trainee is exposed in his didactics to a variety of methods: short and long-term psychodynamic therapy (with its own separated chapters for drives, ego, self psychology, and object relations theories), cognitive, behavioral, interpersonal, supportive types of therapies. In some places motivational, adlerian, existential and rogerian approaches are also discussed. And then “integrative”, which to the unprepared mind, appears to be a hotchpotch of all the above.

Rather confusing, isn’t it?

The trainee is then taught that all therapies have similar rates of success and outcomes (which, by the way, it is not true) and that the single, most important predictor of success in therapy is neither theory, nor method, but the quality of the patient-doctor relationship (and implicitly rapport).

After all this, the trainee rightfully concludes that therapy is mainly about: 1. “getting the patient to like me” – as a resident once told me (as one needs good rapport, remember?) and then 2. merrily mix and match . Can you blame him?

I can’t. I actually get his point.

That would be just fine if the patient gets better. Unfortunately, hastily, non-systematic, on the spur of the moment interventions rarely result in great outcomes. More times than not the patient will not improve or will get worse. Furthermore, following a practice of  mixing and matching in a non-systematic way, one is at a loss when it comes to deciding what to stop and what to continue.

There is a fundamental risk associated with the above, non-systematic approach: the potential of seriously impairing one’s ability to discern what’s doing what. In other words, whatever outcome one’s intervention produces, there is no way of ascertaining a cause and effect relationship. And without learning, there is no growth.

My recommendation: chose one approach. Study the theory. Study the method. Practice. Practice some more. Think critically. Master the method. Understand the theory. Move on to the next theory.

No big surprise here. A systematic approach and practice are the foundation of any type of understanding.


What is the purpose of a formulation?

  1. To summarize the pertinent findings/data
  2. To find the common thread bringing together all the different historical (past, reported) and exam-based (present, observed) clinical data
  3. To inform treatment decisions
  4. To make a prognostic prediction

The above principles are valid regardless of the type [of the formulation]. Good biological, psychological (psychodynamic, behavioral etc.) or interpersonal/psychosocial formulations satisfy all the above requirements.

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