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.
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?
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.
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.
1. Course: ADHD is chronic versus bipolar: episodic. Which also means that you should see ADHD signs during exam, while we might or might not see signs of bipolar on presentation.
2. Long time prognosis: ADHD might get better with time while bipolar tends to get worse with time.
3. Drugs of abuse: ADHD: “cocaine (in general uppers) slow me down”. Bipolar: “I use uppers when I am down, downers when I am hyper”.
4. Family history: bipolar patients have more of a loaded fam hx in terms of affective and psychotic disorders.
5. When in doubt, safety comes first: assume and treat as bipolar (i.e. mood stabilizer) as while this will help a bipolar patient; at the same time, it might not help it would also not harm an ADHD patient. Stimulant first when in doubt is a risky choice: while it would help an ADHD patient, it will also hurt a bipolar patient who will escalade straight into severe mania.
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.
1. Independent psychotic symptoms
2. Historical and quantitative predominance of affective symptoms: e.g. “for most of my life I’ve been depressed/hyper”; “yes, I do hear voices but my major problem is not the voices but my depression. That’s what always gets me hospitalized”.
3. Rapid decompensations and rapid response to meds. Schizophrenia tends to be fairly chronic. Even when it presents with more of an episodic course it is still typically slow to take off and then get under control.