Tag Archive: psychiatric interview

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.

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).

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.

How does it affect you?

Most trainees do at least a fair job in gathering a long list of past and present symptoms and signs of psychiatric and other medical syndromes.

Most trainees also almost always forget to ask this ONE question:

“And how does this affect you?” Where “this” can be depression, anxiety, you fill in the blanks…

What do you get for this one question?

1. Improvement of rapport. As this question is not only a data gathering tool but also shows being concerned and caring about the patient’s experience.

2. A preliminary estimate of the patient’s insight.

“It affects me in a good way. I kind of like it actually.” A manic response.

 “Well, it affects me all right. I would like to have them stop following me.” A psychotic response.

“It drives me nuts. I would like to stop it.” An ego-dystonic response of an OCD patient.

3. When the level of insight is good: An estimate of the level of dysfunction.

“I can still work but I really feel like I am dragging my feet every day.” For a depressed patient this is probably more than mild but less than severe depression.

“It’s more of a nuisance. I am noticing it,  maybe my wife, but no one else”. For a patient complaining of short term memory loss this is probably more than just plain age related memory loss, but less than full blown Alzheimer’s Dementia. Mild cognitive impairment is likely.

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.

There is a lot of discussion about the BPS model. Trouble is that in today’s climate this is more a point of discussion of academical interest than a reality informing our day-to-day assessments and treatment plans. Excuses of why this is are plenty: from the severely limited time allowed in most treatment settings for the regular intake and follow-up,  to the dis-interest of managed care in anything that is not clearly linked to medical/biological outcomes and interventions, viz medications.

It turns out that when one compares a patient-centered with a system-centered approach, the former is both more efficient (i.e. allows for more complete data collection) and more effective (i.e. captures more data per unit of time). Counterintuitive, yes – nevertheless, true.

One way to self-monitor one’s exam focus is to jot down the info in a 3 column format: 1st: biological data; 2nd: psychological data; 3rd: social data. Each piece of data would be placed on a line; the more data, the higher their column. An ideal interview/history should produce 3 columns of fairly comparable sizes, while a biologically/system-centered interview will necessarily result in a pretty sizable biological column and rather small psycho-social columns.

Of course this way of organizing the information is cross sectional in terms of the classical categories of anamnesis, i.e. history of present illness (HPI), past psychiatric, substance and medical history, family history etc.

Instead, each of the above categories will be constructed across the 3 BPS axes. For example, an HPI of recent neuro-vegetative symptoms (B), poor self-esteem (P), and recent break-up with the significant other (S), in context of work stress due to a difficult boss (S), which brings up memories of parental emotional abuse (P), will be divided along the 3 axes. By organizing the information accordingly, one can have a visual cue about the overall balance of the BPS contributors. An obvious unbalance can thus be easily noted and corrected.

Last but not least, by organizing the info visually along the 3 axes, dominant themes become more easily noticeable. Finally, a comprehensive BPS case formulation naturally emerges after this simple act of BPS organizing.

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