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In psychiatry we like to think along bio-psycho-social dimensions. Our current axial diagnosis is a reflection of this.

The reasons for our interest in things beyond the “biological” are straight forward. First, as it’s hard to draw a line in the sand separating where the brain ends and the mind begins and this mind that doesn’t separate clearly from the brain cares about our psychosocial environments. In other words, psychosocial events are, more times than not, an important cause for our thoughts, emotions, and behaviors. This does not mean biology does not matter. But it does mean that any examination of mind/brain continuum needs to include a psychosocial assessment to ensure that the collected data is non-biased and thus valid.

One of the unintended consequences of the DSM descriptive approach has been a shift in the focus of the mental health interview: from the broader themes of nature AND nurture and the implicit goal of attempting to establish cause and effect type of relationships between the different layers of one’s history, to a symptoms-focused, descriptive only approach. The gains in precision came at the price of slashing the context, which, as it turns out, is essential in understanding the deeper levels of pathology. And by “deeper level” I am not referring to the psycho-dynamic foundation of that out-of-consciousness conflict, but only to the fact the there are different levels of description. And chance is that the most superficial layer is, well, the most superficial one. Meaning, subject to much deformation and bias; as such, not nearly as accurate as the deeper levels.

Case and point: A case of chronic exhaustion

Mr. Tiredalot is a middle age gentleman complaining of no longer been able to enjoy things (including sex), feeling exhausted all the time, amotivated, dragging his feet, unable to concentrate, not sleeping for the last few weeks. There are no medical or substance abuse issues. Mr. Tiredalot denies any recent stressors. As he meets DSM criteria for depression he is started on an SSRI.

It turns out that Mr. Tiredalot’s sleep disturbance started after changing his mattress a few weeks back. A softer mattress was bought by his wife as she did not like the prior mattress that she found too hard.  Not only that Mr. Tiredalot does not find the new mattress as comfortable, but going to bed each night brings a lot of resentment about the fact that his wife decided to switch mattress without consulting  him. Going to bed turned into a “nightly” reminder of the fact that she rarely engages him in any decision making. Since the mattress switching conflict began Mr. Tiredalot wakes up in the morning with a slightly sore back and a terrible mood. Each time when he tried to breach the subject of the mattress the wife dismissed it as a “waste of time talking about it as it is a done deal”. Which only further escalated Mr. Tiredalot’s frustration. His troubles/stressors don’t reach the required threshold for an “adjustment disorder” and the patient himself does not identify any of the above as stressors.

This is an example of how an interview focusing exclusively on a description could actually miss the point.

Appearances are misleading and an antidepressant is clearly NOT recommended in this case. To see a couple’s therapist would be the best intervention for this patient at this time.

Understanding the psychosocial context – in this case the primary relationship issues with secondary sleep issues and tertiary mood issues – would not only save this patient from an antidepressant but likely many years of grief in a tense marriage.

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).

“I am co-dependent on my therapist”,  says Mr. Intherapyalot. Is this even a possibility?

Think about it this way: the patient – therapist relationship (and by therapist I am psychiatrists, psychologists, etc.) is characterized by an immense power differential. The therapist is in many respects God-like in the eyes of his patient: omniscient (appearing as if he knows everything about the patient), omnipotent (with the ability of curing deep-seated or maybe even deeper-seeded conflicts), the subject of unfiltered transference (positive for the most part) and yet available.

Who wouldn’t like to have a God like figure on speed dial? So when those always urgent phone calls start coming in the middle of the night, when the patient starts calling repeatedly about trivial matters, when tapering the visits results in increased symptoms, and the discussion of termination is pre-emptied by sudden exacerbations, consider “therapist dependence” in your diagnostic formulation.

Of course, “dependence” on the therapist is not always bad. In fact, during the initial stages of therapy, especially for patients who come from a background of poor object relations, “dependence” might in fact be a good thing. In such instances “dependence” might indicate that the patient is finally able to trust in the context of a safe relationship.

In later stages of therapy however, especially when dependence occurs after relative independence has already been established, chance is that the patient is experiencing a maladaptive regression.

What is the solution? First, as always, prophylaxis is gold. Rather than open-ended therapy decide when the discharge date/the final session will be scheduled from the beginning. There is a lot to be said – and good data as well – supporting the fact that time-limited therapy might be more effective that open-ended therapy.  If the patient manifests dependence do not “up the ante”, in other words, do not offer heroic and out of character solutions (such as special arrangements, rescheduling for more convenient times, changing your process by “doing more as the patient is doing less”). Any such responses can become a positive reinforcement for what in essence is a maladaptive behavior.

Instead, keep doing what you have done all along and do not change the termination date. Chance is that the patient will be able to mobilize enough internal resources to hold it together through termination if you would only give him your vote of confidence that he can do so. For the minority that cannot, a return/continuation of therapy might be recommended. If so, it’s usually better if you let another therapist take over. The rationale for switching therapists follows the idea that one needs to be consistent in preventing positive reinforcements for maladaptive traits or behaviors.

Not to mention that if the patient did not improve within the parameters that you initially discussed you might not be the best therapist (at least for that one patient) and they might really benefit from no longer seeing you.

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.

If you find yourself prescribing neuroleptics for a mood disorder, mood stabilizers for a psychotic disorder and antidepressants left and right for all sort of NOS diagnoses it’s not a bad idea to take a deep breath and a hard look at your diagnoses.

Not that we never prescribe mood stabilizers for schizophrenia, or (in this brave new age of second generation everything) atypicals for mood disorders. We do.

However, even during these times of a relaxed psycho-pharmacology, an understanding of first versus second line, switching and augmenting is still a sine qua non of good doctoring.  Which implies that when your psychotropic does not closely match your patient’s diagnosis you’d better have a good explanation of why that is.

And it wouldn’t hurt either to document it accurately so that the next doctor in line or yourself looking at your old notes will understand your rationale for prescribing outside the standard of care.

You should consider also reviewing and/or appropriately documenting your drug dispensing habits for your patients on major poly-pharmacy type of cocktails. Remember that the evidence base for most poly-pharmacy type of strategies is rather flimsy, while the evidence base for compounded toxicity is gaining momentum.Bottom line: prescribing more than one medication for an indication is not the best charted territory, which by the way includes the unclear evidence-based realm of augmentation strategies.

Red flag combinations? Two or more similar agents prescribed together. This includes , going from rather non-nonsensical to somewhat explainable combinations (and I list here only combinations that I’ve actually seen): two SSRIs, tow SNRIs, SSRI + SNRI, two stimulants, two TCAs, two typical neuroleptics, two atypical neuroleptics, typical + atypical neuroleptic, two mood stabilizers (other than lithium).

Make sure that your medications match your diagnosis and that you have a good rationale for each medication you dispense to a patient.

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?

Details matter.

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.

Don’t differentiate too broadly

It is important to be as informative (i.e. as specific) as you can.

If your diagnosis actuallty fits diagnostic criteria is there a reason to NOT call it as it is?

Sure, you wouldn’t want to be wrong.

But caution considered, wouldn’t you also want to be right?

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.

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