COMMENTARY

Agitated Patients? They May Be Taking Their Cue From You

Derick E. Vergne, MD; Sivan Mauer, MD, MS; Kristina Gaud, MD

Disclosures

August 24, 2016

In This Article

Introduction, and a Case

A 19-year-old woman is admitted to the adult inpatient unit of a university hospital. Although she was calm and collected during the initial 10 minutes, she becomes extremely agitated, screaming at the interviewing psychiatrist doing the admission. This tired psychiatric resident becomes flustered and slightly annoyed, and tells the patient in a somewhat condescending way, "If only you remained seated, maybe we could finish the interview."

The resident, noticing the abrupt change in affect and having read in the patient's history that she has been prone to "extreme fluctuations in mood, sometimes happy and sometimes sad," concludes that a rule-out of bipolar disorder needs to be included on Axis I in the diagnostic formulation section.

The resident's opinion is further solidified when he asks the patient about other aspects of her life while trying to complete the interview. The patient, still very agitated, relates that she suffers from insomnia ("I'm seldom unable to sleep, and when I sleep it's broken, because I think, think, and don't stop thinking!"). She also relates that she tends to be impulsive, and if at some particular time she feels like it, she might go to the nearest mall to buy "whatever the hell I want." After 10 minutes, she takes the clipboard she had been using to fill in a questionnaire on her medical history, throws it at the resident physician, and storms out of the interview room, where she is received by nursing staff.

At this point, looking at the patient's display of nervous energy, irritability, aggressive behavior, and marked mood lability, the resident is triumphantly sure about his potential diagnosis of bipolar disorder, only writing "rule out" in Axis I so as not to give the impression of cockiness.

In this case, attention to transference dynamics would have shed some light onto affect regulation and the ways in which its absence can cloud diagnostic accuracy. The first step in appropriate diagnosis lies in a sound conceptual understanding of the patient's current circumstance, the details of the current presentation as experienced by others, her experience of her illness, an accurate description of the expression of the symptoms or mental status, the context (environmental, cultural, and psychosocial), and the detailed sequential appearance of each symptom with its appropriate context (timing of events leading to the expression of pathology). Only then can the clinician apply a psychodynamic approach to behavior—not in substitution of, but alongside the above descriptive/phenomenological understanding.

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