Treating a patient who has ‘everything’
Patients who endorse multiple psychiatric symptoms and meet criteria for several DSM diagnoses pose diagnostic and therapeutic challenges. In community samples, approximately 40% of patients with a DSM diagnosis have >1 illness, and comorbidity is more frequent in clinical trials.1 We highlight things to consider when managing a patient who has “everything.”
Endorsing ‘everything’ means something in itself. Patients with borderline personality disorder often present with myriad, disparate diagnoses and urgent requests for care.2 Also consider primary or secondary gain, particularly if the patient’s descriptions of symptoms are unusual. Saying “yes” to every question or endorsing highly unusual symptoms described by the interviewer may represent suggestibility related to catatonia or confabulation.
Focus on the most impairing symptom. This may help put other symptoms in context and focus treatment.
Find a common goal. If you can’t pick a simple symptom, move on to helping the patient identify his or her goals by asking questions such as, “Four weeks from now, what would you like to be doing?” Picking an achievable, measurable goal may be therapeutic.
SAFER criteria for symptom validity
State vs trait: has the symptom lasted <12 weeks?
Assessable: can the symptom be measured?
Face validity: does the symptom clearly affect the patient’s behavior and functioning?
Ecological validity: is the symptom valid with our knowledge of its occurrence?
Rule of the 3Ps: is the symptom Persistent; Pathologically disruptive and different than usual; and Pervasive across normal domains?
Source: Reference 3
Multiple diagnoses may be in play, but start by treating one. Many patients meet criteria for multiple diagnoses. There is little evidence about which diagnosis should be treated first. Use your judgment in picking “the best first step” and treat accordingly.
Resist polypharmacy. Target specific symptoms or goals until a clear diagnostic picture emerges.
The authors report no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.
1. Kessler RC, Chiu WT, Demler O, et al. Prevalence, severity, and comorbidity of 12-month DSM-IV disorders in the National Comorbidity Survey Replication. Arch Gen Psychiatry. 2005;62(6):617-627.
2. Gunderson JG. Borderline personality disorder: ontogeny of a diagnosis. Am J Psychiatry. 2009;166(5):530-539.
3. Targum SD, Pollack MH, Fava M. Redefining affective disorders: relevance for drug development. CNS Neurosci Ther. 2008;14(1):2-9.