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 Psychiatry
Mentor
Your Clerkship &
Shelf Exam Companion
SECOND
EDITION
 Psychiatry
Mentor Your Clerkship &
Shelf Exam Companion
SECOND Michael R. Privitera, MD, MS
EDITION Associate Professor of Psychiatry
Director, Consultation/Liaison Psychiatry Service
Director, Mood and Anxiety Disorder Clinic
Medical Director, Strong Family Therapy Services
University of Rochester Medical Center
Rochester, New York

Jeffrey M. Lyness, MD
Professor of Psychiatry & Associate Chair for
Education
Director, Geriatric Psychiatry Program,
Department of Psychiatry
Director of Curriculum, Offices for Medical
Education
University of Rochester Medical Center
Rochester, New York

F.A. DAVIS COMPANY • Philadelphia

F. A. Davis Company
1915 Arch Street
Philadelphia, PA 19103
www.fadavis.com
Copyright © 2009 by F. A. Davis Company
Copyright © 1997 by F. A. Davis Company. All rights reserved. This product is protected by
copyright. No part of it may be reproduced, stored in a retrieval system, or transmitted in any
form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without
written permission from the publisher.
Printed in the United States of America
Last digit indicates print number: 10 9 8 7 6 5 4 3 2 1
Acquisitions Editor: Andy McPhee
Developmental Editor: Andrew Pellegrini
Manager of Content Development: George Lang
Art and Design Manager: Carolyn O’Brien
As new scientific information becomes available through basic and clinical research, recom-
mended treatments and drug therapies undergo changes. The author(s) and publisher have done
everything possible to make this book accurate, up to date, and in accord with accepted stan-
dards at the time of publication. The author(s), editors, and publisher are not responsible for
errors or omissions or for consequences from application of the book, and make no warranty,
expressed or implied, in regard to the contents of the book. Any practice described in this book
should be applied by the reader in accordance with professional standards of care used in regard
to the unique circumstances that may apply in each situation. The reader is advised always to
check product information (package inserts) for changes and new information regarding dose
and contraindications before administering any drug. Caution is especially urged when using
new or infrequently ordered drugs.
Library of Congress Cataloging-in-Publication Data

Privitera, Michael R.
Psychiatry mentor: clerkship and shelf exam companion / Michael R. Privitera, Jeffrey M.
Lyness. — 2nd ed.
p. ; cm.
Rev. ed. of: Psychiatric pearls / Jeffrey M. Lyness. c1997.
Includes bibliographical references and index.
ISBN-13: 978-0-8036-1692-9 (pbk. : alk. paper)
ISBN-10: 0-8036-1692-9 (pbk. : alk. paper)
1. Psychiatry–Handbooks, manuals, etc. I. Lyness, Jeffrey M., 1960- II. Lyness,
Jeffrey M., 1960- Psychiatric pearls. III. Title.
[DNLM: 1. Mental Disorders—diagnosis. 2. Mental Disorders—therapy.
3. Psychiatry–methods. WM 141 P961p 2009]
RC456.L96 2009
616.89–dc22 2008030772
Authorization to photocopy items for internal or personal use, or the internal or personal use of
specific clients, is granted by F. A. Davis Company for users registered with the Copyright
Clearance Center (CCC) Transactional Reporting Service, provided that the fee of $.25 per copy
is paid directly to CCC, 222 Rosewood Drive, Danvers, MA 01923. For those organizations that
have been granted a photocopy license by CCC, a separate system of payment has been arranged.
The fee code for users of the Transactional Reporting Service is: 8036-1692-9/ 09 0 + $.25.
 To the patients whose lives we endeavor to improve

To the students, residents, and fellows who have stimulated

our development as teachers

To our families, for everything

Foreword
Psychiatric clerkships are often formidable experiences for medical
students, not so much because of the grueling hours and physical exertion,
but because psychiatry may seem quite different from other clerkships in
medical school. Psychiatric pathology often evokes stronger personal
reactions in us than most physical diseases seen, and sometimes
encountering the ensuing behaviors that is highly stressful, frightening, or
even personally disturbing. Dealing with some patients who may seem
weird, crazy, suicidal, or violent can shake up the calmest student’s poise.
Issues of personality, emotion, and interpersonal problems may be
hard to understand and sometimes strike too close to home. Getting your
head around some of the diagnostic concepts in psychiatry may be more
difficult, because they often do not lend themselves to neat categories and
because there are so few specific laboratory tests to permit “black and
white” diagnoses. Trying to understand how these frequently vague clinical
syndromes tie in with contemporary neuroscience can be frustrating
because the tie-ins are often inexact. Add to that the varying abilities of
psychiatric faculty and residents to explain what’s going on in plain,
simple English. Medical students on their psychiatry rotations may feel as
if they are not getting close enough teaching, supervision, or support.
For all these reasons, every student can benefit from a psychiatric
mentor. Happily, in this welcome new book, Drs. Privitera and Lyness—
two exceptionally experienced and articulate medical student educators in
Psychiatry—provide an educational package that addresses the “need to
know” facts, concepts, and survival strategies that every clinical clerk will
welcome.
Organized around a set of standardized objectives developed by the
American Directors of Medical Student Education (ADMSEP), the book
starts out with a basic orientation—answers to questions many students
would like to ask but don’t because they are too embarrassed or because

vi
 Foreword vii

no one is around to answer the questions as they come up. In addition, the
introductory section discusses why psychiatry might be important for all
students, regardless of the field of medicine they ultimately choose.
The subject matter itself—covering psychiatric assessment, disorders,
treatments, and treatment settings—is organized in an easy-to-read fashion,
using all the tricks educators have learned to make learning easier for
students. There are easy-to-follow algorithms, illustrations, and practical
tables.
Mentor Tips are highlighted throughout. These are the wise words
you’d hope to hear from instructors, residents, and advisors as you
progress through your work. Major learning points are presented
telegraphically, so you can read and absorb them quickly. The practice
questions provided on the CD-ROM are suitable for self-study or for
studying in a group. Because most psychiatric clerkship directors these
days place about 25% of the total clerkship grade on shelf exams, these
exercises will prove extremely useful.
My guess is that every medical student will find the material in this
book extremely useful. I also suspect that psychiatric residents looking
over your shoulder who have not had the opportunity to see this book
may want to grab it, peruse it, and “borrow” it. So, Mentor Tip: When
you’re around psychiatric residents, hold on tightly to this book!
Another Mentor Tip: Enjoy your clerkship to the fullest. You’re going
to be introduced to some of the most profound human experiences you’re
likely to encounter in your medical career.

Joel Yager, MD
Professor and Vice Chair for Education and Academic Affairs
University of New Mexico School of Medicine
Professor Emeritus, Department of Psychiatry and Biobehavioral Sciences
David Geffen School of Medicine, University of California at Los Angeles
Preface
A New Tool for the Clerkship and Shelf Exam

Psychiatric medicine continues to advance, furthering its mission of

helping the many people who will suffer from a mental disorder at some
time in their lives. In order to give the next generation of clinicians the
very best possible study tools, we have created Psychiatry Mentor, in
which we intend to provide the best preparation possible for the
psychiatric clerkship rotation and shelf exam. This book and its
accompanying electronic study tools are the next best thing to having a
living, breathing mentor by your side 24/7.
Whatever your previous exposure to the field, you no doubt heard
many things about psychiatry and psychiatric patients. Some may have
been pejorative or led you to worry that you are about to encounter
situations that are strange, anxiety-provoking, frightening, or even
dangerous. In fact there are some important differences between your
work in psychiatric settings and that in other medical settings. Learning
about these differences is part of the objectives of the rotation. Obtaining
good-quality clinical data relies more heavily upon your relationship with
the patient as well as from collateral sources of information. However,
you will be relieved to discover that most work in this field is highly
parallel to work in other medical settings.
As with other rotations, you’ll discover that after a week of settling in
you will be more clear on your roles and tasks. If you are like most trainees,
you’ll soon feel comfortable with—even look forward to—coming to work.
Such comfort and enjoyment will stem from the inherent fascinating nature
of the field (not to mention the brilliance, enthusiasm, and friendliness of
your teachers!). The goal of this book, then, is to help you more rapidly reach
the point of feeling competent and comfortable. The choice of topics, or more
precisely the approach to these topics, is modeled on what students have

viii
 Preface ix

found important from a variety of sources. Dr. Lyness led the third-year
medical student clerkship in psychiatry and is now Director of Medical
Student Education in Psychiatry, and Director of Curriculum for the medical
school, at the University of Rochester Medical Center. Dr. Privitera has been
a clerkship mentor for over 20 years, has run small group seminars for
nearly as long, and directed medical student education on the Psychiatry
Consultation/Liaison Service at the same institution.
This book is also relevant to other physician trainees newly joining a
psychiatry service, whether psychiatry residents or residents from another
specialty taking an elective. Many non-physician professional trainees
who work in psychiatric settings are likely to find this book useful as
well, paralleling the critical roles played by many disciplines in delivering
care to the mentally ill.
In this book we consider aspects of the psychiatric rotation itself,
including goals, logistics, and approaches to productive and successful
clerkship performance. We examine the basics en route to mastering the
knowledge base and skills you’ll be working on during the rotation. We also
discuss the framework within which psychiatric care is rendered, including
the settings and the professionals who comprise the relevant staff.
It is our hope that this book will quickly enhance your learning of the
fascinating field of psychiatry and more readily allow you to assist the
patients in need of your care.

Cross-References to ADMSEP Clerkship Objectives

Standard written objectives for clerkships are a valuable tool—both for

teachers, who are responsible for making sure their students learn everything
they need to know, and for students, who need an organized summary of
what is expected of them. The Association of Directors of Medical Student
Education in Psychiatry (ADMSEP) has created such objectives for
Psychiatry clerkships (Academic Psychiatry 1997; 21:179–204), which are
presented at http://www.admsep.org/appendix.html Throughout Psychiatry
Mentor, we have included cross-references to the relevant objectives
within that document. Each ADMSEP citation in the Mentor text (for
example: II 4-6) points to a certain objective. This feature shows our
readers exactly how each Mentor discussion helps to meet the relevant
objectives.
x Preface

A Note About DSM Editions

At the time of writing this book, the edition of the American Psychiatric
Association’s Diagnostic and Statistical Manual of Mental Disorders
(DSM) was DSM-IV-TR. We expect that the next edition, DSM-V, will
probably appear within the next several years. We can expect that DSM-V
will bring important changes to the diagnosis of some kinds of mental
disorders. Readers should understand that DSM-V will supersede any
information herein that, being based on DSM-IV-TR, may no longer be
definitive, despite having been the very latest information available at the
time of this writing.
Michael R. Privitera, MD, MS
Jeffrey M. Lyness, MD
Rochester, New York
Acknowledgments
MRP would like to thank Dr. Jeffrey Lyness for the opportunity to be
part of this education endeavor; Drs. Eric Caine, Glenn Currier, and
Steve Lamberti; and Joanne, David, Natalie, and Mark for their
encouragement and support on this project.

JML would like to thank Drs. Melissa DelBello, Eric Caine, Yeates
Conwell, Laurence Guttmacher, and Mary Lou Meyers for their support
and invaluable comments regarding a previous edition of this book,
Dr. Privitera for his tireless work on this new and improved edition, and
Diane, Colin, Sean, and Trevor for their support, period.

xi
Contents
PART

one
PSYCHIATRY AS A FIELD OF MEDICINE 1
CHAPTER 1 INTRODUCTION TO PSYCHIATRY 1
CHAPTER 2 PERSPECTIVES ON HUMAN BEHAVIOR 11

PART

two
PSYCHIATRIC WORKUP 25
CHAPTER 3 HISTORY AND PHYSICAL EXAMINATION 25
CHAPTER 4 MENTAL STATUS EXAMINATION 41
CHAPTER 5 LABORATORY EVALUATIONS AND PSYCHOLOGICAL
TESTING 63
CHAPTER 6 DIAGNOSTIC IMPRESSION, FORMULATION, AND
PLAN 69

PART
three
PSYCHOPATHOLOGY: DISORDERS AND CLINICAL
PRESENTATIONS 81
CHAPTER 7 PSYCHIATRIC EMERGENCIES AND URGENT CARE
ISSUES 81
CHAPTER 8 COGNITIVE AND SECONDARY (“ORGANIC”)
MENTAL DISORDERS 101

xii
 Contents xiii

CHAPTER 9 MOOD DISORDERS 117

CHAPTER 10 PSYCHOTIC DISORDERS 139
CHAPTER 11 ANXIETY DISORDERS 150
CHAPTER 12 SUBSTANCE USE DISORDERS 165
CHAPTER 13 PERSONALITY TRAITS AND DISORDERS 176
CHAPTER 14 OTHER PSYCHOPATHOLOGICAL CATEGORIES 191

PART

four
PSYCHIATRIC TREATMENTS 211
CHAPTER 15 PSYCHOTHERAPIES 211
CHAPTER 16 PHARMACOTHERAPY 230
CHAPTER 17 OTHER SOMATIC THERAPIES 272

PART

five
TREATMENT SETTINGS AND SUBSPECIALTIES 285
CHAPTER 18 TREATMENT SETTINGS, SYSTEMS, AND OTHER
CLINICAL ISSUES 285
CHAPTER 19 PSYCHIATRIC SUBSPECIALTIES 310
APPENDIX A ANSWERS TO SELF-TEST QUESTIONS 321
APPENDIX B GLOSSARY OF FREQUENTLY USED PSYCHIATRIC
TERMS 334
APPENDIX C ABBREVIATIONS 337
APPENDIX D KEY CONTACTS AND NOTES 341
INDEX 348
one
PART

Psychiatry as a
Field of Medicine
1
CHAPTER
Introduction to
Psychiatry
Michael R. Privitera, MD, MS, and
Jeffrey M. Lyness, MD

I. Overview
A. Welcome to your psychiatry experience! Whatever your previous
exposure to the field, you have probably heard many things about
psychiatry and psychiatric patients. These probably span the range
from pejorative to fascinating, frightening to extremely rewarding.
XXIII 9
B. Our purpose is to help you understand your new experience quickly
and confidently.
C. You will see parallels to other fields of medicine but rapidly
discern and master important differences in psychiatric care.
XXIII 7

1
 PART
2 one Psychiatry as a Field of Medicine

II. Definition of Psychiatry

A. Psychiatry: branch of medicine concerned with diagnosis and
treatment of persons with mental disorders
1. Applied science and craft
2. Draws on numerous aspects of natural, physical, and social
sciences
B. Psychiatrists are physicians who have completed specialty residency
training in psychiatry
C. Mental disorder
1. Mental: thoughts, feelings, and actions
2. Disorder: difficulty manifested by subjective distress or observ-
able dysfunction

III. Relevance to Training in Patient Care

A. Why should I learn psychiatry?
1. Interpersonal technical competence
a. All physicians need to develop skills interacting with patients
and families.
i. Physician-patient relationship: primary tool for gathering
data and initiating therapeutic interventions
b. Psychiatry specifically lends itself to learning these skills.
i. Working with and supervision by professionals highly
skilled and knowledgeable in this area
ii. Receiving feedback about patient interviews, family meet-
ings, difficult interpersonal interactions XXIII 2
iii. Dealing with patients having uncomfortable affects or
behaviors: e.g., mute, withdrawn, angry, and so on
XXIII 5–6
iv. Communicating in difficult situations, XXIII 6 e.g.:
(1) Cognitive or psychotic impairments
(2) Problems accepting diagnosis
(3) Poor treatment compliance due to limited insight
(4) Problems in ability to understand medical options
presented
2. Learning psychopathology
a. All physicians need to understand basics of diagnosis and
treatment of psychopathology.
b. Mental disorders are extremely common.
i. These problems found in all fields of medicine
CHAPTER
1 Introduction to Psychiatry 3

c. These disorders matter:

i. Cause functional disability
ii. Affect individuals, families, others
iii. Affect outcome of comorbid medical disorders, e.g.,
increased risk of death from heart disease, cancer
iv. Can affect compliance with comorbid medical or surgical
treatments
d. Psychiatric treatments work.
i. NIH study: treatments at least as effective as for most
major physical diseases
e. Most patients with psychiatric disorders never seek care from
the “official” mental health system; instead obtain care from
primary care and other medical specialists.
3. Learning biopsychosocial integration (Figs. 1.1 and 1.2)
XXIII 11
a. All clinicians routinely encounter and use a wide variety of
data in planning treatment.
i. Physical symptoms and exam
ii. Laboratory results

Biological
factors

Psychological Social
factors factors

Figure 1.1 Biopsychosocial model. XXIII 11

 PART
4 one Psychiatry as a Field of Medicine

Biosphere

Society-nation

Culture-subculture

Community

Family

Two-person

Person (Experience and behavior)

Nervous system

Organs/organ systems

Tissues

Cells

Organelles

Molecules

Atoms

Subatomic particles

Figure 1.2 Hierarchy of natural systems in the biopsychosocial model.

XXIII 11
CHAPTER
1 Introduction to Psychiatry 5

iii.Behavioral observations of patients and families (including

mental status exam)
iv. Information about social situation and living environment
b. Psychosocial data are often unstated yet are critical to suc-
cessful patient care (can be “elephant in the room”).
c. Psychiatry is a good place to learn to integrate three realms of
bio-psycho-social issues.
IV. Adjustment to Your Psychiatry Rotation
A. Understand logistics
1. Where you need to be and when
2. Call duties
3. Role on the team
4. Responsibilities in patient care
5. Academic/presentation requirements
6. Write-up requirements
7. Learn what is unique to psychiatric patient care
a. Legal status issues
b. Confidentiality issues
8. Preceptor/supervisor—when and how your progress
is reviewed
9. Recommended text(s)
10. Goals and skills to develop
B. Usual “phases” of rotation to master
1. Orientation
a. Normal to feel like a “fish out of water” first few days to
a week
i. New ways of measuring pathology and clinical changes
that are not as concrete as laboratory values or physical
findings
b. Learn how to do psychiatric write-ups

Focus on observing patients and putting these

observations into words (learn the jargon later).

Focus on observing those more skilled in

interviewing. Learn from their experience:
 PART
6 one Psychiatry as a Field of Medicine

i. Learn different ways and styles of obtaining clinical data.

ii. Imagine how you might feel if someone was asking you
the questions needed to obtain information.
iii. Remember sensitivity and respect. XXIII 3
iv. Some patients may interpret your questioning as implying
they are “crazy.” Keep to the medical model (and tone)—
show that your motive in obtaining information is to help
them.
v. Universalize to set people at ease, e.g.: “When some peo-
ple get depressed, their mind may play a trick on them.
Have you ever had experiences of hearing things or seeing
things that were not there?”

Learn elements of write-ups and doing a mental

status exam.

Multidisciplinary team approach is complex, so try

to learn the roles of each discipline.

2. Phenomenology and treatments

a. Become familiar with official terms (jargon).
b. Become familiar with array of treatment options (psychotropic
medications and psychotherapy).

DSM criteria become your “friends.”

Apply what you learned from interviews to diagnostic

categories.

Quickest way to get comfortable with therapeutics is

to learn psychopharmacology.

i. After seeing or hearing about how a drug is used, learn

how the drug fits into class of drugs and why it is selected.

Begin to learn when psychotherapy is

recommended (in general terms). XXI 4–5
CHAPTER
1 Introduction to Psychiatry 7

3. Differential diagnosis
a. You learned phenomenology in different disorders—now
work backwards from symptoms (phenomenology) to
diagnostic category.
b. What medical conditions may present with psychiatric syn-
dromes (mimicking primary [idiopathic] psychiatric disorders)?

DSM has sections on differential diagnosis to

assist you.

Avoid premature closure on a diagnosis.

Consider pros and cons of a few major diagnostic

possibilities.

Remember to consider possible medical causes

of symptoms.

4. Treatment selections
a. Apply your therapeutic knowledge.
b. Be able to recommend major treatment options.
i. When to suggest psychotherapy and for what goals
XXI 4–5
ii. What specific medication would you choose and why
c. Develop some sense of how long a treatment is recommended.
d. Become familiar with issues that affect treatment.
i. Personality disorders
ii. Comorbid medical conditions
iii. Ongoing stressors
iv. Other (e.g., support system, cognitive impairments, and
so on.)

Commit on paper (not in the chart unless cleared

with supervisor) or state to a supervisor what
treatment you would choose and why. Be prepared for
constructive corrections.
 PART
8 one Psychiatry as a Field of Medicine

Be active on the team in treatment selection

decisions.

Try to learn from as many patients as time permits.

See the effect of treatment decisions while you are

on service.

V. Frequently Used Psychiatric Terms

A. Take some time now to study the terms in Appendix B: Glossary of
Frequently Used Psychiatric Terms. This group of key terms gets
your basic psychiatric vocabulary up to speed. XXI 3
VI. Your Evaluation
A. Varies among schools; however, in general:
1. Academic
a. Fund of psychiatric knowledge
b. Skills demonstrated
c. Application of knowledge to clinical reasoning
2. Clinical
a. Ability to gather and organize data for written and oral
presentation
b. Differential diagnosis and management plan
c. Procedural skills (for psychiatry, especially mastering mental
status exam and interviewing skills for patients and families)
3. Interpersonal
a. Works well with colleagues and patients
b. Enthusiasm and energy for subject matter, patient care, and
self-education
c. Professionalism
d. Receptivity to feedback

MENTOR TIPS DIGEST

A. Orientation
• Focus on observing patients and putting these
observations into words (learn the jargon later).
CHAPTER
1 Introduction to Psychiatry 9

• Focus on observing those more skilled in interviewing.

• Learn elements of write-ups and doing a mental status
exam.
• Multidisciplinary team approach is complex, so try to
learn the roles of each discipline.
B. Phenomenology and Treatments
• DSM criteria become your support.
• Apply what you learned from interviews to diagnostic
categories.
• Quickest way to get comfortable with therapeutics is to
learn psychopharmacology.

C. Differential Diagnosis
• DSM has sections on differential diagnosis to assist you.
• Avoid premature closure on a diagnosis.
• Consider pros and cons of a few major diagnostic
possibilities.
• Remember to consider possible medical causes of
symptoms.
D. Treatment Selections
• Record (not in the chart unless cleared with supervisor)
or state with a supervisor what treatment you would
choose and why. Be prepared for constructive
corrections.
• Be active on the team in treatment selection decisions.
• Try to learn from as many patients as time permits.
• See the effect of treatment decisions while you are
on service.

Chapter Self-Test Questions

Circle the correct answer. After you have responded to the questions,
check your answers in Appendix A.
1. Which answer is incorrect? Mental disorders:
a. Affect outcome of comorbid medical disorders.
b. Are mostly managed by psychiatrists, not primary care and other
specialists.
 PART
10 one Psychiatry as a Field of Medicine

c. Can affect compliance with comorbid medical or surgical treatments.

d. Cause functional disability.
2. Difficulty in describing or recognizing one’s own emotions (alex-
ithymia) is a common contribution to which type of disorders?
a. Adjustment disorders
b. Mood disorders
c. Schizophrenia
d. Somatoform disorders
3. The clinician’s conscious or unconscious emotional reaction to the
patient, determined by the clinician’s inner needs, is called:
a. Countertransference.
b. Object relations.
c. Psychosomatic.
d. Transference.

See the testbank CD for more self-test questions.

 2
CHAPTER
Perspectives on Human
Behavior
Michael R. Privitera, MD, MS, and
Jeffrey M. Lyness, MD

I. Introduction
A. “Pathogenesis” in psychiatry must be construed more broadly than
in traditional pathology and physiology; it should include psycho-
logical, and psychosocial, and biological factors.
B. More than one theory may be invoked simultaneously to understand
a patient’s disorder.
1. The disorder may be multifactorial.
2. Different theories may shed important perspectives on essentially
same thing.
C. Treatment modalities affect multiple levels of conceptual organiza-
tion simultaneously.
1. Antidepressants: ameliorate ideational, affective, and somatic
symptoms of depression
2. Psychosocial treatments: also ameliorate ideational, affective,
and somatic symptoms of depression (if mild or moderate level
of severity)
D. Theories that provide insight into a disorder do not necessarily lead
to effective treatments.
1. Psychodynamics: gives a rich perspective on obsessive-
compulsive disorder, but psychodynamic psychotherapy is
ineffective in treating the disorder
2. Neurobiology: enriches understanding of substance dependence,
but psychopharmacology is not a mainstay of treatment for
most

11
 PART
12 one Psychiatry as a Field of Medicine

II. Genetics IV 1
A. Psychiatric disorders still considered idiopathic
B. Importance of genetics varies
1. Largely genetic: pervasive developmental disorder [autism],
bipolar disorder
2. Strongly genetic in some patients and less so in others: major
depression
3. Genetic factors more distant role, or predisposing but not
causative: posttraumatic stress disorder, perhaps many
personality disorders
C. Genetic influence is polygenic for most disorders: multiple genes
in same individual, or different loci in different individuals
D. In most disorders, genetic influence is multifactorial: result of
complex interplay between genetic factors and variety of physio-
logical, developmental, psychological, and social events

III. Neurobiology IV 1–3

A. Altered brain function is at least a concomitant of all altered behavior.
B. Current technology is limited in identifying brain dysfunction.
C. Whether altered brain function is the cause, contributor, or effect
of altered behavior is unknown in most disorders.
1. Neuroimaging abnormalities may be associated with various
disorders.
a. But this is usually nonspecific
b. Diagnosis made on clinical grounds
D. Neurochemistry
1. Focus on “big three” neurotransmitters [norepinephrine,
dopamine, serotonin]
2. Alterations noted in neurotransmitter activity, turnover, or
receptor regulation
3. Others studied
a. Acetylcholine: Alzheimer’s disease
b. Gamma-amino butyric acid (GABA): anxiety disorders
E. Neuroendocrine
1. Hypothalamic-pituitary-adrenal axis
a. Studied in mood disorders, stress response, and suicidal
behavior
2. Thyroid function
a. Mood disorders
CHAPTER
2 Perspectives on Human Behavior 13

3. Female reproductive hormones

F. Psychoneuroendocrinology
1. Brain and immune system communicate bidirectionally
G. Neuroimaging
1. Magnetic resonance imaging (MRI) shows more detail than
computed tomography (CT)
2. From crude assessments of brain atrophy or agenesis (total brain
volume or ventricular-brain ratio) to specific regions or struc-
tures (e.g., dorsolateral prefrontal cortex in schizophrenia or
basal ganglia or frontal lobes in depression)
3. Hopes of determining functional neuroanatomy
a. Radioisotope labeling
i. Positron emission tomography (PET)
ii. Single photon emission computed tomography (SPECT)
b. Functional MRI
H. Neuropathology
1. Brain biopsies rarely conducted; usually not illuminating in
single cases
2. Fine-level neuroanatomic abnormalities may be present
a. Alterations in organization of neuronal architecture in specific
cerebral cortical layers in schizophrenia
I. Sleep architecture (by electroencephalogram [EEG] and systemic
physiology) altered in:
1. Mood disorders
2. Schizophrenia
J. Chronobiology
1. Seasonal biorhythms
2. Circadian (daily) biorhythms
K. Neuropsychological testing
1. Allows examination of cognitive functions that may be tied to
particular neuroanatomic regions or pathways
IV. Psychodynamics XXI 1
A. Concepts and theories dominated American psychiatry after World
War II and still pervasive in lay images about psychiatry
B. Problems during heyday of psychoanalysis
1. Other perspectives often excluded
2. Some practitioners raised expectations too high about ability of
psychoanalysis to explain and lead to effective treatment of all
mental disorders
 PART
14 one Psychiatry as a Field of Medicine

C. Psychodynamic perspectives remain fundamental in understanding

and working with mentally ill patients.
D. Basic concepts of psychodynamic thought
1. The unconscious
a. Much of human mental activity—thoughts, feelings, conflicts,
attempts at problem solving—happens outside of conscious
awareness.
b. At least some unconscious activity cannot be brought easily
into awareness.
c. Human behavior that on surface appears irrational or inexpli-
cable may become understandable (although not necessarily
reasonable or acceptable) by understanding unconscious
processes underlying such behavior.
2. Defense mechanisms XXI 3
a. Originally, term used for unconscious mental acts that allow
individual to mediate (“deal with”) unconscious intrapsychic
conflicts.
i. Typical conflict is between wanting something (“id”) and
simultaneously believing this want is unacceptable
(“superego”)
b. Defense mechanisms come into play as a way out of or way
to mediate conflict.
c. The term “defense mechanism” often broadly includes wide
range of problem-solving or coping skills, including those
that occur consciously and unconsciously. (Table 2.1)
d. They all work, some better (more fully or more flexibly in a
variety of settings) than others.
e. If person has limited repertoire of defenses or relies on more
“primitive” defenses, may not do as well (develop psychiatric
symptoms) under certain stressors.
f. Knowledge of your patient’s defense mechanism is useful in
managing your treatment alliance and in planning psychother-
apeutic treatment.
3. Transference.
a. Crucial to understanding patient-physician relationships
b. When people meet someone new (such as a physician), they
bring their sets of expectations, hopes, fears, and emotional
reactions to the relationship
CHAPTER
2 Perspectives on Human Behavior 15

TA B L E 2.1
Defense Mechanisms* ADMSEP XXI 3

Defense Mechanism Description

Denial Awareness of external reality is kept out of
More “primitive” defenses

consciousness. May reach delusional

proportions (psychotic denial).
Distortion Distortion perception or recollection of
external reality to meet defensive needs.
Projection Unacceptable feelings or wishes are attrib-
uted to others. May reach psychotic pro-
portions (e.g., persecutory delusions).
Projective A more complex defense mechanism that
identification involves a relationship with another
person, such as a psychotherapist.
Unacceptable feelings or wishes are pro-
jected onto the therapist to confirm the
projection. (Example: patient with poor
self-image projects this on the therapist,
with accompanied complaints that the
therapist doesn’t care about the patient.
The patient then acts in such a way to
elicit anger or withdrawal by the thera-
pist, thereby “confirming” the projection.
Splitting Other people are experienced as either
wholly good or bad objects, with associat-
ed positive or negative affects. No gray
zone exists. This may lead to swings
between over idealizing and devaluing
others, to creating splits between “good
More flexibly adaptive defenses

guys” or “bad guys” (e.g., among a multi-

disciplinary treatment team).
Acting out Unacceptable wishes are literally acted
upon, but are not experienced con-
sciously.
Passive- Aggression or rage expressed indirectly
aggressive by inactions such as procrastination or
behavior “forgetting” a task.
Dissociation A substantial, if time-limited, alteration in
one’s consciousness, memory, or sense
of personal identity.
(continued on page 16 )
 PART
16 one Psychiatry as a Field of Medicine

TA B L E 2.1
Defense Mechanisms* ADMSEP XXI 3 (continued)

Defense Mechanism Description

More “primitive” defenses

Displacement Shifting of affects from one object to

another, e.g., after a long frustrating day
at work (with attendant anger at one’s
boss), coming home and yelling at
one’s spouse or kicking the cat.
Repression Unconsciously mediated removal of an
unacceptable impulse or affect from
consciousness.
Externalization Related to but broader than projection,
involves perceiving one’s own attributes
and (more often) liabilities in the envi-
ronment and other persons. Persons
with prominent externalizing styles
blame circumstances and other people
rather than accepting responsibility for
their own actions.
Reaction Consciously experiencing an unaccept-
formation able wish or affect as its opposite.
Intellectualization Using intellectual processes to minimize or
avoid painful affects, impulses, or
thoughts. Closely tied to rationalization,
in which unacceptable behaviors,
thoughts, or feelings are explained away
More flexibly adaptive defenses

as being reasonable.
Altruism Constructively gratifying one’s instincts by
service to others.
Anticipation Reality-based planning for, or worrying
about, future inner discomfort.
Humor The constructive use of humor to manage
difficult thoughts or affects.
Sublimation Productively channeling instincts from
socially unacceptable to acceptable or
desirable ends.
Suppression Consciously choosing or planning to post-
pone attention to a difficult impulse or affect.

*Unconscious, unless otherwise specified.

Adapted from Vaillant GE: Empirical Studies of Ego Mechanisms of Defense. American
Psychiatric Press, Inc., Washington DC, 1986, pp. 105–117.
CHAPTER
2 Perspectives on Human Behavior 17

c. This is “baggage”: based on our personalities and prior expe-

riences (present before meeting new person)
i. Much can be unconscious (not thinking “out loud” about
expectations or affects).
ii. Baggage is real and can profoundly affect the way people
view a new person.
d. In meeting and developing relationship with new physician,
complex interplay between preexisting baggage and external
reality.
4. Countertransference
a. Your own emotional response to a patient colors your
interactions.
b. Is essentially transference of physician toward patient

Prevent your countertransferences from adversely

affecting your interviews and alliance building.

Develop your skills at altering your interview style

or approach in response to specific patient
transference patterns.

V. Behavioral Psychology XXI 1

A. Focus on external, directly observable behaviors
B. Rooted in learning theory
1. Specific behaviors can be promoted or reduced by reinforcers:
responses to the environment that encourage or discourage the
behaviors.

Even natural, helpful responses (e.g., a family’s rallying

of support in an adolescent girl’s suicide attempt) can
serve as a positive reinforcer to undesired behavior (suicidal
behavior). Thus, clinical goal is to help this patient meet her
needs without using suicidal acts.

C. Behavioral techniques used with a variety of disorders and

symptoms
1. All have in common: encouraging (reinforcing) desired behav-
iors and discouraging (extinguishing) dysfunctional or dangerous
behaviors.
 PART
18 one Psychiatry as a Field of Medicine

2. Cognitive psychology XXI 1

a. Studies the way people think
b. In psychiatric disorders, describes characteristic ways people
think while suffering from particular emotional states such as
depression or panic attacks
i. Emotional states stem from problematic thinking
ii. Dysfunctional patterns of thoughts occur automatically
and lead to affective symptoms and other components of
the disorders
iii. Cognitive distortions may affect how one views oneself,
external environment, or future (Table 2.2).
iv. In cognitive therapy, patients learn to identify their dys-
functional thoughts and replace them with more functional,
less distorted thoughts

In some ways this approach is almost a

behavioral therapy applied to internal thoughts.
Often clinicians speak of using combined
cognitive/behavioral techniques.

VI. Group Psychology XXI 1

A. Theories that focus on understanding human behavior manifested
in groups
B. Groups manifest their own properties, affected by:
1. Properties of individuals in group
2. Group size
3. Goals or tasks
4. Leadership
C. Theories of small group dynamics underlie approaches to group
psychotherapy
D. Important also in nonclinical work, such as psychological assess-
ment of organizations (e.g., corporations)
VII. Family Systems XXI 1
A. Families are complex systems that have their own characteristic
patterns of interaction, both within family and in relation to rest
of world (including physician).
B. Behavior within a family takes on a complexity that must be
understood at the level of the family.
CHAPTER
2 Perspectives on Human Behavior 19

TA B L E 2.2
Examples of Cognitive Distortions
Distortion Essential Characteristics

Dichotomous thinking Perceiving things as either/or, black/white,

(all-or–nothing thinking) good/bad, and so forth
Minimization or Selectively prioritizing the importance of
maximization certain facts, such as dwelling on one
(catastrophizing) critical comment made by a coworker
while ignoring his or her many praising
comments
Overgeneralization Basing broad, sweeping beliefs on few or
single incidents
Arbitrary inference Coming to a belief or conclusion without
(jumping to conclusions) direct evidence
Personalization Taking events personally without evi-
dence for such a connection
Selective abstraction Dwelling on one small part of a more
(mental filter) complex, larger situation
Disqualifying the Rejecting positive experiences by
positive insisting that they “do not count”,
despite contradictions by everyday
experiences
Emotional reasoning Assuming that negative emotions reflect
the way things really are
Should statements Motivating yourself (if guilt) or others
(if anger, resentment, frustration) with
“should”s and “shouldn’t”s
Labeling and mislabeling An extreme form of overgeneralization;
attaching a negative label to yourself or
others

Adapted from Burns DD: Feeling Good. Avon Books, 1999.

1. Understand the individuals, but also in the context of their role

in the family
2. Family interaction becomes more than a sum of individuals
C. A patient presenting with psychiatric symptoms cannot be fully
understood without appreciating his or her family history and
current state.
 PART
20 one Psychiatry as a Field of Medicine

D. Meetings with family may be essential for data gathering as well

as assistance to achieve successful psychotherapeutic ends.
VIII. Developmental Perspectives I 3
A. No single, catch-all developmental theory
B. Human development occurs in several areas across life span
1. Physiological
2. Psychological
3. Interpersonal factors
C. May be several theories or perspectives of single domains, such
as personality
D. Two broad perspectives worth considering as you formulate each
patient
1. Where is your patient now in his or her developmental
course, and how successfully (or not) has he or she been in
adapting to demands of current developmental needs and
challenges?.
2. Developmental perspective may offer insights into current
behavioral patterns as influenced by earlier life experiences.

It is important not to oversimplify, e.g., blaming

everything about a patient’s difficulties on “bad
parenting.” Yet, it would be a reasonable postulation that,
for example, repeated childhood abandonment by foster
caregivers has contributed to a 20-year-old’s current poor
sense of self and tendency toward depressive symptoms and
self-destructive acts.

IX. Other Perspectives

A. Cultural: recognize profound influence of culture on psychologi-
cal and interpersonal processes and on expression of, and
response to, psychopathology, as well as on attitudes toward psy-
chiatric and general medical care
B. Interpersonal: focus upon patient’s interaction with others; as a
form of psychotherapy (Interpersonal Psychotherapy, IPT) can
be very effective in treating, for example, major depression
C. Couples: draws upon family and interpersonal theories, with
focus upon a two-person system (dyad)
CHAPTER
2 Perspectives on Human Behavior 21

D. Ethics: perspectives in all of medicine, in psychiatry major focus

related to autonomy and consent
E. Forensic psychiatry XIX 5–8 : includes legal aspects in usual
psychiatric care (informed consent, confidentiality, involuntary
commitment to treatment) and those interfacing with criminal
justice system (relationship of mental disorder to criminal
actions, competency to stand trial, etc.)
F. Community psychiatry XIX 1–4, 9–10 : focus upon populations,
psychopathology from epidemiological perspective, consideration
of health services delivery by studying, modifying or designing
psychiatric systems of care for large numbers of mentally ill
persons

MENTOR TIPS DIGEST

• Prevent your countertransferences from adversely

affecting your interviews and alliance building.
• Develop your skills at altering your interview style or
approach in response to specific patient transference
patterns.
• Even natural, helpful responses (e.g., a family’s
rallying of support in an adolescent girl’s suicide
attempt) can serve as a positive reinforcer to
undesired behavior (suicidal behavior). Thus, clinical
goal is to help this patient meet her needs without
using suicidal acts.
• In some ways patients learning to identify their
dysfunctional thoughts and replace them with more
functional, less distorted thoughts is almost a
behavioral therapy applied to internal thoughts and
often clinicians speak of using cognitive/behavioral
techniques.
• It is important not to oversimplify. Yet, it would be a
reasonable educated speculation to postulate, for
example, that childhood repeated abandonment by
foster care givers has contributed to a 20-year-old’s
current poor sense of self, and tendency toward
depressive symptoms and self-destructive acts.
 PART
22 one Psychiatry as a Field of Medicine

Resources
Burns DD: Feeling Good. Avon Books, 1999.
Vaillant GE: Empirical Studies of Ego Mechanisms of Defense. American
Psychiatric Press, Inc., Washington DC, 1986, pp 105–117.

Chapter Self-Test Questions

Circle the correct answer. After you have responded to the questions,
check your answers in Appendix A.
1. More than one theory of human behavior may be invoked simultane-
ously to understand a patient’s disorder because:
a. A patient’s disorder may be multifactorial.
b. Different theories have equal effectiveness for each disorder’s
treatment.
c. Theories that help us understand a disorder necessarily lead to
effective treatments.
d. Treatment modalities affect one level of conceptual organization at
a time.
2. Of the following, the psychiatric disorder with the strongest genetic
component is:
a. Bipolar disorder.
b. Major depression.
c. Personality disorder.
d. Post-traumatic stress disorder.
3. Neuroendocrine studies that are thought to be important in psychiatric
disorders include all of the following except:
a. Aldosterone regulation.
b. Female reproductive hormones.
c. Hypothalamic-pituitary-adrenal axis.
d. Thyroid function.
CHAPTER
2 Perspectives on Human Behavior 23

4. All of the following are true about neuroimaging studies in psychiatry

except:
a. Crude assessments of brain atrophy or agenesis have been studied.
b. Hopes of determining functional neuroanatomy from radioisotope
labeling.
c. MRI shows less detail over CT.
d. Specific regions or structures have been studied.
5. Which of the following is not one of the three major neurotransmitters
best studied in psychiatric disorders.
a. Dopamine
b. Glycine
c. Norepinephrine
d. Serotonin

See the testbank CD for more self-test questions.

two
PART

Psychiatric
Workup
3
CHAPTER
History and Physical
Examination
Michael R. Privitera, MD, MS, and
Jeffrey M. Lyness, MD

I. Introduction
A. Psychiatric workup: similar in broad outline and in many details to
general medical workup you have been doing.
B. Important points of refinement (although applicable in other
settings) will be highlighted in psychiatry.
C. Become accustomed to and skilled at gathering and organizing
psychological and psychosocial data with the same rigor and detail
you employ with gathering data on physical symptoms, laboratory
values, and other “objective” data.
D. Psychiatric syndromes can be ascertained with same degree of
reliability as most general medical data.

25
 PART
26 two Psychiatric Workup

II. Elements of History and Physical (Table 3.1) I 1–12

A. Identifying data
1. Who: demographic description of patient
2. How: method of referral
a. Self-referred
b. Sent by general medical provider
c. Sent by another mental health provider
d. Psychiatry inpatients: mention patient’s legal status in your
write-up, such as voluntary or involuntary
3. Why: briefly but descriptively: your sense of most important or
most prominent part of patient’s presentation
B. Chief complaint
1. Patient’s words on what he or she sees as most prominent reason
for presenting for care
2. Use direct quotes or paraphrases whenever possible

In psychiatry, comparison between identifying data (ID)

and chief complaint (CC) can be illuminating; e.g., “ID:
This is a 26-year-old single white male admitted from the
emergency department on an involuntary status with
paranoid delusions after being mental hygiene arrested. CC:
‘There’s nothing wrong with me, you should be locking up my
neighbors after what they did to me!’”

C. History of present illness (HPI)

1. Describes what patient is presenting with, but complexities exist
for clinician (as in all fields of medicine) as to the following
questions
a. Do I have full story?
b. When did presentation actually begin?
c. How do I best organize data to describe it?
2. Do I have full story?
a. Sources of information I 2
i. Patient
ii. Relatives or friends
iii. Treaters or other staff involved in patient’s care
iv. Old records
b. Make clear at beginning of your workup what your data
sources are, and estimate their reliability and completeness
CHAPTER
3 History and Physical Examination 27

TA B L E 3.1
Psychiatric Workup ADMSEP I 1,4,5

Element Description
Identifying data Age, race, gender, marital status, referred by
whom for what?
Chief complaint Presenting symptoms, organized syndromically
if possible, and their chronology/context
Medications List all; specify outpatient vs. current inpatient
medications if the patient is an inpatient
Past psychiatric Substance-use history; prior psychiatric
history syndromes, treatments (include psychotropic
medication history and psychotherapy)
Past medical and The usual
surgical history
Family history Psychiatric and medical family history;
genogram; family relationship patterns
Developmental/ Role performances throughout life course;
social history current living and social circumstances
Review of systems The basic medical ROS, plus any relevant
(ROS) psychiatric ROS not already covered
Physical exam The usual, but pay careful attention to the
neurological exam
Mental status exam A significant part of what you’re here to learn.
Components include:
• General appearance and behavior
• Quality of relationship with interviewer
• Psychomotor activity
• Speech
• Mood and affect
• Thought content
• Thought process
• Perceptual disturbances
• Cognitive functions
• Level of consciousness
• Orientation
• Attention
• Memory
• Language
• Fund of knowledge
• Visuospatial skills
(continued on page 28)
 PART
28 two Psychiatric Workup

TA B L E 3.1
Psychiatric Workup ADMSEP I 1,4,5 (continued )
Element Description

• Calculations
• Frontal executive functions
• Abstraction
• Judgment and insight
Laboratory values All current (and any recent and relevant) blood
work, neuroimaging studies, etc.
Diagnostic The Five Axes of DSM
impressions
Formulation How do you understand the nature and poten-
tial etiology of the patient’s presenting prob-
lems? (can include relevant differential diag-
nosis in this section)
Problem list and plan All relevant psychiatric and medical problems
and all relevant biological, psychological,
and social interventions

In psychiatry, where many symptoms are behavioral

and patients may have varying amounts of insight,
collateral information is paramount. This becomes
important not only to assist accurate diagnosis but often
needed in safety assessments now while the patient is
under your care and for discharge decisions if inpatient.

c. At some point (based on urgency to get your write-up into the

chart), make decision to stop and write up what you have
now, knowing it may later be supplemented or supplanted by
what you eventually learn
i. Consider putting in “plan” section what you intend to do
to complete database information-gathering II 6–8

Accept this limitation calmly and humbly, realizing it

goes with the territory.
CHAPTER
3 History and Physical Examination 29

3. When did presentation actually begin?

a. Easier for new recent-onset illness, not so easy for patients
with prior episodes, symptoms, or treatment encounters
b. No one right way to do HPI; do what seems most clinically
sensible

As in other fields of medicine, there may be

ambiguity to what is considered onset of
symptoms; e.g., a patient with schizophrenia may have
had an admission last year, began using cocaine the last
6 days, and began escalating psychosis and suicidal
focus the last 6 hours before coming to the emergency
department. Do your best to figure what is most related
to the current state, but can reference previously
diagnosed with schizophrenia in HPI, with more detail
about this previous diagnosis (dx) in “Past Psychiatric
History” section. Most likely in this case, it would be
best to consider the episode onset around the time
of the recent cocaine use—was this use independent of
worsening psychotic symptoms, or as a result of
worsening symptoms?

4. How do I best organize data? I 7

a. Most common organizer used by neophytes is chronology
i. Advantage: simplicity; an overarching conception of
patient’s illness is not necessary—just report the order
events occurred
ii. Disadvantage: reader needs to pull data together from dif-
ferent parts of chronology to develop a conception of
patient’s illness
b. Better and tighter HPIs use syndromic approach
i. Analogy: like arguing a legal brief
ii. Strands of history in HPI (pertinent positives and nega-
tives) should be filtered and organized to lead inexorably
to “closing argument”—formulation and differential
diagnosis
c. Begin HPI with terse description of patient’s presenting
symptoms, clustered together as much as possible
 PART
30 two Psychiatric Workup

For example, “Ms. Xanadu developed depressive

symptoms including persistently depressed mood
with daily crying spells, feelings of worthlessness, early
morning awakening by 2 hours, and weight loss of
17 pounds. . . . She also noted increasing ‘nervousness,’
which was present continuously but with some variation in
degree. Along with this anxiety, she had dry mouth,
tremulousness, and nausea.”

d. As part of symptom descriptions, include relevant “dimen-

sions” of symptoms
e. Use terse examples to help flesh out your descriptions
For example, after mentioning that a patient had
persecutory delusions, convey the content of these
delusions: “He felt that his neighbors had tried to poison
his food.”

f. Describe context within which patient experiences symptoms

For example, “Anxiety was first noticed after a
disruptive argument with spouse.”

g. Describe general stressors or significant events that have

taken place during time of presentation of symptoms
For example, “Patient has many difficult-to-meet
deadlines at work and learned of the death of a
cousin.”

h. Do not make premature attributions of causality in relation to

stressors—save such causal speculation for the formulation

Exception would be to describe the patient’s own

attributions of causality in the HPI; e.g., “The patient
felt that these worsening depressive symptoms were due to
the stress at work.”

i. Include pertinent negatives

CHAPTER
3 History and Physical Examination 31

For example, for a patient with severe depressive

symptoms, state “no suicidal ideation or diurnal
variation.” If patient has delusions, include “no
hallucinations or gross thought process disruption.”
Differential diagnosis drives whether a “negative” is truly
pertinent (in syndromic approach described earlier).

j. Chronological approach can now be used to describe what

patient tried to do for his or her symptoms, in temporal order;
description should conclude clearly explicating how patient
came to present to you today

For example, “The daughter called the police after her

father threatened her with a knife; he was brought to
the emergency department under mental hygiene arrest.”

D. Medications I 12
1. Full list of all medications (psychotropic and nonpsychotropic)
with dosage schedules if known
2. Indicate drug compliance
3. Describe any recent medication or dose changes and when they
occurred
4. Inpatients: list outpatient medications prior to coming into
hospital as well as current inpatient medications

Making effort to distinguish outpatient versus inpatient

medications helps to more quickly discern possible
reasons for new inpatient symptoms; for example: anxiety
and nightmares if selective serotonin reuptake inhibitors
(SSRIs) were not continued (SSRI discontinuation syndrome),
or delirium and seizures if benzodiazepines were not
continued (benzodiazepine withdrawal)

5. Ask about over-the-counter medications, vitamins, supplements,

herbals, and topical agents
E. Past psychiatric history
1. Substance use history: you may have been taught to include in
social history, but this demeans direct relevance to physical and
mental disorders
 PART
32 two Psychiatric Workup

a.Substance used
b.Doses or amounts
c.Chronology, including frequency and patterns of use
d.Review of pertinent positives and negatives regarding abuse
and dependence
i. Alcoholic blackouts
ii. Withdrawal symptoms
iii. Attempts to cut down or quit
e. Describe any formal outpatient or inpatient substance-abuse
treatments
f. Under social history, you might include psychosocial circum-
stances of substance use, e.g., drinking after work, on week-
ends with spouse, etc
2. Other past psychiatric history
a. Need to ask in several ways to get a complete picture
III 1–10
i. Have you ever seen a psychiatrist or other mental health
professional? (“counselor” or “therapist” may trigger a
patient’s recall)
ii. Have you ever been counseled by your primary care
physician for emotional troubles?
iii. Have you ever been given a “nerve pill” or “sleeping pill”
by a physician?
iv. Have you ever been hospitalized for emotional or psychi-
atric reasons?
v. Have you ever tried to harm or kill yourself in the past?
(may be surprising how many people tell you “yes” after
denying all prior queries about emotional troubles or
treatment)
vi. “Yes” answers should lead to a series of questions
designed to elicit specifics
(1) What diagnoses were given?
(2) What specific symptoms were present?
(3) What treatments were used (including details of
medication trials as doses, duration, adverse effects)?
(4) Response to treatments and subsequent course—did
they return to baseline?
vii. In addition to formal history of psychiatric treatment, ask
about past syndromes that may have been untreated or
long forgotten
CHAPTER
3 History and Physical Examination 33

(1)“Was there ever a time in your life where you felt sad
or blue much of the time for a couple weeks on end?”
“What about a period when your mood was unusually
happy, giddy, or on top of the world?”
(2) For females who have had children, it may be useful to
ask about postpartum depressive symptoms or other
postpartum symptoms of relevance.
3. Time lines, sometimes called life-charting, are a useful way to
rapidly and visually summarize course and progression of ill-
ness, when there have been previous episodes (Fig. 3.1).
F. Past medical and surgical history
1. Because you have spent the rest of your training on this section,
we do not dwell on the details; do not skimp on this section just
because it is a “psych patient” I 10–11
a. Medical illnesses are highly comorbid with psychiatric disor-
ders and are often directly relevant (physiologically or other-
wise) to psychiatric presentation
G. Family history
1. As done in other settings (e.g., genogram, usual disorders may
be conveyed), but ask specifically about psychiatric disorders
2. As mentioned in past history, may have to do some creative (i.e.,
clear and specific) questioning

Write above each major hash mark the year in

Place year of birth here, ten-year increments, e.g., 1962, 1972, etc,
e.g., 1952 up to the closest one to the present year

0 10 20 30 40 50 60 70 80 90 100
Years

Age of the patient at each 10-year mark

Figure 3.1 Patient life chart. Mark on the chart when past episode(s) of
illness occurred and any brief associated useful detail such as hospitaliza-
tions, suicide attempts, first medication treatments, etc.
 PART
34 two Psychiatric Workup

a. Formal contacts with mental health system

b. Untreated, suspected syndromes
c. Hospitalizations (or in “old days,” institutionalizations)
d. Suicide attempts and completions
e. Alcohol and other substance abuse problems
3. If elicit a positive family history, attempt to determine details as
diagnoses, treatments (including specific medications) if known
4. Can include relationships among family members; relevant
aspects of cultural, socioeconomic, or religious background;
prominent or enduring patterns of (mis)communication; areas of
alliance or discord—especially between patient and others
H. Developmental/social history
1. Developmental history I 3
a. Fundamental importance to a full psychodynamic understand-
ing of patient and may yield clues to etiology or clinical phe-
nomenology of current condition

Clinical setting, patient condition, and time available

dictate practicality of obtaining developmental history.

b. Full developmental history

i. Any complications in utero
(1) During pregnancy with, or delivery of, the patient
ii. Developmental milestones (as learned in Human
Development and Pediatrics)
(1) Motor
(2) Cognitive
(3) Social

As a coarse screen in an adult, ask if patient

walked, talked, and in general did things children
do on schedule, or were there any delays?

iii. School years

(1)Completed grades as scheduled
(2)Special or remedial education
(3)Specific grades achieved
(4)Social roles: network of friends; how relate to parents,
siblings, others in household
CHAPTER
3 History and Physical Examination 35

iv. Adolescence
(1)Same questions as above
(2)Dating history
(3)Sexual history
v. Early adulthood—domains of concern are social and
occupational
(1) Spouse or other love/sexual relationships
(2) Friends
(3) Community, religious, sports, or hobby-related
organizations
(4) Other avocational group affiliations
(5) A careful job history, noting patterns of difficulty with
maintaining employment, and try to specify what led to
any troubles: interpersonal conflict; inability to work
effectively
vi. Continue these tasks as you move through adulthood
(1) How patient performed developmental tasks
(2) Reaction to expected or unexpected stressful events:
raising children, illnesses, financial or other job losses,
children leaving household, job promotions or lack
thereof, retirement
2. Social history
a. Current living environment
i. Physical location and layout
ii. Who lives there
iii. Help available
b. Occupation and how well it is going
i. Job performance
ii. Interpersonal relationships at work
c. Religious or other subcultural or community affiliations
d. Current social environment
i. Important people in their life
ii. How much contact with these persons
iii. Qualitative nature of these relationships
iv. Socioeconomic conditions
v. Functional abilities (if not already clear from HPI and
physical history)
vi. Daily routine of patient
I. ROS
Another random document with
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"Is it possible that you were an acquaintance with Mr. Dan
Winterslip?" the detective persisted.
"I—I knew him slightly. But that was many years ago."
Chan stood. "Humbly begging pardon to be so abrupt," he said. He
turned to John Quincy. "The moment of our appointment is eminent
—"
"Of course," agreed John Quincy. "See you again, Captain."
Perplexed, he followed Chan to the street. "What appointment—" he
began, and stopped. Chan was carefully extinguishing the light of
the cigarette against the stone facade of the hotel. That done, he
dropped the stub into his pocket.
"You will see," he promised. "First we visit police station. As we
journey, kindly relate all known facts concerning this Captain Cope."
John Quincy told of his first meeting with Cope in the San Francisco
club, and repeated the conversation as he recalled it.
"Evidence of warm dislike for Dan Winterslip were not to be
concealed?" inquired Chan.
"Oh, quite plain, Charlie. He certainly had no love for Cousin Dan.
But what—"
"Immediately he was leaving for Hawaii—pardon the interrupt. Does
it happily chance you know his date of arrival here?"
"I do. I saw him in the Alexander Young Hotel last Tuesday evening
when I was looking for you. He was rushing off to the Fanning
Islands, and he told me he had got in the previous day at noon—"
"Monday noon to put it lucidly."
"Yes—Monday noon. But Charlie—what are you trying to get at?"
"Groping about," Chan smiled. "Seeking to seize truth in my hot
hands."
They walked on in silence to the station, where Chan led the way
into the deserted room of Captain Hallet. He went directly to the
safe and opened it. From a drawer he removed several small
objects, which he carried over to the captain's table.
"Property Mr. Jim Egan," he announced, and laid a case of tarnished
silver before John Quincy. "Open it—what do you find now? Corsican
cigarettes." He set down another exhibit. "Tin box found in room of
Mr. Brade. Open that, also. You find more Corsican cigarettes."
He removed an envelope from his pocket and taking out a charred
stub, laid that too on the table. "Fragment found by walk outside
door of Dan Winterslip's mansion," he elucidated. "Also Corsican
brand."
Frowning deeply, he removed a second charred stub from his pocket
and laid it some distance from the other exhibits. "Cigarette offered
just now with winning air of hospitality by Captain Arthur Temple
Cope. Lean close and perceive. More Corsican brand!"
"Good lord!" John Quincy cried.
"Can it be you are familiar with these Corsicans?" inquired Chan.
"Not at all."
"I am more happily located. This afternoon before the swim I pause
at public library for listless reading. In Australian newspaper I
encounter advertising talk of Corsican cigarette. It are assembled in
two distinct fashions, one, labeled on tin 222, holds Turkish tobacco.
Note 222 on tin of Brade. Other labeled 444 made up from Virginia
weeds. Is it that you are clever to know difference between Turkish
and Virginia tobacco?"
"Well, I think so—" began John Quincy.
"Same with me, but thinking are not enough now. The moment are
serious. We will interrogate expert opinion. Honor me by a journey
to smoking emporium."
He took a cigarette from Brack's tin, put it in an envelope and wrote
something on the outside, then did the same with one from Egan's
case. The two stubs were similarly classified.
They went in silence to the street. John Quincy, amazed by this new
turn of events, told himself the idea was absurd. But Chan's face
was grave, his eyes awake and eager.
John Quincy was vastly more amazed when they emerged from the
tobacco shop after a brisk interview with the young man in charge.
Chan was jubilant now.
"Again we advance! You hear what he tells us. Cigarette from
Brade's tin and little brother from Egan's case are of identical
contents, both being of Turkish tobacco. Stub found near walk are of
Virginia stuff. So also are remnant received by me from the cordial
hand of Captain Arthur Temple Cope!"
"It's beyond me," replied John Quincy. "By gad—that lets Egan out.
Great news for Carlota. I'll hurry to the Reef and Palm and tell her—"
"Oh, no, no," protested Chan. "Please to let that happy moment
wait. For the present, indulge only in silence. Before asking Captain
Cope for statement we spy over his every move. Much may be
revealed by the unsuspecting. I go to station to make arrangements
—"
"But the man's a gentleman," John Quincy cried. "A captain in the
British Admiralty. What you suggest is impossible."
Chan shook his head. "Impossible in Rear Bay at Boston," he said,
"but here at moorly crossroads of Pacific, not so much so. Twenty-
five years of my life are consumed in Hawaii, and I have many times
been witness when the impossible roused itself and occurred."
 CHAPTER XVII
NIGHT LIFE IN HONOLULU
Monday brought no new developments, and John Quincy spent a
restless day. Several times he called Chan at the police station, but
the detective was always out.
Honolulu, according to the evening paper, was agog. This was not,
as John Quincy learned to his surprise, a reference to the Winterslip
case. An American fleet had just left the harbor of San Pedro bound
for Hawaii. This was the annual cruise of the graduating class at
Annapolis; the war-ships were overflowing with future captains and
admirals. They would linger at the port of Honolulu for several days
and a gay round of social events impended—dinners, dances,
moonlight swimming parties.
John Quincy had not seen Barbara all day; the girl had not appeared
at breakfast and had lunched with a friend down the beach. They
met at dinner, however, and it seemed to him that she looked more
tired and wan than ever. She spoke about the coming of the war-
ships.
"It's always such a happy time," she said wistfully. "The town simply
blooms with handsome boys in uniform. I don't like to have you miss
all the parties, John Quincy. You're not seeing Honolulu at its best."
"Why—that's all right," John Quincy assured her.
She shook her head. "Not with me. You know, we're not such slaves
to convention out here. If I should get you a few invitations—what
do you think, Cousin Minerva?"
"I'm an old woman," said Miss Minerva. "According to the standards
of your generation, I suppose it would be quite the thing. But it's not
the sort of conduct I can view approvingly. Now, in my day—"
"Don't you worry, Barbara," John Quincy broke in. "Parties mean
nothing to me. Speaking of old women, I'm an old man myself—
thirty my next birthday. Just my pipe and slippers by the fire—or the
electric fan—that's all I ask of life now."
She smiled and dropped the matter. After dinner, she followed John
Quincy to the lanai. "I want you to do something for me," she
began.
"Anything you say."
"Have a talk with Mr. Brade, and tell me what he wants."
"Why, I thought that Jennison—" said John Quincy.
"No, I didn't ask him to do it," she replied. For a long moment she
was silent. "I ought to tell you—I'm not going to marry Mr. Jennison,
after all."
A shiver of apprehension ran down John Quincy's spine. Good lord—
that kiss! Had she misunderstood? And he hadn't meant a thing by
it. Just a cousinly salute—at least, that was what it had started out
to be. Barbara was a sweet girl, yes, but a relative, a Winterslip, and
relatives shouldn't marry, no matter how distant the connection.
Then, too, there was Agatha. He was bound to Agatha by all the ties
of honor. What had he got himself into, anyhow?
"I'm awfully sorry to hear that," he said. "I'm afraid I'm to blame—"
"Oh, no," she protested.
"But surely Mr. Jennison understood. He knows we're related, and
that what he saw last night meant—nothing." He was rather proud
of himself. Pretty neat the way he'd got that over.
"If you don't mind," Barbara said, "I'd rather not talk about it any
more. Harry and I will not be married—not at present, at any rate.
And if you'll see Mr. Brade for me—"
"I certainly will," John Quincy promised. "I'll see him at once." He
was glad to get away, for the moon was rising on that "spot of
heart-breaking charm."
A fellow ought to be more careful, he reflected as he walked along
the beach. Fit upon himself the armor of preparation, as Chan had
said. Strange impulses came to one here in this far tropic land; to
yield to them was weak. Complications would follow, as the night the
day. Here was one now, Barbara and Jennison estranged, and the
cause was clear. Well, he was certainly going to watch his step
hereafter.
On the far end of the Reef and Palm's first floor balcony, Brade and
his wife sat together in the dusk. John Quincy went up to them.
"May I speak with you, Mr. Brade?" he said.
The man looked up out of a deep reverie. "Ah, yes—of course—"
"I'm John Quincy Winterslip. We've met before."
"Oh, surely, surely sir." Brade rose and shook hands. "My dear—" he
turned to his wife, but with one burning glance at John Quincy, the
woman had fled. The boy tingled—in Boston a Winterslip was never
snubbed. Well, Dan Winterslip had arranged it otherwise in Hawaii.
"Sit down, sir," said Brade, somewhat embarrassed by his wife's
action. "I've been expecting some one of your name."
"Naturally. Will you have a cigarette, sir." John Quincy proffered his
case, and when the cigarettes were lighted, seated himself at the
man's side. "I'm here, of course, in regard to that story you told
Saturday night."
"Story?" flashed Brade.
John Quincy smiled. "Don't misunderstand me. I'm not questioning
the truth of it. But I do want to say this, Mr. Brade—you must be
aware that you will have considerable difficulty establishing your
claim in a court of law. The 'eighties are a long time back."
"What you say may be true," Brade agreed. "I'm relying more on the
fact that a trial would result in some rather unpleasant publicity for
the Winterslip family."
"Precisely," nodded John Quincy. "I am here at the request of Miss
Barbara Winterslip, who is Dan Winterslip's sole heir. She's a very
fine girl, sir—"
"I don't question that," cut in Brade impatiently.
"And if your demands are not unreasonable—" John Quincy paused,
and leaned closer. "Just what do you want, Mr. Brade?"
Brade stroked those gray mustaches that drooped "in saddened
mood." "No money," he said, "can make good the wrong Dan
Winterslip did. But I'm an old man, and it would be something to
feel financially secure for the rest of my life. I'm not inclined to be
grasping—particularly since Dan Winterslip has passed beyond my
reach. There were twenty thousand pounds involved. I'll say nothing
about interest for more than forty years. A settlement of one
hundred thousand dollars would be acceptable."
John Quincy considered. "I can't speak definitely for my cousin," he
said, "but to me that sounds fair enough. I have no doubt Barbara
will agree to give you that sum"—he saw the man's tired old eyes
brighten in the semi-darkness—"the moment the murderer of Dan
Winterslip is found," he added quickly.
"What's that you say?" Brade leaped to his feet.
"I say she'll very likely pay you when this mystery is cleared up.
Surely you don't expect her to do so before that time?" John Quincy
rose too.
"I certainly do!" Brade cried. "Why, look here, this thing may drag on
indefinitely. I want England again—the Strand, Piccadilly—it's
twenty-five years since I saw London. Wait! Damn it, why should I
wait! What's this murder to me—by gad, sir—" He came close, erect,
flaming, the son of Tom Brade, the blackbirder, now. "Do you mean
to insinuate that I—"
John Quincy faced him calmly. "I know you can't prove where you
were early last Tuesday morning," he said evenly. "I don't say that
incriminates you, but I shall certainly advise my cousin to wait. I'd
not care to see her in the position of having rewarded the man who
killed her father."
"I'll fight," cried Brade. "I'll take it to the courts—"
"Go ahead," John Quincy said. "But it will cost you every penny
you've saved, and you may lose in the end. Good night, sir."
"Good night!" Brade answered, standing as his father might have
stood on the Maid of Shiloh's deck.
John Quincy had gone half-way down the balcony when he heard
quick footsteps behind him. He turned. It was Brade, Brade the civil
servant, the man who had labored thirty-six years in the oven of
India, a beaten, helpless figure.
"You've got me," he said, laying a hand on John Quincy's arm. "I
can't fight. I'm too tired, too old—I've worked too hard. I'll take
whatever your cousin wants to give me—when she's ready to give
it."
"That's a wise decision, sir," John Quincy answered. A sudden feeling
of pity gripped his heart. He felt toward Brade as he had felt toward
that other exile, Arlene Compton. "I hope you see London very
soon," he added, and held out his hand.
Brade took it. "Thank you, my boy. You're a gentleman, even if your
name is Winterslip."
Which, John Quincy reflected as he entered the lobby of the Reef
and Palm, was a compliment not without its flaw.
He didn't worry over that long, however, for Carlota Egan was
behind the desk. She looked up and smiled, and it occurred to John
Quincy that her eyes were happier than he had seen them since that
day on the Oakland ferry.
"Hello," he said. "Got a job for a good book-keeper?"
She shook her head. "Not with business the way it is now. I was just
figuring my pay-roll. You know, we've no undertow at Waikiki, but all
my life I've had to worry about the overhead."
He laughed. "You talk like a brother Kiwanian. By the way, has
anything happened? You seem considerably cheered."
"I am," she replied. "I went to see poor dad this morning in that
horrible place—and when I left some one else was going in to visit
him. A stranger."
"A stranger?"
"Yes—and the handsomest thing you ever saw—tall, gray, capable-
looking. He had such a friendly air, too—I felt better the moment I
saw him."
"Who was he?" John Quincy inquired, with sudden interest.
"I'd never seen him before, but one of the men told me he was
Captain Cope, of the British Admiralty."
"Why should Captain Cope want to see your father?"
"I haven't a notion. Do you know him?"
"Yes—I've met him," John Quincy told her.
"Don't you think he's wonderful-looking?" Her dark eyes glowed.
"Oh, he's all right," replied John Quincy without enthusiasm. "You
know, I can't help feeling that things are looking up for you."
"I feel that too," she said.
"What do you say we celebrate?" he suggested. "Go out among 'em
and get a little taste of night life. I'm a bit fed up on the police
station. What do people do here in the evening? The movies?"
"Just at present," the girl told him, "everybody visits Punahou to see
the night-blooming cereus. It's the season now, you know."
"Sounds like a big evening," John Quincy laughed. "Go and look at
the flowers. Well, I'm for it. Will you come?"
"Of course." She gave a few directions to the clerk, then joined him
by the door. "I can run down and get the roadster," he offered.
"Oh, no," she smiled. "I'm sure I'll never own a motor-car, and it
might make me discontented to ride in one. The trolley's my carriage
—and it's lots of fun. One meets so many interesting people."
On the stone walls surrounding the campus of Oahu College, the
strange flower that blooms only on a summer night was heaped in
snowy splendor. John Quincy had been a bit lukewarm regarding the
expedition when they set out, but he saw his error now. For here
was beauty, breath-taking and rare. Before the walls paraded a
throng of sight-seers; they joined the procession. The girl was a
charming companion, her spirits had revived and she chatted
vivaciously. Not about Shaw and the art galleries, true enough, but
bright human talk that John Quincy liked to hear.
He persuaded her to go to the city for a maidenly ice-cream soda,
and it was ten o'clock when they returned to the beach. They left
the trolley at a stop some distance down the avenue from the Reef
and Palm, and strolled slowly toward the hotel. The sidewalk was
lined at their right by dense foliage, almost impenetrable. The night
was calm; the street lamps shone brightly; the paved street gleamed
white in the moonlight. John Quincy was talking of Boston.
"I think you'd like it there. It's old and settled, but—"
From the foliage beside them came the flash of a pistol, and John
Quincy heard a bullet sing close to his head. Another flash, another
bullet. The girl gave a startled little cry.
John Quincy circled round her and plunged into the bushes. Angry
branches stung his cheek. He stopped; he couldn't leave the girl
alone. He returned to her side.
"What did that mean?" he asked, amazed. He stared in wonder at
the peaceful scene before him.
"I—I don't know." She took his arm. "Come—hurry!"
"Don't be afraid," he said reassuringly.
"Not for myself," she answered.
They went on to the hotel, greatly puzzled. But when they entered
the lobby, they had something else to think about. Captain Arthur
Temple Cope was standing by the desk, and he came at once to
meet them.
"This is Miss Egan, I believe. Ah, Winterslip, how are you?" He
turned again to the girl. "I've taken a room here, if you don't mind."
"Why, not at all," she gasped.
"I talked with your father this morning. I didn't know about his
trouble until I had boarded a ship for the Fanning Islands. I came
back as quickly as I could."
"You came back—" She stared at him.
"Yes. I came back to help him."
"That's very kind of you," the girl said. "But I'm afraid I don't
understand—"
"Oh, no, you don't understand. Naturally." The captain smiled down
at her. "You see, Jim's my young brother. You're my niece, and your
name is Carlota Maria Cope. I fancy I've persuaded old Jim to own
up to us at last."
The girl's dark eyes were wide. "I—I think you're a very nice uncle,"
she said at last.
"Do you really?" The captain bowed. "I aim to be," he added.
John Quincy stepped forward. "Pardon me," he said. "I'm afraid I'm
intruding. Good night, Captain."
"Good night, my boy," Cope answered.
The girl went with John Quincy to the balcony. "I—don't know what
to make of it," she said.
"Things are coming rather fast," John Quincy admitted. He
remembered the Corsican cigarette. "I wouldn't trust him too far," he
admonished.
"But he's so wonderful—"
"Oh, he's all right, probably. But looks are often deceptive. I'll go
along now and let you talk with him."
She laid one slim tanned hand on his white-clad arm "Do be careful!"
"Oh, I'm all right," he told her.
"But some one shot at you."
"Yes, and a very poor aim he had, too. Don't worry about me." She
was very close, her eyes glowing in the dark. "You said you weren't
afraid for yourself," he added. "Did you mean—"
"I meant—I was afraid—for you."
The moon, of course, was shining. The cocoa-palms turned their
heads away at the suggestion of the trades. The warm waters of
Waikiki murmured near by. John Quincy Winterslip, from Boston and
immune, drew the girl to him and kissed her. Not a cousinly kiss,
either—but why should it have been? She wasn't his cousin.
"Thank you, my dear," he said. He seemed to be floating dizzily in
space. It came to him that he might reach out and pluck her a
handful of stars.
It came to him a second later that, despite his firm resolve, he had
done it again. Kissed another girl. Three—that made three with
whom he was sort of entangled.
"Good night," he said huskily, and leaping over the rail, fled hastily
through the garden.
Three girls now—but he hadn't a single regret. He was living at last.
As he hurried through the dark along the beach, his heart was light.
Once he fancied he was being followed, but he gave it little thought.
What of it?
On the bureau in his room he found an envelope with his name
typewritten on the outside. The note within was typewritten too. He
read:

"You are too busy out here. Hawaii can manage her affairs
without the interference of a malihini. Boats sail almost daily. If
you are still here forty-eight hours after you get this—look out!
To-night's shots were fired into the air. The aim will quickly
improve!"

Delighted, John Quincy tossed the note aside. Threatening him, eh?
His activities as a detective were bearing fruit. He recalled the
glowering face of Kaohla when he said: "You did this. I don't forget."
And a remark of Dan Winterslip's his aunt had quoted: "Civilized—
yes. But far underneath there are deep dark waters flowing still."
Boats were sailing almost daily, were they? Well, let them sail. He
would be on one some day—but not until he had brought Dan
Winterslip's murderer to justice.
Life had a new glamour now. Look out? He'd be looking—and
enjoying it, too. He smiled happily to himself as he took off his coat.
This was better than selling bonds in Boston.
 CHAPTER XVIII
A CABLE FROM THE MAINLAND
John Quincy awoke at nine the following morning, and slipped from
under his mosquito netting eager to face the responsibilities of a
new day. On the floor near his bureau lay the letter designed to
speed the parting guest. He picked it up and read it again with
manifest enjoyment.
When he reached the dining-room Haku informed him that Miss
Minerva and Barbara had breakfasted early and gone to the city on a
shopping tour.
"Look here, Haku," the boy said. "A letter came for me late last
night?"
"Yes-s," admitted Haku.
"Who delivered it?"
"Can not say. It were found on floor of hall close by big front door."
"Who found it?"
"Kamaikui."
"Oh, yes—Kamaikui."
"I tell her to put in your sleeping room."
"Did Kamaikui see the person who brought it?"
"Nobody see him. Nobody on place."
"All right," John Quincy said.
He spent a leisurely hour on the lanai with his pipe and the morning
paper. At about half past ten he got out the roadster and drove to
the police station.
Hallet and Chan, he was told, were in a conference with the
prosecutor. He sat down to wait, and in a few moments word came
for him to join them. Entering Greene's office, he saw the three men
seated gloomily about the prosecutor's desk.
"Well, I guess I'm some detective," he announced.
Greene looked up quickly. "Found anything new?"
"Not precisely," John Quincy admitted. "But last night when I was
walking along Kalakaua Avenue with a young woman, somebody
took a couple of wild shots at me from the bushes. And when I got
home I found this letter waiting."
He handed the epistle to Hallet, who read it with evident disgust,
then passed it on to the prosecutor "That doesn't get us anywhere,"
the captain said.
"It may get me somewhere, if I'm not careful," John Quincy replied.
"However, I'm rather proud of it. Sort of goes to show that my
detective work is hitting home."
"Maybe," answered Hallet, carelessly.
Greene laid the letter on his desk. "My advice to you," he said, "is to
carry a gun. That's unofficial, of course."
"Nonsense, I'm not afraid," John Quincy told him. "I've got a pretty
good idea who sent this thing."
"You have?" Greene said.
"Yes. He's a friend of Captain Hallet's. Dick Kaohla."
"What do you mean he's a friend of mine?" flared Hallet.
"Well, you certainly treated him pretty tenderly the other night."
"I knew what I was doing," said Hallet grouchily.
"I hope you did. But if he puts a bullet in me some lovely evening,
I'm going to be pretty annoyed with you."
"Oh, you're in no danger," Hallet answered. "Only a coward writes
anonymous letters."
"Yes, and only a coward shoots from ambush. But that isn't saying
he can't take a good aim."
Hallet picked up the letter. "I'll keep this. It may prove to be
evidence."
"Surely," agreed John Quincy. "And you haven't got any too much
evidence, as I see it."
"Is that so?" growled Hallet. "We've made a rather important
discovery about that Corsican cigarette."
"Oh, I'm not saying Charlie isn't good," smiled John Quincy. "I was
with him when he worked that out."
A uniformed man appeared at the door. "Egan and his daughter and
Captain Cope," he announced to Greene. "Want to see them now,
sir?"
"Send them in," ordered the prosecutor.
"I'd like to stay, if you don't mind," John Quincy suggested.
"Oh, by all means," Greene answered. "We couldn't get along
without you."
The policeman brought Egan to the door, and the proprietor of the
Reef and Palm came into the room. His face was haggard and pale;
his long siege with the authorities had begun to tell. But a stubborn
light still flamed in his eyes. After him came Carlota Egan, fresh and
beautiful, and with a new air of confidence about her. Captain Cope
followed, tall, haughty, a man of evident power and determination.
"This is the prosecutor, I believe?" he said. "Ah, Mr. Winterslip; I find
you everywhere I go."
"You don't mind my staying?" inquired John Quincy.
"Not in the least, my boy. Our business here will take but a
moment." He turned to Greene. "Just as a preliminary," he
continued, "I am Captain Arthur Temple Cope of the British
Admiralty, and this gentleman"—he nodded toward the proprietor of
the Reef and Palm—"is my brother."
"Really?" said Greene. "His name is Egan, as I understand it."
"His name is James Egan Cope," the captain replied. "He dropped
the Cope many years ago for reasons that do not concern us now. I
am here simply to say, sir, that you are holding my brother on the
flimsiest pretext I have ever encountered in the course of my rather
extensive travels. If necessary, I propose to engage the best lawyer
in Honolulu and have him free by night. But I'm giving you this last
chance to release him and avoid a somewhat painful expose of the
sort of nonsense you go in for."
John Quincy glanced at Carlota Egan. Her eyes were shining but not
on him. They were on her uncle.
Greene flushed slightly. "A good bluff, Captain, is always worth
trying," he said.
"Oh, then you admit you've been bluffing," said Cope quickly.
"I was referring to your attitude, sir," Greene replied.
"Oh, I see," Cope said. "I'll sit down, if you don't mind. As I
understand it, you have two things against old Jim here. One is that
he visited Dan Winterslip on the night of the murder, and now
refuses to divulge the nature of that call. The other is the stub of a
Corsican cigarette which was found by the walk outside the door of
Winterslip's living-room."
Greene shook his head. "Only the first," he responded. "The
Corsican cigarette is no longer evidence against Egan." He leaned
suddenly across his desk. "It is, my dear Captain Cope, evidence
against you."
Cope met his look unflinchingly. "Really?" he remarked.
John Quincy noted a flash of startled bewilderment in Carlota Egan's
eyes.
"That's what I said," Greene continued. "I'm very glad you dropped
in this morning, sir. I've been wanting to talk to you. I've been told
that you were heard to express a strong dislike for Dan Winterslip."
"I may have. I certainly felt it."
"Why?"
"As a midshipman on a British war-ship, I was familiar with
Australian gossip in the 'eighties. Mr. Dan Winterslip had an unsavory
reputation. It was rumored on good authority that he rifled the sea
chest of his dead captain on the Maid of Shiloh. Perhaps we're a bit
squeamish, but that is the sort of thing we sailors can not forgive.
There were other quaint deeds in connection with his blackbirding
activities. Yes, my dear sir, I heartily disliked Dan Winterslip, and if I
haven't said so before, I say it now."
"You arrived in Honolulu a week ago yesterday," Greene continued.
"At noon—Monday noon. You left the following day. Did you, by any
chance, call on Dan Winterslip during that period?"
"I did not."
"Ah, yes. I may tell you, sir, that the Corsican cigarettes found in
Egan's case were of Turkish tobacco. The stub found near the scene
of Dan Winterslip's murder was of Virginia tobacco. So also, my dear
Captain Cope, was the Corsican cigarette you gave our man Charlie
Chan in the lobby of the Alexander Young Hotel last Sunday night."
Cope looked at Chan, and smiled. "Always the detective, eh?" he
said.
"Never mind that!" Greene cried. "I'm asking for an explanation."
"The explanation is very simple," Cope replied. "I was about to give
it to you when you launched into this silly cross-examination. The
Corsican cigarette found by Dan Winterslip's door was, naturally, of
Virginia tobacco. I never smoke any other kind."
"What!"
"There can be no question about it, sir. I dropped that cigarette
there myself."
"But you just told me you didn't call on Dan Winterslip."
"That was true. I didn't. I called on Miss Minerva Winterslip, of
Boston, who is a guest in the house. As a matter of fact, I had tea
with her last Monday at five o'clock. You may verify that by
telephoning the lady."
Greene glanced at Hallet, who glanced at the telephone, then turned
angrily to John Quincy. "Why the devil didn't she tell me that?" he
demanded.
John Quincy smiled. "I don't know, sir. Possibly because she never
thought of Captain Cope in connection with the murder."
"She'd hardly be likely to," Cope said. "Miss Winterslip and I had tea
in the living-room, then went out and sat on a bench in the garden,
chatting over old times. When I returned to the house I was
smoking a cigarette. I dropped it just outside the living-room door.
Whether Miss Winterslip noted my action or not, I don't know. She
probably didn't, it isn't the sort of thing one remembers. You may
call her on the telephone if you wish, sir."
Again Greene looked at Hallet, who shook his head. "I'll talk with her
later," announced the Captain of Detectives. Evidently Miss Minerva
had an unpleasant interview ahead.
"At any rate," Cope continued to the prosecutor, "you had yourself
disposed of the cigarette as evidence against old Jim. That leaves
only the fact of his silence—"
"His silence, yes," Greene cut in, "and the fact that Winterslip had
been heard to express a fear of Jim Egan."
Cope frowned. "Had he, really?" He considered a moment. "Well,
what of it? Winterslip had good reason to fear a great many honest
men. No, my dear sir, you have nothing save my brother's silence
against him, and that is not enough. I demand—"
Greene raised his hand. "Just a minute. I said you were bluffing, and
I still think so. Any other assumption would be an insult to your
intelligence. Surely you know enough about the law to understand
that your brother's refusal to tell me his business with Winterslip,
added to the fact that he was presumably the last person to see
Winterslip alive, is sufficient excuse for holding him. I can hold him
on those grounds, I am holding him, and, my dear Captain, I shall
continue to hold him until hell freezes over."
"Very good," said Cope, rising. "I shall engage a capable lawyer—"
"That is, of course, your privilege," snapped Greene. "Good
morning."
Cope hesitated. He turned to Egan. "It means more publicity, Jim,"
he said. "Delay, too. More unhappiness for Carlota here. And since
everything you did was done for her—"
"How did you know that?" asked Egan quickly.
"I've guessed it. I can put two and two together, Jim. Carlota was to
return with me for a bit of schooling in England. You said you had
the money, but you hadn't. That was your pride again, Jim. It's got
you into a lifetime of trouble. You cast about for the funds, and you
remembered Winterslip. I'm beginning to see it all now. You had
something on Dan Winterslip, and you went to his house that night
to—er—"
"To blackmail him," suggested Greene.
"It wasn't a pretty thing to do, Jim," Cope went on. "But you weren't
doing it for yourself. Carlota and I know you would have died first.
You did it for your girl, and we both forgive you." He turned to
Carlota. "Don't we, my dear?"
The girl's eyes were wet. She rose and kissed her father. "Dear old
dad," she said.
"Come on, Jim," pleaded Captain Cope. "Forget your pride for once.
Speak up, and we'll take you home with us. I'm sure the prosecutor
will keep the thing from the newspapers—"
"We've promised him that a thousand times," Greene said.
Egan lifted his head. "I don't care anything about the newspapers,"
he explained. "It's you, Arthur—you and Cary—I didn't want you two
to know. But since you've guessed, and Cary knows too—I may as
well tell everything."
John Quincy stood up. "Mr. Egan," he said. "I'll leave the room, if
you wish."
"Sit down, my boy," Egan replied. "Cary's told me of your kindness
to her. Besides, you saw the check—"
"What check was that?" cried Hallet. He leaped to his feet and stood
over John Quincy.
"I was honor bound not to tell," explained the boy gently.
"You don't say so!" Hallet bellowed. "You're a fine pair, you and that
aunt of yours—"
"One minute, Hallet," cut in Greene. "Now, Egan, or Cope, or
whatever your name happens to be—I'm waiting to hear from you."
Egan nodded. "Back in the 'eighties I was teller in a bank in
Melbourne, Australia," he said. "One day a young man came to my
window—Williams or some such name he called himself. He had a
green hide bag full of gold pieces—Mexican, Spanish and English
coins, some of them crusted with dirt—and he wanted to exchange
them for bank-notes. I made the exchange for him. He appeared
several times with similar bags, and the transaction was repeated. I
thought little of it at the time, though the fact that he tried to give
me a large tip did rather rouse my suspicion.
"A year later, when I had left the bank and gone to Sydney, I heard
rumors of what Dan Winterslip had done on the Maid of Shiloh. It
occurred to me that Williams and Winterslip were probably the same
man. But no one seemed to be prosecuting the case, the general
feeling was that it was blood money anyhow, that Tom Brade had
not come by it honestly himself. So I said nothing.
"Twelve years later I came to Hawaii, and Dan Winterslip was
pointed out to me. He was Williams, right enough. And he knew me,
too. But I'm not a black-mailer—I've been in some tight places,
Arthur, but I've always played fair—so I let the matter drop. For
more than twenty years nothing happened.
"Then, a few months ago, my family located me at last, and Arthur
here wrote me that he was coming to Honolulu and would look me
up. I'd always felt that I'd not done the right thing by my girl—that
she was not taking the place in the world to which she was entitled.
I wanted her to visit my old mother and get a bit of English training.
I wrote to Arthur and it was arranged. But I couldn't let her go as a
charity child—I couldn't admit I'd failed and was unable to do
anything for her—I said I'd pay her way. And I—I didn't have a cent.
"And then Brade came. It seemed providential. I might have sold my
information to him, but when I talked with him I found he had very
little money, and I felt that Winterslip would beat him in the end. No,
Winterslip was my man—Winterslip with his rotten wealth. I don't
know just what happened—I was quite mad, I fancy—the world
owed me that, I figured, just for my girl, not for me. I called
Winterslip up and made an appointment for that Monday night.
"But somehow—the standards of a lifetime—it's difficult to change.
The moment I had called him, I regretted it. I tried to slip out of it—
I told myself there must be some other way—perhaps I could sell
the Reef and Palm—anyhow, I called him again and said I wasn't
coming. But he insisted, and I went.
"I didn't have to tell him what I wanted. He knew. He had a check
ready for me—a check for five thousand dollars. It was Cary's
happiness, her chance. I took it, and came away—but I was
ashamed. I'm not trying to excuse my action; however, I don't
believe I would ever have cashed it. When Cary found it in my desk
and brought it to me, I tore it up. That's all." He turned his tired
eyes toward his daughter. "I did it for you, Cary, but I didn't want
you to know." She went over and put her arm about his shoulder,
and stood smiling down at him through her tears.
"If you'd told us that in the first place," said Greene, "you could have
saved everybody a lot of trouble, yourself included."
Cope stood up. "Well, Mr. Prosecutor, there you are. You're not going
to hold him now?"
Greene rose briskly. "No. I'll arrange for his release at once." He and
Egan went out together, then Hallet and Cope. John Quincy held out
his hand to Carlota Egan—for by that name he thought of her still.
"I'm mighty glad for you," he said.
"You'll come and see me soon?" she asked. "You'll find a very
different girl. More like the one you met on the Oakland ferry."
"She was very charming," John Quincy replied. "But then, she was
bound to be—she had your eyes." He suddenly remembered Agatha
Parker. "However, you've got your father now," he added. "You won't
need me."
She looked up at him and smiled. "I wonder," she said, and went
out.
John Quincy turned to Chan. "Well, that's that," he remarked.
"Where are we now?"
"Speaking personally for myself," grinned Chan, "I am static in same
place as usual. Never did have fondly feeling for Egan theory."
"But Hallet did," John Quincy answered. "A black morning for him."
In the small anteroom they encountered the Captain of Detectives.
He appeared disgruntled.
"We were just remarking," said John Quincy pleasantly, "that there
goes your little old Egan theory. What have you left?"
"Oh, I've got plenty," growled Hallet.
"Yes, you have. One by one your clues have gone up in smoke. The
page from the guest book, the brooch, the torn newspaper, the ohia
wood box, and now Egan and the Corsican cigarette."
"Oh, Egan isn't out of it. We may not be able to hold him, but I'm
not forgetting Mr. Egan."
"Nonsense," smiled John Quincy. "I asked what you had left. A little
button from a glove—useless. The glove was destroyed long ago. A
wrist watch with an illuminated dial and a damaged numeral two—"
Chan's amber eyes narrowed. "Essential clue," he murmured.
"Remember how I said it."
Hallet banged his fist on a table. "That's it—the wrist watch! If the
person who wore it knows any one saw it, it's probably where we'll
never find it now. But we've kept it pretty dark—perhaps he doesn't
know. That's our only chance." He turned to Chan. "I've combed
these islands once hunting that watch," he cried, "now I'm going to
start all over again. The jewelry stores, the pawn shops, every nook
and corner. You go out, Charlie, and start the ball rolling."
Chan moved with alacrity despite his weight. "I will give it one
powerful push," he promised, and disappeared.
"Well, good luck," said John Quincy, moving on.
Hallet grunted. "You tell that aunt of yours I'm pretty sore," he
remarked. He was not in the mood for elegance of diction.
John Quincy's opportunity to deliver the message did not come at
lunch, for Miss Minerva remained with Barbara in the city. After
dinner that evening he led his aunt out to sit on the bench under the
hau tree.
"By the way," he said, "Captain Hallet is very much annoyed with
you."
"I'm very much annoyed with Captain Hallet," she replied, "so that
makes us even. What's his particular grievance now?"
"He believes you knew all the time the name of the man who
dropped that Corsican cigarette."
She was silent for a moment. "Not all the time," she said at length.
"What has happened?"
John Quincy sketched briefly the events of the morning at the police
station. When he had finished he looked at her inquiringly.
"In the first excitement I didn't remember, or I should have spoken,"
she explained. "It was several days before the thing came to me. I
saw it clearly then—Arthur—Captain Cope—tossing that cigarette
aside as we reentered the house. But I said nothing about it."
"Why?"
"Well, I thought it would be a good test for the police. Let them
discover it for themselves."
"That's a pretty weak explanation," remarked John Quincy severely.
"You've been responsible for a lot of wasted time."
"It—it wasn't my only reason," said Miss Minerva softly.
"Oh—I'm glad to hear that. Go on."
"Somehow, I couldn't bring myself to link up that call of Captain
Cope's with—a murder mystery."
Another silence. And suddenly—he was never dense—John Quincy
understood.
"He told me you were very beautiful in the 'eighties," said the boy
gently. "The captain, I mean. When I met him in that San Francisco
club."
Miss Minerva laid her own hand on the boy's. When she spoke her
voice, which he had always thought firm and sharp, trembled a little.
"On this beach in my girl-hood," she said, "happiness was within my
grasp. I had only to reach out and take it. But somehow—Boston—
Boston held me back. I let my happiness slip away."
"Not too late yet," suggested John Quincy.
She shook her head. "So he tried to tell me that Monday afternoon.
But there was something in his tone—I may be in Hawaii, but I'm
not quite mad. Youth, John Quincy, youth doesn't return, whatever
they may say out here." She pressed his hand, and stood. "If your
chance comes, dear boy," she added, "don't be such a fool."
She moved hastily away through the garden, and John Quincy
looked after her with a new affection in his eyes.
Presently he saw the yellow glare of a match beyond the wire. Amos
again, still loitering under his algaroba tree. John Quincy rose and
strolled over to him.
"Hello, Cousin Amos," he said. "When are you going to take down
this fence?"
"Oh, I'll get round to it some time," Amos answered. "By the way, I
wanted to ask you. Any new developments?"
"Several," John Quincy told him. "But nothing that gets us anywhere.
So far as I can see, the case has blown up completely."
"Well, I've been thinking it over," Amos said. "Maybe that would be
the best outcome, after all. Suppose they do discover who did for
Dan—it may only reveal a new scandal, worse than any of the
others."
"I'll take a chance on that," replied John Quincy. "For my part, I
intend to see this thing through—"
Haku came briskly through the garden. "Cable message for Mr. John
Quincy Winterslip. Boy say collect. Requests money."
John Quincy followed quickly to the front door. A bored small boy
awaited him. He paid the sum due and tore open the cable. It was
signed by the postmaster at Des Moines, and it read:
"No one named Saladine ever heard of here."
John Quincy dashed to the telephone. Some one on duty at the
station informed him that Chan had gone home, and gave him an
address on Punchbowl Hill. He got out the roadster, and in five
minutes more was speeding toward the city.
 CHAPTER XIX
"GOOD-BY, PETE!"
Charlie Chan lived in a bungalow that clung precariously to the side
of Punchbowl Hill. Pausing a moment at the Chinaman's gate, John
Quincy looked down on Honolulu, one great gorgeous garden set in
an amphitheater of mountains. A beautiful picture, but he had no
time for beauty now. He hurried up the brief walk that lay in the
shadow of the palm trees.
A Chinese woman—a servant, she seemed—ushered him into Chan's
dimly-lighted living-room. The detective was seated at a table
playing chess; he rose with dignity when he saw his visitor. In this,
his hour of ease, he wore a long loose robe of dark purple silk,
which fitted closely at the neck and had wide sleeves. Beneath it
showed wide trousers of the same material, and on his feet were
shoes of silk, with thick felt soles. He was all Oriental now, suave
and ingratiating but remote, and for the first time John Quincy was
really conscious of the great gulf across which he and Chan shook
hands.
"You do my lowly house immense honor," Charlie said. "This proud
moment are made still more proud by opportunity to introduce my
eldest son." He motioned for his opponent at chess to step forward,
a slim sallow boy with amber eyes—Chan himself before he put on
weight. "Mr. John Quincy Winterslip, of Boston, kindly condescend to
notice Henry Chan. When you appear I am giving him lesson at
chess so he may play in such manner as not to tarnish honored
name."
The boy bowed low; evidently he was one member of the younger
generation who had a deep respect for his elders. John Quincy also
bowed. "Your father is my very good friend," he said. "And from now
on, you are too."
Chan beamed with pleasure. "Condescend to sit on this atrocious
chair. Is it possible you bring news?"
"It certainly is," smiled John Quincy. He handed over the message
from the postmaster at Des Moines.
"Most interesting," said Chan. "Do I hear impressive chug of rich
automobile engine in street?"
"Yes, I came in the car," John Quincy replied.
"Good. We will hasten at once to home of Captain Hallet, not far
away. I beg of you to pardon my disappearance while I don more
appropriate costume."
Left alone with the boy, John Quincy sought a topic of conversation.
"Play baseball?" he asked.
The boy's eyes glowed. "Not very good, but I hope to improve. My
cousin Willie Chan is great expert at that game. He has promised to
teach me."
John Quincy glanced about the room. On the back wall hung a scroll
with felicitations, the gift of some friend of the family at New Year's.
Opposite him, on another wall, was a single picture, painted on silk,
representing a bird on an apple bough. Charmed by its simplicity, he
went over to examine it. "That's beautiful," he said.
"Quoting old Chinese saying, a picture is a voiceless poem," replied
the boy.
Beneath the picture stood a square table, flanked by straight, low-
backed armchairs. On other elaborately carved teakwood stands
distributed about the room were blue and white vases, porcelain
wine jars, dwarfed trees. Pale golden lanterns hung from the ceiling;