Conflict is widespread in medical practice. It is very common for patients to wait until the very end of the consultation to say something like, “Oh, doctor, there is one other thing I wanted to tell you!” That information is often the most important reason the patient sought consultation. The patient may have taken time off from work, paid the appropriate fees, and now does not want to return home without finding out the reason for the symptom. The patient may have hoped the clinician would bring up the subject because it is often too painful for the patient to discuss it. One example of conflict occurs when patients with acute myocardial infarction suffer chest pain for several weeks before the actual event. They convince themselves that it is indigestion or musculoskeletal pain; they do not seek medical attention because they do not want to receive a diagnosis of coronary heart disease. Another example of conflict is a woman with no family history of breast cancer who finds a breast mass during regular self-examination, and does not seek medical attention for several months for fear that the diagnosis is cancer; she wants to find out what the mass is, but the conflict is that she does not want to find out that the mass is cancer, although statistics indicate it may be benign. The health care provider must be able to identify conflict, which is often a precursor of denial, to facilitate care of the patient.

Anxiety

Anxiety is a state of uneasiness in which the patient has a sense of impending danger. It is the fundamental response to stress of any kind, such as separation, injury, social disapproval, or decreased self-esteem. Anxiety and fear are common reactions to the stress of illness. The terms anxiety and fear are often used interchangeably. There are, however, two important differences. First, fear tends to be specific and is triggered by a specific event or object; in contrast, anxiety tends to be more diffuse, often occurring without a specific trigger. Second, fear is more acute and tends to appear rapidly, whereas anxiety develops more slowly and takes longer to resolve. The feelings of loss of control, guilt, and frustration contribute to the patient’s emotional reaction. Illness makes patients feel helpless. Recognizing the body’s mortality leads patients to an intense feeling of anxiety. In addition to the emotional reaction, fear can be manifested physiologically by restlessness, gastrointestinal problems, or headaches. Other common symptoms of anxiety include difficulty falling asleep, nightmares, urinary frequency, palpitations, fatigue, vague aches and pains, paresthesias, sweating, trembling, nausea, a feeling of choking, chills, hot flashes, dizziness, and shortness of breath. It is not uncommon for patients to feel as if they are “falling apart.”

Anxiety disorders can be manifested in many forms:

Depression

Depression is a term used to describe a chronic state of lowering of mood. Some patients have a predilection for depression, but depression is a common state, occurring in more than 20% of all patients with major illnesses, particularly cancer and cardiovascular disease. In its chronic state, depression affects more than 9% of the United States population, or 21 million people. Of these, almost 7%, or 15 million people have coexisting anxiety disorders and substance abuse. Depression is twice as common in women as in men.

Depression is a common psychological response to a loss of any kind: death of a loved one, relationship, health, autonomy, self-esteem, finances, job, or even a hormone (such as thyroid). Certain degrees of depression probably accompany every chronic illness. There are many types of depression; reactive, neurotic, manic, melancholic, and agitated are only a few types. In general, patients with depression have pessimistic tones in speech and a downcast facial expression. They may express feelings of futility and self-accusation. They respond to questions with brief answers. Their speech is slow, their volume is low, and their pitch is monotonous. Depressed patients feel inadequate, worthless, and defeated. They also suffer profound feelings of guilt. A remark such as “You look sad” invites these patients to talk about their depression. Although many depressed patients cannot cry, crying can relieve some severe depressive feelings, even if only momentarily, and thus enables patients to continue their story. Although crying may be brought on by patients’ concern for their own illness, crying usually occurs when patients think of an illness or death of a loved one or of a potential loss. They often have much hostility and resentment and suffer from rejection and loneliness. Self-accusative and self-deprecating delusions can occur in severely depressed patients. When these delusions are present, the feelings of worthlessness are so overwhelming that patients may believe that suicide is the only way out.

Depression may be the most common reaction to illness, as well as the most frequently overlooked. The most important diagnostic symptoms of depression are the following:

Denial

Denial is a coping mechanism that consists of acting and thinking as if a part of reality is not true. It gives one time to adjust to distressing situations, but staying in denial can interfere with treatment and the patient’s ability to tackle challenges. Denial is one of the most common psychological mechanisms of defense and can occur in both patients and health care providers. Denial is often an emotional response to inner tension and prevents a painful conflict from producing overt anxiety. It is actually a form of self-deception. Denial is often observed in patients with terminal illnesses or with chronic, incurable diseases. In general, the more acute the illness, the greater is the patient’s acceptance; the more insidious, the greater the denial.

If a patient is in denial, he or she is not being realistic about something that’s happening in his or her life, although it might be obvious to those around the patient. A patient dying slowly from cancer can observe his or her weight decreasing and the side effects of medications. Frequent visits to the hospital for chemotherapy or radiation therapy confirm the severity of the illness; yet in spite of all this, the patient may continue to deny the illness. He or she makes plans for the future and talks about the time when he or she will be cured. Denial is the psychological mechanism that keeps this patient going. The interviewer should not confront the patient’s denial despite its apparent absurdity. Telling such a patient to “face the facts” is cruel. Breaking down denial in such a patient serves only to add to the dying patient’s misery. However, the patient’s family must understand and accept the poor prognosis.

When a patient is in denial, he or she will:

Figure 2-1 illustrates another example of the tragic sequelae of denial. This man has a basal cell carcinoma of the face. As is discussed in Chapter 5, The Skin, basal cell carcinomas are very slow growing and rarely metastasize; they are locally invasive. Had the patient sought medical attention when the lesion first appeared (and was very small), he would have been totally cured. A person’s denial can be so deep that it prevents him or her from seeing reality and seeking medical attention. It is therefore important for the health care provider to be sensitive to this very powerful psychological mechanism. For another example of denial, see the unfortunate patient with inflammatory breast carcinoma depicted in Figure 13-8.

Projection

Projection is another common defense mechanism by which people unconsciously reject an unacceptable emotional feature in themselves and “project” it onto someone else. It is the major mechanism involved in the development of paranoid feelings. For example, hostile patients may say to interviewers, “Why are you being so hostile to me?” In reality, such patients are projecting their hostility onto the interviewers.

Projection is one of the defense mechanisms identified by Freud. According to Freud, projection is when someone is threatened by or afraid of their own impulses, so they attribute these impulses to someone else. Patients commonly project their anxieties onto doctors. For example, a person in psychoanalysis may insist to the therapist that he knows the therapist wants to rape some women, when in fact the client has these awful urges to rape. Patients who use projection are constantly watching a doctor’s face for subtle signs of their own fears.

As another example of projection, a 42-year-old woman with a strong family history of death from breast cancer has intense fears of developing the disease. During the inspection portion of the physical examination, the patient may be watching the clinician’s face for information. If the clinician frowns or makes some type of negative gesture, the patient may interpret this as “The doctor sees something wrong!” The clinician may have made this expression thinking about the amount of work still to be done that day or what type of medication to prescribe for another patient. The patient has projected her anxiety onto the clinician. The clinician must be aware of these silent “conversations.”

In some instances, projection may have a constructive value, saving the patient from being overwhelmed by the illness.

Regression

Regression is a common defense mechanism by which the patient with extreme anxiety attempts unconsciously to return to earlier, more desirable stages of development. During these periods, the individual enjoyed full gratification and freedom from anxiety. Regressed patients become dependent on others and free themselves from the complex problems that have created their anxiety.

Behaviors associated with regression can vary greatly depending on which stage the person is fixated at:

The Silent Patient

Some patients have a lifelong history of shyness. Some of these individuals lack self-confidence. They are very concerned about their self-image and do not want to say or do the wrong thing. These patients are easily embarrassed. Other individuals become hostile or silent as fear of illness develops. Many silent patients are seriously depressed, which may be a primary response as a result of the illness itself or a secondary response to it. These patients commonly have many of the other signs of depression, as seen in their attitude, facial expressions, and posture. The use of open-ended questions with these patients is usually of little value. Carefully directed questioning may yield some of the answers. You might ask, “Is there a reason for your not answering my questions?”

The young interviewer often has difficulty interviewing the silent patient; the interviewer may feel obligated to speak. Allow the patient periods of silence as the patient may need time to think and remember details. Always be attentive and respectful and watch for nonverbal clues. As mentioned previously, patients who are depressed or worried about their health or lives are relatively silent. If you suspect depression, try refocusing the interview to questions about depression and suicide.

The Overtalkative Patient

The overtalkative patient presents a challenge to the novice interviewer. These patients dominate the interview; the interviewer can hardly get a word in. Every question gets a long answer. Even the answers to “yes-no” questions seem endless. There is usually an aggressive quality to this patient’s communications. Every answer is overdetailed. Do not show your impatience. A courteous interruption followed by another direct question helps focus on the subject of the interview. The use of open-ended questions, facilitations, or silence is to be avoided because these techniques encourage such a patient to continue speaking. You might say to the overtalkative patient, “I am interested to learn more about . . . , but we have a limited time together so I need to ask you some specific questions. Please answer then directly.” If all else fails, the interviewer should try to relax and accept the problem.

The Seductive Patient

One of the most difficult types of patients for the novice to interview and examine is the seductive patient. In many ways, it is more difficult to deal with the seductive patient than with a hostile patient. Many of these patients have one of the personality disorders (e.g., histrionic, narcissistic) and harbor fantasies of developing an intimate relationship with their physician. These patients are often attractive and tend to be flashy in the way they dress, walk, and talk. They commonly offer inappropriate compliments to the interviewer to gain his or her attention. The patients are frequently emotionally labile. Not uncommonly, these patients expose themselves physically early in the interview. The interviewer may elect to cover the patient, but usually this is unsuccessful, as the patient may expose himself or herself again. It is difficult for the interviewer to cope with his or her own feelings when he or she is attracted to such a patient. The feeling of attraction is a natural one, and the interviewer must accept it. However, the interviewer must always maintain a strictly professional demeanor. Empathy and reassurance must be kept to a minimum because these supportive techniques stimulate further fantasies in the patient. The interviewer must always maintain professional distance. It may be necessary to say, “Thank you for your nice compliments, but in order for me to help you, we must keep our relationship strictly professional. I hope you understand.” If necessary, the interviewer should get the advice of someone he or she trusts.

The Angry Patient

Angry, obnoxious, or hostile patients are common. Some make demeaning comments or are sarcastic, whereas others are demanding, aggressive, and blatantly hostile. Some hostile patients may remain silent during most of the interview. At other times, they may make inappropriate remarks that are condescending to the novice or even to the experienced clinician. The interviewer may feel resentment, anger, threatened authority, impatience, or frustration. Reciprocal hostility must be avoided because a power struggle can develop. Accept the patient’s feelings. Don’t react to them.

The interviewer must realize that these reactions are the patient’s responses to illness and not necessarily a response to the interviewer. These reactions may be deeply rooted in the patient’s past. Every interviewer should be aware that the same emotions, such as rage, envy, or fear, are present in both the patient and the interviewer. A patient may express feelings toward the interviewer, who must act in a detached, professional way and should not feel offended or become defensive.

Students of the health care professions may have been taught that they must like their patients to treat them appropriately. Ambivalence in the interviewer can be a problem. Health care providers must treat patients medically correctly and with respect, but in fact, it is not necessary to like the patient to provide good care. Because of their illness, patients may have feelings of loss of control, threatened authority, and fear. Their anger is the mechanism by which they attempt to handle their fears. Once interviewers gain this insight and become aware of their own feelings, they can better treat such patients. Interviewers must accept and restrain their own negative feelings toward the patients so that their professional judgment is not distorted. Interviewers’ awareness of their own anxieties and feelings aids in conducting a more productive interview. Conscious expression of the interviewer’s own feelings in a frank and noninsulting manner facilitates the interviewing process. Regulation and control of the interviewer’s feelings is the goal.

Confrontation may be a useful technique for interviewing such patients. By saying, “You sound very angry,” the interviewer allows patients to vent some of their fears. Another confrontational approach is to say, “You’re obviously angry about something. Tell me what you think is wrong.” Maintain equanimity and avoid becoming defensive. If at the beginning of the interview the patient is angry, try to calm the patient. Proceed slowly with questioning, avoid interpretations, and ask questions that are confined to the history of the present illness.

The Paranoid Patient

The paranoid patient constantly asks, “Why are you asking me that? Do I have . . . ?” When the interviewer asks the many questions in the review of systems, the patient responds, “Who told you about that?” Paranoid patients think there is some devious plan and that people are constantly talking about them. The patient’s suspiciousness can sometimes be handled by the interviewer’s saying, “These are routine questions that I ask all my patients.” Reassurance tends to be threatening to these patients and should not be used because it tends to produce more suspicion. The patient’s delusion is beyond reason. The interviewer should therefore complete the questioning and not try to convince such patients about their false ideations. Avoidance of any anger by the interviewer is of paramount importance.

The Insatiable Patient

Insatiable patients are never satisfied. They have many questions, and despite adequate explanations, they feel that the interviewer has not answered all their questions. They tend to be very sensitive, anxious individuals. These patients are best handled with a firm, noncondescending approach. A definite closing statement is helpful, such as “We have reached the end of our time for today, but I will be back.” Alternatively, the interviewer could say, “We have reached the end of our time for today. I will refer your concerns to Dr. ____.”

The Ingratiating Patient

The ingratiating patient attempts to please the interviewer. Such patients believe that they must provide the “right” answers to satisfy the interviewer. They think that if they answer a question in a way that arouses the disapproval of the interviewer, the interviewer will abandon them. Intense feelings of possible rejection are present in this type of patient. The interviewer must recognize that anxiety is the cause of the patient’s behavior and should try not to respond to that behavior. The interviewer should recognize the patient’s tendency of trying to please and should stress to the patient how important it is to be accurate.

The Aggressive Patient

Many aggressive patients have a personality disorder. Such patients are easily irritated and often fly into a rage when dealing with the normal stresses of daily life. They are domineering and try to control the interview. However, if allowed to have their way, they may be quite pleasant. Frequently, aggressive patients have intense dependency needs that they cannot consciously handle. These patients mask the primary problem by becoming aggressive and hostile to disguise their anxiety and feelings of inadequacy and inferiority. Aggressive patients are difficult to interview. The interviewer must try to avoid areas provoking anxiety early in the interview. Once a rapport is established, the interviewer may attempt to delve into the deeper areas. In general, aggressive patients refuse any type of psychotherapy.

The Help-Rejecting Patient

Help-rejecting patients are usually not hostile. They describe having been seen by many “expert” physicians for help and often tell interviewers that no one can find out what is wrong with them. They return again and again to the doctors’ offices, indicating that the physicians’ suggestions “didn’t work.” Commonly, when a symptom appears relieved, another suddenly appears. These patients use their symptoms to enhance their relationship with their doctors. Such patients are often very depressed, although they may deny it. They believe that they have made many self-sacrifices and have had countless disappointments, which they attribute to their “illness.” The best approach to these individuals is strong emotional support and gentle reasoning. Despite the need for psychiatric help, these patients usually refuse to accept it.

The Demanding Patient

The demanding patient makes demands of everyone: the physician, the nurse, the student, the aide. These patients use intimidation and guilt to force others to take care of them. They view themselves as being neglected and abused. They may have outbursts of anger toward physicians, who may fear for their own reputations. A power struggle may result. Inform the patient that it is good that he or she came in and that you will do everything possible to help.

The Compulsive Patient

Compulsive patients are concerned about every detail of their lives. These patients pride themselves on their ability to solve all problems, but when their health deteriorates, they lose their composure because they cannot deal with ambiguity or uncertainty. They deny their feelings of anger and anxiety, and projection is a common reaction to their illness. In dealing with the compulsive patient, the interviewer must provide very detailed and specific information to the patient in a straightforward manner. The patient should be allowed as much control as possible, and all the possibilities discussed should be explained clearly.

The Dependent Patient

The dependent patient finds life difficult without the help of others. Other persons provide the necessary support, both emotional and physical. If this support is removed, the patient feels hurt and deserted and demands even more help. When dependent persons become ill, they imagine that their illness will lead to loss of their support groups. Thus dependent patients need to be cared for most closely. Sometimes, however, these patients can take advantage of a compassionate health care provider by demanding enormous amounts of time. Be as direct as possible when informing such patients of the appropriate limits without leaving them rejected. The interviewer might say, “You’ve given me a lot to think about. I do have to leave now. Please don’t feel I’m rejecting you. I’ll be back later to discuss some of your other problems.”

The Masochistic Patient

The masochistic, or self-defeating, patient goes through life suffering. Although these patients need to continue to suffer mentally, they do not seek physical abuse or pain. The masochistic patient is dedicated to a life of self-sacrifice. In contrast to other types of patients, this type adapts well to illness and, in fact, may feel threatened by recovery. Thus such patients often frustrate physicians. The goal for these patients is to be able to function despite their problems. Interviewers should not promise cures because this creates more problems for the patient and the health care provider.

The Borderline Patient

Borderline patients are individuals with a personality disorder who have an instability in their personal relationships, engage in impulsive behavior, and have unstable moods. Intense, fluctuating emotions of love and hate are typical of borderline patients. They need emotional support because they are constantly threatened by people and circumstances. It is often very difficult to develop a good doctor-patient relationship with borderline patients because the swings of affect are rapid. Borderline patients are always afraid, but this fear may be masked by outbreaks of anger. These patients are best handled with reassuring words.

The Child Who Is Ill

Children tend always to be “on guard.” Ill children are especially vulnerable and wary. First, they are taken from their “friendly” home environment. Second, doctors, nurses, and students are constantly staring at them with a wide variety of facial expressions. Many older children believe that the physician has some sort of “magical eye” that can see through them and know everything about them. This all adds up to a frightening experience for youngsters. Frequently, tests that cause discomfort may have to be performed by those “people in white.” The health care provider becomes a symbol of danger and pain.

When the physicians, nurses, or technicians take the youngster for a test, the child experiences his or her greatest fear: separation from parents. This separation produces intense fear and anxiety, manifested by wailing, irritability, and aggressive behavior. The child’s fear is that he or she will not see his or her parents again. This fear may actually be subconscious. Health care providers should explain to the child, if old enough, that they know why the child is crying and should assure the child that he or she will see his or her parents soon. Parents should be urged to talk to their children, informing them that the doctor is going to help them. The parents should be careful not to indicate that the doctor will not hurt the child, because if the child has pain as a result of a test, the child-parent relationship may be jeopardized. The parent should be encouraged to stay with the child in the hospital as long as possible and even sleep in the child’s room at night, if permitted. Studies have shown that when parents are permitted to stay with their children, the recovery is quicker and there is less emotional trauma. An important part of caring for children is talking to the parents. If the parents understand the situation, they can do much to help the doctor-child relationship.

Disabled children, like disabled adults, are extremely apprehensive of the atmosphere in the hospital. It reminds them of previous experiences. The interviewer must take time to play with the child while talking to the parent or the person accompanying the child. Complimenting the youngster with statements such as “How pretty you are” or “What a nice outfit you’re wearing” seems to foster good will. These children crave love, affection, and attention. The parent has to be reassured that the staff members are reliable and caring. This will give the parent peace of mind. If a child wishes to keep a favorite toy or blanket, there should be no restrictions. Separation from home and family is a terrible experience for any child, but it is even more so for disabled children, who function better in familiar surroundings.

The Aged Patient

The aged patient requires a lot of attention. Depression is prevalent among older adults. Aged patients must frequently cope with the loss of loved ones and other important persons in their life. They are also stressed by changes in their own self-images and the way they are perceived by others. Deterioration in bodily function also contributes to depression in aged patients.

A patient’s depression may be so severe that he or she may consider suicide a reasonable alternative to living with a severe chronic illness or living alone after the death of a spouse. Among this bereaved population, more deaths within the first 4 years after the spouse’s death result from suicide than from all other causes.

The interviewer must never assume that older patients’ complaints are natural for their age. People do not die of old age; they die of illnesses. Most of these patients are alert and capable of independent living. The ones who are unable to care for themselves are usually accompanied by a family member or an attendant. The interviewer must obtain as much information as possible from these sources. The interviewer should also refrain from using patronizing mannerisms that belittle the individual. A friendly, respectful approach reassures the patient. Aged patients should be advised about everything that will be done to them. This makes patients confident that there will be no unpleasant surprises. Because of advanced age, such patients may be afraid of dying. Those who are afraid should be reassured that everything possible will be done to make them better. Many people survive an illness because of their desire to live and therefore fight to stay alive. Overzealous reassurance is not appropriate for all aged patients; many regard death as a reasonable outcome.

The Widowed Patient

Many widowed patients come to the hospital alone, with the thought that because their spouses are gone, nobody cares about them. They may be suffering from depression as a result of loneliness. The interviewer should inquire gently whether there are any children, relatives, or friends who can be contacted or will come to visit. Such a patient may be at odds with his or her children and may prefer that the children not know that the patient has entered a hospital. In other cases, the family may live far away. The patients do not want their family to worry, so they do not tell the family. In these cases, it is advisable for the clinician to alert the social worker to the particular situation. Volunteers visiting the patient, as well as members of the clergy, can bring soothing counsel. A warm handshake and reassurance are effective ways of putting this patient in a relaxed state of mind. Many widowed patients are quite active. The clinician should not presume that all widowed individuals are isolated.

The Patient with Post-traumatic Stress Disorder

Although the effects of natural calamities and their aftermaths have been recognized since the time of ancient Greece, post-traumatic stress disorder (PTSD) was not included in the American Psychiatric Association’s handbook of psychiatric disorders, the Diagnostic and Statistical Manual of Mental Disorders, until 1980. One of the first descriptions of PTSD was made by the Greek historian Herodotus. In 490 BCE, he described an Athenian soldier who suffered no injury in the Battle of Marathon but became permanently blind after witnessing the death of a fellow soldier. Health care providers are only beginning to recognize the enormous toll that trauma can take in personal suffering and functional impairment. PTSD may also have an effect on future generations through effects on parental or guardian behavior and competence.

For many years, PTSD was considered only a wartime affliction. During World War I, PTSD was called “shell shock,” and during World War II, it was referred to as “combat fatigue.” After the Vietnam War, it was often mistakenly called the “post-Vietnam syndrome.” It has been estimated that 15% of 500,000 veterans of the Vietnam War are affected with PTSD. These patients have a variety of symptoms, including nightmares, sleep disturbances, avoidance reactions, guilt, intrusive memories, and dissociative flashbacks. In addition, as much as 9% to 10% of the U.S. population may have some form of PTSD. Almost 18% of 10 million women who were victims of physical assault have PTSD. Studies have shown that PTSD develops in 2% of people exposed to any type of accident, 30% of those exposed to a community disaster, 25% of those who have experienced traumatic bereavement, 65% of those experiencing nonsexual assault, 85% of battered women in shelters, and 50% to 90% of those who were raped. Of all psychiatric disorders, PTSD poses one of the greatest challenges to the health care provider because of its complexity and variability of signs and symptoms.

In 1987, the revised DSM-III (DSM-III-R) defined PTSD as caused by traumatic events that were “outside the range of usual human experience and that would be markedly distressing to almost anyone.” PTSD is a normal reaction to an abnormal amount of stress. Although trauma is usually considered as an injury to a body part, it may be even more devastating to the psyche. Wounding of emotions, spirit, the will to live, dignity, and the sense of security can be traumatic. Some traumatic events may go on for months or years, whereas others may occur in a few seconds and have the same lasting effects as longer events. In minutes, a person’s sense of self and sense of the world as a secure place can be shattered.

One problem with the DSM-III-R description is that it fails to recognize the importance of the subjective appraisal of the event; this includes the ethnocultural aspects of PTSD. The 1994 edition, DSM-IV, lists PTSD as the only diagnosis that identifies the origin of symptoms from external events rather than from within the individual. All the following DSM-5 criteria must be met to make a diagnosis of PTSD:

Learned helplessness syndrome is a condition frequently seen in trauma survivors, commonly women and children, prisoners of war, concentration camp survivors, refugee camp survivors, or other tortured survivors. The name developed from animal experiments by Seligman (1967, 1975). Animals subjected to electric shocks and unable to escape despite their attempts would sink into listlessness and despair. Later, they were reshocked, but although trained to press a lever to stop the shocks, the animals made no effort to do so. The animals had learned to be helpless. It has been postulated that there is an adrenal neurotransmitter problem in animals and humans exposed to severe, repeated traumatic events that may serve as the biologic basis for the hyperarousal and numbing phases of PTSD.

Although almost any symptom can result from PTSD, some of the more common ones are as follows:

It has become clear that individuals need not be present at a catastrophic event to experience stress symptoms. The terrorist attacks that shook the United States on September 11, 2001, were immediately broadcast on television screens around the world. The events and their aftermath were shown in graphic detail repeatedly after the attacks. Many Americans identified with the victims directly or perceived the unprecedented attacks as directed at themselves as well. Thus even people who were nowhere near the location of the attacks experienced substantial stress responses.

In a study published in the New England Journal of Medicine shortly after the attacks, 90% of the adults surveyed reported experiencing, to at least some degree, one or more symptoms of stress, and 44% of the adults reported a substantial level of at least one symptom of stress (Schuster et al., 2001). Although those closest to the sites of attack had the most substantial stress, respondents throughout the country, from large cities to small communities, reported stress symptoms: 36% of respondents more than 1000 miles from the World Trade Center reported substantial stress reactions, in comparison with 60% of those within 100 miles of the site. Among respondents who lived south of Canal Street in Manhattan (i.e., near the World Trade Center), the prevalence of PTSD was 20% after the attacks, in comparison with 4% before the tragic event. The article notes that more than 130,000 Manhattan citizens suffered from PTSD, depression, or anxiety after the attacks. Other studies have shown that children who were exposed solely through television to horrifying events such as these attacks, the Challenger disaster, the Oklahoma City bombing, and the Gulf Wars experienced trauma-related stress reactions.

Approximately 5 to 8 weeks after the attack on the World Trade Center, a random telephone survey was conducted to estimate the prevalence of increased cigarette smoking, alcohol consumption, and marijuana use among residents of Manhattan (Vlahov et al., 2002). Among 988 persons included, 28.8% reported an increase in use of any of these three substances; 9.7% reported an increase in smoking, 24.6% reported an increase in alcohol consumption, and 3.2% reported an increase in marijuana use. Persons who increased smoking of cigarettes and marijuana were more likely to experience PTSD than were those who did not (24.2% vs. 5.6% for cigarettes; 36.0% vs. 6.6% for marijuana). The study was repeated 6 months later, and the increases were sustained, suggestive of potential long-term health consequences as a result of such disasters.

The Sick Physician

Perhaps the most difficult of all patients to care for is the sick physician. The anxiety of sick physicians should not be underestimated. The expression “A little knowledge is a dangerous thing” applies to the sick physician. Every medical or nursing student goes through the “student syndrome,” which is the suspicion that he or she has been stricken with the disease about which he or she is learning. Imagine the anxiety that occurs when the physician actually is stricken. In addition to anxiety about health, there is the new role identification of being the patient. Physicians feel helpless and have great difficulty divorcing themselves from the role of physician. They constantly ask what the electrocardiogram shows and for the results of blood tests. They may suggest additional tests or may even disagree with the tests that have been ordered. The novice interviewer should provide ample time for the sick physician to express fears and anxieties. With the interviewer’s support, sick physicians eventually recognize and accept their new role as patient.

The Disabled Patient

Disabled patients may come to the hospital with great apprehension and mistrust. They are usually familiar with the shortcomings of hospitals because they have probably been hospitalized for painful tests or surgery. They may be burdened with an inferiority complex and may feel unattractive. The interviewer must take all this into consideration and assure patients that everything will be done to make them comfortable. The interviewer must sort out the emotional problems of disabled persons from the physical ones that brought them to the hospital. A friendly smile or a few kind words can encourage these patients to cooperate, thereby securing a better doctor-patient relationship.

Many disabled people have developed their own routines that work for them. They often do not want medical personnel to impose their way of doing something if the patient’s way works.

Patients with a hearing impairment need to be treated differently from other disabled patients. Sit directly in front of these patients to allow them to benefit from lip reading. Make sure that the lighting in the room is correct so that your face is well illuminated. It is important to speak slowly with appropriate gestures and expressions to punctuate the question. Ask these patients whether it is necessary for you to speak louder. If a patient wears a hearing aid, speaking louder may not be necessary. It might be possible to use your stethoscope and place the earpieces in the patient’s ears and speak into the diaphragm as a microphone. If all else fails, the use of written questions can be helpful.

Another special type of disabled patient is the visually impaired patient. Because the patient with limited or no vision has no reference for you in the room, it is useful for you to occasionally touch the patient on the arm or shoulder. This can be done instead of the more standard nonverbal facilitations, which are of no value in this patient. Always tell the patient who you are and why you are speaking to the patient.

The severely mentally retarded patient must be accompanied by a family member or guardian to provide a proper history.

The Patient with Cancer

The patient with cancer has five major concerns: loss of control, pain, alienation, mutilation, and mortality. Loss of control makes this patient feel helpless. The knowledge of something growing uncontrolled within a patient’s body creates frustration, fear, and anger. Suffering with pain is one of the most feared aspects of cancer. The feeling of alienation stems from the reactions of people around the patient.

Fears of mutilation are common among patients with cancer. The fear of being perceived as lacking “wholeness” contributes to depression and anxiety. The young woman with breast cancer who requires a mastectomy fears that she will be rejected as no longer being a complete woman. Supportive family members are the key in reassuring this patient that they will love her just as they have before her surgery. A diagnosis of cancer makes a patient aware of mortality and leads to intense fear of unremitting pain.

Family members and friends often express grief before death occurs. Resentment and anger may be directed toward the patient with cancer. Physicians often harbor feelings of inadequacy about these patients and have difficulty speaking with them. The patients are thus rejected by their own physician. The physician is afraid that the patient may ask some questions, perhaps about death, that the physician cannot handle. The physician must recognize his or her emotional and behavioral reaction and be realistic about the limitations of medical science.

The interviewer should allow the patient to vent anxieties and should promote dialogue. Listening to the patient enhances the doctor-patient relationship.

The Patient with AIDS

Patients with AIDS are fearful for their lives and of being stigmatized as a member of an undesirable group. The fear and misunderstanding common in high-risk groups result in delays in medical treatment. Denial is the important factor in most of these patients. The patient may have an intense fear of physicians, nurses, students, and paramedical personnel, who may have strong emotions related to this disease and its risk groups. The patient’s fear is paralleled by the anxiety of the hospital workers who have to treat an individual with this disease. Their fear of contracting the disease, even by casual contact, is formidable. These fears are also present among the patient’s friends and family, who often banish the patient from all activities. The patient may have been fired from a job because the employer is afraid of catching the disease. There is an unsympathetic rejection of patients with AIDS. They suffer emotional turmoil, which contributes to intense anxiety, hostility, and depression.

The interviewer should be as supportive as possible without giving false reassurances. The patients should be given as many facts as appropriate, and the staff members tending to them must be educated about the disease.

The Dysphasic Patient

The dysphasic patient has an impairment of speech and cannot arrange words correctly. Dysphasia is usually caused by a cerebral lesion, such as a stroke. The degree of dysphasia can vary enormously and can be as extensive as almost complete aphasia. Although patients may appear relatively unresponsive, they may be totally aware of all conversation. Therefore all discussions conducted in the presence of such patients must be undertaken with the assumption that the patient can understand. Before the interview, the interviewer may give patients a pen and paper to determine whether they can respond by writing “Yes” and “No” answers.

The Psychotic Patient

Psychotic patients have an impairment of their reality-testing abilities. They have a gross inability to communicate effectively. They may also suffer from hallucinations, delusions, or feelings of persecution. Psychotic patients cannot deal with their fear. They are constantly struggling with the ever-changing demands of their environment. It is most important to recognize the psychotic patient early and remain as calm as possible. If the patient has had violent episodes, make sure assistance is standing by.

In general, interviewing psychotic patients presents a difficult task for the inexperienced interviewer. Some of these patients tend to be inarticulate and preoccupied with fantasies, whereas others are reasonably lucid. The symptoms and signs of their psychosis are not usually evident at first assessment. There are several clues to the existence of a psychosis. Interviewers should pay particular attention to the speech pattern and its organization. Is there a jumble of ideas? Psychotic patients are easily distracted, and the interviewer must constantly remind them of the subject. These patients fail to complete any chain of thought and cannot follow any idea to completion. They can have bizarre impressions about their bodies. They may complain that they have noticed that one arm has recently shortened or that their external genitalia have suddenly shrunk or enlarged. In addition, they may have evidence of an inappropriate affect; for example, a patient may laugh while telling about the death of a friend or relative.

A special type of psychotic personality disorder is found in patients with Munchausen‘s syndrome. Such patients are the classic hospital malingerers. They are pathologic liars and travel from clinician to clinician, from hospital to hospital. They complain of a wide variety of symptoms and, in fact, create signs of illness to seek an advantage. Their histories are well rehearsed, and they have a masochistic perpetuation of self-injury. For example, the patient with Munchausen’s syndrome may actually prick the skin under a fingernail so that it will not be obvious, drop some blood into the urine, and call the clinician, stating that there is blood in the urine. These patients frequently seek out painful diagnostic and therapeutic procedures. At times, they may even undergo unnecessary surgical procedures.

The Demented or Delirious Patient

Demented patients have lost previously acquired intellectual function, most typically memory. Delirious patients have a disorder of consciousness that does not allow them to interact correctly with the surroundings. Demented patients frequently become more confused when taken out of their normal environment, especially at night. The term sundowning is used in such circumstances. Fear is common in both types of patients. In interviewing these patients, clinicians must try to be sensitive to their emotions as much as possible, and above all, try to allay their fears. Interviewers must be particularly aware of questions that may be possibly threatening to the patient.

Patients with an organic mental syndrome present a special problem. At times, these patients seem lucid; at other times, they are disoriented with regard to person, place, or time. If the patient is able to answer some of the questions, the interviewer should record the answers. The same questions should be asked again later to determine whether the patient will respond similarly. These patients have defects in attention span, memory, and abstract thought. Interviewers should be alert to inconsistent and slow, hesitant responses. On occasion, patients may interject some humor to try to cover up for their difficulty in memory. A careful mental status examination indicates the problem. It may be useful to remind the patient of your name and tell him or her that you will ask for the name in a few minutes. Frequently, such patients have forgotten it. Never correct these patient’s errors, and if they ask the same question again, never tell them that you already answered the question. This is a definite way to close down the interview as the patient will feel stupid and reluctant to answer other questions. Furthermore, because the histories these patients give may not be reliable, it is always useful to have another family member present when interviewing the patient with impaired cognitive abilities.

If the patient lacks the capacity for decision making, a determination of surrogacy will be necessary. In the best-case scenario, the patient may have previously appointed an agent; in the worst-case scenario, the court may need to become involved. Try to determine if the patient has a durable power of attorney for health care or a health care proxy.¹ If the patient does not have an advance directive or health care proxy, the surrogate will need to make decisions based on principles of “substituted judgment” (what the patient would have decided) or “best interest” (what the surrogate judges to be best for the patient).

The Acutely Ill Patient

The acutely ill patient merits prompt attention. In these situations, a concise history and physical examination are in order. A careful history of the present and past illnesses must be taken expeditiously so that the diagnosis may be made and treatment begun. It may be appropriate in this setting to interview the patient while performing the physical examination; time is of the essence. However, patients who are acutely ill may respond to questions more slowly than normal because of pain, nausea, or vomiting. Be considerate of their problems, and allow them time to answer questions. After a patient’s condition has been stabilized, there will be time to go back and take a more complete history.

The Surgical Patient

Patients faced with a surgical procedure may be frightened despite a calm appearance. They may feel helpless and out of control. The fear of anesthesia, disfigurement, disability, or death is always present. The fear of not awakening from the anesthesia can be devastating. When they awaken, will they find that their body is no longer “whole”? Did the surgeon find something that was not expected? These patients fear the unknown. A question about the surgeon’s ability is an expression of the patient’s anxiety. Often, patients have tests and are told the results are normal “except” for a small area: they will need surgery to “check it out.” This lack of communication by the surgeon adds to the patient’s anxiety. A surgeon’s schedule is frequently erratic. Surgery may be delayed or postponed, which adds to the surgical patient’s anxiety and anger. Many possible communication difficulties exist. The best way to avoid the unnecessary anxiety-provoking situations is to maintain open communication among the patient, the physician, and the patient’s family. In the postoperative period, the patient’s relief over having lived through surgery may be displayed in a variety of ways. The patient may be apathetic and show a general lack of interest or may be moody, irritable, aggressive, angry, or tearful. Subconsciously, patients may wish to harm the surgeon for “cutting” into their bodies, whereas consciously they want to thank the surgeon. This dichotomy may be the root of the anger so commonly seen in postoperative patients. In other patients, depression may be seen as a result of the loss of part of the body. The best example of this is the “phantom limb.” Patients who have undergone an amputation of a leg frequently claim sensation in their lost limb. Some of this may be physiologic, but certainly some of the phantom leg pain is related to depression. The caring interviewer should allow the patient time to release these tensions and feelings of loss.

The Alcoholic Patient

Alcoholic patients are both physiologically and psychologically dependent on alcohol. Most of the time, interviewers conduct the sessions when the patient is not inebriated. Excessive drinking is often an attempt to deaden feelings of guilt and failure. The more patients drink, the more they are abandoned by their family and friends. They feel castigated and alone. They are left to their only “friend”: alcohol. They are often ready to talk, and their account of their drinking habits may be interesting. Alcoholic patients generally have a low opinion of themselves. They may even be upset about their persistent drinking habits. Their hatred of themselves may be a manifestation of a self-destructive wish. Alcoholic patients may also have fears about sexual inadequacy or homosexuality. It is not easy to open up such topics because these patients are likely to respond explosively. The sensitive interviewer should approach these issues in a manner that is neither condescending nor moralistic.

The Psychosomatic Patient

Just as physical illness can produce psychological problems, so can psychological problems create physical ailments. The intimate interaction of the mind and body is clearly demonstrated in the psychosomatic disorder.

Psychosomatic patients express emotional discomfort and distress in the form of bodily symptoms. They may be totally unaware of the psychological stress in their lives or the relationship of stress to the symptoms.

There are many ways of dealing with psychosomatic patients. First, identify the disorder: Do not miss the possible diagnosis of an affective or anxiety disorder. Treatment of somatization is directed toward teaching the patient to cope with the psychological problems. Be aware that somatization operates unconsciously; the patient really is suffering. Above all, the patient should never be told that his or her problem is “in your head.” Anxiety, fear, and depression are the main psychological problems associated with psychosomatic illness. The list of associated common symptoms and illnesses is long and includes chest pain, headaches, peptic ulcer disease, ulcerative colitis, irritable bowel syndrome, nausea, vomiting, anorexia nervosa, urticaria, tachycardia, hypertension, asthma, migraine, muscle tension syndromes, obesity, rashes, and dizziness. Answers to an open-ended question such as “What’s been happening in your life?” often provide insight into the problems.

Finally, the interviewer should legitimize patients’ suffering by acknowledging that their suffering is real. The interviewer must help patients recognize the way in which stress can create physical suffering. Giving patients the freedom to discuss hopes and fears is often more beneficial than a written prescription for medications.

The Dying Patient

Few patients are as conscious of taking up a clinician’s time as those who have less time remaining. Dying patients may initially have many questions, but as time goes by, they ask less and less of their health care providers.

Many health care providers have a dread of death that is so intense that they behave irrationally. They avoid patients who are dying or those with incurable diseases. The emotional needs of the dying patients may be largely ignored. Many patients have a greater fear of the process of dying than of death itself. The fear of living as a chronically ill patient can be almost as intolerable as (and often more so than) the fear of death.

Dying patients may suffer from the pain, nausea, or vomiting caused by the disease or treatment. They may be rejected by their families, hospital staff members, or even their own physicians. Many patients have strong feelings of anger, guilt, resentment, and frustration: “Why me?” “It should have been diagnosed earlier.” They may envy healthy individuals. They may deny their imminent death; this is the first stage of dying. Not uncommonly, a dying patient is interviewed and does not tell the interviewer about the illness. Even when asked specifically about the disease, the patient may deny any knowledge of having a fatal disease. This mechanism of denial allows the patient to cope with life as it is. Each person faces death differently. Some can deal with it head-on; others cannot. Some approach it with fear and tears, whereas others grow to accept it as an inevitable event. Given sufficient time and the necessary understanding, most dying patients can arrive at the final stage of dying: acceptance. This stage is characterized by apathy and social withdrawal. Counselors specifically trained in the grieving process are often helpful to the patient, family, and health care providers.

Once a patient has come to grips with the fact that he or she has a terminal disease, the patient may ask, “Am I going to die?” The interviewer cannot answer this question as asked, and so he or she should then ask the patient, “What are you afraid of?” The patient may then indicate that he or she is afraid of dying in pain or dying alone. The interviewer can then answer these questions by saying that he or she will do everything possible to make sure that the patient will not have pain or that they or their associates will be with the patient throughout the duration of the illness.

The dying patient needs to speak with someone. The clinician should be alert for subtle clues that the patient wishes to discuss the topic of death. For example, if a patient remarks that his “wife is well provided for,” it is correct to pursue this point by making an interpretive statement such as, “I sense that you are very worried about your illness.” Although the conversation that ensues might be emotionally draining for the interviewer, the interviewer must allow the dying patient to speak. Sometimes the most appropriate response to an expression of grief is a thoughtful period of silence.

The bibliography for this chapter is available at studentconsult.com.