Chapter 2
The Patient’s Responses
It is our duty to remember at all times and anew that medicine is not only a science, but also the art of letting our own individuality interact with the individuality of the patient.
Albert Schweitzer (1875–1965)
Responses to Illness
Health is characterized by a state of well-being, enthusiasm, and energetic pursuit of life’s goals. Illness is characterized by feelings of discomfort, helplessness, and a diminished interest in the future. Once patients recognize that they are ill and possibly face their own mortality, a series of emotional reactions occurs, including anxiety, fear, depression, denial, projection, regression, anger, frustration, withdrawal, and an exaggeration of symptoms. These psychological reactions are general and are not specific to any particular physical illness. Patients must learn to cope not only with the symptoms of the illness but also with how life is altered by the illness.
Conflict
Conflict is an important medical and psychological concept to understand. Patients live with conflict. What is conflict? Conflict exists when a patient has a symptom and wants to have it evaluated by a member of the health care team, but the patient does not want to learn that it represents a “bad” disease process.
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:
• Generalized anxiety disorder—lacks specific traumatic event or focus for concern
• Agoraphobia—anxiety about being in a place or situation from which escape may be difficult
• Phobias—uncontrollable fear about the presence or anticipation of something
• Acute stress disorder—symptoms occur within 4 weeks of the event and last from 2 weeks to a month
The young man who has been stricken with a heart attack feels helpless. As he lies in his intensive care unit bed, he begins to recognize that he really is mortal. The patient believes that he must depend on everyone and everything: the nurse, the doctor, the intravenous line, even the monitor. His anxiety, based on helplessness, is a normal response to his illness. His sudden illness and the threat of possible death oppose his belief that he is indestructible.
A 72-year-old man who has lived alone for years since his wife’s death is admitted to a hospital for a transurethral prostatectomy. He is anxious that he may become dependent on his children. He may be more threatened by his fear of dependency than by the illness itself.
The hospitalized patient who is brought to the radiology department for a routine chest x-ray film and is forced to wait for 2 hours for a transporter to bring her back to her room suffers anxiety. She is angry that she has been left waiting and perhaps has missed some visitors, but she says nothing. Her anxiety is based on the fear of expressing anger to the nurses and staff members on the floor. She believes that if she were to express her anger, the hospital personnel might interfere with her medical care.
Some hospitalized patients cannot accept the love and care expressed by family or friends. This inability to accept tenderness is a common source of anxiety. Such patients feel threatened by these affectionate acts because they serve to reinforce their dependency.
All patients who are admitted to a hospital experience anxiety. The patients must put their most important commodity, their lives, into the hands of a group of strangers who may or may not be competent to assume responsibility for the patients’ survival.
It is most important for the interviewer to identify the causes or roots of a patient’s fear or anxiety, as well as to acknowledge the existence of the patient’s feelings without expressing judgment. Whenever possible, the interviewer should provide some information to allay the patient’s fear or anxiety.
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:
• Markedly diminished interest or pleasure in almost all activities (anhedonia)
• Insomnia
• Change in appetite or weight
• Feelings of guilt or worthlessness
As an example of severe depression, consider the following case of a 23-year-old law student. He is engulfed by anxiety when he is diagnosed with acquired immune deficiency syndrome (AIDS). When his friends and family learn of the illness, he is immediately excluded from all relationships. He has extreme feelings of guilt and low self-esteem. He is found later hanged in his parents’ attic. His only way of coping with his illness has been through suicide.
Suicide is a major public health concern. Approximately 30,000 people die by suicide each year in the United States. More people die by suicide annually than by homicide. Suicide is often committed out of despair, the cause of which can be attributed to a mental disorder such as depression, bipolar disorder, schizophrenia, alcoholism, or drug abuse. Suicide ranks as the eleventh leading cause of death in the United States. It is the second leading cause among 25- to 35-year-olds and the third leading cause among 15- to 24-year-olds. Suicide rates are four times higher for men than women. In 2010, more than 13% of all U.S. high school students reported that they had contemplated suicide in the preceding year. There are an estimated 10 to 20 million nonfatal attempted suicides every year.
The risk of suicide is greater if a behavior is new or has increased, and if it seems related to a painful event, loss, or change. The following signs may mean someone is at risk for suicide:
• Talking about wanting to die or to kill themselves
• Looking for a way to kill themselves, such as searching online or buying a gun
• Talking about feeling hopeless or having no reason to live
• Talking about feeling trapped or in unbearable pain
• Talking about being a burden to others
• Increasing the use of alcohol or drugs
• Acting anxious or agitated; behaving recklessly
• Withdrawing or isolating themselves
Suicide is tragic, but it is often preventable. Knowing the risk factors for suicide and who is at risk can help reduce the suicide rate. Interviewers must not ignore any talk of suicide. If patients bring up suicidal thoughts, interviewers must get the assistance of someone experienced in the field immediately.
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:
• Refuse to acknowledge a stressful problem or situation.
In its strictest sense, denial is an unconscious process. Denial can sometimes obstruct proper medical care. A woman presents to a breast clinic with an orange-sized mass in one breast. The mass has already started to ulcerate, with a resultant foul-smelling infection. When asked how long she has had the mass, she responds that she noticed it “just yesterday.” When a patient is in denial, it is often best to interview a reliable informant in addition to the patient.
Patients can be in denial about anything that makes them feel vulnerable or threatens their sense of control, such as:
Patients can be in denial about something that is happening to them or to someone else.
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.
For example, consider a middle-aged married man who has recently been told that he has inoperable lung cancer that has already spread to his bones. He is stricken with grief and intense anxiety. There are so many unanswered questions. How long will he live? Will his last months be plagued with unremitting pain? How will his wife be able to raise their young child by herself? How will she manage financially without his income? Through regression, the patient can flee this anxiety by becoming childlike and dependent. The patient becomes withdrawn, shy, and often rebellious; he now requires more affection.
Another example is a teenager who learns that the cause of his 6-month history of weakness and bleeding gums is acute leukemia. He learns that he will spend what little time he has left in the hospital undergoing chemotherapy. His reaction to his anxiety may be regression. He now needs his parents at his bedside around the clock. He becomes more desirous of his parents’ love and kisses. His redevelopment of enuresis (bed wetting) is part of his psychological reaction to his illness.
A final example is a 25-year-old woman with inflammatory bowel disease who has had many admissions to hospitals for exacerbations of her disease. She fears the future and the possibility that a cancer may have already started to develop. She is engulfed by a feeling of terror and apprehension. She fears that some day she may require a colostomy and that she will be deprived of one of her most important functions: bowel control. She acts inappropriately, has temper tantrums, and is indecisive. Her dependency on her parents is a manifestation of regression.
Responses to the Interviewer
Much of the enjoyment of medical practice comes from talking with patients. Each patient brings a challenge to the interviewer. Just as there are no two identical interviews, there are no two people who would interview the same patient in the same manner. This section describes a few characteristically troubling patient “types” and indicates some strategies for how the interview may be modified in each case.
Many of the patients to be described can arouse intensely negative feelings in the interviewer; as such, these patients have been collectively called “the hateful patient.” The interviewer should recognize these feelings and deal with them directly so that they do not interfere with the interaction. The interviewer must recognize early in the interaction the general characteristics of these patient types so that he or she can facilitate the interview appropriately.
A variety of pejorative labels have unfortunately been given to many of these patient types. The labels serve only to reduce the interviewer’s stress through the use of humor. This humor is demeaning to patients and can ultimately prevent them from receiving the proper medical care they deserve.
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 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
