Doctor & patient relationship

Doctor & Patient

·         Establish alliance

·         Transference situation

·         Countertransference

·         Personality style & coping mechanisms

·         Defense mechanisms

·         Culture/transcultural

·         compliance

ØInterview techniques:

•Techniques to improve skill in Medical history& Psychiatric history taking

lOpen ended questions (e.g.: describe the pain)

•Nonstructured

•Not close potential areas

•Allow variety of responses

•Facilitate conversation

•Children usually have difficulty with this questions

lDirect questions (e.g.: did it wake you up?)

•Yes-No questions

•Clarify information

•Use when emergency

•Ptx with cognitive disorder

•Over talkative patient

•Sexually provocative patient

lLeading questions (Avoid to use them)

•E. g.: You really feel better, don’t you?

Ø  Interview Strategies

•Support

•Empathy

•Validation

•Facilitation

•Reflection

•Repetition

•Silence

•Confrontation

•Interpretation

•Recapitulation

ØDefense mechanisms & illness (patients and even doctors use them frequently. To know the different defense mechanism will understand better patient’s or doctor’s behavior, even understand why sometimes inconvenient or frustrating experience is part of daily medical practice)

Defense mechanisms are unconscious SERVANTS TO keep conflicts out of conscious mind. They are unconscious for the patient and for the doctors, but determine good or bad, efficient or disappointing relationship

They function is

lDecrease anxiety

lType of used defense mechanism depend on maturity and coping style of the personality

l We are talking about good and highly efficient (mature) and not so good, less mature defense mechanisms

Ø  Mature defense mechanisms:

·         Altruism

·         Humor

·         Sublimation

·         Suppression

Ø  Less mature defense mechanisms

·         Acting out

·         Denial

·         Displacement (from unacceptable to acceptable)

·         Dissociation (dissociative amnesia)

·         Identification

·         Intellectualization

·         Isolation of affect

·         Projection (prejudice, paranoia)

·         Rationalization

·         Reaction formation (act opposite)

·         Regression

·         Somatization

·         Splitting (good guy bad guy – Borderline personalities – not ony movie heroes)

·         Undoing (superstitions, rituals)

Transference reactions

·         Transference: (e.g.: to caregivers, psychotherapist, teachers)

·         Positive: overidealize; sexual somebody

·         Negative: base of resentment

·         Countertransference

·         Transference reactions sometimes can cloud correct medical judgment

In doctor ptx situation for example they are

lBarrier to obtain information and compliance

lE.g. Denial

lProtect patient from face with emotional and physical consequences

lHinders ptx seek medical help

lE.g. Regression

lDesire for more attention and time

lHinders interaction

Transference reactions arise dilemmas in doctor patient relationship. This is much more so and certainly difficult to realize in mentally sick patient and doctor relationship

ØHow to give information

lTelling the complete truth about diagnosis & prognosis is obligatory

lAvoid religious, philosophical and patronizing statements

lInformation to a competent ptx should be given directly and not to/through relatives

lInformation to relatives can be given only with permission of the ptx

lChildren should be informed in age appropriate way

lIf parents do not want the child to be informed, the physician should follow the parent’s wish

ØHow doctor can participate in decisions for patients

lDoctor is not to decide what ptx shall do

•But facilitate decision making

lProvide information to ptx to make decision:

•Informed decision

Ø Sometimes patients are too difficult to handle. You rather want to send tha patient to another doctor or health professional. This is called “Abandonment.” What is best to do in this situation?

lDo NOT refer ptx to another doctor if she

lAnnoying

lSeductive

lAngry

lRefer ptx to another Dr. if she

lOut of your competence

lRequires service you don’t want to perform (abortion)

Important to understand your patient’s personality traits, coping styles in normal life and in case if illness (and your coping styles too) There are personality traits, personality types and personality disorders which result in different coping styles during different life situations.

Mild variations are different types of personalities, but when those personality traits are making frequent troubles for the person (and for everyone around her/ him) we are talking about personality disorders

ØPD’s are:

•Chronic and lifelong

•Dg on axis II

• 

ØList of classification of personality disorders:

•Cluster A

•Paranoid

•Schizoid

•Schizotypal

•Cluster B

•Histrionic

•Narcissistic

•Antisocial

•Borderline

•Cluster C

•Avoidant

•Obsessive-compulsive

•Dependent

Cluster A

ØParanoid PD. This person is:

•Distrustful

•Suspicious

•Litigious

•Attributes responsibility for own problems to others

•Interpret motives of others as malevolent

•Blames physician for the illness

•Overtly sensitive to a perceived lack of attention from the physician

ØSchizoid: This person has/is

•Long history of social withdrawal

•Detached

•Restricted emotions

•Little emotional connections

•Even more withdrawn during illness

ØSchizotypal: This person shows

•Bizarreness

•Peculiar appearance

•Magical thinking

•Oddity in Thought and Behavior

•Not psychotic

•Even more odd when sick

Cluster B

ØHistrionic. This person is

•Attention seeking

•Extroverted

•Overemotional

•Sexually provocative

•Shallow, vain

•Unable to maintain intimate relationship

•Don Juan or Femme Fatale

•Dramatic in reporting of symptoms

•Approach physician inappropriate seductive way during illness

ØNarcissistic. This person is

•Pompous

•Preference of special entitlements

•Lack of empathy for others

•Feels superior to others

•Illness is a threat to her self image

•Demanding when ill or also when not

ØAntisocial personality

•Refuse social norms

•Dishonest

•Conduct disorder as child criminal as adult

•The classical psychopath or sociopath

•No concern for others

•Fails to learn from experience

•Cruel without any remorse

ØBorderline personality

•Erratic unstable behavior & mood

•Experiences and complains Boredom

•Feeling of aloneness

•Impulsiveness

•Suicide attempts

•Self injuries & autoagression

•Associated with mood swings and eating disorders

•Mini psychotic episodes

•Brief periods of loss of contact with reality

•Overidealize others, but for short while

•Overreact

•Splitting (world is only made of good guys and bad  guys)

Cluster C

ØAvoidant

lTimid

lFear of being rejected

lSocially withdrawn

lInferiority feelings

lAvoids medical treatment & tests

ØObsessive – Compulsive person

lPerfectionalist

lOrderly (up to frustrating or comical level)

lStubborn

lIndecisive

lUltimately inefficient

lFear loss of control

lFollows orders to letters

ØDependent

lPoor self confidence

lOthers make decision instead her/him

lTake for granted others responsibility for her/him

lUltimate role: ‘The abused spouse’

lHelpless

lDesire attention

lExcessive need to be cared for by others

ØPassive – aggressive

lProcrastinate

lInefficient

lSullen and morose

lOutwardly compliant + inwardly defiant

lAsk for help but do not comply

ØGeneral attributes

lHistrionic, borderline, dependent, antisocial , schizotypal: 2-3% prevalence in population

lObsessive-compulsive, narcissistic, avoidant, schizoid: 1% or less prevalence

lManifested @ early adulthood

lBefore 18 y: we describe as “conduct disorder”

lNo insight

lLack of awareness

lThey suffer & makes suffer others

lTherapy is difficult and not really efficient

How personality traits are related with coping sickness?

ØCluster A personality type becomes more withdrawn in case of illness

ØCluster B likely to become more emotional, even seductive in case of illness (use close ended questions if you can with this patient)

ØCluster C personality will show more anxiety and fear in case of illness, might became more controlling or frustrated, or needy

Therefore compliance & adherence to therapeutic regimes is

ØNot related with

lIntelligence

lEducation

lSex

lReligion

lMarital status

lRace

lSocioeconomic status

ØBut Related with:

lPersonality traits

lDefense mechanisms

Diagnostic formulation in DSM IV (DSM IV TR) system

15 major diagnostic group PLUS other conditions:

1.      Delirium, dementia, amnesic and other cognitive disorders

2.      Caused by general medical conditions (organic)

3.      Substance related

4.      Schizophrenia & other psychotic disorders

5.      Mood

6.      Anxiety

7.      Somatoform

8.      Factitious

9.      Dissociative

10.  Sexual & gender identity

11.  Eating

12.  Sleep

13.  Impulse control

14.  Adjustment

15.  Personality disorders

16.  Other conditions (e.g. medically induced movement disorders, neglect, abuse)

lMultiaxial system:

nAxis I: clinical disorders

nAxis II: personality disorders and mental retardation

nAxis III: general medical conditions

nAxis IV: psychosocial & environmental problems

nAxis V: The global assessment of functioning scale (GAF):

n1: inability to maintain minimal personal hygiene, danger to self

n100: superior social & occupational functioning, no emotional problems

In addition also can be used

A.     Subtypes:

nE.g. schizophrenia, catatonic type

B.     Specifiers:

nFeatures

nSeverity

nPartial or full remission

nNOS (not otherwise specified)

nE.g. major depressive disorder with atypical features

Case Studies:

v  A 39-year-old woman presents to the outpatient mental health clinic at the request of her oncologist 3 weeks after being diagnosed with metastatic breast cancer. The patient denies strong feelings in relation to the diagnosis, but talks a great deal about the epidemiology of breast cancer and the available treatment options. Which of the following defense mechanisms

(A) sublimation

(B) dissociation

(C) intellectualization

(D) rationalization

(E) self-observation

Answer

(C) Intellectualization is the utilization of abstract thinking to deal with or cover internal or external stressors; in this case, the unacceptable feelings of having cancer. Sublimation is a defense mechanism employed to deal with unacceptable feelings or desires by channeling them into socially acceptable behaviors. Like sublimation, rationalization is a defense against undesired motivations, but in this case, the motivations are concealed by elaborate and reassuring explanations that avoid the actual underlying motives. Dissociation is a defense mechanism that deals with stressors with a breakdown of the usual integration of memory, behavior, and perception. Self-observation is a defense mechanism involving the reflection of one’s own thoughts and behavior with appropriate responses.

v  After being severely reprimanded by his employer, a man goes home and is extremely nasty to his wife. What is his behavior an example of?

(A) sublimation

(B) dissociation

(C) displacement

(D) rationalization

(E) conversion

Answers

(C) The man is naturally angry, anxious, and sensitive at being reprimanded by his employer. He has found it difficult to express his feelings toward the disturbing person, the employer. Instead of suppressing or repressing the anger, or sublimating his tension in more forceful work, he displaces his anger onto a safer target, his wife. This is an example of displacement.

v  A psychiatrist discovers that she is frustrated and easily angered with one of her patients for no obvious reason. While talking to a colleague, she admits that the patient reminds her of her abusive father. Which of the following best describes the clinician’s reaction?

(A) transference

(B) countertransference

(C) reaction formation

(D) displacement

(E) projection

Answer

 (B) Transference, in strict terms, is the patient’ re-experiencing of past experiences in the setting of psychoanalytic psychotherapy. Countertransference is the analyst’s (or therapist’s) response to this. These terms have come to mean the transferring of emotions and feelings that one has from one’s past to the other person; in the case of transference, the feelings are experienced in the patient and relate to how he or she feels about the therapist. In the case of countertransference, the feelings are experienced in the analyst or therapist and reflect how he or she feels about the patient. Reaction formation, displacement, and projection are all defense mechanisms used by the ego to keep potentially anxiety-provoking feelings out of awareness. Reaction formation is the formation of thoughts that are opposite to the anxiety provoking feelings. Displacement is the transferring of a feeling toward an object that is less threatening, as in the family pet or one’s spouse or children. Projection is the false attribution of one’s own unacceptable feelings to another.

v  A 42-year-old woman presents to a therapist with a history since early adolescence of dramatic mood swings, quickly becoming deeply depressed for hours to days, usually in response to separation from a loved one. She also admits to “rage attacks,” where she will break items, scream, or scratch herself superficially on her arms. She claims to drink in “binges,” up to 1–2 pints of hard liquor at a time. She has had over 30 sexual partners, many times without using contraception. Which of the following defense mechanisms is most likely employed by this patient?

(A) altruism

(B) intellectualization

(C) splitting

(D) sublimation

(E) undoing

Answer

(C) The patient meets the criteria for borderline personality disorder characterized by rapid mood swings, efforts to avoid abandonment, chronic feelings of emptiness, intense anger outbursts, impulsivity, fluctuations between idealization and devaluation, and recurrent self-mutilation or suicidality. Persons with this personality disorder commonly employ primitive defense mechanisms, such as denial, projective identification, and splitting. Splitting is dividing up individuals into “all good” or “all bad” categories. Intellectualization and undoing are considered neurotic defenses, while altruism and sublimation are mature defenses.

v  A34-year-old woman complains of a 3-month history of “feeling down” that has steadily worsened. After losing her job as a sales representative 1 month ago, she has been living with her parents and has not looked for work. The patient reports that she is unmotivated to do anything even the things she used to enjoy. She says that “nothing really matters...I don’t matter.” She has been sleeping 10–14 hours a night and has no appetite. More than once, she has pondered suicide as a possible escape route.

1. Given this patient’s diagnosis, what is the likelihood that she would fail to suppress her cortisol levels in a dexamethasone suppression test?

(A) 10%

(B) 30%

(C) 50%

(D) 70%

(E) 90%

2. What is the likelihood that she would have a blunted response of TSH to an administration of TRH?

(A) 10%

(B) 30%

(C) 50%

(D) 70%

(E) 90%

Answers

1. (C) This is one of the most important biological findings in affective disorder research. Studies show that in major depression, about half of all patients do not have blunted cortisol levels to an administration of dexamethasone the night before. This is thought to indicate abnormal feedback control in the hypothalamic-pituitary-adrenal axis in major depression. Patients with psychotic depression are even more likely to have poor dexamethasone suppression.

2. (B) About 30% of all patients with major depression do not show an increase of TSH with administration of TRH.

v  You are asked to give a psychiatric consultation on a 28-year-old woman with systemic lupus erythematosus who was admitted to the medical service. After you see her, one of your medical colleagues tells you that she will no longer speak to any of them because she hates all of them and insists on seeing you because you are the best doctor in the hospital. The psychodynamic term best used to describe the patient’s conflict is which of the following?

(A) acting out

(B) externalization

(C) regression

(D) splitting

(E) sublimation

Answer

(D) Splitting is the view that people around you are either all good or all bad. It is common in patients with borderline personality disorder although there is no other evidence of that in this case. Acting out generally represents the enactment of a behavior coming from an impulse that had presented conflict to relieve the sense that the conflict exists at all.

Externalization, a generalized form of projection, represents the tendency to believe in the existence of patterns of behavior in others that is really true about oneself. Regression is a return to patterns of relating, thinking, or feeling that had come before one’s current developmental stage. For example, many medical professionals who return home may act as if they are teenagers with regard to their parents or other hometown friends. Sublimation is the channeling of drives or conflicts into goals that eventually become gratifying. For example, some people remember being afraid of blood and hospitals and worked out these fears in medical school training.

v  A 37-year-old woman, who works the night shift at a local grocery store taking inventory, reports that her childhood and college years were uneventful but happy. She spends most of her time alone when she is not at work. She does not venture out of her house and her social contacts are limited to work-related interactions with coworkers. She is an avid plant lover and she spends most of her free time taking care of her indoor plants. She reports that she is quite content with her life. The most accurate diagnosis for this patient is which of the following?

(A) agoraphobia

(B) avoidant personality disorder

(C) schizoid personality disorder

(D) schizotypal personality disorder

(E) autistic disorder

Answer

 (C) Persons with schizoid personality are reclusive and do not mind the lack of social interaction. Agoraphobia is tied to the fear of panic symptoms in public. Such symptoms are not mentioned in this case. Persons with avoidant personality are shy and fearful of social rejection. However, their lack of socialization is distressing to them. Schizotypal persons can have schizoid features but they also have bizarre thinking. Patients with autism have pronounced deficits in language, communication, and socialization, which are not prominently reflected in this case of a woman who had uneventful but happy formative years.