Comprehensive History Taking for the Non-Psychiatrist M. STRAKER, M.D., F.A.P.A.,» Montreal - PDF

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Canad. Med. Ass. J. General Practice: History Taking 39 Comprehensive History Taking for the Non-Psychiatrist M. STRAKER, M.D., F.A.P.A.,» Montreal To an increasing degree the psychiatrist is oriented

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Canad. Med. Ass. J. General Practice: History Taking 39 Comprehensive History Taking for the Non-Psychiatrist M. STRAKER, M.D., F.A.P.A.,» Montreal To an increasing degree the psychiatrist is oriented to the community and general hospital either as consultant, therapist, or collaborator in overall pa tient management. In these new roles, he becomes a more comprehensive physician and also conveys psychiatric insights to his colleagues. Psychological factors and the patient's person ality style influence the development and course of every disease, complicating diagnosis and effec tive treatment. It is a basic requirement that a good working alliance be established between pa tient and physician. This is assisted by compre hensive history taking, which clarifies the lifesetting in which the illness began, the patient's personality and his habitual reactions of emotional regression under stress. It will also point up errors introduced by the patient, omissions, and distortions in offering the subjective data which the physician must evaluate. Seven major personality types and appropriate physician responses are outlined: the dependent demanding oral patient, the orderly controlled obsessive, the dramatic seductive nysteric, the longsuffering masochist, the querulous paranoid, the overbearing narcissist and the aloof withdrawn schizoid. The non-psychiatrist can resolve complex and puzzling medical problems if he has an increased awareness of how emotional forces complicate ill ness and if he can exploit comprehensive history taking to the full. HPHE role of the psychiatrist in the continuum -*. of medical services is still in evolution. For centuries past, the psychiatrist has been the physician to the mad, and via jokes and jibes it has been implied that he is often a little mad himself. The more charitable have described him as less scientific than other physicians. How ever, in the last half-century the evolution of a systemic theory of personality development, especially in the area of depth psychology, has provided a base for the application of tradi tional scientific methods in the study of the whole man. To this should be added the promis ing contributions from biochemistry, physiology and psychopharmacology. The psychiatrist has moved out of professional isolation in the asylum hospital. The latter itself Presented at a meeting of the Quebec Medical Associa tion, Montreal, June 3, 1966.?Associate Professor of Psychiatry, McGill University, and Associate Psychiatrist, Montreal General Hospital, Montreal, Quebec. Reprint requests to: Dr. M. Straker, Suite 660, 3550 Cote des Neiges Road, Montreal, Quebec. Le psychiatre oriente de plus en plus son activite sur la collectivite et Thopital general, ou il remplit les roles de consultant, de therapeute ou de collaborateur dans le traitement global du malade. Dans ces nouveaux roles, il devient lui-m6me un medecin plus complet et donne a ses confreres des apercus de psychiatrie. Des elements psychologiques et la personnalit6 du malade influencent la genese et 1'eVolution de toutes les maladies, venant ainsi compliquer surtout le diagnostic et l'application de traitements efficaces. 11 est indispensable qu'une franche et constructive collaboration s'etablisse entre le malade et son medecin. Ceci peut etre facilit par une anamnese complete, qui jettera la lumiere voulue sur les circonstances de la vie du malade qui ont entoure le debut de la maladie, sur la personnalit du malade et ses reactions coutumieres de regression emotive sous l'influence du stress et permettra de deceler les erreursj introduites par le malade, omissions, ses ses fantaisies et ses distorsions, de sorte que le medecin disposera des donnees subjectives qu'il doit evaluer. L'auteur indique les sept types principaux de personnalite et l'attitude approprie que doit prendre le medecin. Ces types sont: la personnalit^ exigeante et d^pendante, la personnalite obsessionnelle m&hodique, l'hysterique, le masochiste, le paranoide, le sujet atteint par le narcissisme et le schizoi'de. Le medecin non specialise en psychiatrie pourra resoudre des problemes medicaux complexes et troublants s'il est conscient du fait que les forces emotionnelles compliquent la maladie, et en exploitant a fond la methode de l'anamnese approfondie. is disappearing and being replaced by the newer community-based psychiatric institutes and psy chiatric units in general hospitals. In his newer roles, the psychiatrist is in much closer profes sional contact with his medical colleagues, with whom he now shares the same patient, the same philosophical and scientific objectives of ob servation, diagnosis and therapy, the same insti tutions.particularly the general hospital, and the same scientific societies. From the closer contact and common interest much good has already come and much will still come. The cynical query whether the psychiatrist is also a physician is disappearing as psychiatrists learn more about scientific medicine from their medi cal colleagues by listening and learning, and through the osmosis which operates in the gen eral hospital setting. The psychiatrist's skills, in sights and special orientation are valuable in 40 General Practice: History Taking Canad. Med. Ass. 3. Jan. 7,1967, vol. 96 medical problems of shared interest; he can provide broad and useful psychological insights which will be helpful to other physicians. Thus, the earlier function of the psychiatrist which restricted him to the insane has now been broadened to include the study of psychological factors that contribute to ill health, whether somatic or psychological. He restates the indivisibility of mind and body, and re-emphasizes that therapeutic interactions between patient and physician can modify the natural course of an illness and promote recovery. In practical terms, psychiatric insights can help the nonpsychiatrist in dealing with difficult patients. The psychiatrist can show the general physician how to gather essential medical data (historytaking) that can be useful in medical problemsolving (diagnosis), and may assist also in treat ment, particularly in those areas where the personalities of the patient and physician interact. Depth psychology assumes that any person's behaviour and attitudes are influenced by con flicts between deep strivings and defences against these strivings, developed in a slow adaptive process under the influence of environ mental pressures and demands. Underlying con flicts are revived and intensified at times of stress, and an illness represents one form of in creased stress. Thus, the patient's personality style , represented by his characteristic emo tional responses to stress, will always modify illness by enlarging an or reducing symptoms and complaints, or by adding new dimensions to it. In this way, secondary emotional impacts stimu lated by the illness are always superimposed and influence the evolution of the underlying disease. In diagnosis and management, it is of first im portance to differentiate between organic and psychogenic disorders. The latter diagnosis must be made not by exclusion of organic disease but by establishing positive findings to support each psychogenic diagnosis. It is important also to know that one diagnosis does not exclude the other. Organic and neurotic disorders can exist together, either independently or in an inseparable union, but each element must be evaluated and assessed. The penalty for failure to make an accurate diagnosis is obvious. The effects of inaccurate diagnoses are multiplied by inadequate and/or ineffective treatment. Querido1 has described the part that emotional factors play in readmissions to general hospitals. From a study and follow-up of 2500 general-hospital admissions he stated that 56% of those admitted had predominantly somatic disorders, and 80% of these were cured or had remission of symptoms following organically oriented treatment techniques. Eighteen per cent of patients had somatic problems, but also had psychological problems that were sepa rate from or added to the organic disorder. Only 44% of these responded to the treatment provided in the same setting. In a third group of patients (21% of the total) who had marked intertwining of psychological and organic prob lems, somatic therapies produced improvement in only 38%. The remaining 5% of admissions had entirely psychiatric disorders, and organic disease was ruled out. Kaufman and Bernstein2 have reported similar findings after reviewing 1000 problem patients on the outpatient medical services department at Mt. Sinai Hospital, New York. The persisting difficulties of patients who do not respond to traditional medical and surgical therapies often evidence of emotional problems which are have not been attended to. There is no need to refer further to such studies, since the theme is familiar. The hope is that more comprehensive clinical assessments will become the rule as the psychiatrist moves into the general hospital setting. Here, he may function as a consultant or as part of an opera tional team, giving and receiving information at all levels. His concern is still psychiatry, but within the larger framework of medicine.3 He may treat psychiatric patients in a general hos pital setting, even on the medical wards, and this has done much to combat the traditional stigma of mental illness. Treatment on medical wards also encourages earlier treatment and with this comes more complete and longer-lasting remissions.4 Problems in Interviewing The importance of adequate history taking in reaching a diagnosis and deciding on therapy can hardly be overemphasized. A good history should provide 90% of the data required to reach a provisional diagnosis; the latter is con firmed or modified by data obtained by physical or laboratory examination. Many patients, how ever, are poor witnesses.they exaggerate some complaints and minimize others. Some leave out important information because of anxiety about what the complaints may indicate in the way of disease. Some invent complaints that express their own phantasies of illness, or in this way express their hopes of what the physician will be or do for them. In essence, the emotional reac tion of the patient, expressing his own person ality responses under stress, has a marked effect on the material that will be presented to the Canad. Med. Ass. J. Jan , vol. 96 General Practice: History Taking 41 physician, when he gives the history and de scribes the development of his complaints. This response, the transference reaction , distorts objective data in many ways. The term implies that the physician is not perceived by the patient only as a doctor who diagnoses and treats dis eases, but also is irrationally invested with emo tional values derived from past and earlier life figures of great importance to the patient. Under the stress of illness, patients undergo emotional regression and respond to the doctor's interest and intervention with more and more emotion ally charged reactions. In the positive trans ference reaction the patient has sublime confi dence that his doctor is next to God. This reaction is reminiscent of the child's transient and blind adoration of mother or father, who he feels is all-knowing, all-protecting, omnipotent. In negative transference, the patient manifests suspicion, mistrust, antagonism and hostility, and constantly tests the physician's efforts and skills. This can be compared to the disillusioned sulking child whose interaction pattern is expressed by the Oh yeah? philosophy. An assessment of the patient's personality is often crucial in history-taking. It is important to realize that, without consciously intending to lie, patients can rarely tell the truth. Their un conscious and conscious emotional drives lead to distortions that make the truth difficult to establish. Kahana and Bibring5 at the Beth Israel Hos pital, Boston, have described the varied person ality types and their impact on medical management. These types are as follows: (1) The dependent overdemanding patient (oral type). These patients urgendy demand attention, advice and limitless care; only when protection is provided can they feel secure. Their demands are great, so that they easily become disappointed, frustrated and depressed. Often they are excessive eaters, drinkers, smokers, and easily become addicted to medicines. When sick, their emotional regression makes them more infantile, more dependent and demanding. The appropri ate physician-response is to provide adequate physical care that is reassuring and, in a setting of non-punitive patience, to establish limits. (2) The orderly controlled patient (obsessive). Self-control and discipline are especially important to this individual. His inner conflict between compliance and rebellion is expressed by rigidity and stubbornness. If he is ill, emo tional regression threatens loss of control and leads to indecision. The appropriate physicianresponse is to discuss the findings and proce dures fully, to treat the patient as a full partner, and to be willing to yield in unimportant matters. (3) The dramatic seductive patient (hysterical). These patients are teasing, jealous, attentiondemanding, and emphasize their defencelessness to evoke a gallant response. They search for an idealized romanticized relationship with the doc tor. They often use denial and make poor informants. When ill and emotionally regressed, they feel weak, unattractive, punished for the forbidden wishes of childhood. Their attempts to deny such fears lead to flirtatious and sexu ally teasing behaviour. The physician's response should be warm but he must avoid emotional entanglement. The patient needs many oppor tunities to discuss pent-up feelings. (4) The long-suffering patient (masochist). These patients create their own bad luck by making poor choices and overdoing things. They deny themselves, overexert themselves for others, exhibit their sufferings to evoke praise from others. To suffer has become a technique to expiate unconscious guilt, and has been fostered by the childhood experience of being rewarded in sickness or in pain. During the emotional re gression of illness, the symptoms are accentuated, the complaints are more fervent, and symptom improvement is denied. The search for love and protection is manifested through in creased suffering, a state that can become irritating and disappointing to the doctor. Physician response should tacitly acknowledge the patient's need to suffer but he should urge the patient to get well in order to show consideration for others. (5) The querulous patient (paranoid). This type is oversensitive, suspicious and vulnerable; these patients are really expressing a deep under lying concern about their own faults and weak nesses. They disclaim the existence of these unwanted traits in themselves, project them to others, and then attack them. When ill, they feel more vulnerable and get angry. The appropriate physician response is to avoid conflicts and argu ments, to maintain a friendly distance and ex plain the clinical management. Do not argue with the patient, but acknowledge how difficult it is to be sick, and request co-operation. (6) Superiority complex patient (Narcissistic). Such persons are arrogant, demanding, patronizing; they see themselves as all-powerful. This is a reaction to underlying fears of inadequacy. The patient competes with the physician, always looking for weaknesses to exploit. If ill, the selfimage of omnipotence is threatened. Implicitly, the physician should acknowledge the patient to be a person of importance, and treat him with respect. 42 General Practice: History Taking Canad. Med. Ass. J. (7) The aloof patient (schizoid). This patient is reserved, aloof, independent, uninvolved. Underneath, he is often fragile, oversensitive, easily upset. When he is ill, there is a further withdrawal. The physician should acknowledge the unsociability without retaliative aloofness. A quiet reassuring interest should be maintained. In history-taking, the physician will be greatly assisted if he is aware of and uses his under standing of the patient's personality. As noted, some patients deny symptoms or allude to them only indirectly. The man who comes in for a check-up may be having sexual difficulties which are difficult for him to discuss or may have a fear of cancer which expresses itself as a mild depressive state and which he regards as too foolish to mention . The youngster who appears overconcerned about some trivial cos metic defect may actually be trying to convey a deep fear of being different and peculiar. The woman who complains of headaches may really be trying to allude to emotional headaches related to an unhappy marriage, an intra-family problem, etc. The older patient who has all sorts of somatic complaints without much in the way of organic findings may be describing the depressing and lonely life that follows the death of a spouse, or some other significant emotional loss. Complaints about fatigue and sleep dis turbances should stimulate the doctor to make further enquiries to clarify the state of the pa tient's emotional equilibrium. Increasingly in recent years attention has centred on countertransference problems. It used to be that if the physician-patient relation ship did not go well, the patient was routinely blamed as too sick , uncooperative, poorly motivated, etc, and was thereupon dismissed. The physician's own emotional biases, person ality defences and blind spots can, however, block the establishment of a working alliance between patient and doctor, or can introduce special problems in management. According to Bogdonoff,6 countertransference can give rise to error in medical care and can influence the natural history of disease. I have described the effect of such factors in the management of geriatric patients and in outpatient psychiatric practice.7' 8 The ideal physician response to each patient requires flexibility and individuality of approach which encourages the establishment of an optimal climate for healthy physician-patient interaction. Undue rigidity on the doctor's part, the intrusion of personal dislike or bias regard ing race, colour or creed, or antipathy to specific personalities will distort the workup, manage ment and course of the illness. If he cannot modify or control his own distorting emotional reactions in a given situation, the physician should be honest with himself and withdraw from the case, after he makes sure that another physician is available. A step short of this, which can be very helpful, is to ask for another opinion; a colleague can then evaluate developments in the case from a different and neutral point of view. History-taking is a crucial step in establishing a useful working relationship and in obtaining data necessary to an accurate diagnosis. It also may suggest treatment techniques that are likely to be effective. The physician's medical re sponsibility is not limited to his professional (scientific) services but embraces the appro priate use of his own personality in transactions with the patient: thus the science of medicine is complemented by the art of medicine. Problems in Diagnosis The major errors and failures in diagnosis those of omission rather than commission. The are physician still responds to his medical under graduate routines and places psychoneurosis at the bottom of the list in differential diagnoses. This diagnosis was finally arrived at by exclud ing all other possibilities. The obvious error here is that any diagnosis must be supported by posi tive signs, not by absent or negative ones. Also, this approach implies that an organic disorder excludes a psychiatric one and vice versa: a dangerous misconception in either situation. In the differential diagnosis of complex medi cal situations, failure to consider the importance of personality and emotional pro
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