The Patient

and Jeffrey R. Strawn2



(1)
Department of Psychiatry and Child Psychiatry, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, USA

(2)
Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati, Cincinnati, Ohio, USA

 



Abstract

By inquiring into a patient’s life story, with attention to his or her relationships with family, friends, and coworkers as well as to the person’s accomplishments and hardships, the psychiatric consultant will glean invaluable information and will be able to better understand the patient’s strengths and weakness. Such an understanding will almost certainly enhance treatment efforts and outcomes. Additionally, the reader should now appreciate that in approaching the difficult psychiatric consultation, it is critical to have a grasp of the patient’s cognitive skills, capacity for cognitive and affective flexibility , and temperament style. Systematically assessing the patient’s defense mechanisms , personality and attachment styles, cognitive and affective flexibility, and temperament provide the psychiatric consultant with a window into why some of the members of a treatment team may have difficulty interacting with patient and his or her family and will inform the psychiatric consultant’s interventions.


You always make each day a special day. By just youre being you. Theres only one person exactly like you in the whole world. And thats you yourself

—Fred Rogers “Mr. Rogers” (1928–2003)



3.1 From the Inside Out


In the training of psychiatrists who treat adults as well as those who focus on children and adolescents , the empathic doctor–patient relationship is recognized as the foundation upon which all successful treatments are constructed. Establishing rapport with the patient, with mutual respect, facilitates the desired treatment outcomes and, as such, is the sine qua non of psychiatric practice. Patients who suffer from mental illness are necessarily asked, when possible, to share the history of their history of present illness with a timeline that establishes when they first noticed their symptoms, the frequency of symptoms, variations in the intensity of symptoms over time, along with precipitating and perpetuating factors. Over the course of the traditional psychiatric evaluation, the clinician may quickly become focused on elucidating risk factors, identifying predictors of treatment response, and determining which “symptoms” meet threshold criteria for a disorder. Thus, with the standard use of the Diagnostic and Statistical Manual of Mental Disorders 5th Edition (DSM5, American Psychiatric Association 2013), the diagnosis is based on a collection of signs, and symptoms that have been well defined. Importantly, however, when a diagnosis is based solely on the use of DSM5 criteria, critical insight into an effective treatment regimen may be lost. The role of patients within the difficult psychiatric consultation can be determined using information they themselves provide. By inquiring about the patient’s life story, which includes experiences that have shaped their personality, with attention to their relationships with family, friends, and coworkers as well as to their accomplishments and hardships, we gain a better understanding of the patient’s strengths and weaknesses that will enhance or interfere with treatment efforts. The consulting psychiatrist is charged with incorporating the information obtained from the patient, from his or her family, and also other sources (e.g., prior medical or psychiatric treatment records, etc.) into the recommendations for the treatment team, whether they be psychopharmacologic or psychotherapeutic (Table 3.1).


Table 3.1
A comparison of a traditional DSM5 -based approach to the patient’s history (left) and an approach that includes both DSM5 criteria and the patient’s life story (right)









The patient is a 17-year-old adolescent with a history of generalized anxiety disorder and social anxiety disorder . At initial outpatient presentation, the patient described persistent fear of social situations, was preoccupied by how his peers perceived him, and avoided most social activities, including school. He had demonstrated limited improvement in school avoidance and withdrawal from social situations, despite ongoing cognitive-behavioral psychotherapy and fluoxetine, which had been titrated to 20 mg daily and reportedly worsened his anxiety. The patient and his mother also described intense concern about his future, a constant sense of inner tension and restlessness, as well as anxious ruminations that were associated with initial and middle insomnia. Moreover, he described recurrent headaches in times of anxiety, and he had recently terminated his part-time employment at a local restaurant.

Fluoxetine was discontinued, and over 8 weeks, sertraline monotherapy was initiated and titrated to 150 mg daily. Although there was some improvement in his subjective anxiety , he reported persistent social anxiety. Over the following 2 months, the patient experienced a continuing decrease in his anxiety, was less concerned about others’ perceptions of him, and was able to attend church and begin applying for a part-time job. He also reported improvement in his anxiety-related insomnia, a decrease in his sense of inner tension and restlessness, and diminished somatic symptoms. Nevertheless, he continued to fear being away from home and avoided social activities with friends.

John is a 17-year-old adolescent who has had severe anxiety since his parents divorced (when he was 11), due to his father’s affair with another woman. John struggled with significant anxiety and met DSM5 criteria for generalized anxiety disorder and social anxiety disorder . When John and his mother first met the psychiatrist, his mother appeared hesitant in her interactions and seemed untrusting. She explained that since her divorce, it had been “just John and me” and shared that both were close, adding that, “He is totally open about everything with me.” John said little and seemed to seek regular reassurance from his mother when asked questions. He gradually began to speak of how he avoided most social situations and instead spent time at home with his mother. During prior treatment with weekly cognitive-behavioral psychotherapy and fluoxetine, provided by their last psychiatrist, the closeness between parent and child, which seemed to be interfering with John’s adolescent developmental progress, were not addressed. John expressed worry over his future and described a constant sense of inner tension and restlessness, as well as anxious ruminations that were associated with initial and middle insomnia. He also shared that he feared that something would happen to his mother if he were not available to her. John and his mother were seen on a weekly basis in psychodynamic family therapy, and soon, after his symptoms improved, he began to socialize more and his mother began to encourage John to attend the therapy sessions alone as she was better able to tolerate his steps toward independence. However, given that John continued to experience some residual anxiety, his psychiatrist initiated sertraline monotherapy and titrated the sertraline to 150 mg daily).


The reader will note that the latter approach elucidates the manner in which the patient’s symptoms fluctuated with regard to family-system issues and his prior developmental experiences

While keeping the DSM5 in mind as a resource for the psychiatric consultant, we will review the importance in consultative work of understanding the patient’s life story. This understanding should not be limited to a person’s psychodynamic aspects; the clinician should also consider the contribution of the patient’s innate temperament and social cognition in the formation of their psychodynamic self against the backdrop of the family and of the social and cultural environment in which they have lived. One might describe this approach as a grasp of the interplay between the forces of nature and nurture. Although many psychodynamic and attachment-theory texts pay limited attention to cognitive functioning and temperament in forming personality, contemporary research has demonstrated that individual’s genetic makeup is a determining factor, and it has also expanded our understanding of the many ways that family, friends, and life events mediate the selection of the experiences stored in what is often referred to as implicit relational memory, which some consider the basis of the psychodynamic self (Mancia 2006). Herein, we will briefly review the manner in which cognitive functioning and temperament can have a profound impact on how a person approaches the life’s complexities and, more importantly, how they manage adversity, as in the case of a medical or psychiatric illness. As Sander Koole, PhD, eloquently noted, “Emotion regulation emerges as one of the most far-ranging and influential processes at the interface of cognition and emotion” (Koole 2009).


3.2 Cognitive Functioning


In understanding a patient, it is important to take into account their cognitive abilities, particularly with regard to the norms of their age. In routine practice, clinicians commonly perform a mental-status examination and may write a brief comment about the patient’s cognitive function (e.g., fund of knowledge, logical process, etc.). Such a superficial evaluation may be disadvantageous, however, in approaching consultations where parties are at a treatment impasse, as the clinician may remain unaware that core cognitive capacities are the root of the problem. At a minimum, the psychiatric consultant should assess whether the patient has the ability to interpret what their treatment plan involves without major distortions. When in physical or psychological distress, a patient may temporarily be unable to process the many diagnostic results or treatment recommendations. An example: during his colonoscopy, Dr. Adams, a competent internist, becomes overwhelmed when told by his gastroenterologist that he has a “malignant-looking polyp.” He returns to work and finds himself forgetting the names of his recently hired nursing staff and is unable to recall the agenda items for his administrative meetings. His mental status would indicate superior intelligence at baseline and currently having difficulties with memory and reasoning due to preoccupation with a possible malignancy in his colon. In contrast, a 25-year-old woman is diagnosed with idiopathic thrombocytopenic purpura, and treatment with corticosteroids is recommended. She is told to avoid activities that could cause injury and to limit her use of alcohol. Her hematologist is surprised at the intense and hostile reaction, as he has shared that her prognosis is very good and that improvement could be expected within a short period of time. Believing that she had been diagnosed with “blood cancer” and was called an “alcoholic,” the patient becomes irate and threatens to take legal action against the hematologist. A psychiatric consultation is requested, and it is found that the patient has struggled most her life with a receptive-language disorder that results in her misinterpreting information, though she excels in visual and hands on tasks. The psychiatric consultant asks the hematologist to make use of visual materials to explain the patient’s illness in more detail and to draw a timeline describing how the corticosteroids are to be taken and tapered off. The effects of alcohol in slowing the production of platelets are also visually explained. Though the patient’s “mental status” may have been reported as of “average intelligence,” this reduction fails to capture the receptive-language deficits that would likely place her in the below-average range for reciprocal verbal exchanges. Assessing her cognitive function revealed the way to approach the problem. In short, when one embarks in clinical decision making, it is critical to assess the person’s cognitive abilities. Not only can cognitive strengths and weaknesses affect a patient’s ability share personal experiences with others, they can also significantly influence the understanding and management of their illness and their interactions with the treatment team. As with Dr. Adams, reasoning can be temporarily impaired due to anxiety about one’s own well-being, and “viewing the world as a safe and predictable place and seeing oneself as a competent agent in that world are important psychosocial resources for handling stress” (Turner and Roszell 1994) will allow for use of inner strengths. In extreme cases of bereavement or depression , the patient may present with what appears as severe cognitive deficits and having access to a baseline cognitive evaluation can help the clinician discover and appeal to their innate strengths.

In difficult psychiatric consultations, there are times when the consultant, the family, or the treatment team may request formal cognitive testing. In these cases, families are usually relieved to have concrete evidence of their ailing relative’s strengths and limitations, and once they understand the reasons their loved one’s experience of the treatment team is repeatedly misinterpreted, their anxieties diminish. Imaging studies have shown structural and functional brain abnormalities associated with the presence of these cognitive and linguistic communication disorders (Delgado et al. 2011; Frodl and Skokauskasm 2012; Lai 2013; Webster et al. 2008). Moreover, by some reports, 10 % of the general population has learning weaknesses, and among this group, many have formal learning disabilities (Altarac and Saroha 2007; Cooper et al. 2007).

Considering these statistics, it is not surprising that learning disorders or learning weaknesses may be frequently observed in difficult psychiatric consultations—not only in the patient, but, as illustrated in the vignette below, also in family members, whose cognitive deficits may prevent them from recognizing the patient’s limitations.


The Learning-Disabled Adolescent


A 16-year-old girl is admitted to a general pediatric inpatient unit for the treatment and management of her diabetes. During her stay, she shares with the treatment team that she feels overwhelmed in managing her diabetes and that the day before, while at school, she had suicidal ideation and felt like “just letting go of life.” The treatment team requests a psychiatric consultation to assess the patient’s safety and to evaluate for possible depression , as they have stabilized her blood sugars and are “ready to discharge her.” The treating physician requests that the treatment-team social worker provide the education needed for the patient and mother to manage the diabetes at home. As the psychiatric consultant completes the evaluation of the patient and her mother, the treatment-team social worker arrives and proceeds to explain, to the patient and her mother, the complexities of diabetes management, the ramifications of poorly controlled blood sugars, and the need for careful monitoring of her blood sugars. Thereafter, the social worker asks the adolescent if she is willing to assume responsibility in managing her diabetes and also asks her mother if she is willing to help her daughter follow through with the recommendations. The psychiatric consultant is not surprised when the patient and her mother readily agree to accept responsibility. They had shared with the consultant that they usually are agreeable to recommendations made by doctors, “even though sometimes we have trouble understanding them.” They both fear being seen as difficult if they raise any questions or ask for information to be repeated. However, the patient had previously revealed to the consulting psychiatrist that, upon entering high school, “things got worse. I couldn’t remember any of the details about my assignments. I failed math, and I just didn’t understand what the teachers said unless I could write it down.” Her mother, in tears, had shared that when she was an adolescent it was confirmed that she had a learning disorder, that she “barely made it through high school” and had recently begun attending a technical college that provided tutoring in math and a scribe to help her with classroom work. She was hoping to have her daughter formally tested at school “for a learning problem,” saying, “She is just like me, poor kid.” Upon probing further, the consulting psychiatrist found that patient had struggled for some time with her learning difficulties, though with the help of her supportive family, she felt that “I really am not a quitter, I just need help. I don’t pay attention because I can’t understand.” With this in mind, the psychiatric consultant—noting that the treatment-team social worker was delivering all her recommendations verbally—intervened, explaining to the social worker that the patient and her mother were withholding their problems with memory and verbal comprehension in order be perceived as a pleasant and compliant family, and that although they both were “willing,” they were not “able” to assume full responsibility with the recommendations made. Making the social worker aware of the patient and mother’s learning problems, he asked for the recommendations to be delivered in writing to help the family. The social worker’s response that “We have never approached matters this way” is discouraging in that it suggests the limited attention generally given to cognitive skills, and this may explain the frequent issues of non-compliance in adolescent diabetes clinics.


Cognitive and Affective Flexibility


As part of any evaluation of a patient’s cognitive function, the capacity for cognitive and affective flexibility , also referred to as social cognition , should be assessed. Cognitive and affective flexibility are the aspects of cognition that allow the individual to psychologically approach situations with a degree of openness about the fact that their experience is influenced by another person’s state of mind and by the contextual, social, and culturally appropriate norms, and to tolerate some degree of uncertainty.

Cognitive and affective flexibility involve several components: executive function , attention, working memory , and emotion regulation (Johnson 2009; Schmeichel et al. 2008). A child reacts with glee as he or she infers that it is acceptable to play with the toys in the physician’s office because they are available in an open bin. An adult is disappointed and understands his or her sports team lost when seeing the scoreboard. Moreover, when a person initially refuses to take medications, they implicitly understand the societal disapproval—family member or physician—even if not present, and the negative medical consequences and proceeds to take the medication. Cognitive and affective flexibility precede the development of language skills which typically emerge from 2 to 5 years of age (Blackwell et al. 2009). Cognitive and affective flexibility permit persons to expand awareness and to accept multiple solutions to novel or unpredictable events. Thus, when there is limited cognitive and affective flexibility, a patient may have less adaptability and less interest in engaging with his or her treatment team. In such a situation, the patient may view the treatment team as interfering with his or her life, may minimize the seriousness of his or her illness and may have difficulties with compliance.

Assessing cognitive and affective flexibility can be done briefly during the routine evaluation. When patients are frightened about their well-being due to a medical or psychiatric illness, the clinician can ease their minds and build rapport by spending a brief amount of time asking a few personal questions, reassuring the patient that they are viewed as a whole person and not as a diagnostic entity. In the course of this exchange, the consultant, in an effort to assess cognitive and affective flexibility , may ask the patient to share their view of themselves, their life achievements and accomplishments, and the importance of their relationship to their spouse, children, and friends before the illness was diagnosed. The interview is intended not to minimize the complexities of the illness but rather to understand the impact it will likely have on the patient and their family system and whether the system will be able to psychologically and cognitively comply with the treatment-team recommendations.


Brief Assessment of Cognitive and Affective Flexibly in Adults






  • History of the patient’s view of himself before the illness was diagnosed.


  • History of the patient’s achievements and accomplishments.


  • History of the patient’s preferred activities with others, including spouse, children, and friends.


  • Discussion of how the treatment team can best respond to the patient’s emotional needs (e.g., a post-rounding “check in” with the patient and/or family, allowing family or colleagues to visit the patient after “visiting hours”).


Cognitive and Affective Flexibility in Adolescents


For a medical or psychiatric illness in an adolescent, the diagnosis and recommended treatment are often shared simultaneously with the patient and his or her parents. In spite of their normal developmental fears and worries about their well-being, adolescents should be allowed to be active participants regarding their need for more information about their illness and the course of action concerning it. How the psychiatric consultant can best help the treatment team communicate with adolescents will depend on the patient’s level of cognition and cognitive and affective flexibility . Assessment in adolescents is less complex than with younger children, in that developmentally adolescents begin to have capacities similar to that of adults in understanding the nature of their illness, and their reactions are less influenced by fantasy. It is important to keep in mind that some adolescents respond better to the treatment team when humor is used to engage with them before providing information about their illness. In the example later in this chapter, Jason is comfortable with closeness and uses healthy defense mechanisms (humor, sublimation) that the psychiatric consultant notices and employs to establish an alliance. This allows Jason to later jovially ask the consultant to accompany him to the hospital cafeteria for lunch to discuss his ambivalence in continuing with his chemotherapy. In contrast, other adolescents may prefer a professional, intellectual demeanor. This serious approach allows some adolescents to use isolation of affect and, at times, periods of denial regarding the severity of their illness, which may help them comply with treatment recommendations and improve outcome. The psychiatric consultant should be prepared to encourage the treatment-team leader, who may not be the right personality “fit” for a given patient, to recognize that the information may be best received if delivered by a different team member (e.g., a resident or nurse) with experience in working psychologically with adolescents. This presents the psychiatric consultant with an opportunity for a teachable moment that will educate the treatment team in the developmentally different cognitive and emotional abilities of adolescents (Bleiberg 2000; Steinberg 2005).


Brief Assessment of Cognitive and Affective Flexibility in Adolescents






  • History of the patient’s preferred activities with others including parents, friends, and dating.


  • History of the patient’s birthday celebrations, favorite persons that attended, and gifts received.


  • Review of achievements and accomplishments they feel proud of.


  • History of favorite video games, music, and sports activities.


  • Discussion with the patient of how the treatment team can best respond to their emotional needs (e.g., a post-rounding “check in” with the patient and/or family, allowing peers to visit the adolescent patient after “visiting hours.”)


Cognitive and Affective Flexibility in Preschool and School-Age Children


The diagnosis and treatment of a medical or psychiatric illness in preschool and school-age children is commonly shared with the parents but not with the child, as it is often considered to be overwhelming for them. Despite the belief that informing the child may lead to many fears and worries, some young children are interested in knowing about the implications their diagnosis and treatment plan will have on age-appropriate activities: playing, reading, etc. As with any patient, particularly children, there is no one-size-fits-all approach. Communication with any child should depend on his or her level of cognition as well as his or her cognitive and affective flexibility. The assessment of these in preschool and school-age children is complex in that it needs to take into account the norms of their developmental stages, with input from their parents or caregivers to corroborate their responses, and involves a review of any cognitive delays that may have been present before the medical or psychiatric illness. The responses given by preschool and school-age children can be colored by healthy fantasy, and may be exaggerated due to the stress of illness. Ascertaining the extent of a child’s understanding of their illness is critical so that the treatment team can learn to explain the diagnosis and its treatment at his or her level. When being told about their illness, some children will respond better with the use of drawings, and some may prefer an intellectual approach and welcome the use of written materials. The treatment team may have members better able to go to the childs level, and careful delegation of who will communicate the information can reduce anxiety in young patients, thereby facilitating cooperation with procedures and compliance with treatment. The psychiatric consultant may also need to help the treatment-team leader recognize that another team member—such as a resident or nurse, someone with natural abilities in working psychologically with young children—will be better able to communicate with the patient without causing undue stress. This provides the psychiatric consultant an opportunity for a teachable moment, in which the treatment team learns about the developmentally different cognitive and emotional abilities of young children. For young and anxious children, treatment teams should strongly consider involving the patient’s parents in the delivery aspects of the treatment plans, if they are not also overwhelmed by their own anxiety. In many cases, parents can serve as caring conduits for their child.

In working with children, and at times adolescents , the consulting psychiatrist may utilize a “time-tried” projective technique often referred to as the “three wishes scenario .” In this frequently employed technique, children are asked to imagine they find a magic genie’s lamp, from which they release a genie who will grant them three wishes. The children are encouraged to request whatever they hope for. In using this technique, the clinician can assess defense styles, cognitive and affective flexibility , and avoid the anxiety produced by direct questioning. Importantly, this exercise in consultation work is not intended to be used clinically to develop a hypothesis regarding the psychological meaning of the three wishes as would be in a psychotherapeutic process. The patient’s responses may be concrete and limited, indicating the impoverished age-related fantasy life of a child who is likely to fear and misinterpret treatment and will need a great deal of reassurance. By contrast, when the answers and approach to the scenario reflect rich and healthy fantasies—wish for good response to treatment, to return home, etc.—the child will likely be engaged in their recovery process and aware of what is needed of them. In addition, the child’s responses to all three wishes should be assessed within the context of their family situation. As an example, a consulting psychiatrist evaluating a 10-year-old girl admitted to the neurology service for status migranosis (intractable headaches) inquires as to the girl’s “three wishes.” The patient describes her wish for the headaches to be gone, for her family to be happy, and, with playful affect, for a new Smartphone with unlimited texting. Her wishes reflect underlying healthy defense mechanisms , caring and concern for her family, and her ability to see herself as integrated within an age-appropriate, stable environment. By contrast, a 10-year-old girl with limited cognitive and affective flexibility who is admitted under the same circumstances may wish “to be on a TV show, to have all the video games in the world,” and then with some hesitation adds, “I want to go home.” These wishes reveal a limited understanding of her role within the context of her larger world and a perception that the illness is foreign to her “everyday self.”


Brief Assessment of Cognitive Flexibility in Preschool and School-Age Children






  • Elicit the child’s recollection of prior birthday parties and favorite gifts received.


  • Ask who the child enjoyed having attend the birthday parties.


  • Review the child’s achievements and accomplishments as well as other experiences that have made him or her feel proud.


  • Obtain a history of their favorite toys, games, video games, and movies.


  • Use the common “projective technique” of asking the child, “What would you ask for if a genie granted you three wishes?”


3.3 Temperament


Temperament refers to the “stable moods and behavior profiles observed in infancy and early childhood.” Though its first description can be found in Ancient Greece two millennia ago (Kagan 1994), temperament came to the forefront in developmental psychology and child psychiatry in the 1960s and 1970s (Thomas and Chess 1977). The relevance that temperament styles have in consultation-liaison work is multifaceted. Although there have been many classification schemes, Thomas and Chess (1999) are recognized for their landmark scientific contribution to the study of temperament. Their seminal work has achieved general consensus in that its expression has been consistent across situations and over time. In their study, Thomas and Chess longitudinally evaluated 141 children over 22 years, from early childhood until early adulthood (1982, 1986). Over the course of this evaluation, nine temperament traits became apparent and are described in more detail later in this chapter.


Temperament Traits Derived from Thomas et al. (1970)






  • Activity level


  • Rhythmicity or regularity


  • Approach or withdrawal responses


  • Adaptability to change


  • Sensory threshold


  • Intensity of reactions


  • Mood


  • Distractibility


  • Persistence when faced with obstacles

The work of Thomas and Chess confirmed what the British psychoanalyst and father of attachment theory John Bowlby , MD, (1907–1990) had hypothesized: a child’s temperament influences how the child is experienced by their parents and significantly shapes how the parents interact with the child (Bowlby 1999). This way of thinking, where an active and bidirectional relationship exists between the child and caregiver, represented a significant point of divergence from the previously accepted understanding of the infant as a passive recipient and product of his or her environment (Mahler et al. 1973). In essence, the child began to be seen as a full contributor to the “goodness of fit” (Thomas and Chess 1999) between the child and the parents or caregivers. The two researchers found that “some children with severe psychological problems had a family upbringing that did not differ essentially from the environment of other children who developed no severe problems,” and later added that “domineering authoritarian handling by the parents might make one youngster anxious and submissive and another defiant and antagonistic.” Thus, “theory and practice of psychiatry must take into full account the individual and his uniqueness” (Thomas et al. 1970). Furthermore, it is important to note that temperament in infancy and early childhood is influenced not only by heredity but also by environmental experiences (Emde and Hewitt 2001), and as a consequence, temperament is recognized as pivotal to our current understanding of attachment theory (Chap. 2).

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Dec 3, 2016 | Posted by in PSYCHOLOGY | Comments Off on The Patient

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