3rd Objectives - Difficult pt Flashcards
(10 cards)
Transference
o Process of a patient unconsciously and inappropriately projecting emotional and behavioral reactions from significant figures in the past onto people in the present.
(ie. displacement is onto the psychiatrist)
Countertransference
o The process where the physician unconsciously projects behavioral or emotional reactions toward the patient in response to the patients behavior.
Challenges with significant expressions of unconscious processes
- The patient may be angry, hostile, demanding, or obsequious not because of the reality of the relationship with the psychiatrist but because of former relationships and patterns of behaviors.
- Failure to recognize this process can lead to the psychiatrist inappropriately reacting to the patient’s behavior as if it were a personal attack on the psychiatrist.
Obstacles and alternative ways to obtaining a good history in patients with PSYCHOSIS
- Patients are often frightened and guarded
- May be actively hallucinating during interview leading to inattentive and distracted.
- May have suspicions regarding the purpose of the interview.
- Interviewer alter the usual format and adapt the interview to match the capacity and tolerance of the patient.
- Helpful to ask that patient about a specific instance of a hallucinations.
- Helpful to shift the attention back to the patient’s rather than the examiner’s beliefs and acknowledge the need for more information.
- Avoided sustained direct eye contact as this may be perceived as threatening.
- Helpful to ask directly about such fear
Identify obstacles and alternative ways to obtaining a good history in patients who are; DEPRESSED
- Impaired motivation and may not spontaneously report their symptoms.
- Feelings of hopelessness, lack of engagement.
- More direct questioning rather than an open-ended format.
Identify obstacles and alternative ways to obtaining a good history in patients who are; POTENTIAL SUICIDE
- Suicide assessment should be performed for all patients including prior history, family history of suicide attempts and completed suicides, and current ideation, plan, and intent.
- Asked about current thoughts of suicide and if thought are present and what is the patients intent.
- Presence of psychotic symptoms should be assessed.
- Interviewer should pursue this line of questioning in detail if the patient has taken any preparatory steps to move forward with the plan.
- If the patient is to be viewed to be at imminent risk and take action to secure the safety of the patient
Identify obstacles and alternative ways to obtaining a good history in patients who are; HOSTILE
• Be aware of safety features,
remain calm.
- Acknowledge and diffuse the anger.
- Focus on aspects of real pain.
- Deal with legitimate reasons for anger.
- Clarify your role as a physician, must remain safe at all times.
- Embark on mutual problem solving.
- Avoid confrontation and increased hostility.
- Clarify problems with the system.
- Suggest ways to have follow-up that are less frustrating.
Identify obstacles and alternative ways to obtaining a good history in patients who are; AGITATED
- Decrease excess stimulation as much as feasible
- Interviewer aware of own body position and avoid postures that could be seen as threatening, including clenching hands or hands behind back
- Approach interview in a calm, direct manner, and take care not to bargain or promise to elicit cooperation in the interview
Identify obstacles and alternative ways to obtaining a good history in patients who are; POTENTIALLY VIOLENT
- If the patient makes threats or gives some indication that he or she may become violent outside the interview setting, then further assessment is necessary.
- Past episodes of violence should be explored as to setting, what precipitated the episode, and what was the outcome or potential outcome (if the act was interrupted).
- What has helped in the past in preventing violent episode should be explored.
Identify obstacles and alternative ways to obtaining a good history in patients who are; DECEPTIVE
- Patients lie or deceive their psychiatrists for many different reasons
- Some are motivated by secondary gain
- Some patients may deceive, not for an external advantage, but for psychological benefits of assuming a sick role
- Gather collateral information regarding the patient
- Broad understanding regarding the patient outside the interview setting
- Discrepancies in symptom severity between self-report and collateral information may suggest deception
- There are some psychological tests that can help in further evaluate the reliability of the patient.
