Showing papers in "International Journal of Psychiatry in Medicine in 1970"
TL;DR: A tentative framework for conceptualization of the ways in which people cope with the stress and challenges of disease is presented and a brief discussion of the major determinants of coping is given.
Abstract: Growing interest in the psychological and social aspects of physical illness and disability has extended to all facets of the behavior of patients. The ways in which people cope with the stress and challenges of disease is the subject of this paper. The writer presents a tentative framework for conceptualization of this aspect of illness behavior. A brief discussion of the major determinants of coping is given. The latter include intrapersonal, disease-related and environmental variables. Coping behavior is a resultant of multiple factors reflecting a patient's specific dispositions as well as characteristics of his total situation during a given episode of illness and its different phases. The way in which the patient copes with his illness spells the difference between optimum recovery or psychological invalidism. It is the doctor's task to recognize his patient's mode of coping and help him employ the most adaptive and effective coping strategies.
416 citations
TL;DR: Parallels are drawn between Freud's description of “negative therapeutic reaction” and characteristics of the “crock,’ and practical suggestions are offered for the early recognition and treatment of these people.
Abstract: The so-called “crock” is a familiar and difficult patient for physicians to treat. This paper presents, through case illustration, one example of the treatment and course of such patients and descr...
106 citations
TL;DR: The role of dependency and independence in chronic illness, the use of denial as a major defense mechanism, alterations in body image, attitudes towards life and death are all discussed in terms of the psychological reactions to the stress of hemodialysis.
Abstract: Chronic hemodialysis for terminal renal failure is an example of medical progress in which the patient faces new, and at times overwhelming, psychological stresses. Dependence upon machines for survival is a recurrent theme of man’s response to artificial organs. In cardiac surgical patients, the patient experiences this dependence in the Intensive Care Unit with its mechanical respirators, electrocardiograms, and computerized monitoring devices. In postcardiotomy deliria, patients often project their feelings upon these devices and have illusory experiences in which they perceive the machines as menacing. Usually the ICU stay and this type of dependence on machines is of short duration. However, with dialysis it is chronic and lifelong in nature. Put in one form or another the patient must learn to “live with the machine.” Through patients’ thoughts and fantasies we can learn a great deal about this relationship with an inanimate object which becomes an essential part of the patient’s life.
73 citations
TL;DR: Three groups of women of different socioeconomic extraction, some with and some without chronic pelvic pain, were studied gynecologically and psychiatrically and a central conclusion is that chronic pelvicPain appears more closely related to the presence of psychiatric disturbance than to the existence of organic pelvic pathology, which is an inconstant finding.
Abstract: Three groups of women of different socioeconomic extraction, some with and some without chronic pelvic pain, were studied gynecologically and psychiatrically. Regardless of the presence or absence of organic pelvic pathology, pelvic pain patients showed considerable psychopathology clinically and by psychological testing, mainly mixed character disorders with predominant schizoid features. They usually were eager to undergo hysterectomy. Those who received a hysterectomy generally became pain-free, but often they seemingly substituted for it other symptoms (mostly psychological). Pelvic pain patients of different socioeconomic extraction had similar psychological characteristics. A central conclusion is that chronic pelvic pain appears more closely related to the presence of psychiatric disturbance, which is a constant finding, than to the presence of organic pelvic pathology, which is an inconstant finding.
69 citations
TL;DR: By studying actual transcripts of conversations between varieties of physicians and patients, one can define factors which contribute to both clarity and distortion in doctor-patient communication.
Abstract: Physicians too often fail to recognize that what they tell patients is sometimes not understood by patients. The conditions which interfere with adequate understanding include the anxiety of the patient about what is being told to him as well as his intelligence, experience and opportunities to question his medical informant. Factors affecting the physician's ability to communicate clearly relate primarily to the clarity and simplicity of his language, his own anxiety about what he is telling the patient and his providing opportunities for the patient to feed back to him indications of comprehension. The ethical implications of distorted communication between doctors and patients are of great importance. With increasingly complex mutilating and debilitating procedures available to physicians, the patient's capacity to understand what is explained to him is crucial to his ability to give informed consent. By studying actual transcripts of conversations between varieties of physicians and patients, one can ...
38 citations
TL;DR: It is the author's impression that in actual practice many physicians tend to resist informing their patients of the diagnosis in a direct manner and are inclined to be quite selective in informing only those patients described as self-reliant, independent and able to face reality.
Abstract: Although there are increasing numbers of disciplined observations and studies about the dying patient, the question remains as to whether they have been read and put into practice. This paper reports on a current study aimed at exploring how physicians actually work with patients suffering from fatal illnesses. Responding to a questionnaire on their methods of managing dying patients were 59 internists, 76 surgeons, 25 gynecologists, 13 general practitioners and 5 psychiatrists. Sixty-six percent of the physicians said they sometimes inform patients of a malignancy, 25 percent said they always tell the patient, and only 9 percent said they never tell the patient. The fact that very few physicians apparently feel justified in saying they never inform a patient about a fatal diagnosis is in itself a modification of previous practice. However, judging from answers to other questions, it is the author's impression that in actual practice many physicians tend to resist informing their patients of the diagnosis...
37 citations
TL;DR: At University Hospitals of Cleveland over the past nine years the psychiatric emergency population has doubled, there has also been a shift to a younger age group, evidence of better motivation, reduced incidence of hospitalization, and increased use of medications.
Abstract: Psychiatric emergency evaluation and treatment are an increasingly important part of current psychiatric practice. Psychiatry residency training has been affected accordingly. Of particular importance has been the need to characterize the emergency population seen and to describe the changes in this population over time. At University Hospitals of Cleveland over the past nine years the psychiatric emergency population has doubled. There has also been a shift to a younger age group, evidence of better motivation, reduced incidence of hospitalization, and increased use of medications. At this hospital, Negro females constituted the largest group and contained the highest percentage of patients receiving medications. Possible reasons for these findings are discussed.
19 citations
TL;DR: A highlight of recent sleep EEG research achievements, a summary of original work performed in the laboratory concerning sleep EEG characteristics of normal females during late and early pregnancy, and a discussion of the possible relevance of these sleep studies to postpartum emotional disturbance are provided.
Abstract: The present paper provides a brief review of the medical and psychiatric literature concerning the incidence, symptomatology, and etiology of the postpartum psychoses and less severe emotional disturbances. A highlight of recent sleep EEG research achievements, a summary of original work performed in our laboratory concerning sleep EEG characteristics of normal females during late and early pregnancy, and a discussion of the possible relevance of these sleep studies to postpartum emotional disturbance is also provided.
17 citations
TL;DR: I am convinced that the new “hard” and “soft” techniques will enable us to practice better medicine and help us to approximate Nathaniel Hawthorne's ideal of a good physician.
Abstract: To explain illness adequately and sensitively is not an easy matter. To tell patients brusquely just the name of their illness, or to lecture to them pedantically may be as bad as to tell them nothing, and only slightly better than to lie to them. To inform patients, to clarify their ideas, to interpret their apprehensions, requires the ability to listen with empathy and to appraise the patient's capacity to understand and “take it.” It requires patience and proper timing—as opposed to a rigid technique—and sticking with one's patients for better and for worse. It demands maturity and control of one's own emotions as a physician. This may be much harder for the physician than the traditional authoritative approach of protecting the patient from the truth. The gifted physician will use the newer techniques intuitively. Most others will have to learn through practice and precept. I believe that these principles and attitudes can be taught today quite well by sensitivity training in groups and, less economically, in an individual preceptorship. The “soft” approach can be effectively combined with the hard approach of a computerized information-gathering technique. I am convinced that the new “hard” and “soft” techniques will enable us to practice better medicine and help us to approximate Nathaniel Hawthorne's ideal of a good physician.
14 citations
TL;DR: The author describes one approach to a more “therapeutic” understanding and management of the dying patient and the emotional significance of the process of dying.
Abstract: Death and dying have always had deep emotional significance. But there is clearly an increasing scientific and objective interest in the process of terminal illness, dying and death, of special sig...
13 citations
TL;DR: Clinical psychiatric observations carried out during these two years helped to identify five factors that influence the patient's and the family's attitudes to home dialysis: the financial situation and the “set-up” as well as the ”normal” apprehension and fear of dialysis.
Abstract: This report on the difficulties of training patients for home dialysis is based on two years of experience with eight patients. In that period only one patient has gone on home dialysis; another is...
TL;DR: It would seem that the institution of such service meetings provides a significant advance in total patient care, as the patient's care and staff morale are improved.
Abstract: This paper presents a commonly known event which is uncommonly practiced consisting of a meeting of all personnel involved in the care of renal transplant patients meeting together once a week. The purpose is to coordinate and facilitate the total care of these patients. The discussions involve the medical, social, psychological, and financial aspects of the lives of these patients as well as the functioning of the service. Information and suggestions can be exchanged and policy, additional care, and changes in management can be effected.Such meetings promote increased knowledge of the patient and improved functioning of the service team. The patient's care and staff morale are improved. It would seem that the institution of such service meetings provides a significant advance in total patient care.
TL;DR: A patient who responds to visual loss with depression requires at least a psychiatric consultation to aid the ophthalmologist in the management of the patient.
Abstract: Emotional stress is known to accompany visual problems. This fact is apparent in patients with real or threatened acute loss of vision. Patients usually respond to a loss of vision in one of three ...
TL;DR: Factors including the acuteness of medical illness, its treatability, the age of the child, and the nature of the emotional disorder were found to be related to the pediatrician's failure to recognize the need for consultation.
Abstract: A study of the incidence and range of psychopathology in a random sample of admissions to a pediatric hospital revealed: (a) an unexpectedly high incidence of children manifesting psychopathology or difficulties in emotional adaptation considered by the child psychiatrist to warrant psychiatric consultation (63.7 percent); (b) the pediatric staff requested consultation on nine of fifty-one of these children (17.6 percent) considered to manifest difficulties in emotional adaptation.Factors including the acuteness of medical illness, its treatability, the age of the child, and the nature of the emotional disorder were found to be related to the pediatrician's failure to recognize the need for consultation.The usefulness of random screening procedures is considered as a teaching device to alert pediatricians to the existence of psychopathology which they otherwise might not recognize.
TL;DR: It is recommended that the study of the theory and prevention of suicide be made an integral part of the medical school curriculum and that family interviewing and counseling be incorporated into both medical school education and post-graduate training.
Abstract: Suicide is a broad social problem, the full scope of which extends beyond the medical profession. The physician is, nevertheless, one of the most important figures in the field of suicide preventio...
TL;DR: Group sessions on a newly formed pediatric ward for adolescents offer a nonthreatening opportunity for patients to meet and get to know one another; they provide a forum where patients can combat against submitting to a passive role by actively participating in advising on ward policy and patient concerns, and they provided a built-in safety-valve in times of ward disruption due to deaths or other stresses.
Abstract: This paper reports on our three-year experience with weekly patient meetings on a newly formed pediatric ward for adolescents The meetings are voluntary, and any topic may be discussed Representative material is presented regarding patients' responses to food, the ward routines, interactions with the staff, and death We have found that the group sessions offer a nonthreatening opportunity for patients to meet and get to know one another; they provide a forum where patients can combat against submitting to a passive role by actively participating in advising on ward policy and patient concerns, and they provide a built-in safety-valve in times of ward disruption due to deaths or other stresses It is our belief that one of the major reasons for the ward's success has been the ease of patient-staff communications fostered by these meetings
TL;DR: The symbolism of the heart, as the life-sustaining organ, the meaning of death, and the importance of the motivation to live are three interrelated facets representative of man's response to having his heart operated on.
Abstract: The impact of heart surgery has many ramifications for the patient. With studies of mitral commissurotomies in the early 1950's, we begin to learn of man's response to newer surgical and medical procedures which radically change the course of life. In the area of heart surgery, the dramatic and prevalent postoperative psychoses occurring in intensive care units have been discussed, along with the intimate relationship existing between preoperative emotional slate and postoperative outcome. The symbolism of the heart, as the life-sustaining organ, the meaning of death, and the importance of the motivation to live are three interrelated facets representative of man's response to having his heart operated on. New technology in physical medicine leads to new insights in psychological medicine and thereby underscores the pressing need for greater collaboration amongst all specialists concerned with patient care.
TL;DR: The use of repeat prescriptions in medical practice is examined as a way of dealing with patients' personal emotional problems and as an attempt to diminish conflicts in doctor-patient relations.
Abstract: In this article, Dr. Balint examines the use of repeat prescriptions in medical practice as a way of dealing with patients' personal emotional problems and as an attempt to diminish conflicts in doctor-patient relations.A clinical and statistical study of 1,000 patients of 10 medical practitioners suggests that repeat prescription patients need and seek a reliable, continuing, but non-threatening relationship with a physician as a substitute gratification for frustrations in certain life experiences. This search can lead to frequent contacts with doctors. resulting in tense or negative relationships which tend to be superficially relieved by introduction of the “repeat prescription regime.” Illness-centered medicine (“traditional diagnosis”) is contrasted with patient-centered medicine (“overall diagnosis”) in terms of their respective influence on the patient, his illness, and on the development of the relationship to his doctor.
TL;DR: There is some evidence that methods which increase or substitute for REM sleep may eventually be useful in facilitating emotional adjustment, and most hypnotic drugs should be used after careful consideration of the possible psychological effects.
Abstract: Recent sleep research has shown that the conventional concept of sleep as a period of inactivity for recovery from fatigue is outmoded. Active neurophysiological mechanisms regulate the sleep cycle in a manner similar to other circadian rhythms. The slow wave (NREM) part of the sleep cycle appears to be involved in recovery from muscular fatigue; the dreaming (REM) part appears to be involved in psychological adaptation to life events. Since most hypnotic drugs suppress REM sleep, they should be used after careful consideration of the possible psychological effects. For example, some depressions may be alleviated by agents which suppress dreaming at the cost of isolating the patient from his inner emotional life. Chloral hydrate, chlordiazepoxide, and diazepam avoid this problem because they do not affect REM sleep. Some sleep disorders like severe nightmares may be treated by suppressing deep NREM sleep. Other disorders like enuresis and narcolepsy appear to be psychosomatic conditions and require a medical psychological-approach. There is some evidence that methods which increase or substitute for REM sleep may eventually be useful in facilitating emotional adjustment.
TL;DR: A patient's refusal to undergo a medical procedure may be life threatening and also may lead to feelings which damage the doctor-patient relationship, so efforts to engage in a direct struggle against the refusal often lead to further frustration whereas a more investigative approach often leads to an understanding of the causes of the refusal.
Abstract: A patient's refusal to undergo a medical procedure may be life threatening and also may lead to feelings which damage the doctor-patient relationship. Efforts to engage in a direct struggle against...
TL;DR: Clinicians' problems with the identification of anxious patients and some factors associated with differential perception of patients' anxiety levels are demonstrated and social distance and counter-transference are suggested.
Abstract: An investigation of anxiety in 100 general medical inpatients showed that the attending physicians rated about one-third of the patients as highly anxious. Comparisons between the physician's and nurses' ratings and the patients' scores on four standardized anxiety scales revealed that there was differential perception of the patients' anxiety levels. An analysis of the physicians' ratings, nurses' ratings, and the scores on the anxiety scales, in terms of the patients' sociodemographic characteristics, pointed to factors associated with the differential perception of anxiety. Physicians tended to overrate young patients and high SES patients as having greater anxiety than the scales indicated and both physicians and nurses consistently underrated the blacks' and the lower SES patients' anxiety levels. The results demonstrated clinicians' problems with the identification of anxious patients and indicate some factors associated with differential perception of patients' anxiety levels. We suggest social dis...
TL;DR: There were seventeen known suicide attempts, but no known suicides in a six month follow-up period, contrasted with the results of a similar study done nine years previously at the same hospital and with a study done by the Cleveland Suicide Prevention Center, both of which found several suicides in the follow- up period.
Abstract: Suicide attempts or suicide ideation are often of critical importance in defining a psychiatric emergency. Follow-up studies of the psychiatric emergency population for the subsequent incidence of attempted or completed suicide are needed to identify high and low risk groups and to measure the effectiveness of the psychiatric emergency service. Suicide problems were presenting symptoms in 28.2 percent of psychiatric emergency evaluations seen in a three month period. The 10–29 decades for females and the 10–19 decade for males were represented significantly more often than older decades. Race and marital status were not related to suicide problems. There were seventeen known suicide attempts, but no known suicides in a six month follow-up period. This finding was contrasted with the results of a similar study done nine years previously at the same hospital and with a study done by the Cleveland Suicide Prevention Center, both of which found several suicides in the follow-up period. Possible reasons for the different results are discussed.
TL;DR: This striking example of psychosis following successful cardiac valvotomy illustrates well the occasional reaction of the cardiac cripple who has learned to “use” his heart disease to avoid the responsibilities of an individual with a normal heart.
Abstract: EDITOR’S NOTE:-This striking example of psychosis following successful cardiac valvotomy illustrates well the occasional reaction of the cardiac cripple who has learned to “use” his heart disease to avoid the responsibilities of an individual with a normal heart (see Abram’s article, pp. 277-94). The relevance of this phenomenon to psychodynamic formulation and successful psychotherapy is articulately described in Dr. Galdston’s case report.
TL;DR: The theme of independent striving, overburden and depletion was a common feature of the emotional setting preceding the onset of a peptic ulcer, whereas the theme of rebellion versus compliance was often noted in patients with ulcerative colitis.
Abstract: Specificity in “psychosomatic” disease is reconsidered and a direct comparison is made of 22 patients with ulcerative colitis and 25 patients with peptic ulcer in terms of a variety of categories. ...
TL;DR: The Structured Psychiatric Interview is intended for use in surveys of population subgroups defined in terms of nonpsychiatric criteria including, for example, general medical patients, and remains primarily an epidemiological instrument for economic measurements of mental disorder within and between populations.
Abstract: The Structured Psychiatric Interview is intended for use in surveys of population subgroups defined in terms of nonpsychiatric criteria including, for example, general medical patients. Its purpose is to elicit evidence of current mental pathology, utilizing the essential clinical skills of the examiner within the context of a structured situation. No diagnostic inferences are made at this stage. (Such inferences would be both inappropriate and unwise without additional information about the individual subject.) Unlike some existing structured interviews, it does not purport to be a “psychological test for psychopathology,” thus avoiding questionable assumptions about the propriety of summating molecular behaviors to arrive at a “quantitative evaluation of the individual for psychopathology.” Insofar as it represents an organized phenomenological examination, it will be of value in the individual case, but it remains primarily an epidemiological instrument for economic measurements of mental disorder with...
TL;DR: An introductory course is described that has been effective in communicating interview techniques to groups of students working closely with a perceptor by alternating demonstration and didactic instruction with trial and error exercises.
Abstract: In this article the logistics utilized in conveying a specific type of interviewing technique to students, previously reported on, are outlined. Specifically described is an introductory course that has been effective in communicating interview techniques to groups of students working closely with a perceptor by alternating demonstration and didactic instruction with trial and error exercises. Since psychiatrists are increasingly used in teaching and directing interviewing courses in medical schools, it is suggested that they be intimately involved in planning these programs.
TL;DR: The authors present a valuable account of their very successful experience of integrating psychiatric services into their community general hospital without the establishment of a segregated psychiatric unit.
Abstract: In these times when psychiatric treatment is becoming more acceptable to the general hospital and its community, it is important to explore the many ways in which optimal treatment and training can be made available at least expense and maximal utilization of existing personnel. The authors present a valuable account of their very successful experience of integrating psychiatric services into their community general hospital without the establishment of a segregated psychiatric unit. The benefits accruing to this approach in terms of patient care, community service, and teaching value for all personnel concerned with good patient care are discussed in detail. The special relevance of the trained psychiatric nurse to the success of such programs is underscored.
TL;DR: General practitioners, following a six-month to one-year postgraduate training, are engaged in the care of a selected group of such chronic psychiatric cases as incapacitated neurotics, stabilized schizophrenics, chronic brain syndromes, and so forth.
Abstract: General practitioners, following a six-month to one-year's postgraduate training, are engaged in the care of a selected group of such chronic psychiatric cases as incapacitated neurotics, stabilized schizophrenics, chronic brain syndromes, and so forth. Drugs and supportive therapy are used. The patients are seen by the general practitioners in their private offices. The participating general practitioners meet in weekly or biweekly conferences for consultation with their psychiatric instructors, a social worker and secretary. Some fifty patients have been carried over the past two and one-half years by six or seven general practitioners. The project is funded by foundation grants which also cover the general practitioners' fees. It has helped to keep patients in their communities and has obviated the need for rehospitalization in the vast majority of cases. More than half the patients are now gainfully employed or work part-time under sheltered conditions.
TL;DR: Ability of patients to follow through with aftercare was remarkably poor, and relapse rate was especially high among those patients who returned to the addict community.
Abstract: A follow-up study of twenty narcotics addicts admitted to a university hospital is described. Only seven patients were free of addictions at time of follow-up. Ability of patients to follow through with aftercare was remarkably poor, and relapse rate was especially high among those patients who returned to the addict community. Relapse rate among patients treated on the psychiatric service was less than for those treated on the medical service. Family history of alcoholism in particular was associated with a poor prognosis. Other factors which seemed to have some bearing on prognosis are described. A discussion of some of the problems encountered in treating the narcotics addict is included.
TL;DR: The need for appropriate selection of patients for consultation, and the means of referral, is underscored, with the high prevalence rate of emotional distress in general medical and surgical patients.
Abstract: Growing numbers of psychiatric services in general hospitals emphasize the importance of psychiatric consultation as part of comprehensive medical care. The literature supports the high prevalence rate of emotional distress in general medical and surgical patients. This paper underscores the need for appropriate selection of patients for consultation, and the means of referral. The psychiatrist is faced with the important challenge of bringing the humanizing force of consultation to forms of medical treatment which are becoming increasingly technological.