Acute psychologic disturbances in the course of hospitalization of patients with chronic illness.

Abstract Comprehensive management of acute psychologic disturbances in patients suffering from various chronic illnesses in the hospital setting requires consideration of the current stress the patient is under, the patient's predisposition to anxiety as a result of past experience, and the psychologic resources currently available and supportive to the patient in meeting these stresses. Predisposition to anxiety is an important consideration in shaping the form and mode of expression of the patient's reaction to the pain, disability, and uncertainty which are inevitable in these illnesses. On the supportive side is the trust by the patient in his doctor and in other hospital personnel. The critical issue in acute psychologic disturbance of various sorts appears to lie in the fact that the more these patients are under the real necessity of trusting others with their prospects for health, their bodies, and their lives, the greater their anxiety about being deserted by the very people on whom they depend and need. Such situations of fundamental anxiety evoke a reaction of hypervigilance or hyperalertness to any sign or clue in the environment that the expected “desertion” is coming about or may come about. This is so, independent of the fact that members of the professional staff may have little awareness of these feelings. In such situations anxiety-laden misinterpretations of perception and meanings of events in the hospital environment occur. The general behavior and reactions of significant people, especially doctors and nurses, are scanned for anything felt as strange or irregular, and minor differences in attitude or expression are felt to have special import. Such fear-laden distortions or meanings that are special to the patient tend to go uncorrected because the very anxiety that provokes them also makes the patient feel that talking about his fears can only make matters worse. The exclusive devotion of the patient's attention only to ominous or nonominous signs in the environment makes it almost certain that little attention can be given to potentially reassuring perceptions and exchanges with people. If no factor of relief enters the situation, the patient feels, and comes to be, in fact, more and more isolated from the protective and supportive quality of the relationships with the hospital personnel and especially from his physician. He is then exposed to the stress of his own worst interpretations of his illness and the hospital situation and is simultaneously deprived of the expectation of understanding and support from others. In such situations a wide variety of acute psychologic disturbances, either as symptoms or as behavior, may make themselves manifest. Disturbances of psychotic proportion, signing out of hospital, severe anxiety attacks, episodes of frank panic, as well as intensification of depressive trends may all occur. The critical factor in the prevention of such episodes or in their management when they do occur lies in the understanding of or failure to understand the patient's “build-up” of fear-laden distortions of meaning of the events and relationships in the hospital environment, especially within the doctor-patient relationship. For the patient, getting things into words with the physician and feeling understood is the best antidote for such distortions. The realization that childish and irrational fears are not repugnant to the physician and can be heard and accepted as such is also a great help. This is true whether the distortion is an easily understandable misconception or, in fact, an actual delusion. The chief source of error in the clinician's handling of the psychologic aspects of such situations is neither a lack of expertness or interest nor a failure to spend time with the patient. It is more likely to be an assumption on the part of the clinician that under stresses so great any anxiety or any psychopathology is a natural consequence of the realistically great stresses of the illness. Having, so to speak, made a “diagnosis,” the physician fails to make further inquiry and may attempt prematurely, and, to the patient, unrealistically, to offer support and reassurance. Because in these situations the physician does not, in fact, understand what is troubling the patient, the reassurance does no good and may even be felt by the patient as an indication that he should certainly not voice his real concern and fears. If there is relatively sudden appearance of anxiety or of other manifestations of acute psychologic disturbance in the course of hospitalization of patients with chronic illness, the safest and most useful assumption is that these are not reactions to the actual illness or real threat, as the physician sees it, but more likely a reaction to threat of the supportive aspects of the patient-physician relationship. At times the expert help of a psychiatrist may be desirable or mandatory. But it is hoped that this discussion with clinical examples will, in many situations, assist the clinician to enhance and expand the supportive and protective aspects of the doctor-patient relationship.