Delusion is a condition where a person holds on to a belief even if strong evidence suggests otherwise.
Primary Psychiatry May 21, Dr. Bursztajn is associate clinical professor of psychiatry and Mr. The authors thank A. The authors report no financial, academic, or other support of this work. Abstract How does managed care contribute to the psychiatric hazards of medical illness?
How can primary care physicians and psychiatrists as treaters or consultants recognize and manage the clinical dynamics that result, together with their liability implications? For patients in managed healthcare settings, a latent subjective sense of captivity triggered by care restrictions can exacerbate feelings of helplessness and hopelessness brought on by the threat of serious illness.
In the extreme, some patients will experience the escalating distress characteristic of posttraumatic stress disorder. The introductory, ongoing, and termination phases of the treatment alliance are analyzed as focal points for particular clinical interventions.
In this atmosphere, patients and their physicians—who face the threat or actuality of a major illness—may experience heightened feelings of helplessness and hopelessness, especially when healthcare benefits are denied.
In this atmosphere, physicians often avoid consideration of treatment alternatives they view as likely to be denied by a managed care reviewer, or feel compelled to focus on the catastrophic possibility in the differential diagnosis to obtain otherwise denied benefits.
The sense of virtual clinical captivity that patients and physicians can experience in the face of benefit denial need not be taken as a fait accompli. By becoming aware of the dynamics and dilemmas of the physician-patient relationship under managed care, treating physicians can create greater freedom for their patients and themselves to work together effectively.
Useful clinical interventions can be implemented to recover a sense of choice in the doctor-patient relationship, while decreasing liability risk, by effectively anticipating, preparing for, identifying, and responding to the distress that is likely to accompany managed care restriction of clinical care.
There are compelling clinical and ethical considerations favoring a proactive stance by physicians who are aware of potential negative managed care influences on their patients. Given that helplessness and hopelessness have been documented to be predictors of negative patient outcomes eg, in breast cancer ,5 the undermining of the clinical process and the resulting loss of trust also undermine the potential for healing relationships and, in turn, the likelihood of positive health outcomes.
Physicians who work to reverse this process are not just protecting themselves from liability, but also providing quality care by protecting patients from the consequences of helplessness, hopelessness, and distrust. Serious illness can heighten dependency while bringing with it feelings of helplessness, hopelessness, and distrust associated with depression.
When faced first with a lack of choice of a provider, and then with restriction or even denial of care, the vulnerable patient, already feeling like a prisoner of the threat of serious illness, may now also begin to feel like a lonely captive of the healthcare system. What care will I receive?
The resulting anxiety and depression can lead to a greater likelihood of dissatisfaction with medical care9 and to an impaired capacity to act on that dissatisfaction by changing health plans.
Often, the treating physician may not have freely chosen to be part of a particular managed care organization MCO nor to treat a particular patient, except as the best of a set of undesirable choices or the lesser of necessary evils.
The physician is also likely to have experienced a substantial reduction of economic and professional autonomy in the shift to managed care. Like the patient, the physician may have few options and insufficient time to recognize, reflect upon, process, and put into perspective the feelings engendered by the managed healthcare context.
This reaction is especially likely, however, if the physician faces one frustrated, recalcitrant patient after another in a time-pressured managed care setting.
Physicians are far from immune to the contagion of pessimism that can sweep through an institutional atmosphere, as in end-of-life care.
Physicians who risk being penalized for caring for patients when, in the judgment of an anonymous third-party reviewer, there is no medical necessity to do so, are more likely to succumb to institutional pressures.
In the extreme, some clinicians will automatically advise the patient and their family that only low-cost palliative measures be taken, not mentioning the more costly, intensive alternatives that may hold out a slim but real hope for the patient. For example, a physician who is concerned about being identified as readily willing to hospitalize a patient for observation and evaluation will tend to avoid the risk of being deselected by the MCO.
This avoidance can manifest itself in the doctor-patient encounter as a fixed, overly rigid stance or a reluctance to present alternatives to the patient other than the treatment least likely to engender MCO scrutiny. Such an attitude interferes with the informed-consent process vital to clinical care, and is often a pivot point in liability.
Of course, some denials of benefits by MCOs do represent a genuine effort to weed out unnecessary treatments and excessive costs. Ideally, medically appropriate care considers the whole patient. Such guidelines are often very selective as to the evidence they cite, as in the paucity of studies with outcome measures that reflect quality-of-life issues or the widespread neglect of many well-grounded outcome studies showing the efficacy of mental health treatment for patients with many medical and surgical conditions.
In any case, decision making for patients in the aggregate is no substitute for individualized clinical decision making. To begin with, it is helpful for the treating clinician to keep in mind the complex interactions between medical and psychiatric disorders that are often obscured by various managed care influences, such as the lack of time to take a careful history that is objective and empathic.
Although psychiatric consultation or referral is helpful in cases that present special difficulties, it is now less accessible than ever given the restrictions of managed health care.
In a person who has had a life-threatening illness, such suffering can sometimes rise to the level of disorders in the posttraumatic stress disorder PTSD spectrum. Thus, it is important not to write off patients in panic as simply hypochondriacal because of time pressure associated with managed care.
If a person presents with symptoms similar to those that marked a previous life-threatening illness, the physician first rules out a recurrence of that illness. When there has been a recurrence, any posttraumatic sequelae need to be attended to, even in the face of managed care constraints.
It is helpful for physicians to keep in mind that a patient who suffers from PTSD or other emotional vulnerabilities is especially susceptible to an exacerbation or recurrence of symptoms. Even if a recurrence of the illness has been ruled out, the illness may have left a vulnerability in that the emotional memory of its painful and frightening initial presentation may be reactivated simply by the recurrence of general symptoms.when anxiety is not normal.7 When is shyness pathological?
Many children whose anxiety causes them severe distress, like those with selective mutism, are dismissed.
as “just shy.” At the same time, people worry about How can we tell the difference between regular shyness and clinical anxiety?. We used Bayesian network principles in the analysis of potential causal relationships between pathologic subjective halitosis, olfactory reference syndrome, social anxiety, and preoccupations with body part odors (e.g., body, foot, mouth, and armpit).
I guess that we all have times when we feel anxious. It may be prior to a job interview, or perhaps whether a family meal will go well etc etc. these everyday anxieties have a foundation in fact and will resolve themselves. Pathological anxiety is.
“But sometimes, anxiety seems to take on a life of its own and becomes really pathological. I want to understand how our brains function in a normal, optimal range without getting into this pathological .
These disguise, rather imperfectly, the Existential Anxiety and Normal Anxiety which transforms into symptoms of Neurotic Anxiety. * Left unaddressed, or addressed merely through the implementation of techniques to manage it, Neurotic Anxiety leads to stagnation, rigidity and .
Aug 22, · This video answers the question: What is the difference between pathological narcissism and narcissistic personality disorder. When we .