Pearls

In this information age, people can learn more about their health than ever before. This free flow of knowledge, however, fosters in some patients unrealistic expectations of psychiatric treatment that can impair your doctor-patient relationship.

Several sources can fuel patient expectations:

Direct-to-consumer advertising. Pharmaceutical companies promote their products through direct mail, television, radio, newspapers, magazines, and other media.

Some patients self-diagnose and interpret these advertisements to mean that they will be “cured” after a cursory evaluation and a brief course of treatment. Some patients also believe that depression is as easy to treat as a common infection and are unaware of the differential diagnoses and comorbidities that complicate assessment and treatment.

The Internet. Pharmaceutical companies, mental health providers, current and former patients, nonprofit organizations, government agencies, and antipsychiatry groups operate Web sites. Bulletin boards, newsgroups, list serves, chat groups, and unsolicited e-mail are other online vehicles for health information. The quality, reliability, and objectivity of information varies.^1-2

Anecdotal experiences. Patients hear about psychiatric treatment from friends and significant others, and read or hear personal accounts from books, talk shows, news reports, and magazines. These anecdotal experiences can create misperceptions concerning the frequency of visits, duration of treatment, and medication options.

Referral sources can influence patient perceptions about the scope and limitations of treatment. For instance, upon learning that a managed care organization is authorizing five visits, patients may conclude that they can be “cured” in just five visits.

Other patients may want only a diagnostic evaluation, such as a second opinion, forensic consultation, or disability assessment. These patients may expect the clinician to complete the evaluation in only one visit with-out collateral history or diagnostic studies.

As psychiatrists, we should ensure that our patients have correct information about mental disorders and reasonable expectations of our services. The following strategies can improve patient rapport and satisfaction.

Address patients’ expectations during the initial psychiatric evaluation. Finding out what a patient thinks—and knows—about his or her disorder at the start may reduce misunderstandings later on.

Ask specific questions. Open-ended queries to elicit patients’ perceptions may help initially, but cognitive dys-functions, hidden agendas, and a lack of awareness may keep the patient from disclosing his or her expectations.

Ask specifically what services the patient is seeking and ascertain his or her experience with other physicians and mental health professionals. For instance, ask a new patient what he or she expects to achieve in the first visit.

Educate the patient. After the initial evaluation, discuss the scope and limitations of psychiatric services as they apply to the patient’s disorder. This will help you better understand and meet the patient’s needs, even if his or her expectations and yours seem worlds apart at first. Some patients, such as those with cognitive impairment or borderline personality disorder, may need continued education during follow-up visits.

Patients sometimes request treatments that are novel or unproven. Explore their expectations of these medications, and educate them as to why these modalities are contraindicated.

Direct the patient to trusted sources. For example, Web sites that display the Health On the Net Foundation’s Code of Conduct (HON Code) or E-Health Code of Ethics seals are self-regulated and reputable.

In this information age, people can learn more about their health than ever before. This free flow of knowledge, however, fosters in some patients unrealistic expectations of psychiatric treatment that can impair your doctor-patient relationship.

Several sources can fuel patient expectations:

Direct-to-consumer advertising. Pharmaceutical companies promote their products through direct mail, television, radio, newspapers, magazines, and other media.

Some patients self-diagnose and interpret these advertisements to mean that they will be “cured” after a cursory evaluation and a brief course of treatment. Some patients also believe that depression is as easy to treat as a common infection and are unaware of the differential diagnoses and comorbidities that complicate assessment and treatment.

The Internet. Pharmaceutical companies, mental health providers, current and former patients, nonprofit organizations, government agencies, and antipsychiatry groups operate Web sites. Bulletin boards, newsgroups, list serves, chat groups, and unsolicited e-mail are other online vehicles for health information. The quality, reliability, and objectivity of information varies.^1-2

Anecdotal experiences. Patients hear about psychiatric treatment from friends and significant others, and read or hear personal accounts from books, talk shows, news reports, and magazines. These anecdotal experiences can create misperceptions concerning the frequency of visits, duration of treatment, and medication options.

Referral sources can influence patient perceptions about the scope and limitations of treatment. For instance, upon learning that a managed care organization is authorizing five visits, patients may conclude that they can be “cured” in just five visits.

Other patients may want only a diagnostic evaluation, such as a second opinion, forensic consultation, or disability assessment. These patients may expect the clinician to complete the evaluation in only one visit with-out collateral history or diagnostic studies.

As psychiatrists, we should ensure that our patients have correct information about mental disorders and reasonable expectations of our services. The following strategies can improve patient rapport and satisfaction.

Address patients’ expectations during the initial psychiatric evaluation. Finding out what a patient thinks—and knows—about his or her disorder at the start may reduce misunderstandings later on.

Ask specific questions. Open-ended queries to elicit patients’ perceptions may help initially, but cognitive dys-functions, hidden agendas, and a lack of awareness may keep the patient from disclosing his or her expectations.

Ask specifically what services the patient is seeking and ascertain his or her experience with other physicians and mental health professionals. For instance, ask a new patient what he or she expects to achieve in the first visit.

Educate the patient. After the initial evaluation, discuss the scope and limitations of psychiatric services as they apply to the patient’s disorder. This will help you better understand and meet the patient’s needs, even if his or her expectations and yours seem worlds apart at first. Some patients, such as those with cognitive impairment or borderline personality disorder, may need continued education during follow-up visits.

Patients sometimes request treatments that are novel or unproven. Explore their expectations of these medications, and educate them as to why these modalities are contraindicated.

Direct the patient to trusted sources. For example, Web sites that display the Health On the Net Foundation’s Code of Conduct (HON Code) or E-Health Code of Ethics seals are self-regulated and reputable.

In this information age, people can learn more about their health than ever before. This free flow of knowledge, however, fosters in some patients unrealistic expectations of psychiatric treatment that can impair your doctor-patient relationship.

Several sources can fuel patient expectations:

Direct-to-consumer advertising. Pharmaceutical companies promote their products through direct mail, television, radio, newspapers, magazines, and other media.

Some patients self-diagnose and interpret these advertisements to mean that they will be “cured” after a cursory evaluation and a brief course of treatment. Some patients also believe that depression is as easy to treat as a common infection and are unaware of the differential diagnoses and comorbidities that complicate assessment and treatment.

The Internet. Pharmaceutical companies, mental health providers, current and former patients, nonprofit organizations, government agencies, and antipsychiatry groups operate Web sites. Bulletin boards, newsgroups, list serves, chat groups, and unsolicited e-mail are other online vehicles for health information. The quality, reliability, and objectivity of information varies.^1-2

Anecdotal experiences. Patients hear about psychiatric treatment from friends and significant others, and read or hear personal accounts from books, talk shows, news reports, and magazines. These anecdotal experiences can create misperceptions concerning the frequency of visits, duration of treatment, and medication options.

Referral sources can influence patient perceptions about the scope and limitations of treatment. For instance, upon learning that a managed care organization is authorizing five visits, patients may conclude that they can be “cured” in just five visits.

Other patients may want only a diagnostic evaluation, such as a second opinion, forensic consultation, or disability assessment. These patients may expect the clinician to complete the evaluation in only one visit with-out collateral history or diagnostic studies.

As psychiatrists, we should ensure that our patients have correct information about mental disorders and reasonable expectations of our services. The following strategies can improve patient rapport and satisfaction.

Address patients’ expectations during the initial psychiatric evaluation. Finding out what a patient thinks—and knows—about his or her disorder at the start may reduce misunderstandings later on.

Ask specific questions. Open-ended queries to elicit patients’ perceptions may help initially, but cognitive dys-functions, hidden agendas, and a lack of awareness may keep the patient from disclosing his or her expectations.

Ask specifically what services the patient is seeking and ascertain his or her experience with other physicians and mental health professionals. For instance, ask a new patient what he or she expects to achieve in the first visit.

Educate the patient. After the initial evaluation, discuss the scope and limitations of psychiatric services as they apply to the patient’s disorder. This will help you better understand and meet the patient’s needs, even if his or her expectations and yours seem worlds apart at first. Some patients, such as those with cognitive impairment or borderline personality disorder, may need continued education during follow-up visits.

Patients sometimes request treatments that are novel or unproven. Explore their expectations of these medications, and educate them as to why these modalities are contraindicated.

Direct the patient to trusted sources. For example, Web sites that display the Health On the Net Foundation’s Code of Conduct (HON Code) or E-Health Code of Ethics seals are self-regulated and reputable.

In this information age, people can learn more about their health than ever before. This free flow of knowledge, however, fosters in some patients unrealistic expectations of psychiatric treatment that can impair your doctor-patient relationship.

Several sources can fuel patient expectations:

Direct-to-consumer advertising. Pharmaceutical companies promote their products through direct mail, television, radio, newspapers, magazines, and other media.

Some patients self-diagnose and interpret these advertisements to mean that they will be “cured” after a cursory evaluation and a brief course of treatment. Some patients also believe that depression is as easy to treat as a common infection and are unaware of the differential diagnoses and comorbidities that complicate assessment and treatment.

The Internet. Pharmaceutical companies, mental health providers, current and former patients, nonprofit organizations, government agencies, and antipsychiatry groups operate Web sites. Bulletin boards, newsgroups, list serves, chat groups, and unsolicited e-mail are other online vehicles for health information. The quality, reliability, and objectivity of information varies.^1-2

Anecdotal experiences. Patients hear about psychiatric treatment from friends and significant others, and read or hear personal accounts from books, talk shows, news reports, and magazines. These anecdotal experiences can create misperceptions concerning the frequency of visits, duration of treatment, and medication options.

Referral sources can influence patient perceptions about the scope and limitations of treatment. For instance, upon learning that a managed care organization is authorizing five visits, patients may conclude that they can be “cured” in just five visits.

Other patients may want only a diagnostic evaluation, such as a second opinion, forensic consultation, or disability assessment. These patients may expect the clinician to complete the evaluation in only one visit with-out collateral history or diagnostic studies.

As psychiatrists, we should ensure that our patients have correct information about mental disorders and reasonable expectations of our services. The following strategies can improve patient rapport and satisfaction.

Address patients’ expectations during the initial psychiatric evaluation. Finding out what a patient thinks—and knows—about his or her disorder at the start may reduce misunderstandings later on.

Ask specific questions. Open-ended queries to elicit patients’ perceptions may help initially, but cognitive dys-functions, hidden agendas, and a lack of awareness may keep the patient from disclosing his or her expectations.

Ask specifically what services the patient is seeking and ascertain his or her experience with other physicians and mental health professionals. For instance, ask a new patient what he or she expects to achieve in the first visit.

Educate the patient. After the initial evaluation, discuss the scope and limitations of psychiatric services as they apply to the patient’s disorder. This will help you better understand and meet the patient’s needs, even if his or her expectations and yours seem worlds apart at first. Some patients, such as those with cognitive impairment or borderline personality disorder, may need continued education during follow-up visits.

Patients sometimes request treatments that are novel or unproven. Explore their expectations of these medications, and educate them as to why these modalities are contraindicated.

Direct the patient to trusted sources. For example, Web sites that display the Health On the Net Foundation’s Code of Conduct (HON Code) or E-Health Code of Ethics seals are self-regulated and reputable.

In this information age, people can learn more about their health than ever before. This free flow of knowledge, however, fosters in some patients unrealistic expectations of psychiatric treatment that can impair your doctor-patient relationship.

Several sources can fuel patient expectations:

Direct-to-consumer advertising. Pharmaceutical companies promote their products through direct mail, television, radio, newspapers, magazines, and other media.

Some patients self-diagnose and interpret these advertisements to mean that they will be “cured” after a cursory evaluation and a brief course of treatment. Some patients also believe that depression is as easy to treat as a common infection and are unaware of the differential diagnoses and comorbidities that complicate assessment and treatment.

The Internet. Pharmaceutical companies, mental health providers, current and former patients, nonprofit organizations, government agencies, and antipsychiatry groups operate Web sites. Bulletin boards, newsgroups, list serves, chat groups, and unsolicited e-mail are other online vehicles for health information. The quality, reliability, and objectivity of information varies.^1-2

Anecdotal experiences. Patients hear about psychiatric treatment from friends and significant others, and read or hear personal accounts from books, talk shows, news reports, and magazines. These anecdotal experiences can create misperceptions concerning the frequency of visits, duration of treatment, and medication options.

Referral sources can influence patient perceptions about the scope and limitations of treatment. For instance, upon learning that a managed care organization is authorizing five visits, patients may conclude that they can be “cured” in just five visits.

Other patients may want only a diagnostic evaluation, such as a second opinion, forensic consultation, or disability assessment. These patients may expect the clinician to complete the evaluation in only one visit with-out collateral history or diagnostic studies.

As psychiatrists, we should ensure that our patients have correct information about mental disorders and reasonable expectations of our services. The following strategies can improve patient rapport and satisfaction.

Address patients’ expectations during the initial psychiatric evaluation. Finding out what a patient thinks—and knows—about his or her disorder at the start may reduce misunderstandings later on.

Ask specific questions. Open-ended queries to elicit patients’ perceptions may help initially, but cognitive dys-functions, hidden agendas, and a lack of awareness may keep the patient from disclosing his or her expectations.

Ask specifically what services the patient is seeking and ascertain his or her experience with other physicians and mental health professionals. For instance, ask a new patient what he or she expects to achieve in the first visit.

Educate the patient. After the initial evaluation, discuss the scope and limitations of psychiatric services as they apply to the patient’s disorder. This will help you better understand and meet the patient’s needs, even if his or her expectations and yours seem worlds apart at first. Some patients, such as those with cognitive impairment or borderline personality disorder, may need continued education during follow-up visits.

Patients sometimes request treatments that are novel or unproven. Explore their expectations of these medications, and educate them as to why these modalities are contraindicated.

Direct the patient to trusted sources. For example, Web sites that display the Health On the Net Foundation’s Code of Conduct (HON Code) or E-Health Code of Ethics seals are self-regulated and reputable.

In this information age, people can learn more about their health than ever before. This free flow of knowledge, however, fosters in some patients unrealistic expectations of psychiatric treatment that can impair your doctor-patient relationship.

Several sources can fuel patient expectations:

Direct-to-consumer advertising. Pharmaceutical companies promote their products through direct mail, television, radio, newspapers, magazines, and other media.

Some patients self-diagnose and interpret these advertisements to mean that they will be “cured” after a cursory evaluation and a brief course of treatment. Some patients also believe that depression is as easy to treat as a common infection and are unaware of the differential diagnoses and comorbidities that complicate assessment and treatment.

The Internet. Pharmaceutical companies, mental health providers, current and former patients, nonprofit organizations, government agencies, and antipsychiatry groups operate Web sites. Bulletin boards, newsgroups, list serves, chat groups, and unsolicited e-mail are other online vehicles for health information. The quality, reliability, and objectivity of information varies.^1-2

Anecdotal experiences. Patients hear about psychiatric treatment from friends and significant others, and read or hear personal accounts from books, talk shows, news reports, and magazines. These anecdotal experiences can create misperceptions concerning the frequency of visits, duration of treatment, and medication options.

Referral sources can influence patient perceptions about the scope and limitations of treatment. For instance, upon learning that a managed care organization is authorizing five visits, patients may conclude that they can be “cured” in just five visits.

Other patients may want only a diagnostic evaluation, such as a second opinion, forensic consultation, or disability assessment. These patients may expect the clinician to complete the evaluation in only one visit with-out collateral history or diagnostic studies.

As psychiatrists, we should ensure that our patients have correct information about mental disorders and reasonable expectations of our services. The following strategies can improve patient rapport and satisfaction.

Address patients’ expectations during the initial psychiatric evaluation. Finding out what a patient thinks—and knows—about his or her disorder at the start may reduce misunderstandings later on.

Ask specific questions. Open-ended queries to elicit patients’ perceptions may help initially, but cognitive dys-functions, hidden agendas, and a lack of awareness may keep the patient from disclosing his or her expectations.

Ask specifically what services the patient is seeking and ascertain his or her experience with other physicians and mental health professionals. For instance, ask a new patient what he or she expects to achieve in the first visit.

Educate the patient. After the initial evaluation, discuss the scope and limitations of psychiatric services as they apply to the patient’s disorder. This will help you better understand and meet the patient’s needs, even if his or her expectations and yours seem worlds apart at first. Some patients, such as those with cognitive impairment or borderline personality disorder, may need continued education during follow-up visits.

Patients sometimes request treatments that are novel or unproven. Explore their expectations of these medications, and educate them as to why these modalities are contraindicated.

Direct the patient to trusted sources. For example, Web sites that display the Health On the Net Foundation’s Code of Conduct (HON Code) or E-Health Code of Ethics seals are self-regulated and reputable.

When training residents to perform the mental status examination, I ask them such questions as “What color are the patient’s shoes?” Too often, in their haste to describe the patient’s ability to spell “world” backwards, they miss the obvious. Board certification examinees also tend to not see a patient’s well-healed wrist scars or facial droop.

Head-to-toe observation of a patient may uncover an undisclosed disorder, condition, or life situation that could affect treatment. Here’s what I look for at the first evaluation:

As the patient enters the room Observe the gait for a limp, shuffle, or other classic signs of illness or injury. Is there evidence of Parkinson’s disease (stooped posture, slow to get started, decreased arm swing, slow to turn)? Is the patient steady on his or her feet? (If not, sensory or cerebellar ataxia may be present.) Is there a foot drop (lower motor neuron disease)? Do the patient’s shoes drag or scrape (spastic hemiparesis from a prior stroke)?

The head Note the quantity and distribution of hair. Is it combed or brushed (ability to care for self, hemineglect)? Is there evidence of unusual hair loss (trichotillomania, hypothyroidism, lupus, side effects from medications)? Any scarring on the scalp (accidental or intentionally-inflicted trauma) or general skull deformities (enlarged in hydrocephalus, Paget’s disease)? Are the ears low-set (fragile X syndrome, other congenital diseases)? Any scarring on the ears (past trauma)?

The face Is there acne (Cushing’s syndrome, ovarian dysfunction, reaction to lithium), telangiectasias (acne rosacea, lupus), or hypopigmentation? Vitiligo may reveal an autoimmune disorder. Hyperpigmentation may point to metastatic melanoma, drug abuse, or endocrinopathies such as Addison’s disease or ectopic ACTH syndrome.

Are there facial scars or bruising (abuse)? Any evidence of characteristic facies (acromegaly, Parkinson’s or Cushing’s disease)? Are the parotid glands enlarged (eating disorders, diabetes, cirrhosis)? Any tics or stereotypies (drug abuse, Tourette’s syndrome)? Does the facial expression match what the patient is saying? Psychologic defense mechanisms may be at work or even malingering.

The mouth Any lip sores (sexually transmitted diseases), angular stomatitis (vitamin deficiencies), or bad dentition (drug abuse, age-related dementia, homelessness)?

The eyes Does the patient make normal eye contact? Is he or she wearing dark glasses (depression, posttraumatic stress disorder, drug abuse)? Is gaze palsy (head injuries, Wernicke’s syndrome) or icterus (hepatic disease) present? Are the sclera discolored or bloodshot (alcohol withdrawal, marijuana abuse)? Are the pupils dilated (atropine, mushroom abuse) or pinpoint (opioid use)?

The neck Any thyroid enlargement (goiter), tracheostomy scar (past trauma or suicide attempt), or inspiratory contraction of sternomastoid muscles (pulmonary disease)? Any evidence of dystonia (neuroleptic malignant syndrome or neuroleptic-induced dystonia)?

Hands and arms Are there overt scars (past trauma, self-mutilation, suicide attempts) or bruising (abuse)? Are the fingernails appropriately maintained? Any evidence of clubbing (cardiopulmonary disease, GI inflammation, cirrhosis) or tremor (alcohol or other drug withdrawal, Parkinsonism, cerebellar infarct)? Even the presence of tattoos, a wedding band, or other jewelry can speak volumes about the patient’s stability. A tattoo can be a form of self-mutilation, while pendants and charms may offer clues to the patient’s spiritual beliefs.

Clothing Is the clothing clean and well maintained, or are buttons and zippers inappropriately fastened (dementia)? Is the clothing not age-appropriate (personality disorders), overtly drab and dark (depression), or outlandish (mania)? Is it not seasonable (homelessness, dementia)?

When training residents to perform the mental status examination, I ask them such questions as “What color are the patient’s shoes?” Too often, in their haste to describe the patient’s ability to spell “world” backwards, they miss the obvious. Board certification examinees also tend to not see a patient’s well-healed wrist scars or facial droop.

Head-to-toe observation of a patient may uncover an undisclosed disorder, condition, or life situation that could affect treatment. Here’s what I look for at the first evaluation:

As the patient enters the room Observe the gait for a limp, shuffle, or other classic signs of illness or injury. Is there evidence of Parkinson’s disease (stooped posture, slow to get started, decreased arm swing, slow to turn)? Is the patient steady on his or her feet? (If not, sensory or cerebellar ataxia may be present.) Is there a foot drop (lower motor neuron disease)? Do the patient’s shoes drag or scrape (spastic hemiparesis from a prior stroke)?

The head Note the quantity and distribution of hair. Is it combed or brushed (ability to care for self, hemineglect)? Is there evidence of unusual hair loss (trichotillomania, hypothyroidism, lupus, side effects from medications)? Any scarring on the scalp (accidental or intentionally-inflicted trauma) or general skull deformities (enlarged in hydrocephalus, Paget’s disease)? Are the ears low-set (fragile X syndrome, other congenital diseases)? Any scarring on the ears (past trauma)?

The face Is there acne (Cushing’s syndrome, ovarian dysfunction, reaction to lithium), telangiectasias (acne rosacea, lupus), or hypopigmentation? Vitiligo may reveal an autoimmune disorder. Hyperpigmentation may point to metastatic melanoma, drug abuse, or endocrinopathies such as Addison’s disease or ectopic ACTH syndrome.

Are there facial scars or bruising (abuse)? Any evidence of characteristic facies (acromegaly, Parkinson’s or Cushing’s disease)? Are the parotid glands enlarged (eating disorders, diabetes, cirrhosis)? Any tics or stereotypies (drug abuse, Tourette’s syndrome)? Does the facial expression match what the patient is saying? Psychologic defense mechanisms may be at work or even malingering.

The mouth Any lip sores (sexually transmitted diseases), angular stomatitis (vitamin deficiencies), or bad dentition (drug abuse, age-related dementia, homelessness)?

The eyes Does the patient make normal eye contact? Is he or she wearing dark glasses (depression, posttraumatic stress disorder, drug abuse)? Is gaze palsy (head injuries, Wernicke’s syndrome) or icterus (hepatic disease) present? Are the sclera discolored or bloodshot (alcohol withdrawal, marijuana abuse)? Are the pupils dilated (atropine, mushroom abuse) or pinpoint (opioid use)?

The neck Any thyroid enlargement (goiter), tracheostomy scar (past trauma or suicide attempt), or inspiratory contraction of sternomastoid muscles (pulmonary disease)? Any evidence of dystonia (neuroleptic malignant syndrome or neuroleptic-induced dystonia)?

Hands and arms Are there overt scars (past trauma, self-mutilation, suicide attempts) or bruising (abuse)? Are the fingernails appropriately maintained? Any evidence of clubbing (cardiopulmonary disease, GI inflammation, cirrhosis) or tremor (alcohol or other drug withdrawal, Parkinsonism, cerebellar infarct)? Even the presence of tattoos, a wedding band, or other jewelry can speak volumes about the patient’s stability. A tattoo can be a form of self-mutilation, while pendants and charms may offer clues to the patient’s spiritual beliefs.

Clothing Is the clothing clean and well maintained, or are buttons and zippers inappropriately fastened (dementia)? Is the clothing not age-appropriate (personality disorders), overtly drab and dark (depression), or outlandish (mania)? Is it not seasonable (homelessness, dementia)?

When training residents to perform the mental status examination, I ask them such questions as “What color are the patient’s shoes?” Too often, in their haste to describe the patient’s ability to spell “world” backwards, they miss the obvious. Board certification examinees also tend to not see a patient’s well-healed wrist scars or facial droop.

Head-to-toe observation of a patient may uncover an undisclosed disorder, condition, or life situation that could affect treatment. Here’s what I look for at the first evaluation:

As the patient enters the room Observe the gait for a limp, shuffle, or other classic signs of illness or injury. Is there evidence of Parkinson’s disease (stooped posture, slow to get started, decreased arm swing, slow to turn)? Is the patient steady on his or her feet? (If not, sensory or cerebellar ataxia may be present.) Is there a foot drop (lower motor neuron disease)? Do the patient’s shoes drag or scrape (spastic hemiparesis from a prior stroke)?

The head Note the quantity and distribution of hair. Is it combed or brushed (ability to care for self, hemineglect)? Is there evidence of unusual hair loss (trichotillomania, hypothyroidism, lupus, side effects from medications)? Any scarring on the scalp (accidental or intentionally-inflicted trauma) or general skull deformities (enlarged in hydrocephalus, Paget’s disease)? Are the ears low-set (fragile X syndrome, other congenital diseases)? Any scarring on the ears (past trauma)?

The face Is there acne (Cushing’s syndrome, ovarian dysfunction, reaction to lithium), telangiectasias (acne rosacea, lupus), or hypopigmentation? Vitiligo may reveal an autoimmune disorder. Hyperpigmentation may point to metastatic melanoma, drug abuse, or endocrinopathies such as Addison’s disease or ectopic ACTH syndrome.

Are there facial scars or bruising (abuse)? Any evidence of characteristic facies (acromegaly, Parkinson’s or Cushing’s disease)? Are the parotid glands enlarged (eating disorders, diabetes, cirrhosis)? Any tics or stereotypies (drug abuse, Tourette’s syndrome)? Does the facial expression match what the patient is saying? Psychologic defense mechanisms may be at work or even malingering.

The mouth Any lip sores (sexually transmitted diseases), angular stomatitis (vitamin deficiencies), or bad dentition (drug abuse, age-related dementia, homelessness)?

The eyes Does the patient make normal eye contact? Is he or she wearing dark glasses (depression, posttraumatic stress disorder, drug abuse)? Is gaze palsy (head injuries, Wernicke’s syndrome) or icterus (hepatic disease) present? Are the sclera discolored or bloodshot (alcohol withdrawal, marijuana abuse)? Are the pupils dilated (atropine, mushroom abuse) or pinpoint (opioid use)?

The neck Any thyroid enlargement (goiter), tracheostomy scar (past trauma or suicide attempt), or inspiratory contraction of sternomastoid muscles (pulmonary disease)? Any evidence of dystonia (neuroleptic malignant syndrome or neuroleptic-induced dystonia)?

Hands and arms Are there overt scars (past trauma, self-mutilation, suicide attempts) or bruising (abuse)? Are the fingernails appropriately maintained? Any evidence of clubbing (cardiopulmonary disease, GI inflammation, cirrhosis) or tremor (alcohol or other drug withdrawal, Parkinsonism, cerebellar infarct)? Even the presence of tattoos, a wedding band, or other jewelry can speak volumes about the patient’s stability. A tattoo can be a form of self-mutilation, while pendants and charms may offer clues to the patient’s spiritual beliefs.

Clothing Is the clothing clean and well maintained, or are buttons and zippers inappropriately fastened (dementia)? Is the clothing not age-appropriate (personality disorders), overtly drab and dark (depression), or outlandish (mania)? Is it not seasonable (homelessness, dementia)?

Properly performing the examination for the abnormal involuntary movement scale (AIMS) is, in my view, crucial to detecting antipsychotic-induced tardive dyskinesia and other movement disorders. Yet I’ve found that many psychiatrists perform this examination either improperly or not at all.

The problem sometimes lies in getting psychiatric patients to follow directions during the exam. Patient cooperation is absolutely critical to doing the exam correctly.

The following are common problems encountered during the AIMS exam:

• The patient refuses to remove his or her shoes. You cannot visualize the feet and accurately assess for movement disorders while the patient is wearing shoes.
  
• The patient is tense. For part of the exam, patients must sit in a chair with their arms relaxed and hanging down at the sides. Too often, though, patients hold their arms rigid, thus masking involuntary movement.
  
• The patient’s tongue is improperly positioned. The tongue should be relaxed in the bottom of the mouth, with the tip touching the back of the bottom teeth or lower lip. Sometimes patients deliberately curl up their tongues or raise them to the roofs of their mouths.
  
• The patient is not familiar with the exam. Many patients either have never heard of the AIMS exam or—in the case of some patients with schizophrenia—do not remember that they previously received the exam.
  
• The patient cannot—or will not—follow directions. For example, some cognitively impaired patients find it difficult to touch their thumbs to their fingertips while keeping their mouths open. Sometimes it is easier for them to do rapid alternating hand movements instead.
  

The following advice can help you surmount these obstacles:

Describe the exam. Start by explaining to the patient, “Your medication places you at risk of developing a movement disorder, so I need to monitor you for involuntary movement. This exam will take less than 10 minutes. It won’t hurt, but you will need to take off your socks and shoes.”

Make sure you are facing the patient. I find that having the patient’s chair aligned directly opposite mine makes it easier to relate to patients and improves their ability to follow directions.

Offer an incentive. I dispense a free pair of socks to patients who complete the exam. Although some affluent patients refuse the free socks, most patients (especially poorer ones) are happy to accept them.

For some patients, I use the socks as a “bribe” (“If you take off your shoes, I’ll give you these socks.”) For others, the socks are a reward for compliance.

Get the patient to relax. If any part of the patient is tense, use a favorite relaxation technique. I tell the patient to breathe deeply and “make believe you’re a pillow.”

Reinforce compliance. Make sure the patient knows you appreciate his or her cooperation. Praise the patient who follows your directions.

Reschedule the exam if necessary. If you cannot get the patient to cooperate that day, stop the exam and try it again during the next visit or as soon as the patient presents in a better mood. Consider having a counselor discuss the exam with the patient in the interim.

Properly performing the examination for the abnormal involuntary movement scale (AIMS) is, in my view, crucial to detecting antipsychotic-induced tardive dyskinesia and other movement disorders. Yet I’ve found that many psychiatrists perform this examination either improperly or not at all.

The problem sometimes lies in getting psychiatric patients to follow directions during the exam. Patient cooperation is absolutely critical to doing the exam correctly.

The following are common problems encountered during the AIMS exam:

• The patient refuses to remove his or her shoes. You cannot visualize the feet and accurately assess for movement disorders while the patient is wearing shoes.
  
• The patient is tense. For part of the exam, patients must sit in a chair with their arms relaxed and hanging down at the sides. Too often, though, patients hold their arms rigid, thus masking involuntary movement.
  
• The patient’s tongue is improperly positioned. The tongue should be relaxed in the bottom of the mouth, with the tip touching the back of the bottom teeth or lower lip. Sometimes patients deliberately curl up their tongues or raise them to the roofs of their mouths.
  
• The patient is not familiar with the exam. Many patients either have never heard of the AIMS exam or—in the case of some patients with schizophrenia—do not remember that they previously received the exam.
  
• The patient cannot—or will not—follow directions. For example, some cognitively impaired patients find it difficult to touch their thumbs to their fingertips while keeping their mouths open. Sometimes it is easier for them to do rapid alternating hand movements instead.
  

The following advice can help you surmount these obstacles:

Describe the exam. Start by explaining to the patient, “Your medication places you at risk of developing a movement disorder, so I need to monitor you for involuntary movement. This exam will take less than 10 minutes. It won’t hurt, but you will need to take off your socks and shoes.”

Make sure you are facing the patient. I find that having the patient’s chair aligned directly opposite mine makes it easier to relate to patients and improves their ability to follow directions.

Offer an incentive. I dispense a free pair of socks to patients who complete the exam. Although some affluent patients refuse the free socks, most patients (especially poorer ones) are happy to accept them.

For some patients, I use the socks as a “bribe” (“If you take off your shoes, I’ll give you these socks.”) For others, the socks are a reward for compliance.

Get the patient to relax. If any part of the patient is tense, use a favorite relaxation technique. I tell the patient to breathe deeply and “make believe you’re a pillow.”

Reinforce compliance. Make sure the patient knows you appreciate his or her cooperation. Praise the patient who follows your directions.

Reschedule the exam if necessary. If you cannot get the patient to cooperate that day, stop the exam and try it again during the next visit or as soon as the patient presents in a better mood. Consider having a counselor discuss the exam with the patient in the interim.

Properly performing the examination for the abnormal involuntary movement scale (AIMS) is, in my view, crucial to detecting antipsychotic-induced tardive dyskinesia and other movement disorders. Yet I’ve found that many psychiatrists perform this examination either improperly or not at all.

The problem sometimes lies in getting psychiatric patients to follow directions during the exam. Patient cooperation is absolutely critical to doing the exam correctly.

The following are common problems encountered during the AIMS exam:

• The patient refuses to remove his or her shoes. You cannot visualize the feet and accurately assess for movement disorders while the patient is wearing shoes.
  
• The patient is tense. For part of the exam, patients must sit in a chair with their arms relaxed and hanging down at the sides. Too often, though, patients hold their arms rigid, thus masking involuntary movement.
  
• The patient’s tongue is improperly positioned. The tongue should be relaxed in the bottom of the mouth, with the tip touching the back of the bottom teeth or lower lip. Sometimes patients deliberately curl up their tongues or raise them to the roofs of their mouths.
  
• The patient is not familiar with the exam. Many patients either have never heard of the AIMS exam or—in the case of some patients with schizophrenia—do not remember that they previously received the exam.
  
• The patient cannot—or will not—follow directions. For example, some cognitively impaired patients find it difficult to touch their thumbs to their fingertips while keeping their mouths open. Sometimes it is easier for them to do rapid alternating hand movements instead.
  

The following advice can help you surmount these obstacles:

Describe the exam. Start by explaining to the patient, “Your medication places you at risk of developing a movement disorder, so I need to monitor you for involuntary movement. This exam will take less than 10 minutes. It won’t hurt, but you will need to take off your socks and shoes.”

Make sure you are facing the patient. I find that having the patient’s chair aligned directly opposite mine makes it easier to relate to patients and improves their ability to follow directions.

Offer an incentive. I dispense a free pair of socks to patients who complete the exam. Although some affluent patients refuse the free socks, most patients (especially poorer ones) are happy to accept them.

For some patients, I use the socks as a “bribe” (“If you take off your shoes, I’ll give you these socks.”) For others, the socks are a reward for compliance.

Get the patient to relax. If any part of the patient is tense, use a favorite relaxation technique. I tell the patient to breathe deeply and “make believe you’re a pillow.”

Reinforce compliance. Make sure the patient knows you appreciate his or her cooperation. Praise the patient who follows your directions.

Reschedule the exam if necessary. If you cannot get the patient to cooperate that day, stop the exam and try it again during the next visit or as soon as the patient presents in a better mood. Consider having a counselor discuss the exam with the patient in the interim.

A patient becomes a candidate for inpatient care when he or she poses a threat to his or her own safety or to that of others—whether due to chronic psychosis, suicidal tendencies, paranoia, or the health risks of a psychiatric condition such as anorexia nervosa. The threat may be immediate. Still, you may find the path to hospitalization strewn with roadblocks ranging from managed care, to the patient and his or her family, to simple red tape.

If you decide that inpatient care is best for the patient, the following advice may help expedite the disposition process.

Be clear about why admission is needed. Articulating the clinical reasons for hospital care to insurance providers, emergency-room attendings, and inpatient unit directors is an important part of the admission process. The following questions can help determine the need for inpatient care:

• Is the patient imminently dangerous?
  
• Is the patient able and willing to cooperate with a less restrictive course of treatment?
  
• Does the patient have a viable support system?
  

A favorable answer to all three questions generally allows the psychiatrist to avoid hospital treatment.

Armed with historical and clinical data that address these questions, the clinician can effectively explain why inpatient care is indicated. Managed care networks are more likely to approve hospitalization for patients who are acutely dangerous to themselves or others than for patients who are not. The patient's medical history must illustrate the danger of not pursuing inpatient care. Emphasize any recent change in suicidal or homicidal ideation. Document if the patient has ever attempted suicide, or if anyone in his or her family completed a suicide. Also learn if the patient has ever exhibited violence, and watch for a significant change in the patient’s behavior or symptoms (e.g., feelings of extreme paranoia or fear).

Define the goals of hospitalization. Remember that hospitals expect clear, concise goals for treatment. Ideally, an inpatient unit will act as a consultant to a patient’s outpatient clinical therapist. An outpatient or emergency clinician should clarify what is expected during a hospital stay.

Often, one goal is to have the hospital act as a temporary support system. This may occur if the suicidal patient has been evicted from his living quarters, or if he needs further intensive observation because family caregivers are exhausted or ill. In other cases where a worsening mood disorder, psychosis, or agitation is present, close observation and medication may be indicated.

Overall, constant communication and coordination between outpatient decision-makers and inpatient doctors are crucial. Communicate directly with the emergency room if the patient is to be triaged there; this will facilitate effective acute management and will arm personnel with information necessary to formulate the optimal treatment disposition.

Measure the patient’s ability and willingness to follow doctors’ orders. A patient’s unwillingness to cooperate with outpatient care can also help convince decision-makers that the patient should be hospitalized. For example, if a patient with hypomania is attending clinical appointments but is refusing medication, he or she may need more structure to prevent full relapse.

Also, make sure the patient is telling you the whole truth about his or her level of risk. For example, a psychiatrist in the emergency room may consult with police officers who have just picked up a patient; the psychiatrist might learn that the patient had been trying to jump over the railing of a bridge when the police found him—a fact the patient had concealed during the interview. In this situation, such knowledge will help prove that outpatient care is inappropriate.

A patient becomes a candidate for inpatient care when he or she poses a threat to his or her own safety or to that of others—whether due to chronic psychosis, suicidal tendencies, paranoia, or the health risks of a psychiatric condition such as anorexia nervosa. The threat may be immediate. Still, you may find the path to hospitalization strewn with roadblocks ranging from managed care, to the patient and his or her family, to simple red tape.

If you decide that inpatient care is best for the patient, the following advice may help expedite the disposition process.

Be clear about why admission is needed. Articulating the clinical reasons for hospital care to insurance providers, emergency-room attendings, and inpatient unit directors is an important part of the admission process. The following questions can help determine the need for inpatient care:

• Is the patient imminently dangerous?
  
• Is the patient able and willing to cooperate with a less restrictive course of treatment?
  
• Does the patient have a viable support system?
  

A favorable answer to all three questions generally allows the psychiatrist to avoid hospital treatment.

Armed with historical and clinical data that address these questions, the clinician can effectively explain why inpatient care is indicated. Managed care networks are more likely to approve hospitalization for patients who are acutely dangerous to themselves or others than for patients who are not. The patient's medical history must illustrate the danger of not pursuing inpatient care. Emphasize any recent change in suicidal or homicidal ideation. Document if the patient has ever attempted suicide, or if anyone in his or her family completed a suicide. Also learn if the patient has ever exhibited violence, and watch for a significant change in the patient’s behavior or symptoms (e.g., feelings of extreme paranoia or fear).

Define the goals of hospitalization. Remember that hospitals expect clear, concise goals for treatment. Ideally, an inpatient unit will act as a consultant to a patient’s outpatient clinical therapist. An outpatient or emergency clinician should clarify what is expected during a hospital stay.

Often, one goal is to have the hospital act as a temporary support system. This may occur if the suicidal patient has been evicted from his living quarters, or if he needs further intensive observation because family caregivers are exhausted or ill. In other cases where a worsening mood disorder, psychosis, or agitation is present, close observation and medication may be indicated.

Overall, constant communication and coordination between outpatient decision-makers and inpatient doctors are crucial. Communicate directly with the emergency room if the patient is to be triaged there; this will facilitate effective acute management and will arm personnel with information necessary to formulate the optimal treatment disposition.

Measure the patient’s ability and willingness to follow doctors’ orders. A patient’s unwillingness to cooperate with outpatient care can also help convince decision-makers that the patient should be hospitalized. For example, if a patient with hypomania is attending clinical appointments but is refusing medication, he or she may need more structure to prevent full relapse.

Also, make sure the patient is telling you the whole truth about his or her level of risk. For example, a psychiatrist in the emergency room may consult with police officers who have just picked up a patient; the psychiatrist might learn that the patient had been trying to jump over the railing of a bridge when the police found him—a fact the patient had concealed during the interview. In this situation, such knowledge will help prove that outpatient care is inappropriate.

A patient becomes a candidate for inpatient care when he or she poses a threat to his or her own safety or to that of others—whether due to chronic psychosis, suicidal tendencies, paranoia, or the health risks of a psychiatric condition such as anorexia nervosa. The threat may be immediate. Still, you may find the path to hospitalization strewn with roadblocks ranging from managed care, to the patient and his or her family, to simple red tape.

If you decide that inpatient care is best for the patient, the following advice may help expedite the disposition process.

Be clear about why admission is needed. Articulating the clinical reasons for hospital care to insurance providers, emergency-room attendings, and inpatient unit directors is an important part of the admission process. The following questions can help determine the need for inpatient care:

• Is the patient imminently dangerous?
  
• Is the patient able and willing to cooperate with a less restrictive course of treatment?
  
• Does the patient have a viable support system?
  

A favorable answer to all three questions generally allows the psychiatrist to avoid hospital treatment.

Armed with historical and clinical data that address these questions, the clinician can effectively explain why inpatient care is indicated. Managed care networks are more likely to approve hospitalization for patients who are acutely dangerous to themselves or others than for patients who are not. The patient's medical history must illustrate the danger of not pursuing inpatient care. Emphasize any recent change in suicidal or homicidal ideation. Document if the patient has ever attempted suicide, or if anyone in his or her family completed a suicide. Also learn if the patient has ever exhibited violence, and watch for a significant change in the patient’s behavior or symptoms (e.g., feelings of extreme paranoia or fear).

Define the goals of hospitalization. Remember that hospitals expect clear, concise goals for treatment. Ideally, an inpatient unit will act as a consultant to a patient’s outpatient clinical therapist. An outpatient or emergency clinician should clarify what is expected during a hospital stay.

Often, one goal is to have the hospital act as a temporary support system. This may occur if the suicidal patient has been evicted from his living quarters, or if he needs further intensive observation because family caregivers are exhausted or ill. In other cases where a worsening mood disorder, psychosis, or agitation is present, close observation and medication may be indicated.

Overall, constant communication and coordination between outpatient decision-makers and inpatient doctors are crucial. Communicate directly with the emergency room if the patient is to be triaged there; this will facilitate effective acute management and will arm personnel with information necessary to formulate the optimal treatment disposition.

Measure the patient’s ability and willingness to follow doctors’ orders. A patient’s unwillingness to cooperate with outpatient care can also help convince decision-makers that the patient should be hospitalized. For example, if a patient with hypomania is attending clinical appointments but is refusing medication, he or she may need more structure to prevent full relapse.

Also, make sure the patient is telling you the whole truth about his or her level of risk. For example, a psychiatrist in the emergency room may consult with police officers who have just picked up a patient; the psychiatrist might learn that the patient had been trying to jump over the railing of a bridge when the police found him—a fact the patient had concealed during the interview. In this situation, such knowledge will help prove that outpatient care is inappropriate.

A patient becomes a candidate for inpatient care when he or she poses a threat to his or her own safety or to that of others—whether due to chronic psychosis, suicidal tendencies, paranoia, or the health risks of a psychiatric condition such as anorexia nervosa. The threat may be immediate. Still, you may find the path to hospitalization strewn with roadblocks ranging from managed care, to the patient and his or her family, to simple red tape.

If you decide that inpatient care is best for the patient, the following advice may help expedite the disposition process.

Be clear about why admission is needed. Articulating the clinical reasons for hospital care to insurance providers, emergency-room attendings, and inpatient unit directors is an important part of the admission process. The following questions can help determine the need for inpatient care:

• Is the patient imminently dangerous?
  
• Is the patient able and willing to cooperate with a less restrictive course of treatment?
  
• Does the patient have a viable support system?
  

A favorable answer to all three questions generally allows the psychiatrist to avoid hospital treatment.

Armed with historical and clinical data that address these questions, the clinician can effectively explain why inpatient care is indicated. Managed care networks are more likely to approve hospitalization for patients who are acutely dangerous to themselves or others than for patients who are not. The patient's medical history must illustrate the danger of not pursuing inpatient care. Emphasize any recent change in suicidal or homicidal ideation. Document if the patient has ever attempted suicide, or if anyone in his or her family completed a suicide. Also learn if the patient has ever exhibited violence, and watch for a significant change in the patient’s behavior or symptoms (e.g., feelings of extreme paranoia or fear).

Define the goals of hospitalization. Remember that hospitals expect clear, concise goals for treatment. Ideally, an inpatient unit will act as a consultant to a patient’s outpatient clinical therapist. An outpatient or emergency clinician should clarify what is expected during a hospital stay.

Often, one goal is to have the hospital act as a temporary support system. This may occur if the suicidal patient has been evicted from his living quarters, or if he needs further intensive observation because family caregivers are exhausted or ill. In other cases where a worsening mood disorder, psychosis, or agitation is present, close observation and medication may be indicated.

Overall, constant communication and coordination between outpatient decision-makers and inpatient doctors are crucial. Communicate directly with the emergency room if the patient is to be triaged there; this will facilitate effective acute management and will arm personnel with information necessary to formulate the optimal treatment disposition.

Measure the patient’s ability and willingness to follow doctors’ orders. A patient’s unwillingness to cooperate with outpatient care can also help convince decision-makers that the patient should be hospitalized. For example, if a patient with hypomania is attending clinical appointments but is refusing medication, he or she may need more structure to prevent full relapse.

Also, make sure the patient is telling you the whole truth about his or her level of risk. For example, a psychiatrist in the emergency room may consult with police officers who have just picked up a patient; the psychiatrist might learn that the patient had been trying to jump over the railing of a bridge when the police found him—a fact the patient had concealed during the interview. In this situation, such knowledge will help prove that outpatient care is inappropriate.

A patient becomes a candidate for inpatient care when he or she poses a threat to his or her own safety or to that of others—whether due to chronic psychosis, suicidal tendencies, paranoia, or the health risks of a psychiatric condition such as anorexia nervosa. The threat may be immediate. Still, you may find the path to hospitalization strewn with roadblocks ranging from managed care, to the patient and his or her family, to simple red tape.

If you decide that inpatient care is best for the patient, the following advice may help expedite the disposition process.

Be clear about why admission is needed. Articulating the clinical reasons for hospital care to insurance providers, emergency-room attendings, and inpatient unit directors is an important part of the admission process. The following questions can help determine the need for inpatient care:

• Is the patient imminently dangerous?
  
• Is the patient able and willing to cooperate with a less restrictive course of treatment?
  
• Does the patient have a viable support system?
  

A favorable answer to all three questions generally allows the psychiatrist to avoid hospital treatment.

Armed with historical and clinical data that address these questions, the clinician can effectively explain why inpatient care is indicated. Managed care networks are more likely to approve hospitalization for patients who are acutely dangerous to themselves or others than for patients who are not. The patient's medical history must illustrate the danger of not pursuing inpatient care. Emphasize any recent change in suicidal or homicidal ideation. Document if the patient has ever attempted suicide, or if anyone in his or her family completed a suicide. Also learn if the patient has ever exhibited violence, and watch for a significant change in the patient’s behavior or symptoms (e.g., feelings of extreme paranoia or fear).

Define the goals of hospitalization. Remember that hospitals expect clear, concise goals for treatment. Ideally, an inpatient unit will act as a consultant to a patient’s outpatient clinical therapist. An outpatient or emergency clinician should clarify what is expected during a hospital stay.

Often, one goal is to have the hospital act as a temporary support system. This may occur if the suicidal patient has been evicted from his living quarters, or if he needs further intensive observation because family caregivers are exhausted or ill. In other cases where a worsening mood disorder, psychosis, or agitation is present, close observation and medication may be indicated.

Overall, constant communication and coordination between outpatient decision-makers and inpatient doctors are crucial. Communicate directly with the emergency room if the patient is to be triaged there; this will facilitate effective acute management and will arm personnel with information necessary to formulate the optimal treatment disposition.

Measure the patient’s ability and willingness to follow doctors’ orders. A patient’s unwillingness to cooperate with outpatient care can also help convince decision-makers that the patient should be hospitalized. For example, if a patient with hypomania is attending clinical appointments but is refusing medication, he or she may need more structure to prevent full relapse.

Also, make sure the patient is telling you the whole truth about his or her level of risk. For example, a psychiatrist in the emergency room may consult with police officers who have just picked up a patient; the psychiatrist might learn that the patient had been trying to jump over the railing of a bridge when the police found him—a fact the patient had concealed during the interview. In this situation, such knowledge will help prove that outpatient care is inappropriate.

A patient becomes a candidate for inpatient care when he or she poses a threat to his or her own safety or to that of others—whether due to chronic psychosis, suicidal tendencies, paranoia, or the health risks of a psychiatric condition such as anorexia nervosa. The threat may be immediate. Still, you may find the path to hospitalization strewn with roadblocks ranging from managed care, to the patient and his or her family, to simple red tape.

If you decide that inpatient care is best for the patient, the following advice may help expedite the disposition process.

Be clear about why admission is needed. Articulating the clinical reasons for hospital care to insurance providers, emergency-room attendings, and inpatient unit directors is an important part of the admission process. The following questions can help determine the need for inpatient care:

• Is the patient imminently dangerous?
  
• Is the patient able and willing to cooperate with a less restrictive course of treatment?
  
• Does the patient have a viable support system?
  

A favorable answer to all three questions generally allows the psychiatrist to avoid hospital treatment.

Armed with historical and clinical data that address these questions, the clinician can effectively explain why inpatient care is indicated. Managed care networks are more likely to approve hospitalization for patients who are acutely dangerous to themselves or others than for patients who are not. The patient's medical history must illustrate the danger of not pursuing inpatient care. Emphasize any recent change in suicidal or homicidal ideation. Document if the patient has ever attempted suicide, or if anyone in his or her family completed a suicide. Also learn if the patient has ever exhibited violence, and watch for a significant change in the patient’s behavior or symptoms (e.g., feelings of extreme paranoia or fear).

Define the goals of hospitalization. Remember that hospitals expect clear, concise goals for treatment. Ideally, an inpatient unit will act as a consultant to a patient’s outpatient clinical therapist. An outpatient or emergency clinician should clarify what is expected during a hospital stay.

Often, one goal is to have the hospital act as a temporary support system. This may occur if the suicidal patient has been evicted from his living quarters, or if he needs further intensive observation because family caregivers are exhausted or ill. In other cases where a worsening mood disorder, psychosis, or agitation is present, close observation and medication may be indicated.

Overall, constant communication and coordination between outpatient decision-makers and inpatient doctors are crucial. Communicate directly with the emergency room if the patient is to be triaged there; this will facilitate effective acute management and will arm personnel with information necessary to formulate the optimal treatment disposition.

Measure the patient’s ability and willingness to follow doctors’ orders. A patient’s unwillingness to cooperate with outpatient care can also help convince decision-makers that the patient should be hospitalized. For example, if a patient with hypomania is attending clinical appointments but is refusing medication, he or she may need more structure to prevent full relapse.

Also, make sure the patient is telling you the whole truth about his or her level of risk. For example, a psychiatrist in the emergency room may consult with police officers who have just picked up a patient; the psychiatrist might learn that the patient had been trying to jump over the railing of a bridge when the police found him—a fact the patient had concealed during the interview. In this situation, such knowledge will help prove that outpatient care is inappropriate.

As populations are becoming more diverse, increasing numbers of foreign-born patients are entering psychiatric practices and emergency services.

At the same time, clinicians are having trouble navigating cultural roadblocks to treatment. Little research has been done in treating the foreign-born patient, and few studies exist to guide us in the standard of care.^1,2 The following three hurdles are common when examining the foreign-born patient:

1. Language. Many immigrant patients do not understand medical terminology, and some English terms, such as “depression,” do not translate exactly into other languages. Trying to understand a patient’s own words or hearing a family member or friend try to explain the problem often leads to misinterpretation, or the gravity of the situation may be lost in the translation.
   
2. Fears of “loss of face.” For cultural reasons, the patient may perceive mental disorders as a sign of weakness and is loath to admit that a problem exists.
   
3. Dependence on family. The patient is reluctant to accept help from someone outside the immediate family.
   

The following advice can help you overcome cultural barriers to treatment:

Learn about the patient’s culture. Picking up on cultural traits can help you gain the patient’s trust.

For example, many Asian people are stoic; they bow profusely as a gesture of respect, yet with minimal affect. In Africa, some tribal members introduce themselves not only with their names but by reciting their entire ancestry. To interrupt this recitation is considered disrespectful. Westerners tend to be bold and more direct, whereas Easterners are more philosophical, vague, and abstract.

Cultural practices can be researched on the Internet. (For example, typing “Asian” and “cultural differences” into a search engine located a “primer” on Japanese culture.) Discussions with the patient’s family may also help.

Take a patient’s request seriously, no matter how frivolous it sounds. Some foreign-born female patients may ask to be assigned to a female clinician in your group or to be referred to another psychiatrist. For example, Islamic women cannot have male therapists because their religion and culture forbid close contact with men without the accompaniment or approval of a male relative. Indian women also have trouble talking to male doctors because of deep-seated cultural restrictions.

Foreign-born patients often do not come forward for help unless their condition becomes desperate. Your sensitivity to issues that seem trivial and far from your own experience may be initially difficult, but your openness enhances and strengthens the therapeutic alliance.

Make sure the patient understands you. Some foreign-born patients may agree with the doctor at all times, mostly because they do not wish to offend someone they hold in high esteem. In contrast, a curt or short response may reveal a guarded attitude or indicate a lack of understanding.

To ensure understanding, get specific answers. If necessary, politely rephrase the question. Be very patient.

Use a qualified interpreter, either a mental health professional or a resident or practicing colleague who speaks the patient’s language.

Qualified interpreters should be professional and precise in relaying your concerns and cautions to the patient. You will need to communicate medication options carefully and to express that you understand the stigma the patient’s culture attaches to mental illness.

Many hospitals today have interpreters available on staff—either volunteers to be called in emergencies or on-call contract personnel.

As populations are becoming more diverse, increasing numbers of foreign-born patients are entering psychiatric practices and emergency services.

At the same time, clinicians are having trouble navigating cultural roadblocks to treatment. Little research has been done in treating the foreign-born patient, and few studies exist to guide us in the standard of care.^1,2 The following three hurdles are common when examining the foreign-born patient:

1. Language. Many immigrant patients do not understand medical terminology, and some English terms, such as “depression,” do not translate exactly into other languages. Trying to understand a patient’s own words or hearing a family member or friend try to explain the problem often leads to misinterpretation, or the gravity of the situation may be lost in the translation.
   
2. Fears of “loss of face.” For cultural reasons, the patient may perceive mental disorders as a sign of weakness and is loath to admit that a problem exists.
   
3. Dependence on family. The patient is reluctant to accept help from someone outside the immediate family.
   

The following advice can help you overcome cultural barriers to treatment:

Learn about the patient’s culture. Picking up on cultural traits can help you gain the patient’s trust.

For example, many Asian people are stoic; they bow profusely as a gesture of respect, yet with minimal affect. In Africa, some tribal members introduce themselves not only with their names but by reciting their entire ancestry. To interrupt this recitation is considered disrespectful. Westerners tend to be bold and more direct, whereas Easterners are more philosophical, vague, and abstract.

Cultural practices can be researched on the Internet. (For example, typing “Asian” and “cultural differences” into a search engine located a “primer” on Japanese culture.) Discussions with the patient’s family may also help.

Take a patient’s request seriously, no matter how frivolous it sounds. Some foreign-born female patients may ask to be assigned to a female clinician in your group or to be referred to another psychiatrist. For example, Islamic women cannot have male therapists because their religion and culture forbid close contact with men without the accompaniment or approval of a male relative. Indian women also have trouble talking to male doctors because of deep-seated cultural restrictions.

Foreign-born patients often do not come forward for help unless their condition becomes desperate. Your sensitivity to issues that seem trivial and far from your own experience may be initially difficult, but your openness enhances and strengthens the therapeutic alliance.

Make sure the patient understands you. Some foreign-born patients may agree with the doctor at all times, mostly because they do not wish to offend someone they hold in high esteem. In contrast, a curt or short response may reveal a guarded attitude or indicate a lack of understanding.

To ensure understanding, get specific answers. If necessary, politely rephrase the question. Be very patient.

Use a qualified interpreter, either a mental health professional or a resident or practicing colleague who speaks the patient’s language.

Qualified interpreters should be professional and precise in relaying your concerns and cautions to the patient. You will need to communicate medication options carefully and to express that you understand the stigma the patient’s culture attaches to mental illness.

Many hospitals today have interpreters available on staff—either volunteers to be called in emergencies or on-call contract personnel.

As populations are becoming more diverse, increasing numbers of foreign-born patients are entering psychiatric practices and emergency services.

At the same time, clinicians are having trouble navigating cultural roadblocks to treatment. Little research has been done in treating the foreign-born patient, and few studies exist to guide us in the standard of care.^1,2 The following three hurdles are common when examining the foreign-born patient:

1. Language. Many immigrant patients do not understand medical terminology, and some English terms, such as “depression,” do not translate exactly into other languages. Trying to understand a patient’s own words or hearing a family member or friend try to explain the problem often leads to misinterpretation, or the gravity of the situation may be lost in the translation.
   
2. Fears of “loss of face.” For cultural reasons, the patient may perceive mental disorders as a sign of weakness and is loath to admit that a problem exists.
   
3. Dependence on family. The patient is reluctant to accept help from someone outside the immediate family.
   

The following advice can help you overcome cultural barriers to treatment:

Learn about the patient’s culture. Picking up on cultural traits can help you gain the patient’s trust.

For example, many Asian people are stoic; they bow profusely as a gesture of respect, yet with minimal affect. In Africa, some tribal members introduce themselves not only with their names but by reciting their entire ancestry. To interrupt this recitation is considered disrespectful. Westerners tend to be bold and more direct, whereas Easterners are more philosophical, vague, and abstract.

Cultural practices can be researched on the Internet. (For example, typing “Asian” and “cultural differences” into a search engine located a “primer” on Japanese culture.) Discussions with the patient’s family may also help.

Take a patient’s request seriously, no matter how frivolous it sounds. Some foreign-born female patients may ask to be assigned to a female clinician in your group or to be referred to another psychiatrist. For example, Islamic women cannot have male therapists because their religion and culture forbid close contact with men without the accompaniment or approval of a male relative. Indian women also have trouble talking to male doctors because of deep-seated cultural restrictions.

Foreign-born patients often do not come forward for help unless their condition becomes desperate. Your sensitivity to issues that seem trivial and far from your own experience may be initially difficult, but your openness enhances and strengthens the therapeutic alliance.

Make sure the patient understands you. Some foreign-born patients may agree with the doctor at all times, mostly because they do not wish to offend someone they hold in high esteem. In contrast, a curt or short response may reveal a guarded attitude or indicate a lack of understanding.

To ensure understanding, get specific answers. If necessary, politely rephrase the question. Be very patient.

Use a qualified interpreter, either a mental health professional or a resident or practicing colleague who speaks the patient’s language.

Qualified interpreters should be professional and precise in relaying your concerns and cautions to the patient. You will need to communicate medication options carefully and to express that you understand the stigma the patient’s culture attaches to mental illness.

Many hospitals today have interpreters available on staff—either volunteers to be called in emergencies or on-call contract personnel.

Auditory hallucinations, delusions, and command hallucinations are common symptoms in schizophrenic patients. These often persist even with the use of antipsychotic medications.

How can you respond when a patient is expressing command hallucinations with voices that are threatening and distressful? I have found that the following psychological interventions help:

Acknowledge that these experiences are quite real to the patient, but that as a therapist, you have not had any similar experiences. This allows the patient to retain the sense of the validity of these experiences without fostering them.

Display a sense of understanding. Empathize with the schizophrenic patient’s experience of being overwhelmed by hallucinations and delusions. Acknowledging the distress that these hallucinations create in the patient’s mind will help build a therapeutic alliance.¹ It may help to make a comment such as, “You must be exhausted considering what you’ve been through,” without actually agreeing that every hallucination and delusion is real.

Urge the patient to try to ignore or reduce the intensity of the voices and hallucinations. I strive to help the patient "discount" these experiences with the knowledge that the voices will most likely continue. I often use the analogy of a radio that can be turned down; similarly, the patient can attempt to reduce the volume of the voices so that they may become less troubling.

Several methods exist for helping patients reduce the intensity of the voices or hallucinations. I suggest that the patients focus on something that is positive, such as art, music, or reading. I have found that this distraction often works.

Remind the patient that he or she is in charge. Despite what the voice is commanding, remind the patient that he or she has the final authority to follow or not follow the commands. This tends to empower the patient to regain control of his or her actions and behavior despite the commands. This is difficult for some patients.

For example, I might say to the patient, “If a negative voice is telling you to harm yourself, you can control your actions.” As part of treatment I praise and encourage healthy behavior. Then together as doctor and patient with some time, effort, support, and medication, we work toward finding a positive outcome and to ensure the patient’s safety.

I have found that these interventions tend to reduce the severity of the hallucinations in certain patients, used in the context of a trusting and supportive doctor-patient relationship and in conjunction with the use of antipsychotic medication.

Auditory hallucinations, delusions, and command hallucinations are common symptoms in schizophrenic patients. These often persist even with the use of antipsychotic medications.

How can you respond when a patient is expressing command hallucinations with voices that are threatening and distressful? I have found that the following psychological interventions help:

Acknowledge that these experiences are quite real to the patient, but that as a therapist, you have not had any similar experiences. This allows the patient to retain the sense of the validity of these experiences without fostering them.

Display a sense of understanding. Empathize with the schizophrenic patient’s experience of being overwhelmed by hallucinations and delusions. Acknowledging the distress that these hallucinations create in the patient’s mind will help build a therapeutic alliance.¹ It may help to make a comment such as, “You must be exhausted considering what you’ve been through,” without actually agreeing that every hallucination and delusion is real.

Urge the patient to try to ignore or reduce the intensity of the voices and hallucinations. I strive to help the patient "discount" these experiences with the knowledge that the voices will most likely continue. I often use the analogy of a radio that can be turned down; similarly, the patient can attempt to reduce the volume of the voices so that they may become less troubling.

Several methods exist for helping patients reduce the intensity of the voices or hallucinations. I suggest that the patients focus on something that is positive, such as art, music, or reading. I have found that this distraction often works.

Remind the patient that he or she is in charge. Despite what the voice is commanding, remind the patient that he or she has the final authority to follow or not follow the commands. This tends to empower the patient to regain control of his or her actions and behavior despite the commands. This is difficult for some patients.

For example, I might say to the patient, “If a negative voice is telling you to harm yourself, you can control your actions.” As part of treatment I praise and encourage healthy behavior. Then together as doctor and patient with some time, effort, support, and medication, we work toward finding a positive outcome and to ensure the patient’s safety.

I have found that these interventions tend to reduce the severity of the hallucinations in certain patients, used in the context of a trusting and supportive doctor-patient relationship and in conjunction with the use of antipsychotic medication.

Auditory hallucinations, delusions, and command hallucinations are common symptoms in schizophrenic patients. These often persist even with the use of antipsychotic medications.

How can you respond when a patient is expressing command hallucinations with voices that are threatening and distressful? I have found that the following psychological interventions help:

Acknowledge that these experiences are quite real to the patient, but that as a therapist, you have not had any similar experiences. This allows the patient to retain the sense of the validity of these experiences without fostering them.

Display a sense of understanding. Empathize with the schizophrenic patient’s experience of being overwhelmed by hallucinations and delusions. Acknowledging the distress that these hallucinations create in the patient’s mind will help build a therapeutic alliance.¹ It may help to make a comment such as, “You must be exhausted considering what you’ve been through,” without actually agreeing that every hallucination and delusion is real.

Urge the patient to try to ignore or reduce the intensity of the voices and hallucinations. I strive to help the patient "discount" these experiences with the knowledge that the voices will most likely continue. I often use the analogy of a radio that can be turned down; similarly, the patient can attempt to reduce the volume of the voices so that they may become less troubling.

Several methods exist for helping patients reduce the intensity of the voices or hallucinations. I suggest that the patients focus on something that is positive, such as art, music, or reading. I have found that this distraction often works.

Remind the patient that he or she is in charge. Despite what the voice is commanding, remind the patient that he or she has the final authority to follow or not follow the commands. This tends to empower the patient to regain control of his or her actions and behavior despite the commands. This is difficult for some patients.

For example, I might say to the patient, “If a negative voice is telling you to harm yourself, you can control your actions.” As part of treatment I praise and encourage healthy behavior. Then together as doctor and patient with some time, effort, support, and medication, we work toward finding a positive outcome and to ensure the patient’s safety.

I have found that these interventions tend to reduce the severity of the hallucinations in certain patients, used in the context of a trusting and supportive doctor-patient relationship and in conjunction with the use of antipsychotic medication.

Auditory hallucinations, delusions, and command hallucinations are common symptoms in schizophrenic patients. These often persist even with the use of antipsychotic medications.

How can you respond when a patient is expressing command hallucinations with voices that are threatening and distressful? I have found that the following psychological interventions help:

Acknowledge that these experiences are quite real to the patient, but that as a therapist, you have not had any similar experiences. This allows the patient to retain the sense of the validity of these experiences without fostering them.

Display a sense of understanding. Empathize with the schizophrenic patient’s experience of being overwhelmed by hallucinations and delusions. Acknowledging the distress that these hallucinations create in the patient’s mind will help build a therapeutic alliance.¹ It may help to make a comment such as, “You must be exhausted considering what you’ve been through,” without actually agreeing that every hallucination and delusion is real.

Urge the patient to try to ignore or reduce the intensity of the voices and hallucinations. I strive to help the patient "discount" these experiences with the knowledge that the voices will most likely continue. I often use the analogy of a radio that can be turned down; similarly, the patient can attempt to reduce the volume of the voices so that they may become less troubling.

Several methods exist for helping patients reduce the intensity of the voices or hallucinations. I suggest that the patients focus on something that is positive, such as art, music, or reading. I have found that this distraction often works.

Remind the patient that he or she is in charge. Despite what the voice is commanding, remind the patient that he or she has the final authority to follow or not follow the commands. This tends to empower the patient to regain control of his or her actions and behavior despite the commands. This is difficult for some patients.

For example, I might say to the patient, “If a negative voice is telling you to harm yourself, you can control your actions.” As part of treatment I praise and encourage healthy behavior. Then together as doctor and patient with some time, effort, support, and medication, we work toward finding a positive outcome and to ensure the patient’s safety.

I have found that these interventions tend to reduce the severity of the hallucinations in certain patients, used in the context of a trusting and supportive doctor-patient relationship and in conjunction with the use of antipsychotic medication.

Auditory hallucinations, delusions, and command hallucinations are common symptoms in schizophrenic patients. These often persist even with the use of antipsychotic medications.

How can you respond when a patient is expressing command hallucinations with voices that are threatening and distressful? I have found that the following psychological interventions help:

Acknowledge that these experiences are quite real to the patient, but that as a therapist, you have not had any similar experiences. This allows the patient to retain the sense of the validity of these experiences without fostering them.

Display a sense of understanding. Empathize with the schizophrenic patient’s experience of being overwhelmed by hallucinations and delusions. Acknowledging the distress that these hallucinations create in the patient’s mind will help build a therapeutic alliance.¹ It may help to make a comment such as, “You must be exhausted considering what you’ve been through,” without actually agreeing that every hallucination and delusion is real.

Urge the patient to try to ignore or reduce the intensity of the voices and hallucinations. I strive to help the patient "discount" these experiences with the knowledge that the voices will most likely continue. I often use the analogy of a radio that can be turned down; similarly, the patient can attempt to reduce the volume of the voices so that they may become less troubling.

Several methods exist for helping patients reduce the intensity of the voices or hallucinations. I suggest that the patients focus on something that is positive, such as art, music, or reading. I have found that this distraction often works.

Remind the patient that he or she is in charge. Despite what the voice is commanding, remind the patient that he or she has the final authority to follow or not follow the commands. This tends to empower the patient to regain control of his or her actions and behavior despite the commands. This is difficult for some patients.

For example, I might say to the patient, “If a negative voice is telling you to harm yourself, you can control your actions.” As part of treatment I praise and encourage healthy behavior. Then together as doctor and patient with some time, effort, support, and medication, we work toward finding a positive outcome and to ensure the patient’s safety.

I have found that these interventions tend to reduce the severity of the hallucinations in certain patients, used in the context of a trusting and supportive doctor-patient relationship and in conjunction with the use of antipsychotic medication.

Auditory hallucinations, delusions, and command hallucinations are common symptoms in schizophrenic patients. These often persist even with the use of antipsychotic medications.

How can you respond when a patient is expressing command hallucinations with voices that are threatening and distressful? I have found that the following psychological interventions help:

Acknowledge that these experiences are quite real to the patient, but that as a therapist, you have not had any similar experiences. This allows the patient to retain the sense of the validity of these experiences without fostering them.

Display a sense of understanding. Empathize with the schizophrenic patient’s experience of being overwhelmed by hallucinations and delusions. Acknowledging the distress that these hallucinations create in the patient’s mind will help build a therapeutic alliance.¹ It may help to make a comment such as, “You must be exhausted considering what you’ve been through,” without actually agreeing that every hallucination and delusion is real.

Urge the patient to try to ignore or reduce the intensity of the voices and hallucinations. I strive to help the patient "discount" these experiences with the knowledge that the voices will most likely continue. I often use the analogy of a radio that can be turned down; similarly, the patient can attempt to reduce the volume of the voices so that they may become less troubling.

Several methods exist for helping patients reduce the intensity of the voices or hallucinations. I suggest that the patients focus on something that is positive, such as art, music, or reading. I have found that this distraction often works.

Remind the patient that he or she is in charge. Despite what the voice is commanding, remind the patient that he or she has the final authority to follow or not follow the commands. This tends to empower the patient to regain control of his or her actions and behavior despite the commands. This is difficult for some patients.

For example, I might say to the patient, “If a negative voice is telling you to harm yourself, you can control your actions.” As part of treatment I praise and encourage healthy behavior. Then together as doctor and patient with some time, effort, support, and medication, we work toward finding a positive outcome and to ensure the patient’s safety.

I have found that these interventions tend to reduce the severity of the hallucinations in certain patients, used in the context of a trusting and supportive doctor-patient relationship and in conjunction with the use of antipsychotic medication.