Descriptive Psychopathology: The Signs and Symptoms of ...

109 Chapter 5: Examination style, structure, and techniqueskills, confidence, and flexibility enhance the patient’s positive feelings for theexaminer, the medical opinions offered, and the treatments prescribed. The substantial“placebo effect” seen in clinical trials reflects the importance of the interpersonalqualities of the treaters. 3 In clinical practice it is an ally, eliciting earlyreassurance that the condition will resolve with continued treatment. A gooddoctor–patient relationship maximizes the placebo effect and compliance.Examination settingPatients with behavioral syndromes are encountered in all clinical settings andoften under difficult circumstances. In emergency rooms, safety is the primaryconcern for both patient and staff. 4 While “panic” buttons in examination roomsare necessary, their use is “too little, too late”. The situation is already violent.Quick assessment of the potential for violence, using techniques to minimizeinjury (see below), and a ready escape route, provide the best insurance againstassault. The same pertains on inpatient units. When the threat of violence ispalpable, the rules of safety supercede the need for privacy, and the patient is seenin an open area or with other staff and, if needed, security personnel present.For non-violent patients, examination rooms are best configured so that thepatient and examiner do not directly face each other as this positioning isthreatening to some patients. Chairs set “kitty-corner”-style present a more informal,anxiety-reducing image. Patients who have suffered childhood abuse may feelclaustrophobic in a small examination room. In hospital consultation settings,the patient is often bed-ridden and the psychiatrist stands. If appropriate, holdingthe patient’s hand or placing a hand on the patient’s shoulder during theexamination is reassuring.Examination ground rulesMost patients seeing a psychiatrist for the first time have the “movie” image inmind. Many reluctantly come to the assessment at the urging of their family orgeneral medical physician. Helping the patient to understand the ground rulesof the evaluation reduces tension. The identity of all persons present and thepurpose and procedures of the examination are explained. Permission isrequested for the examination phase requiring touching the patient. For veryanxious patients or those with cognitive difficulties, the presence of a familymember can be invaluable. If asked to wait outside the room, it is helpful to bringthe family member back in to discuss the findings and recommendations. Beforethis discussion, the patient is asked if any information is “off-limits”, and suchwishes are honored, unless not informing the family member presents a danger tothe patient or others. Before ending the evaluation, what needs to be done nextis discussed.