Emergency medicine clinics of North America
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Emerg. Med. Clin. North Am. · Feb 2024
ReviewDifficult Patients: Malingerers, Feigners, Chronic Complainers, and Real Imposters.
Malingering is the intentional production of false or grossly exaggerated symptoms motivated by internal and external incentives. The true incidence of malingering in the emergency department is unknown because of the difficulty of identifying whether patients are fabricating their symptoms. ⋯ Several case studies are presented and analyzed from a medical ethics perspective. Practical recommendations include use of the NEAL (neutral, empathetic, and avoid labeling) strategy when caring for patients suspected of malingering.
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Depressive disorders encompass a spectrum of diagnoses and are more common in women and transgender individuals. Diagnosis involves thorough history-taking and exclusion of underlying medical disorders. The emergency physician should assess the risk of self-harm and consider environmental and social factors prior to disposition.
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Hyperactive delirium with severe agitation is a clinical syndrome of altered mental status, psychomotor agitation, and a hyperadrenergic state. The underlying pathophysiology is variable and often results from sympathomimetic abuse, psychiatric disease, sedative-hypnotic withdrawal, and metabolic derangement. ⋯ Safety of the patient and of the medical providers is paramount and the emergency department should be prepared to manage these patients with adequate staffing, restraints, and pharmacologic sedatives. Treatment with benzodiazepines, antipsychotics, or ketamine is recommended, followed by airway protection, supportive measures, and cooling of hyperthermia.
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A quality clinical interview helps establish a good collaborative relationship with the patient. This is especially important when emergency physicians conduct a psychiatric interview. Familiarity with interview techniques, empathic listening, and observation of nonverbal cues, behavior, and appearance enhance diagnostic excellence.
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Emerg. Med. Clin. North Am. · Feb 2024
ReviewRecognizing and Responding to Patients with Personality Disorders.
Caring for patients with personality disorders and traits presents unique challenges for physicians and other providers. The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, recognizes 10 personality disorders, which are organized into 3 clusters (A, B, and C) based on shared diagnostic features. Personality disorders or traits create difficulty in clinical and interpersonal interactions, promoting missed diagnosis or underdiagnosis, nonadherence to medical recommendations, or other dangerous outcomes. It is important to recognize patients with potential personality disorders and understand strategies to achieve optimal patient interactions and best possible medical outcomes.