That is not good. Missing a tic disorder on the child adolescent pychiatry oral boards is as serious as missing Tardive Dyskinesia on the general psychiatry oral boards. Here is some important information on how to not to miss tics on your exam.

Let’s start by defining tics. A tic is a sudden, repetitive, nonrhythmic, stereotyped motor movement or vocalization involving discrete muscle groups.

How can tics be missed? Here is an important list of reasons you should know about that can lead you to miss tics. Reviewing this list will help you better recognize them.

Tics can be subtle. If you’re not paying attention you can miss them. They can be subtle grimaces or shoulder movements or throat clearings. They can be an expiration of air through the nose that sounds like someone has a stuffy nose.

Tics are suppressable (yet irresistable). Preceding a tic is an increasing urge to engage in the tic. Think of having a strong itch that you feel compelled to scratch. This means that the person with a tic can suppress the tic for a short period of time, perhaps until the person finishes the sentence and the interviewer looks away.

Tics decrease during periods of concentration, as when a person is being interviewed and attending closely to the questions and to their own responses. The tics may manifest more frequently in that quiet interval in between questions, just when the interviewer has his/her head down and is writing notes.

Complex motor tics may appear to be coordinated and goal-directed movements, in other words,  not like tics. Examples can include the lifting of the arm to touch or brush back hair, or movements that appear like the person is adjusting thier clothes or their position on their chair.

Persons with tics will often use camouflaging movements or vocalizations to hide their tic. For example, if a person has a tic of their arm flinging upward, they can follow it by brushing their hair back with that hand. This has the effect of making the tic appear as a voluntary and goal-directed movement. Or someone with a tic of the neck that twists their head and can then lift their hand to adjust their collar, as if the tic was a voluntary movement to relieve some discomfort related to their clothing. Or consider coprolalia, the most dramatic although not that common of a symptom (about 10-15% of persons with Tourette’s experience this symptom). If someone has the tic of shouting out the ‘F’ word, they can camouflage it by saying somethink like ‘fudge and cream.” If you ask them about it they may say, “Oh, I was just thinking of my favorite ice cream. I think I’ll get some on the way home.”

Here is a link to a adolescent explaining her Tourette’s Disorder. She manifests some dramatic phonic and motor tics. I chose this clip because it is not exploitative and because this girl wants to educate people about her condition.
http://www.youtube.com/watch?v=KgwJZp5SxDo 

I hope this helps.

Take care and happy studies.

Jack Krasuski, MD
877-225-8384

1. Learn the patient’s ‘idioms of distress.” This term refers to the words and the underlying concepts the patient uses to explain to himself and to others his illness and the broader life problems he experiences. For example, some patients talk about chemical imbalances while other may blame punishment by God, or possession by evil spirits. Examiners are assessing you on your ability to attend to these idioms of distress and to incorporate them into your presentation, including into your treatment plan. For the treatment to be effective you have to speak the patient’s conceptual language. Otherwise you may not get buy-in.

2. Learn the evolution of the patient’s difficulties. Psychiatric conditions don’t just present themselves full blown one day. There are a series of events through which the patient progresses that lead ultimately to the full blown syndrome. In the first minutes of the interview start finding out how the patient got to the point in their lives that they are at right now. In particular, attend to what circumstances / people patients attribute their difficultes to: their abusive spouse, their childhood abuse, losing their job, being non-compliant with treatment, presence of a medical condition, or use of drugs – among many others. These contributors are important to note because they should be addressed in the treatment plan. Why? Because these stressors / contributors, if they continue in place, will prevent the patient from recovering from their psychiatric illness or will pull them right back into it if they have recovered. Stressors and other modifiable contributors need to be minimized or eliminated or the patient needs to be ‘inoculated’ against them. In any case, the treatment plan without a focus on stressors and other contributors is incomplete.

3. Learn about the patient’s mental status, especially their thought processes. So, as the patient is speaking about their illness and life difficulties, listen not only to the content of their story but also attend to the patient’s ability to elaborate a coherent description. Note any paucity of speech, paucity of thought content, perseverations, tangentiality or circumstantiality, flight of ideas, presence of neologisms, etc. You will also have the opportunity to attend to other aspects of the mental status, such as abnormalities in engagement, attention, affect, motor function, insight, judgment, and impulse control, and for possible presence of internal preoccupations, hallucinations or delusions.

4. And last, this more open-ended part of the interview is a great time to build rapport. Your careful listening and active engagement will make the patient feel respected. Rather than follow your agenda, you will permit the patient to tell his or her story helped along by your well-positioned facilitating statements. I will present you with some examples of facilitating statements in the next post.

Send me your comments and questions.

Thanks and happy studies

Jack Krasuski, MD
877-225-8384

I was sent to the VA and interviewed a married man in his early 30s who stated that he was on an inpatient PTSD unit.  He was a Gulf War veteran.  The pt was initially nondisclosing and almost confrontational.  It took me about 15 minutes to build rapport. He would make statements like “Easy doc, I’m just getting to know you.”  I backed off and let him talk initially, but I sacrificed a great deal of time to do this.  He eventually opened up after I made an empathic statement when he spoke of his war-time trauma.  I then began screening him for PTSD and he stated, “Are you sure that you’re not a doctor?  No one has ever asked me these questions before.” 

During the interview, he also may have had a flashback. (I was not peppering him with questions and stated that he need not retell traumatic details.) He asked for “a minute,” to recompose hiself which I gave him.  When he was quiet, I leaned over and told him, “you’ve been through a lot.”  From the remaining time, I was able to get a 4-month history of PTSD symptoms, a firearm at home, a history of 3 head traumas, a history of aggression, a history of alcohol abuse, estrangement from his father because his father does not like his wife, and a possible history of depression. 

Because of limited time, I only did a cursory review of psychotic symptoms, which seemed only to reveal flashbacks and not first-rank symptoms.  I did not have time to screen for mania or other anxiety spectrum disorders.  I did a quick cognitive screen, which revealed nothing significant, though he did mention memory loss. 

I remembered to ask about HIV, Hep B/C, and his military history.  With one minute remaining, I went back and asked him if he would tell his doctor about his aggressive thoughts towards others.  He agreed he’d do so and then said that if the examiners failed me, he’d come after them. He was joking and conveying that he thought I was doing a good job.

During the presentation, I focused on safety (especially aggression towrads others), PTSD, alcohol use, depression, and head trauma.  During my presentation of the past psychiatric history, one of the examiners cut me off and asked me to estimate his IQ.  I stated that he possibly had borderline intellectual functioning vs mild mental retardation. (I regret saying mild MR).  My examiner then asked me to estimate his IQ, which I said 84, but that further neuropsychological testing is necessary.  My examiner then asked me what the IQ range is for mild MR and I told him that I would have to look it up.  He asked me why I though his IQ was low and I answered that the patient had a limited vocabulary and did not use complex clauses in his sentences.  The examiner then moved on and asked me to present the usual things (biopsychosocial formulation, etc.)  I made my differential diagnosis broad: PTSD, Mood disorders (carefully mentioning that I could not rule out a bipolar disorder-this actually elicited a nod from my stone-faced examiner!), alcohol dependence/abuse, personality changes due to head trauma, dementia/amnestic disorder due to head trauma.  On Axis II, I stated a tentative diagnosis of Borderline Personality traits and Borderline Intellectual Functioning vs. Mild MR.

During the treatment questioning, I stated that I would need to gather more history from other providers, especially because he did not recall his medical history, medications, and details of the one psychiatric hospitalization. Also, that I’d order a medical workup (CBC, head CT, neuropsych teating etc.), and focus on safety. I stated that I would have him remove the firearm from his home and interview him further regarding his aggressive thoughts.  I stated that he belonged on an inpatient unit until these safety concerns could be evaluated and addressed. 

Then they asked me about medications with my working diagnosis of PTSD, chronic.  I chose sertraline and quetiapine, stating that I would stay away from benzos and hypnotics because of his history of alcohol use.  The same examiner who asked me about IQ, then asked me, “Does he have any strengths?”  I stated that he had a sense of humor (the pt sassed me a few times during the interview) and seemed to have a strong relationship with his wife which could be a protective factor.  They went on to ask me about countertransference issues.  I presented the idealization during the interview that could make me feel overly positively towards him and the eventual possible devaluation with treatment that could leave me feeling frustrated and angry.  I stated that my job would be to maintain a consistent, patient stance.  I was then cut off.  The other examiner then asked me “He said something about his family, what would you do about it.”  I said that he was estranged from his father because of his choice to marry his wife and I stated that family therapy would be indicated so that he and his father could communicate in an assertive, nondisparaging manner.  The senior examiner then stated, “I think that time is up.”  There were 2 minutes remaining on my clock.

I felt bad about this whole exam because I felt flustered during the interview with the patient’s initial guardedness and then idealizing transference.  I did not do an adequate review of systems, though I did state numerous times during my presentation that “I did not ask about [insert syndrome].” I’m kicking myself for the IQ response and have realized that I forgot to inquire about his education, or present it during the Q&A.  I also felt as though the examiners never gave me time to do an adequate problem-intervention list for this complicated patient.  I should also add that one examiner sat perpendicularly to me the whole time and picked at her nails during my entire interview and my Q&A session.

Jack’s Response

Thank you anonymous for your careful and detailed case presentation. Let me add that since you wrote me, you’ve learned that you passed your exam. Congratulations!

These are the lessons I learned from this case that I’d like to share with you.

1. Almost everyone who takes the exam feels frustrated and uncertain during and after the exam (See previous post.) I mention this to inoculate you against allowing these feelings to derail you. Just accept that when you take the exam, you’re going to be kicking yourself for messing something up. Why do I predict this? Because no one does a perfect interview and presentation. But you don’t have to! Just like this candidate, even when your performance is less than perfect (this candidate missed screening for mania, for example), you can pass – and most candidates do. I’ve even had a candidate who forgot to ask about suicide who ended up passing her exam. I don’t recommend this. Rather, I’m highlighting this fact so that you never give up even if some aspect of the exam is not going your way.

2. One very positive factor in this candidate’s interview was that he was empathic with the patient. Sure, he felt frustrated that the patient took half the interview to warm up and open up to the candidate. But he kept that frustration in check and continued to cautiously and sensitively interview the patient. He paused when necessary and communicated empathic concern at the appropriate times. One of my mottos applies here – Sometimes the best way to go fast in the interview (that is, gather a good amount of data) is to go slow. And conversely, sometimes if you try to go fast, you end up going slow. Imagine how this patient would have reacted if this candidate tried to bulldoze his way past the patient’s initial resistance or tried to pepper him with questions as he was undergoing a flashback. The patient probably would have shut down and rejected the psychiatrist, who would have been left with less information, with a defiant patient, and with examiners unhappy with the candidate’s unempathic performance.

3. The other questions that I’m sure left a positive impact on the examiners were the questions on medical history. Yes, remember to ask every patient about HIV and HEp B and C, especially veterans. If you have an examiner who practices in the VA system, they expect these questions to be asked routinely and assess a candidate negatively who doesn’t assess these areas. Also, the questions on miitary history were a crucial area of questioning with this patient.

4. My last point is that the examiners did not seem very encouraging or positive towards the candidate. The question and answer period was cut off before time was up. The one examiner was stone-faced. The other examiner kept pushing questions regarding the patient’s intellectual functioning that could have felt like they were pushing the candidate to make a mistake. Also, the candidate didn’t feel he got his footing presenting the treatment plan due to the frequent interruptions. My point is that all this happened and still the examiners passed this candidates. You should never allow yourself to get discouraged due to a negative or challenging demeanor of the examiners. Their behavior reflects their beliefs of what an examiner should act like. Very often it is not an accurate reflection of their judgment of you. Many candidates pass with stern or even mean examiners while others fail even with supportive and acknowledging examiners. So do your best to ignore ther examiners stance, facial expression, tone of voice, etc.

Today’s Quote

“Where your talents and the needs of the world cross, there lies your vocation.” – Aristotle

Jack Krasuski, MD

877-225-8384

My thoughts on this topic were prompted by an email I received from a psychiatry oral board candidate. She wrote me:

Candidate’s Comments While Awaiting Her Board Exam Results

“I don’t believe I put forth a passing performance…..my anxiety choked me yet again. I am now awakening from a dead sleep shouting “gabapentin…gabapentin…..thiamine…folate!!!”

“I hope the trauma reaction clears soon and I can once again tolerate solid food ….

“I will likely be seeking admission to the next course…does Jack recommend taking the year to prepare, or, alternatively, getting back on the horse and riding as soon as the ABPN can accommodate me?  I am kind of afraid of horses now…..not unlike little Hans.”

Jack’s Response About His Own Board Exam

I can totally relate to this candidate’s reaction. On my last oral board exam – the one I actually ended up passing – I had a case of of a woman with OCD and an eating disorder. The patient was not responding to her SSRI. During my presentation, when asked what to do next, I said that she deserves a trial of clomipramine. The examiner asked me what issue specific to this patient would be of concern in starting the clomipramine.

Since the patient had a hx of a suicide attempt, I said that the concern was the risk of lethal overdose since clomipramine is a TCA, lethal in overdose. The examiner nodded and said “our time is up.” As soon as the door shut behind me I thought “seizure risk!” since clomipramine has an elevated seizure risk as compared to other antidepressants. I was so sure I was going to fail, I drove around the rest of the day in my rental car in the Massachusetts’s country-side (my exam took place in Boston) feeling a dark gloom. The weight of that day was oppressive as I burned up the hours until I had to go to the airport.

I was relieved to find out a month later that I passed, but to this day am not sure I deserved to given my failure to mention the seizure risk in the context of an eating disorder.

I’m not sure there are any lessons for you here. Perhaps I would say, if you are feeling gloomy as you await your exam results, know that you are not alone. For some people those weeks of waiting are actually emotionally harder than the weeks after learning that they failed the exam. At least with the results known, the healing can begin.

And the second, possible lesson is that even if you feel your performance was lacking, that doesn’t mean you failed. Sometimes the hardest judges are the candidates themselves.

Last, the good news is that the ABPN now provides results much more quickly than in previous years. For the psychiatry part 2 boards, the wait is 2-3 weeks as compared to the 4-6 weeks common when I took my boards.

That’s it for now. Take care and I’ll have another post next week.

Take care and
Happy Studies

Jack Krasuski, MD
877-225-8384

      .

The problem is this: the treatment plan for most patients is long and complex. Not infrequently, oral board candidates get lost and present a treatment plan lacking clarity and completeness. The following image presents the simple concept that will help you  achieve laser-clarity in the treatment plan. The treatment plan must address problems that fall in two categories: current problems and anticipated problems.

Psychiatric treatment plans must address both current problems (Acute Treatment) as well as anticipated problems (Maintenance Treatment)

 An example to make this clear. When a patient with Alcohol Dependence currently has out of control drinking, that is a current problem. When this same patient with Alcohol Dependence is currently in recovery (not drinking), he faces an anticipated problem, one not currently present but one highly likely to occur in the future. Why is a problem not currently present even a problem? Because most (MOST!) psychiatric conditions are recurrent. Even periods of being symptom-free and dysfunction-free, are likely to be followed by periods of recurrence. In fact, one of my greatest insights into treating patients with addictions is this – I learned to think of them and to treat them like my patients with Bipolar Disorder. That means I assumed and anticipated that a relapse would occur at some point in their future.

I know that this simple insight is obvious and not much of an insight at all. But its simple clarity, made me sooo much more effective and also confident in treating patients with substance-use disorders. I realized my job was to help them acheive sobriety when they were using AND it was my job to help them maintain their sobriety when they were sober. And, by the way, it is the latter part of the job, providing optimal maintenance treatment is the weak point of many of the treatment plan presentations I observe.

Now, I want you to think through all the psychiatric conditions that are chronically recurrent. Almost all! Mood, anxiety, psychotic, substance-use, somatoform, sleep, sexual, eating disorders. So is delirium, suicide risk, and risk of violence.

   Today’s Quote

“He is able who thinks he is able.”  Buddha

Thanks and happy studies …

Jack Krasuski, MD
Executive Director
877-225-8384

      .

Question 1

  
“Jack, For the Psychiatry MOC exam, for questions regarding indications for use of a particular medication, such as carbamazepine, should we use FDA and/or APA guidelines?”

Jack’s Response: The ABPN exams in neurology and psychiatry don’t directly ask the exam-taker to identify if a medication is FDA indicated for a particular disorder or what stage it is included in within any particular treatment algorithm.

Instead, a common exam question-type is a presentation of a clinical vignette (i.e., a description of a patient’s signs and symptoms) that has the exam-taker choose the best, for example, medication option for the disorder described in the clinical vignette. The best answer out of the response options will be the medication that is either FDA indicated and / or shows up in a well-established treatment algorithm for that disorder. The other response options will fall into one of the following categories: 1) a medication with less well established effectiveness, which is likely to not be FDA approved or towards the top of a treatment algorithm, or 2) a well established medication that is used only in cases of treatment resistance to the more commonly used medication when the question does not suggest treatment resistance, or 3) a completely inappropriate medication.

So, to answer the question, an exam-taker need not memorize whether a medication is FDA indicated vs. on a treatment algorithm but has to recognize the best treatment choice from the provided options.

Question 2

   
“Jack, I just finished my exam and I don’t feel good about it at all. There were so many questions I felt unsure about. I studied really hard and feel disappointed by my performance. Do you have any insight into what’s going on?”

Jack’s Response: My answer to this question is related to my previous answer. Note from the question response categories I delineated above that the response options do not include one treatment intervention that is completely right on and four others that are completely inappropriate. Rather the response options range from the most appropriate intervention through to somewhat appropriate interventions that are either less well established or lower in the treatment algorithm and then through to completely inappropriate choices.

What is the implication of being confronted with such a range of response options? In my experience even exam candidates who end up with really high scores, leave the exam not feeling particularly confident of their exam performance. The reason is that when you take the exam, you will have a percentage of questions that you are completely clueless about, a percentage of questions that you are absolutely sure you answered correctly. And their is a large percentage of questions you feel only somewhat sure about. You have excluded perhaps three response options as being wrong, and are left to choose between two possibilities. This is very common given that the questions are specifically written to give you this range of very appropriate, somewhat appropriate, and clearly inappropriate treatment interventions. So even when you get the answer right, you leave the exam not being all that sure.

This point I’m making is important because some doctors start to panic when they confront a long series of questions the anwers to which they remain unsure about. Guess what? Almost everyone feels that way. 

Today’s Quote

Here’s a quote from James Cameron, the director of Avatar, who has this to say about starting a career or avocation in movie-making. I like his attitude, which is a “just do it” approach.

“Pick up a camera. Shoot something. No matter how small, no matter how cheesy, no matter whether your friends and your sister star in it. Put your name on it as director. Now you’re a director. Everything after that you’re just negotiating your budget and your fee.” – James Cameron

          .

An optimal treatment plan should have the following three features. 

1. It needs to be comprehensive

2. If needs to focus on resolution (or recovery) and not only response

3. It needs to be specific to the patient

To give this important area its due, I will cover each topic in turn. Today I tackle number 1.

1:  Comprehensive Treatment Plans 

This means that a treatment plan must address and seek to resolve every problem that is included on Axis I, Axis II, Axis III, and Axis IV.

Now, you are fully aware that as a mental health clinician you must deal with the problems on Axis I and II. But you may discount the need to address issues on Axis III since these are medical issues. But you do indeed need to identify and address them. Here is an example: Obesity. This is how I would phrase my intervention plan for this single issue.

“Problem: Obesity. This patient has gained 40 lbs since starting on olanzapine one year ago. These are the steps I will take to address this problem. One, I will begin weighing the patient,   measuring his waist circumference, and measuring blood pressure at each monthly appoint. Two, I will order labs needed to assess for metabolic syndrome. That includes a fasting glucose, electrolytes, and a lipid profile. Three, I will engage the patient in a conversation encouraging a implementation of a regular exercise program. Four, I will refer to a dietician who will educate and aid the patient in developing healthier eating habits. And fifth, I will cross titrate the patient to a more weight-neutral atypical antipsychotic, such as aripiprazole.”

So you see, even something like obesity, a condition coded on Axis III, has an entire set of interventions that a psychiatrist should take.

Now, let’s move to Axis IV. Recall, that on Axis IV, we code “Psychosocial and Environmental Problems.” Now, if you’ve always filled out Axis IV but never really thought about why you were doing so, OR if you thought about it but didn’t really know why this needed to be done, now here’s your answer. You fill out Axis IV because it is your job to address and resolve every one of the problems on Axis IV.

Yes, I know that these are not psychiatric or medical problems. These are, nevertheless, problems your patient is facing and is unlikely to get better unless these problems are lessened. Here’s an sample presentation for “Financial Problem.”

“This patient has recently lost his job. He has already fallen behind on paying his gas bill for his home heating as well as on his mortgage payments. His gas has already been turned off and winter is approaching. So , number 1, I will have the patient work with a social worker who I will direct to complete a form for the gas company that allows restarting the gas even with non-payment when the non-payment is due to medical illness or other hardship. Two, I will have the social worker help the patient contact his mortgage owner in order to work out a payment plan to avoid the patient being foreclosed and ending up homeless. Three, I have concerns about this patient’s ability to obtain adequate food. On further interview I would focus on this issue. If I has remaining doubts, I would send out an occupational therapist or member of the Assertive Community Treatment team to evaluate the patient’s access to food. Concretely, I want to know what food the patient has in his house. There are food pantries that patient can be directed to obtain the food he needs….”

I could go on. My point is that every problem needs to be addressed and every problem, in turn, is likely to call for several appropriate interventions.

Last point on comprehensiveness. You have bio, and psycho, and social interventions available to you in your treatment armamentarium. (That’s why we call this a biopsychosocial treatment plan.) As you address each problem, consider the entire range of biopsychosocial tools at your disposal.

One of the few positive things I can say about the psychiatry oral boards in the US, is that your treatment plan need not be realistic. Many interventions may actually not be available in your area. But it doesn’t matter: present an ideal plan.

Today’s Quote

“Teach this triple truth to all: A generous heart, kind speech, and a life of service and compassion are the things which renew humanity.” The Buddha

Take care and …

Happy Studies

Jack Krasuski, MD

877-225-8384

   .

Expanded Military History

1. Dates and Branch of Service: Army, Navy, Marines, Air Force

2. Military Occupation Specialty: The MOS is the”job” the veteran had in the military.

3. Type of Discharge: Honorable, General, Dishonorable

4. Military Pension? Service Connection?

5. Combat Exposure?

6. Number of Deployments

7. Medical Consequences: exposure to chemicals, traumatic brain injury

Patient States, “I can’t do it.”

The patient was a man in his 60’s whose chief complaint was that he “can’t do it.” The psychiatrist, rather than clarifying what he meant, launched into a review of systems. She was quite frustrated by the fact that the patient did denied all psychiatric symptoms and a history of treatment.

The patient added spontaneously at one point that he came to be interviewed because he wanted to get some advice about his problem but was embarrassed to go to the clinic to get evaluated. The psychiatrist seemed not to understand what the patient thought his problem was but never asked him to explain. The patient, sensing the psychiatrist’s apparent lack of interest in his problem, would spontaneously interject snippets of information about his problem throughout the interview, but without success in engaging the psychiatrist’s interest. He mentioned things like that he hadn’t been sure if he couldn’t do it with his wife only or if this problem extended to other women. He later said he had been unfaithful to his wife to see if he “could do it” with another woman.

During the presentation to the examiner, the psychiatrist never showed she had an inkling that the patient was referring to impotence or erectile dysfunction, as it’s referred to now on TV commercials. She never mentioned these terms and was surprised when the examiner explained the nature of the man’s chief complaint.

Patient States, “I just got back from Angola where I spent seven years for murder.”

The psychiatrist who interviewed this very large, very mean-looking man who came to the interview with a duffle bag, asked the patient about his drug use history. The patient responded that he had been clean for a long time. The doctor responded with a congratulations. The patient responded with “I just got back from Angola where I spent seven years for murder. I’ve been living in the shelter since I got out a couple of weeks ago.” He was explaining how he was able to maintain his sobriety for so long.

During the presentation the candidate reported that the “patient had recently returned from an extended stay in Africa!”

The joke here, if I can call it that, is that the patient was referring to the Angola Louisiana State Penitentiary. From the website I read that is one of the largest and most notorious maximum security prisons in the country!

Now before you beat up on me for being hard on a couple of tense psychiatrists preparing for their oral boards, let me say this in my defense. I’m not being hard on them for not understanding something the patient said – it happens all the time to me. After all, so many of our patients are members of groups to which we don’t belong, groups that have their own conceptualizations and jargon. What type of groups? Like Vietnam War veterans, teenaged anoroxics, ex-convicts, etc.

So again, there is no shame in not understanding an idiom or unknown term. The problem is not having the gumption to follow up and clarify. I shudder to think how much miscommunication occurs between patient and psychiatrist. The lesson here is please, please ask the patient simply and without hesitation some version of, “What did you mean by that?”

That’s the best way to avoid having me writing about you here.

Today’s Quote

“The fact that you are willing to say, ‘I do not understand, and it is fine,’ is the greatest understanding you could exhibit.” – Wayne Dyer

Take care and happy studies ….

Jack Krasuski, MD

877-225-8384

Certain patients are easier to interview than others. Some patients who are defensive, have been rejected or traumatized, or have Cluster B features, may not easily open up. In fact, they may do more than simply not open up. They may actually give you a hard time!

Now here’s the thing. Most of these patients actually do NOT want you to fall apart or to reject them. They are giving you a hard time, especially at the beginning of an interview, but they want you to succeed! They want you to keep your cool, stay interest in them, and not curl up into a wimpering former professional.

So why are they “playing hard to get,” are somewhat intimidating, or provide you with vague or frustrating responses? The answer is because many of these “difficult patients” fear rejection.  Many of them have a history of neglect or abuse. Their way of deciding whether a mental health professional is worth opening up to is to “test” them. So they make themselves difficult to interview in some way. This goes on for as long as it takes them to decide that you “passed the test.” Again, that means you did not fall apart and did not reject them either emotionally or outright. On the Psychiatry oral board exam, this testing period often lasts just a few minutes. In your practice, especially in individual therapy when the stakes are much higher, the testing may play out over several sessions.

Once you pass the “test” these patients often become very open and forth-coming. On the board exam this is a unalloyed good thing. You can ride this out for the rest of your half hour interview and bask in the positive transference. In your practice it is also a good thing but only for a while. Eventually, these patients will again get scared of being so close to another human being that they will again close up, get difficult, and start the testing cycle all over again.

Now, it is true that a certain number of patients who are difficult are not exactly interested in your success. They are difficult, mean, intimidating, etc. And that is just the way they are now and that’s the way they’ll be later too. In my experience this is a smaller number of patients than the number for whom being this way is their way of (temporarily) testing you.

Let me end with this practical advice. When you get a patient who is difficult at the beginning, don’t despair. Many times they will open up and stop being so tough.  Your job is to keep your cool, maintain your interest in them, and avoid conveying rejection towards them. If you have an experience that matches this scenario or one that contradicts it, please share it with us. Leave a comment. Thanks.

Today’s Quote

“Here is the test to find whether your mission on Earth is finished: if you’re alive, it isn’t.” – Richard Bach

Take care and Happy Studies

Jack Krasuski, MD

877-225-8384

      .