(Automatic transcript - may present inaccuracies)

>> W.H. Potter: We're all here. So let's start. Now anything that I may say today I will not wish to imply that you are expected to be psychiatrists. On the other hand, neither do I wish to imply that I feel you are absolved from all responsibility to know at least as much about psychiatry as psychiatrists are expected to know about general medicine. Some of what I will talk about might be thought of as ordinary or commonplace and the obvious, but it is not the obvious that I wish to point out. It is however some of the implications of the obvious that I hope I shall be able to stress. It is obvious that people solicit the services of a physician because of a complaint. Well, a complaint such as pain, discomfort, fatigue or lassitude or uneasiness. Or they may complain of disturbances of form and function that interfere with personal well being or that adversely affect adaptive capacities. In the majority of instances the complaint is a subjective or interpersonal experience. Oh, such as my appetite is poor or I feel tired all the time, and statements like that. Whatever the complaint may be, it must be carefully explored so that it can be accurately evaluated. In brief, then, the complaint constitutes the core of the physician's daily practice, and represents that from which the patient seeks relief. The meaning of the complaint or what it stands for arises from, the physician learns in part by carefully interviewing the patient. Every clinician in his diagnostic study should attempt to evaluate the patient's verbally communicated symptomotology and medical history in terms of the objective findings and within the framework of the total personality and life experiences of the patient. Too often, unfortunately, unless the complaint is supported by objective physical findings, the patient is dismissed with the conclusion that there is nothing wrong with him. However clinical experience has demonstrated that some [inaudible] usually exist for the complaint even though the objective physical findings are within so-called normal range. For example, let us assume that three women come to a physician's office, each more or less anxious and each complaining of a lump in the breast. In case number one the examinations discloses a [inaudible] breast. In cases number two and number three the physical examination does not confirm the subjective complaint. In patient number two as she is encouraged to talk about herself it is found that she is married and childless and that she and her husband made their home with her ailing, widowed mother. It appears also that she has been a devoted daughter even to the extent that she felt she could not give the proper care to her mother if she and her husband had had a family of their own. She also indicates in some way that she considers her husband unfair and unjust because he has been critical of her attentiveness to her mother's demands. She tells of her attacks of vertigo and nausea from time to time, usually in connection with some situational stress. It is learned, too, that her mother died some 4 or 5 years ago of a breast carcinoma, since which time she has felt lonely and unfulfilled. So thus starting with her complaint of a lump in the breast it is found that she was an insecure, already dependent person who had been unable to adapt to the demands of married life. And that she had been incapable of adjusting herself to the loss of her mother. Now she fears that, like her mother, she, too, has a cancer of the breast. Case number 3 is depressed and complains that she is restless and sleepless and her appetite is poor, that she is steadily losing weight and has become so tense that she can hardly carry on her duties as a housewife. She has a feeling impending disaster and fears that her body and its functions are rapidly disintegrating. For some weeks she has convinced herself that she has a hidden cancer. She has no desire to live and has contemplated suicide. She may reveal none of this story, however, unless the medical investigation gives her an opportunity to do so and [inaudible] some skillful interrogation about her mood, feeling, output of energy and daily activities. Now what is the physician's responsibility to each of these patients? In case number 1 there's a tumor still undiagnosed as to type, perhaps, but obviously she is a person who will be referred for surgical consultation. In cases number 2 and number 3 there is no evidence of organic disease, but both are major psychiatric problems. One a neurosis and the other a psychosis. Each presents a physical complaint. Each shows clinical evidence of emotional upheaval and each is in need of medical help. The negative physical findings, however, do not release the physician from his responsibility for the patient since illness due to emotional cause is just as debilitating as is illness due to physical causes, and sometimes more so. Now we'd be naive to believe that a patient thus motivated by emotional conflict would give up her complaint because the doctor merely tells her of the negative physical findings. A statement that or to the effect that nothing is wrong will affect patients in different ways. Commonly some patients then fear that they have some mysterious unknown hidden illness which eludes diagnosis. Many will question the physician's competence and under the pressure of their anxiety and concern become medical or clinic shoppers, an uneconomical and emotionally end result of professional myopia. Now and then a compliant patient who has a great respect for authority will try to dismiss the complaint because the doctor said there was nothing wrong, but the underlying emotional problem that expressed itself through the physical complaint may remain or increase. And the symptoms may remain or shift. Now the point illustrated by these brief clinical sketches is that the subjective complaint is that aspect of illness which the patient presents to the doctor. A subjective complaint inevitably has clinical meaning. It is important to the patient and it is in itself an objective finding.

>> Closing out the case with a statement, no positive physical findings, may satisfy the physician, but it does not begin to meet the needs of the patient. Now what about the case study? The case study that does not include information about the patient as a person is incomplete and may be misleading. Some physicians, despite their interest in a knowledge of the personal aspect of illness, seldom venture beyond a classical medical history and examination because they believe they do not have the know how or skill to study the patient as a person or to evaluate the patient's attitude towards himself and others or the situations in which the patient gets upset. To these doctors it should be reassuring to know that it can become a simple and uncomplicated matter to get a good personal history along with a medical history in any given case and without the expenditure of an undue amount of time. The case material cited in this discussion was abstracted from case studies, most of which were made by third and fourth year medical students on the general hospital wards during their [inaudible] experience. It should not be assumed, however, that a doctor by virtue of his knowledge of the somatic systems is necessarily equipped to ask meaningful questions. We have all discovered that what question is asked or how and when may be determine what significant information of a highly personal nature will be given. Also if the doctor knows what he is looking for he can develop competence in how to look for it. It is not necessary for the physician to acquire new methods of clinical investigation to evaluate the patient and his emotional problems. It is essential, however, for him to organize the skills he already has and plan to use these as a procedure for evaluating the patient as a person. An essential component of any planned approach to elucidate the more personal aspects of illness is to cultivate an unhurried manner and allow one's sincere interest in the patient to express itself. This will do much to establish the rapport necessary to enable most patients to talk about personal and social problems and in the long run is time saving since it often leads directly to the identification of and a positive diagnosis of the nature of the emotional disturbance. Leading questions free from implied criticism or prejudice, asked in a sympathetic, friendly, matter-of-fact way, plus good listening, will encourage most patients to talk freely. It is well also to remember that most patients are keyed up or anxious on first contact with a doctor. And may be ready and are likely to be ready to talk about their troubles if given an opportunity. If the doctor allows them to feel that he's interested in them, they may be ready to respond to well timed and well phrased questions which may indicate their personal fears, dissatisfactions and insecurities which can then be related appropriately to the complaint or illness. Now there are many opportunities to amplify the personal history by well directed or well timed questions during repeat visits or even while the patient is undergoing special tests such as fractional gastric analysis or X-ray studies. Personal information is best obtained by the doctor as the patient offers a clue or an opening while obtaining the past medical history. For instance, in the case of patient number 2 inquiry about the number of children would have been made in taking a medical history. When she replied none the tactful exploration of why not would have naturally followed and in her explanation her solicitous care for her mother would have become apparent. When the family history was inquired into, the question, "How have you felt since your mother died?" would have come about naturally when the patient gave the information about her mother's death. While reviewing the history of the present illness --

>> The doctor should learn what the patient thinks about this illness and its causes and its possible effects on his security. Illness, disability, or symptoms are often important sources of anxiety or points about which long standing tensions accumulate much as iron filings arrange themselves about the poles of a magnet. Illness is regarded by some patients as a frustration and they may be resent it and everything connected with it such as the doctors, nurses, hospitals, clinics, or even treatment itself. Some patients react to illness [inaudible]. Their morale [inaudible] and they feel a hopeless, what's the use, reaction. The tendency to exaggerate illness may represent either anxiety or a conscious or unconscious desire to use the illness for personal gain. To make loved ones worry and feel sorry or for compensation, sympathy, or escape from difficult life situations. The magical concept of illness as a punishment or atonement for personal [inaudible] some individuals who attempt to get rid of their guilt and fears in this way. Attitudes such as, "What have I done to deserve this?" are sickroom phrases [inaudible] doctors. It is particularly important, too, to review illness in relation to the setting in which it occurs. There may be a relationship. Symptomotology may have its onset in association with an emotional crisis or it may be preceded by a long period of pressures and insecurities or it [inaudible] in relation to stress. The biographical history, as it's sometimes called, bears the same relationship to personality diagnosis as the medical history does to the medical diagnosis. In medical illness, for instance, we inquire into the medical history of the family and about infection disease, injuries, surgery, occupation, habits as to food and drink. In certain symptomotology the patient's medical past because we know that the genetic factors in the life history of pathological conditions are diagnostically significant. Similarly, personality problems too have a developmental history. The frustrations and satisfactions experienced during infancy and childhood constitute the groundwork for the emotional organization, mental attitudes and reaction patterns of the personality. The amount of opportunity for personal achievement at school at a play, the degree of stability and security in the environment, the frustrations and tensions related to physical health, the amount of development of intelligence, the family interrelationships, all are of paramount importance. When these factors depend to a large extent to the kind of adaptive capacity the person will have as an adult in work, in marriage, and in group participation, it is this adaptive capacity which will determine how the patient reacts to or utilizes illness.

>> Since many psychological problems ranging from simple personality maladjustment to psychotic reactions have both physical and mental symptoms, every doctor should evaluate the patient as a person so that he may relate these personal data to the medical history and the physical examination in order finally to be able to make a comprehensive diagnosis. Now in brief the following points might serve as a practical guide to making a personality study. First [inaudible] exercise to establish a good rapport by displaying an active interest in the patient and by avoiding expressions of prejudice or personal judgment. Second the patient should be given an opportunity to talk freely and spontaneously and the physician should be alert to the opportunities the patient gives him during the medical history and examination to ask well timed provocative questions. Third, the second prior to and immediately prevailing at the onset of the illness should be carefully surveyed and a physician should be alert to any possible relationship between symptoms and stress situations. Four, the patient should be encouraged to express his ideas, feelings and concerns about his complaint or illness. Fifth, a brief survey should be made of, A, the past and present family interrelationships, B, the upbringing in the home, C, school life, D, work life and economic situation, E, social and personal interpersonal interrelationships. And finally reactions such as moodiness, depression, indifference, excessive worry, excitability, changes in energy output and intolerance to pain should be noted since these may be contributing factors in the clinical picture. Now let me introduce the subject of anxiety. And make a few comments about it. In order to establish a baseline for medical management and treatment, the physician should be alert to the presence of anxiety to determine how severe it is and evaluate its exact role in the current clinical picture. Anxiety or emotional stress is an inevitable bedfellow of almost any illness since illness represents a realistic threat to the security of most patients. Anxiety often appears in forms other than its overt manifestations of fear, apprehension or disturbances of mobility and secretion of the viscera. Like a focus of chronic infection, anxiety may be latent and yet a potential source of insidious or cataclysmic breakdown in psychological and physiological homeostasis. It is anxiety and its inner sources which so often make some well people sick, some sick people sicker, and convalescence from sickness sometimes longer. The recognition of anxiety as a concomitant, predisposing, or causative factor in somatic disease is one of the important trends in modern medicine. But while anxiety is a problem in body mind pathology, like fever it is one of the defense reactions of the organism. Fear is a basic defense reaction, as is anxiety, even though anxiety consists of illusory or anticipatory fears. The tendency to anticipate danger and thus to be frightened when none is actually present or probable springs occasionally from ignorance, but most often from attitudes and feelings people have about themselves and their environment as a result of earlier frightening or unrewarding experiences. By and large, the emotional values of past experiences determine the values attributed to the realities and satisfactions of the present and the anticipations of the future. Therefore it is not only that which happens contemporaneously that is important, but how these events are equated in terms of the past emotional conditioning of the patient. A case in point is that of an 8 year old boy who developed an acute confusional panic a few days after his circumcision. In the past his mother, driven by her anxiety to suppress his normal masturbatory activities, had told him on occasions that the doctor would cut off his penis if he did not stop touching it. To this child, apparently, the operations represented the materialization of his mother's threat. Without understanding his previous experiences, his post operative reaction of panic would not have been properly evaluated and treated. Now how does anxiety complicate a clinical picture in somatic illness? Some patients create additional problems by denying their anxiety, as illustrated by this case. The 45 year old business executive with a peptic ulcer who had had several hospital admissions responded almost immediately to treatment upon admission to the hospital, but his symptoms became aggravated when it was time for him to leave the hospital. He was friendly, affable and talkative, and to direct questions said that he did not have a worry in the world. As his marriage and his childhood were brought into the discussion by his physician, he dropped his defenses and wept as he spoke of his motherless, lonely, insecure childhood, his hopes for warmth, affection and children in marriage, and his bitter resentment and feelings of hopelessness in finding himself married to a cold, demanding woman who was unable to bear children. He told of the long hours he put in on his job, including evening conferences as an escape from the home situation.

>> When it came time for him to go home again the hospital, with his sympathetic and solicitous nurse in care, was an interlude of security. For some patients a medical situation has a special personal significance, as illustrated by the following case. The unmarried woman of 28 was admitted to the obstetrical service at the 8th month of her pregnancy with a recommendation from the prenatal clinic for induced labor. She had chronic rheumatic endocarditis and it was questionable that her cardiac reserve was sufficient to see her through labor. A few hours after admission she became depressed, panicky, tense, apprehensive, restless and sleepless. There was in addition anorexia, nausea, and vomiting. Blood and urine chemistries were normal. The personal interview gave her a chance to describe how anxiety ridden she had been for many years. Shortly after a severe attack of acute pneumatic fever at the age of 7, her father had died of coronary disease. Her brother, 3 years older, had become very protective of her and in a sense replaced her father so that she became quite dependent upon him.

>> [Inaudible] now recall they ran an exaggerated sense of cardiac [inaudible] which encouraged her dependency and retreat from self sufficient activity. Here is seen how in order to avoid the anxiety that would be precipitated by independent living she maintained a dependent state of inactivity quite beyond that indicated by the limitations of her cardiac reserves.

>> When her brother married some years later, a hostile relationship developed between the patient and the brother's wife. Sometime later the patient fell in love with her present husband, then had to contend with a sister in law's repeated hostile warnings that she never could be a good wife and never could bear a child. As she described these personal experiences, it became clear how crucial the outcome of her pregnancy was to her. The wish to have a live baby was reinforced by her need to improve her self esteem and personal pride through being a successful wife and mother. Thus when threatened with [inaudible] she became acutely depressed and anxious. In some patients the symptoms of an illness are exaggerated beyond that warranted by the organic factors. Sometimes the underlying anxiety is related to life situations and attitudes quite remote from the illness itself. An elderly lady was admitted to the hospital with arrhythmia, palpitation, and anorexia.

>> -- for some time, but there is not significant cardiac [inaudible]. She had been living with a married daughter since her husband's death 3 years or so before admission. Now limited housing space and an increase in the size of the family through the birth of 2 children made it essential to try and put her care [inaudible] help of her daughter who reassured her she would not be abandoned. These fears were resolved and her medical symptoms thereby relieved. Not infrequently patients become highly unreasonable in their desire to leave the hospital. These requests should be carefully evaluated as they may be expressions of anxiety. Such a case is that of a patient under treatment for cardiac failure who became disturbed about remaining in the hospital and insisted on going home. Efforts to convince her of the inadvisability of going home on a stretcher because of the medical risks at first failed. Later, however, a 20 minute interview brought out her neurotic fear of being deserted and her excessive dependency upon her husband. Her obsessive demands to go home thus were better understood and a solution of immediate problem became possible. Special permission from the hospital administration was obtained for a 30 minute visit by her husband each evening while she was in the hospital. This provided an effective sedative for her separation anxiety and made it possible for her to remain in the hospital as long as was indicated by her cardiac problem. [Inaudible] in some patients reports an escape from current problems and fears. The 27 year old house painter by trade had had 6 previous hospital admissions. On each admission he complained of vague abdominal pains, general weakness, and shortness of breath on exertion. Thank you so much.

>> On 2 admissions he said that he had been passing blood in his urine. He told of having been diagnosed as having pneumatic heart disease, appendicitis, lead poisoning and kidney disease. The medical data about his previous hospitalizations was not confirmatory of any of these diagnoses and a recheck of his somatic systems did not explain his symptomotology. In checking through his life history it was noted that he was anorectic throughout childhood which he himself had attributed to weak kidneys. As a child he was shy, retiring, and dominated by an aggressive younger brother. Considerable of a mama's boy, he never seemed able to stand up for his own rights. He was regarded as weak and sickly by the family and often stayed out of school at examination time complaining of some vague, ill defined illness. All these hospital admissions had occurred since his marriage and in connection with family situations which required some additional effort on his part. And as a response to these stresses he became ill. In this patient there's a lifelong tendency to view himself as weak and sickly. There were medical experiences which reinforced this concept of himself and there is a well established pattern of escape into illness in the face of difficulty. And then there are some emotionally starved patients who on becoming ill find that their loved ones feel sorry for them and that the illness brings to them a good deal of personal attention. These people are those who feel unloved, who need more love and it's provided for them. A case in point is that of a 65 year old woman who was treated for pneumonia in her own home. She'd refused hospitalization. During the height of her illness she was exceedingly demanding of attention from her family, but refused to have a nurse. Her convalescence was complicated by her resistance to getting out of bed and her complaints of constant chest pains and [inaudible]. The family devoted practically their entire time to her, were up most of the night with her and obviously were worried and harassed. Her behavior during illness was a means of coercing love and attention from one married daughter in particular who when her mother became ill came home to assist in her care after a strained absence of some 3 or 4 years following the mother's violent objection to the marriage and to the man whom she married. The situation was relieved when the daughter was helped to handle her mother's opposition to her marriage in a more adult or mature way. Refusal of elective surgery is another common problem in medical management where assurance may be ineffective unless time and effort have been given to exploring the basis for refusal. Hostile edicts of you consent to his operation or else variety are seldom productive for the desired results. A case in point is that of a patient who had an excessive need to feel strong and independent and to whom an operation therefore represented a threat to his need for virility and independence. He's a 45 year old skilled mechanic who ran his own business and dominated his family with firm benevolence and proudly claimed that he had never been ill a day in his life. Both of his parents had died of long drawn out illnesses which as a child made a lasting impression upon him. He was admitted to the hospital for a strangulated [inaudible] hernia which was reduced by manipulation. When told in a [inaudible] fashion that he needed surgical repair for his hernia, he promptly refused, said he would get a truss and made ready to leave the hospital. At this point a fourth year medical student who noticed that the patient was in a pretty [inaudible] state of mind gave the patient a chance to talk. The patient told him of how he had led an independent life, of how he had taken pride in his capacity to make his own decisions, and declared that no doctor was going to tell him what to do. A discussion of hernias, the mechanics of the surgical repair, the usual outcome of the operation, and the superior of this over wearing a truss helped the patient to feel less threatened by outside interference. And enabled him to decide to accept the recommendation. Somewhat related to this are those patients who have built up within themselves an exaggerated concept of invulnerability to disease. Out of their need for independence and self sufficiency they consider illness some kind of a personal weakness. They frequently make difficult patients and tend to reject medical advice.

>> They are best handled by an intelligible explanation of the illness and its treatments with a scrupulous avoidance of authoritativeness, thus enabling them to feel that they are participating in the decisions and plans for their medical care and treatment. Not a few of the surgical repeaters, those who have had multiple operations, are very good at convincing doctors through their symptomotology to operate upon them. These patients are sometimes mild cases of schizophrenia or hysteria. Others are persons with hypochondriasis or delusions of bodily change. Some use illness to satisfy an insatiable need for love and attention. Some use illness and particularly surgical operation as a means of neutralizing unconscious guilt feelings. Now what about the realities of illness in medical experience as anxiety [inaudible] forces? You do well to remember that some reality associated situations, situations associated with illness, are anxiety provoking. More most people illness or disability is a threat to economic and social security, to pride and self esteem and sometimes it is a threat to personal relationships with family, friends and coworkers. Many medically and surgically ill persons out of ignorance or fear increase their emotional tensions by occupying themselves with speculations about their symptoms and illnesses. Sometimes identifying themselves with some particular person who had a frightening illness. For instance, a family history of chronic illness or the death of a close relative or friend may sharpen the patient's anxiety about his own condition and provide risks for the [inaudible] of anxious rumination. Some medical surgical conditions while not necessarily more serious than others, may be particularly frightening. Examples of this are eye injuries, progressive loss of vision, carcinoma or disfiguring infections of the female breast, injuries and other major disorders of the male genitalia, or the symptom of [inaudible]. Since these and some other conditions are particularly prone to provoke anxiety, the physician can be of maximum medical help by making it possible for the patient to discuss his concomitant anxiety so that these may be dealt with realistically. Patients with chronic somatic disease also present complicated problems. It is not possible for anyone to be chronically ill without being seriously affected in some aspect of his life. Emotional, social, occupational or financial. Those patients to whom we refer with irritation and frustration as clinic crocks are people who have been affected by their illness in these areas of their lives. Frequently these patients are suffering from a plethora of diagnostic assaults at the expense of any serious consideration of the personal equation in illness. Through an understanding of their personal environmental needs their anxiety may be diluted. And they might be helped to a better level of adaptation even though the illness persists. As physicians, therefore, it is our responsibility to be alert to the stresses inherent in the experience of hospitalization too and routine clinical procedures to which patients are exposed. Now despite the streamlining and modernization of hospital and clinic care in the past 25 years, more consideration of the patient as a personality is still indicated. It is more a matter of chance than planning that the reception accorded to patient upon his admission to the hospital or clinic is warm and friendly and implies a promise of personal interest. People are even more sensitive when they are ill. They feel helpless and dependent. How they are received may affect their confidence in the hospital or clinic and their willingness to cooperate with medical advice and treatment. The attitudes of the resident in turn and nursing staff toward the patient can do much to keep irritations and uncertainties at a minimum. If as much energy were expended in finding out why some patients are over demanding, uncooperative and complaining as is usually expended in condemning and scolding them --

>> These self same patients could be helped and the staff would be [inaudible]. Granted [inaudible] food and poor food service inevitably have unfavorable repercussions on the morale of patients. The preparation and serving of food is as important as its calories and vitamins. Food in all its aspects is of no minor emotional importance. And the effect and the tensions that arise from insufficient [inaudible] and unattractively served food should not be neglected. When the visiting of hospital patients is still arranged for the convenience of the staff and other employees rather than regulated according to the needs of the patient how the patient reacts to being visited and to those who visit him, to what extent his tensions may be relieved by the regulations as a therapeutic adjunct are matters deserving of more attention than is usually given to them. Preoperative anxiety in some patients is due to faulty ideas or fear of hospital procedures, the anesthetic, surgery or the illness. Concerns such as these can often be dispelled promptly if the patient is encouraged to discuss his worries and fears, a personal service that should be part of a preoperative plan just as the administration of sedatives and hypnotics. Surgical and nursing procedures which are simple and familiar to doctors and nurses may be unfamiliar and frightening to many patients. Logical explanation and honest reassurance may help the preoperative patient and relieve his tensions. In the clinic, patients waiting around of crowded, hard benches is conducive to neither mental nor physical comfort. An appointment system would eliminate much of this mental and physical stress. It would allow the patient to maintain some privacy and therefore his self esteem and would eventuate better clinic organization and improved morale of the clinic personnel. The practice in many clinics of any doctor available seeing a patient on return visits is obviously extremely wasteful and unscientific. Furthermore, it eliminates one of the most important aspects of medical practice, the doctor patient relationship. Most patients are vitally interested in learning what ills them. In many clinics each department tends to operate as a hierarchy. Some patients are referred from one department to another and in the end are hopelessly confused and discouraged because no doctor has taken the time to tie together the various examinations and findings and give the patient a simple understandable interpretation of the problem. Sometimes we say that when a case record goes to 100 pages and weighs 5 pounds and the patient's been fairly traumatized the case is likely to be referred to psychiatry. In brief then from the preceding case material and discussion it will be seen that in the evaluation of anxiety there are 3 points to be considered. First what are the established attitudes the patient has about himself, his life experiences and other people? Second, what are the reality stresses to which the patient is subjected? A, the reality stress is concerned with extra personal, the reality stresses which are extra personal or environmental such as the job, finances, food, clothing, housing, family, hospital routines and practices and so forth. And the reality stresses concerned with the illness itself, duration and course, the amount of pain, discomfort, disability and frustration it imposes upon the patient.

>> And third, what is the patient's capacity for controlling and coping with anxiety and how does he react to it and cope with it? Now about psychotherapy. In discussing psychotherapy as it can be used by the general physician, first it is important to realize that well considered therapy of any kind cannot be practiced by a set or rigid formula. In diabetes, for instance, the patient's dietary habits and demands of his job, his caloric needs, his weight, his age, the presence or absence of a complicating hypertension or infection, where and how he lives, his metabolic limitations and potentialities, his attitudes toward his disease collectively determine among other things how much insulin is to be used, when, and how often. Second a sound working knowledge of pathology is essential to doing effective therapy in all fields, including that of psychiatry. The essence of pathology, whether it be tissue pathology or psychopathology, is that dynamic process which gives rise to functional and structural regression disorganization and disintegration. The changes in function and structure that are commonly conceived of as constituting the body of pathology are the manifestations of the process. Therefore the therapist tries not only to detect and define pathological change, but to understand these changes as representative of dynamic processes. It is the pathological process rather than its manifestations toward which therapy eventually will be directed. Now most physicians can develop some practical and effective psychotherapeutic skills to relieve anxiety. These should be part of a plan and should be based upon certain principles. And what are these principles? They're 3 in number. First since psychotherapy is concerned with the treatment of the person, it must be related to specific knowledge of the patient as a person. For instance, to have arranged for the husband of the woman with cardiac failure to visit her daily in order to alleviate her anxiety was a logical procedure based on an evaluation of her personal or emotional needs. Second a good working relationship between the patient and the doctor is essential in psychotherapy. In all therapy, as far as that goes. Therefore to be effective the physician must develop techniques for establishing this kind of relationship which can then be used both in investigation and treatment. And the third principle? The general physician as distinguished from the specially trained physician in psychiatry should limit himself to dealing with the patient's conscious concerns and helping the patient adapt to his reality problems. The general physician should not do excessive or ill advised probing. He should work only with those problems which are within the awareness of the patient. Interpretation of unconscious motivations by the general physician is not useful or necessary and can be harmful. For instance, in the case of the overly dependent woman in cardiac failure who insisted on leaving the hospital the medical resident, although recognizing the likelihood of infantile dependency [inaudible], neither discussed these with her nor did he attempt to deal with them by interpretation. He did however handle her fear of being alone or abandoned by arranging for daily visits from her husband. Now the physician who is not a trained psychiatrist, if he is guided by these 3 principles can relieve anxiety in various ways. I have listed a dozen of them. First by encouraging the patient to talk and express his feelings, anxieties, frustrations and worries. This provides for emotional catharsis and at least temporary relief from tension. Second by careful, thoughtful, painstaking history which gives the patient reassurance [inaudible] the physician is thus more fully informed about him. Third by a careful unhurried physical examination which is reassuring since it is concrete evidence to the patient of professional interest and competence. Fourth by refraining from unwarranted repetitious tests and examinations. These give reassurance neither to the patient nor to the physician in the long run. Fifth by trying to understand the patient as a person which builds good rapport. Sixth by a simple and clear discussion and explanation of an illness and its practical implications in the patient's current life which helps to enlist the patient's cooperation and participation in treatment. Seventh by helping the patient in many adjustment necessitated by an illness, the kind of support that is so often needed yet too often neglected. Become familiar with the community resources which might be used constructively where indicated. Eighth by respecting and meeting the needs of the patient for dependency, for his needs to help make decisions and plans concerned with illness. Ninth by never doubting the reality of a symptom to a patient, especially for those patients who use illness as a crutch or as an escape. The physician, however, can help a patient to realize that the symptom or illness is not as incapacitating as feared and thus build up the patient's confidence in his ability to cope with illness. This will improve the patient's self esteem, help him to utilize his own strengths, and decrease his need for dependency. Tenth interpret the illness to the family. Encourage constructive family attitudes. Enlist the family's assistance, but never disclose personal confidences to the family. Many patients benefit from the support they can get from an informed family member or [inaudible]. Eleventh, the frequency with which a patient is seen should be part of a plan. Sometimes small doses, as it were, of supportive therapy at frequent intervals are more effective than long visits at infrequent intervals. And finally this is being done in some clinics. Many patients, particularly those with chronic disease, get support and encouragement from others with similar illnesses. Therefore some type of group therapy sessions as an adjunct to the individual visits to the doctor's office or clinic may be utilized. Now in conclusion I would -- I should like to reemphasize that as physicians and without regard for our special medical interests our job is to study and treat the human organism in its various aspects of functioning in relation to the environmental setting. Each of us has his own particular professional orientation and techniques for investigation and study, but we are each studying, investigating, and treating the same identical organism which functions and operates as a coordinated whole. This concept of a human being functioning with an integrated oneness cannot be overemphasized since there is an increasing evidence of the imperativeness for coordinated and comprehensive diagnosis and therapy. Illness is something more than a [inaudible] with a patient in a hospital bed. It is something more than an emotional -- It is something more than a hypertensive condition of a patient waiting on a clinic bench. It is something more than an emotional conflict in a patient in a psychiatrist's office. Illness of any kind involves a total person living in a specific environment in which he works, plays, love, hates and fears. How a particular person was raised, his specific fears, doubts, and hates which have developed, how and where and with whom he now lives and works in terms of satisfactions or lack of satisfactions, what his strengths and weaknesses are, what the scars of former sickness and emotional scars of earlier experiences are, the story of his present illness and his physiological and psychological symptoms all make up the composite picture of what the patient is like when he presents himself through the complaint.

>> These are the emotional components of illness which the doctor can learn to recognize, evaluate, and to treat together with its physical manifestations.

[ Applause ]