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Beyond the Presenting Complaint
Beyond the Presenting Complaint MYRON
F.
WEINER, M.D.
• Frequently the presenting complaint is simply the admission ticket to the office of the physician or dentist. It is that which the individual can use to place himself in the role of patient in need of health care. The chief complaint is often not the patient's chief concern, and for the sake of this discussion let us make a sharp distinction. A person's chief complaint is the reason he gives the physician or dentist for seeking medical help. His chief concern is that which troubles him and that for which he would like to be able to seek help were he able to admit it, either to himself or to the person from whom he seeks help. In most cases a patient's chief complaint will be his chief concern. The chief concern of this paper will be with those individuals in whom the chief complaint is not the chief concern. The task, then, is to establish how to determine the patient's chief concern and deal with it in the most appropriate manner while at the same time not disregarding his chief complaint. A person whose chief complaint coincides with his chief concern is obviously a person who is not in conflict and whose complaint can be dealt with at face value. For the individual who has conflict, which may be either conscious or unconscious, the story is quite different. This individual's chief complaint will probably point to an aspect of his chief concern, but equally important, it will give some important clues as to his mode of handling conflictual situations. Review of Basic Concepts
It will be worthwhile to briefly review some of the mental mechanisms most comPresented at the Academy of Psychosomatic Medicine Seminar, "Comprehensive Medicine for the Family Dentist," Dallas, Texas. Dr. Weiner is Clinical Assistant Professor of Psychiatry. University of Texas Southwestern Medical School, Dallas, Texas.
monly used to deal with emotional conflict. Psychological conflict may be conscious or unconscious, and defenses against psychological conflict may be conscious or unconscious. We may, for the sake of simplicity, conceive of psychological conflict as a state in which there are two opposing wishes or drives, neither of which can be completely relinquished. The primary psychological mechanism by which conflict is kept from consciousness is repression - the active process of forgetting. The conscious equivalent of repression is suppression - literally putting thoughts or ideas out of one's conscious mind. When repression is not adequate to maintain conflict on an unconscious level, a number of auxiliary mechanisms may be called into play. They are: 1. Displacement - a shift of concern away from the original area of concern, the chief mechanism in phobias. 2. Reaction formation - doing the opposite of what one would most like to do. 3. Undoing - symbolically revising in thought or action. This mechanism, together with reaction formation, underlies the obsessive-compulsive neuroses. 4. Denial - unawareness of external threat. 5. Regression - reverting to an earlier, successful means of adaptation, common to all states of psychological decompensation. 6. Projection - attributing to another what one abhors in one's self, the basic mechanism of the paranoid process. 7. Rationalization - a "rational" reason for an irrational act. 8. SUbstitution - gratifying a wish related to the wish held in check, the basic mechanism in sexual deviation. 9. Sublimation - the gratification of a wish in a socially acceptable way.
The presence of unconscious conflict leads to the psychological state of anxiety, or objectless fear. The psychological defense mechanisms listed above are used in varying combinations throughout life by every person. Every in-
310
Volume X
BEYOND THE COMPLAINT -
dividual has a preferred set of defense mechanisms which are utilized in times of inner turmoil. For a more complete exposition, the reader is referred to the latest edition of Modern Clinical Psychiatry by Noyes and Kolb l • Of the mechanisms listed above, we will consider denial, displacement, repression, and suppression in relation to the manner in which they obscure a patient's chief concern.
The Routine Checkup - A Gambit of Denial This is a frequent gambit, and it is probably the most deceptive of all the varieties of admission tickets to the office of a healthcare professional. One becomes aware that this is a gambit or a ruse by initially noting the patient's level of anxiety. That is to say, it doesn't make sense for a person coming in for a routine checkup to be either severely anxious or totally without anxiety or fear. A marked degree of anxiety may be denied but is readily detected by the accompanying rapid heartbeat, flushing or pallor, tremulousness, and sweating. Exaggerated lack of concern also suggests anxiety. It is my experience that going through the usual rapid routine system review with the "anxiety-less" individual may be very unproductive. There are many individuals who cannot bring themselves to complain. They require that complaints be elicited or dragged out from them. This is fairly typical of the self-sufficient individual who cannot admit that he has concern for himself but will indicate that either his spouse has pushed him into making an appointment or that he just happened to have an opening in his schedule and he thought it would be a good idea to drop by. To this sort of individual, there are several useful sorts of challenge. One effective challenge is to ask, "Why now? Is there any particular reason why you wanted to be examined at this point in time?" This question, followed by a few seconds of silence, may allow for the expression of some concern. One may also ask, "Even though this is only a routine check, perhaps you've noticed something recently that concerns you or disturbs you." Questions such as these may turn up September-October 1969
WEINER
concerns of which the patient is only half aware. The patient who operates in this manner illustrates the use of the psychological mechanism of denial. When denial is employed in this way, one asks two questions: What is being defended against? Why now? Denial can be used to advantage when a man is in combat. It enables him to cope on a day to day basis. Exaggerated denial in the medical or dental office may suggest one of two things. This may be an habitual reaction to all stress, to the threat of physical illness, or may be a temporarily exaggerated reaction in the area of physical health overlapping from an attempt to deal with other concerns. A man who comes in for a routine dental checkup may eventually become willing to admit, after observation suggests that he is grinding his teeth, that his jaws do ache a little in the mornings. A suggestion that this may be related to emotional pressures may lead to the source of the environmental or internal emotional pressure and may open the way for a referral. The exaggerated use of denial may pose many problems in prescribing a therapeutic regime. One may be certain that the regime will not be followed unless approached in the proper psychological context. Here again one must ask, ''What is being denied?" and "Why now?" One obtains a history from our hypothetical man with bruxism by asking how things are going. In response to his initial reply of, "Swell," one asks how things are going at work, then at home, and then in the patient himself. Is he satisfied with himself? With some patience, one may elicit a history of grudging submission to authority in an individual who takes out his smouldering anger on his dentition. He may have recently been given an assignment which he deemed unfair but felt he dared not protest because the man just beneath him is in competition for his job. How best to save his teeth? Since the problem is one of denial of anger toward an authority figure, the best approach is nonauthoritarian. An educational approach might work. The notion that tooth-grinding may be 311
PSYCHOSOMATICS
the result of emotional pressures can be forwarded. It can then be suggested that there are several possible approaches, ranging from conscious attempts to relax one's jaws at bedtime to tranquilizers, or psychotherapy. The choice can be then left to the patient, who is unable to use his mechanism of hostile pseudocompliance against the dentist. It is his choice, and he is hurting himself, not his dentist, by following up with halfway measures. The Red Herrins -
A Gambit of
Displacement By red herring I mean a complaint which draws attention away from an individual's chief psychological concern. Some red herrings are easy to spot; others are not. A person who comes in complaining of a pain that begins in the left upper incisor, wanders down to the mandible and then up again to the bridge of the nose can be readily recognized as an individual with an emotional problem which has been displaced and converted into physical symptomatology. I can recall a patient who was afraid to see a dentist and open her mouth for a dental examination. She had had electroshock therapy in the past and said she recalled having to hold an airway in her mouth. She presumed that the persistent memory of this was the source of her trouble. I saw her at weekly intervals for a period of time because of numerous phobias from which she suffered, including her fear of examination of her mouth. She had been married for a year at the time I guessed what lay beneath her red herring concern. When I asked the question that pointed to what lay behind her fear of dental examination, she discontinued treatment with me. I asked how things were going sexually. She replied that she and her husband had never had sexual relations and that she did not care to discuss the issue any further. This woman's concern was the result of an upward displacement of her fear of sexuality. A milder form of red herring complaint is illustrated by a dental patient who suffered a gum ulceration in the region of an extracted 312
tooth. Her real concern was fear that her pain was the beginning of a malignancy similar to that of a friend who had recently ungergone a series of mutilating procedures. Another type of displacement is concern for the health of another. The best example here is the over-anxious mother who is perpeutally dragging little Jimmy or Susie in for one trivial complaint or another. It becomes evident after a number of sessions that mother and child have come for treatment of the mother's anxiety. One must ask, anxiety about what? Is she displacing hypochondriacal concerns from herself onto the child? This is often the case and can usually be ascertained by casually questioning the mother about her own medical and dental problems. Parents of this sort usually reply initially by stating that they hate to take medicines and see a doctor only when absolutely necessary. It just happens to be necessary fairly frequently, and when one symptom subsides, another emerges. Helping the parent who is projecting his own hypochondriasis is a difficult job and often cannot be accomplished. It is perhaps best dealt with by stating firmly to the parent that there is nothing wrong with the child. My experience is that one must have developed a fairly good relationship over a period of time before one can begin to confront an individual of this sort. The "concerned parent" gambit may also represent another more serious (for the child) type of displacement. In this latter type of displacement the parent is attempting to find a way to deal with wishes to harm or torture his child. Answer? Take him to Dr. Jones. Dr. Jones will make him suffer. Psychologically this is a variant on the battered child syndrome with the doctor used as the punishing agent. In medical circles this is commonly played out between a mother and her obese daughter. Psychologically it runs something like this: The daughter feels deprived of her mother's love and uses food as a substitute. This in turn enrages the mother. The mother does not see herself as a rejecting, punishing person. She gets the doctor to play this role while she worries about the Volume X
BEYOND THE COMPLAINT -
child's underactive thyroid. The milder forms of displacement of this sort can often be handled by direct confrontation of the parent with the fact that the child is being brought in unnecessarily and with the suggestion that the child be simply brought in every six months for a routine visit unless some emergency arises. The individual who displaces all of his or her psychological concerns onto his body and then demands some sort of extended painful procedure has been the subject of a previous paper 2 •
The "ForN,otten" Complaint Repression
A Gambit of
The forgotten complaint is remembered either over the telephone after a recent visit or as the patient is on the way out the office door. It is frequently prefaced with the phrase, "By the way, I just wanted to mention...." The trick is to somehow more fully elucidate the complaint and allow for an adequate examination. The psychological mechanism of suppression or repression is operative here and is suggestive that the casually-mentioned complaint is probably the individual's chief concern. A physician noted a melanotic blotch on his perineum and shortly afterward made an appointment for his yearly physical. By the time of his examination, he had "forgotten" this. On the way out of the internist's office after a negative examination, he said, "Oh, by the way. . . ." The melanotic area was examined and found to be a pigmented nevus. Why the need for repression? Two years
September-October 1969
WEINER
previously a physician friend had died of a malignant melanoma. As indicated above, the best way to deal with this sort of situation is to restructure it so an adequate history and examination may be undertaken. One can say, "I'm glad you mentioned that. I would like to spend some more time with you either now or in the near future to explore this with you further, for an incomplete examination would be unfair to you." The exaggerated use of psychological defense mechanisms in no way precludes physical illness. A recent study, in which computer-analyzed psychological tests were administered to medical patients, indicated that not only do neurotic patients become physically ill, but the stress of physical illness and pain is related to behavior patterns typically described as neurotic\ SUMMARY
We must consider not only what the patient complains of and how he complains of it but also what he does not complain of. These data give us some clues to the psychological functioning of the patient and provide information not only about his real concerns but also how they may be dealt with. BIBLIOGRAPHY
1. Noyes, A. P. and Kolb, L. C.; Modern Clinical Psychiatry, 7th ed. W.B. Saunders, Phila-
delphia, 1968. pp. 61-76. 2. Weiner, M. F. and Land, M.: Psychiatry, psychosomatics, and dentistry, Psychosomatics, 8: 338-341, November-December, 1967. 3. Kurland, H. D. and Hammer, M.: Emotional evaluation of medical patients, A.M.A. Arch. Gen. Psychiat., 19; 72-78, July, 1968.
313
F.
WEINER, M.D.
• Frequently the presenting complaint is simply the admission ticket to the office of the physician or dentist. It is that which the individual can use to place himself in the role of patient in need of health care. The chief complaint is often not the patient's chief concern, and for the sake of this discussion let us make a sharp distinction. A person's chief complaint is the reason he gives the physician or dentist for seeking medical help. His chief concern is that which troubles him and that for which he would like to be able to seek help were he able to admit it, either to himself or to the person from whom he seeks help. In most cases a patient's chief complaint will be his chief concern. The chief concern of this paper will be with those individuals in whom the chief complaint is not the chief concern. The task, then, is to establish how to determine the patient's chief concern and deal with it in the most appropriate manner while at the same time not disregarding his chief complaint. A person whose chief complaint coincides with his chief concern is obviously a person who is not in conflict and whose complaint can be dealt with at face value. For the individual who has conflict, which may be either conscious or unconscious, the story is quite different. This individual's chief complaint will probably point to an aspect of his chief concern, but equally important, it will give some important clues as to his mode of handling conflictual situations. Review of Basic Concepts
It will be worthwhile to briefly review some of the mental mechanisms most comPresented at the Academy of Psychosomatic Medicine Seminar, "Comprehensive Medicine for the Family Dentist," Dallas, Texas. Dr. Weiner is Clinical Assistant Professor of Psychiatry. University of Texas Southwestern Medical School, Dallas, Texas.
monly used to deal with emotional conflict. Psychological conflict may be conscious or unconscious, and defenses against psychological conflict may be conscious or unconscious. We may, for the sake of simplicity, conceive of psychological conflict as a state in which there are two opposing wishes or drives, neither of which can be completely relinquished. The primary psychological mechanism by which conflict is kept from consciousness is repression - the active process of forgetting. The conscious equivalent of repression is suppression - literally putting thoughts or ideas out of one's conscious mind. When repression is not adequate to maintain conflict on an unconscious level, a number of auxiliary mechanisms may be called into play. They are: 1. Displacement - a shift of concern away from the original area of concern, the chief mechanism in phobias. 2. Reaction formation - doing the opposite of what one would most like to do. 3. Undoing - symbolically revising in thought or action. This mechanism, together with reaction formation, underlies the obsessive-compulsive neuroses. 4. Denial - unawareness of external threat. 5. Regression - reverting to an earlier, successful means of adaptation, common to all states of psychological decompensation. 6. Projection - attributing to another what one abhors in one's self, the basic mechanism of the paranoid process. 7. Rationalization - a "rational" reason for an irrational act. 8. SUbstitution - gratifying a wish related to the wish held in check, the basic mechanism in sexual deviation. 9. Sublimation - the gratification of a wish in a socially acceptable way.
The presence of unconscious conflict leads to the psychological state of anxiety, or objectless fear. The psychological defense mechanisms listed above are used in varying combinations throughout life by every person. Every in-
310
Volume X
BEYOND THE COMPLAINT -
dividual has a preferred set of defense mechanisms which are utilized in times of inner turmoil. For a more complete exposition, the reader is referred to the latest edition of Modern Clinical Psychiatry by Noyes and Kolb l • Of the mechanisms listed above, we will consider denial, displacement, repression, and suppression in relation to the manner in which they obscure a patient's chief concern.
The Routine Checkup - A Gambit of Denial This is a frequent gambit, and it is probably the most deceptive of all the varieties of admission tickets to the office of a healthcare professional. One becomes aware that this is a gambit or a ruse by initially noting the patient's level of anxiety. That is to say, it doesn't make sense for a person coming in for a routine checkup to be either severely anxious or totally without anxiety or fear. A marked degree of anxiety may be denied but is readily detected by the accompanying rapid heartbeat, flushing or pallor, tremulousness, and sweating. Exaggerated lack of concern also suggests anxiety. It is my experience that going through the usual rapid routine system review with the "anxiety-less" individual may be very unproductive. There are many individuals who cannot bring themselves to complain. They require that complaints be elicited or dragged out from them. This is fairly typical of the self-sufficient individual who cannot admit that he has concern for himself but will indicate that either his spouse has pushed him into making an appointment or that he just happened to have an opening in his schedule and he thought it would be a good idea to drop by. To this sort of individual, there are several useful sorts of challenge. One effective challenge is to ask, "Why now? Is there any particular reason why you wanted to be examined at this point in time?" This question, followed by a few seconds of silence, may allow for the expression of some concern. One may also ask, "Even though this is only a routine check, perhaps you've noticed something recently that concerns you or disturbs you." Questions such as these may turn up September-October 1969
WEINER
concerns of which the patient is only half aware. The patient who operates in this manner illustrates the use of the psychological mechanism of denial. When denial is employed in this way, one asks two questions: What is being defended against? Why now? Denial can be used to advantage when a man is in combat. It enables him to cope on a day to day basis. Exaggerated denial in the medical or dental office may suggest one of two things. This may be an habitual reaction to all stress, to the threat of physical illness, or may be a temporarily exaggerated reaction in the area of physical health overlapping from an attempt to deal with other concerns. A man who comes in for a routine dental checkup may eventually become willing to admit, after observation suggests that he is grinding his teeth, that his jaws do ache a little in the mornings. A suggestion that this may be related to emotional pressures may lead to the source of the environmental or internal emotional pressure and may open the way for a referral. The exaggerated use of denial may pose many problems in prescribing a therapeutic regime. One may be certain that the regime will not be followed unless approached in the proper psychological context. Here again one must ask, ''What is being denied?" and "Why now?" One obtains a history from our hypothetical man with bruxism by asking how things are going. In response to his initial reply of, "Swell," one asks how things are going at work, then at home, and then in the patient himself. Is he satisfied with himself? With some patience, one may elicit a history of grudging submission to authority in an individual who takes out his smouldering anger on his dentition. He may have recently been given an assignment which he deemed unfair but felt he dared not protest because the man just beneath him is in competition for his job. How best to save his teeth? Since the problem is one of denial of anger toward an authority figure, the best approach is nonauthoritarian. An educational approach might work. The notion that tooth-grinding may be 311
PSYCHOSOMATICS
the result of emotional pressures can be forwarded. It can then be suggested that there are several possible approaches, ranging from conscious attempts to relax one's jaws at bedtime to tranquilizers, or psychotherapy. The choice can be then left to the patient, who is unable to use his mechanism of hostile pseudocompliance against the dentist. It is his choice, and he is hurting himself, not his dentist, by following up with halfway measures. The Red Herrins -
A Gambit of
Displacement By red herring I mean a complaint which draws attention away from an individual's chief psychological concern. Some red herrings are easy to spot; others are not. A person who comes in complaining of a pain that begins in the left upper incisor, wanders down to the mandible and then up again to the bridge of the nose can be readily recognized as an individual with an emotional problem which has been displaced and converted into physical symptomatology. I can recall a patient who was afraid to see a dentist and open her mouth for a dental examination. She had had electroshock therapy in the past and said she recalled having to hold an airway in her mouth. She presumed that the persistent memory of this was the source of her trouble. I saw her at weekly intervals for a period of time because of numerous phobias from which she suffered, including her fear of examination of her mouth. She had been married for a year at the time I guessed what lay beneath her red herring concern. When I asked the question that pointed to what lay behind her fear of dental examination, she discontinued treatment with me. I asked how things were going sexually. She replied that she and her husband had never had sexual relations and that she did not care to discuss the issue any further. This woman's concern was the result of an upward displacement of her fear of sexuality. A milder form of red herring complaint is illustrated by a dental patient who suffered a gum ulceration in the region of an extracted 312
tooth. Her real concern was fear that her pain was the beginning of a malignancy similar to that of a friend who had recently ungergone a series of mutilating procedures. Another type of displacement is concern for the health of another. The best example here is the over-anxious mother who is perpeutally dragging little Jimmy or Susie in for one trivial complaint or another. It becomes evident after a number of sessions that mother and child have come for treatment of the mother's anxiety. One must ask, anxiety about what? Is she displacing hypochondriacal concerns from herself onto the child? This is often the case and can usually be ascertained by casually questioning the mother about her own medical and dental problems. Parents of this sort usually reply initially by stating that they hate to take medicines and see a doctor only when absolutely necessary. It just happens to be necessary fairly frequently, and when one symptom subsides, another emerges. Helping the parent who is projecting his own hypochondriasis is a difficult job and often cannot be accomplished. It is perhaps best dealt with by stating firmly to the parent that there is nothing wrong with the child. My experience is that one must have developed a fairly good relationship over a period of time before one can begin to confront an individual of this sort. The "concerned parent" gambit may also represent another more serious (for the child) type of displacement. In this latter type of displacement the parent is attempting to find a way to deal with wishes to harm or torture his child. Answer? Take him to Dr. Jones. Dr. Jones will make him suffer. Psychologically this is a variant on the battered child syndrome with the doctor used as the punishing agent. In medical circles this is commonly played out between a mother and her obese daughter. Psychologically it runs something like this: The daughter feels deprived of her mother's love and uses food as a substitute. This in turn enrages the mother. The mother does not see herself as a rejecting, punishing person. She gets the doctor to play this role while she worries about the Volume X
BEYOND THE COMPLAINT -
child's underactive thyroid. The milder forms of displacement of this sort can often be handled by direct confrontation of the parent with the fact that the child is being brought in unnecessarily and with the suggestion that the child be simply brought in every six months for a routine visit unless some emergency arises. The individual who displaces all of his or her psychological concerns onto his body and then demands some sort of extended painful procedure has been the subject of a previous paper 2 •
The "ForN,otten" Complaint Repression
A Gambit of
The forgotten complaint is remembered either over the telephone after a recent visit or as the patient is on the way out the office door. It is frequently prefaced with the phrase, "By the way, I just wanted to mention...." The trick is to somehow more fully elucidate the complaint and allow for an adequate examination. The psychological mechanism of suppression or repression is operative here and is suggestive that the casually-mentioned complaint is probably the individual's chief concern. A physician noted a melanotic blotch on his perineum and shortly afterward made an appointment for his yearly physical. By the time of his examination, he had "forgotten" this. On the way out of the internist's office after a negative examination, he said, "Oh, by the way. . . ." The melanotic area was examined and found to be a pigmented nevus. Why the need for repression? Two years
September-October 1969
WEINER
previously a physician friend had died of a malignant melanoma. As indicated above, the best way to deal with this sort of situation is to restructure it so an adequate history and examination may be undertaken. One can say, "I'm glad you mentioned that. I would like to spend some more time with you either now or in the near future to explore this with you further, for an incomplete examination would be unfair to you." The exaggerated use of psychological defense mechanisms in no way precludes physical illness. A recent study, in which computer-analyzed psychological tests were administered to medical patients, indicated that not only do neurotic patients become physically ill, but the stress of physical illness and pain is related to behavior patterns typically described as neurotic\ SUMMARY
We must consider not only what the patient complains of and how he complains of it but also what he does not complain of. These data give us some clues to the psychological functioning of the patient and provide information not only about his real concerns but also how they may be dealt with. BIBLIOGRAPHY
1. Noyes, A. P. and Kolb, L. C.; Modern Clinical Psychiatry, 7th ed. W.B. Saunders, Phila-
delphia, 1968. pp. 61-76. 2. Weiner, M. F. and Land, M.: Psychiatry, psychosomatics, and dentistry, Psychosomatics, 8: 338-341, November-December, 1967. 3. Kurland, H. D. and Hammer, M.: Emotional evaluation of medical patients, A.M.A. Arch. Gen. Psychiat., 19; 72-78, July, 1968.
313