Consulting with Medical Patients

By Robert T. | Clinical Psychiatry News, May 2008 | Go to article overview

Consulting with Medical Patients


Robert T., Clinical Psychiatry News


Some years ago, an elderly gentleman began to experience hiccups after eye surgery. He also had a history of car-diovascular disease. After 5 days of medical intervention, such as breathing into a paper (not plastic) bag, using vagal stimulation, drinking glasses of water rapidly, swallowing ice, and putting pressure on his eyeballs, nothing worked.

The patient took phenobarbital and chlorpromazine in moderation, but both medications proved equally ineffective. Finally, a medical attending asked me what I could do to help stop these uncontrolled hiccups, which at this point were becoming detrimental to the patient's well-being.

As we know, hiccups originate most often from irritation of afferent or efferent nerves that control respiratory muscles, especially the diaphragm. Before I was consulted on this case, both a psychiatrist and a psychologist had seen the patient and had tried to explore some of the stresses and anxieties in his life, and nothing was working. Both of them failed. In fact, they caused the patient more distress, anger, and irritation with their questions.

I explained to the internist that I would gladly see the patient but had no intention of discussing psychological issues. I also said I would like two of my residents in the short-term therapy program I ran to accompany me. He agreed. My plan was to develop a simple behavior program aimed at getting him to relax and alter what had become his endless and obsessive focus on the hiccups.

When I saw the patient, he was unhappy, irritable, and in no mood to hear the word psychiatrist. Besides, he was not "nuts," he said. I was there only to offer him a technique to "maybe" stop the hiccups, I explained. The word "maybe" worked, because it implied no promises.

I had little interest in knowing where the patient had gone to school or the nature of his work or family relationships. I did, however, ask the patient what he had done for a living. His response: "Okay, show me the technique."

I asked the patient to close his eyes and imagine seeing the ocean. "Why?" he asked. I encouraged him to get prepared for the technique. I was going to teach him. All this time, the patient was hiccupping, and remained unhappy and distressed.

He was able to imagine the ocean, and said, "So what now?" What now was to distract him with an imagined movie screen, because at this point, I knew that he had the capacity for imagination based on his success in seeing the ocean.

With the screen, my suggestion was for him to imagine or see an ocean scene and try to see himself at the beach. He was able to do this. I made it clear this was now his movie screen and he could go wherever he wanted on that screen of his. The next step was for me to help him see himself hiccupping on that big movie screen.

I emphasized the importance of the patient seeing himself hiccupping on the screen. One of the residents was on the far side of the chair in which the patient was sitting, and I encouraged the patient to see himself hiccupping on the screen while the resident and I took turns speaking repetitively. My goal was to create a home-made stereo effect for better concept.

The purpose was to capture the patient's imagination and obsessive thinking about the ever-present hiccups by reciprocal inhibition, leading to distraction and subsequent cessation of the hiccups. The outcome was a slowing down of the hiccups, and after about 20 minutes, they stopped altogether. I was a hero for the day.

Because of my experience with behavior modification techniques, hypnosis, and cognitive therapy, I often have been called over the years to do medical/surgical consultations to offer something different from the more traditional kind of psychiatric interview/formulation. The strategy I used not only was successful, it was straightforward.

The need is great for psychiatric services and care on medical and surgical units today. …

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