Patients have an array of thoughts about their illness or injury that trigger their feelings and drive their actions. Physicians should recognize and understand some common and predictable emotional responses that we see in our “good” patients.(1)
SIX COMMON REACTIONS TO ILLNESS AND HOSPITALIZATION
Below are six of the most common reactions to illness and hospitalization.
Regression
Regression refers to childlike stages of emotional functioning in response to illness or injury. Many patients begin acting like children right before our eyes, looking to us as parental figures. This response to illness encourages increased physical and emotional dependency on caregivers during illness, permitting patients to rest and recover from acute illnesses or during exacerbation of chronic illness. Physicians and nurses value the dependency associated with regression because these patients follow the medical team’s direction without question.Denial
Denial can take many forms. It can be an unconscious response to anxiety and help keep worry at bay. One form, suppression, involves pushing the thought of illness out of the mind. Suppression can contribute to better functioning and is considered a relatively healthy psychological defense mechanism. For example, a person being treated for thyroid cancer can suppress the thought of being ill and return to work while undergoing treatment.
True denial is a deleterious defense mechanism in which the patient contradicts or disbelieves the information or diagnosis received from the physician.
Repression refers to the unintentional movement of an idea from consciousness to unconsciousness. This form of denial can be maladaptive when the patient forgets to attend appointments, forgets to take medications, and ignores various restrictions.
True denial is a deleterious defense mechanism in which the patient contradicts or disbelieves the information or diagnosis received from the physician. For example, patients with coronary artery disease may explain away chest pain symptoms as heartburn and not related to their heart disease. They cannot face the implications of having a heart attack, so they deny the symptoms. Unfortunately, this type of denial can be life-threatening.Control by gaining knowledge
Some individuals have personalities that prompt them to want to control every situation. They find it particularly upsetting when others make decisions for them regarding their illness or treatment. They believe they can reduce uncertainty and obtain a better outcome by knowing everything there is to know. With a few clicks of a mouse, they access a treasure trove of information to help make informed decisions about the best specialists and the best treatment.
Healthcare providers may perceive these individuals as irritating and overly concerned with the minutiae of care, bringing in long lists of questions, taking hourly blood pressure readings, and reporting multiple minor symptoms. It is important to recognize these patients’ need to control their situations and to answer all their questions as completely as is appropriate and as time allows. Allow them to participate as much as possible in their treatment. These individuals follow discharge instructions to the letter, so those instructions should be curated wisely.
These highly ordered, controlling patients tend to take an active role in caring for themselves and are generally appreciated by clinicians for being compliant.Anxiety
People may imagine the worst scenarios after a quick Internet search of their symptoms and become anxious. A certain amount of worry or anxiety is normal when experiencing trauma or visiting the emergency department.
Anxiety can be experienced as an internal state of fearfulness that can also manifest through physical symptoms such as palpitations, sweating, and nausea. When unrelieved, persistent, or recurrent anxiety can exert a negative influence on disease and the process of healing.
These common patient reactions to illness of worry and anxiety are normal and are to be expected, to some degree, in every person. In evolutionary terms, anxiety served our ancestors well when great danger lurked outside their dwellings. While advancements in medicine and therapeutics have progressed tremendously, clinicians know that some people will have anxiety that is out of proportion to their symptoms. For example, they fear death and disability as a result of common occurrences such as childbirth, appendicitis, or streptococcal infection. However, because anxiety and dramatic behavior frequently overlay the presentation of serious illness, physical symptoms of agitation, tachycardia, and palpitations require a complete workup to exclude more serious pathology. The diagnosis of a “panic attack” must always be a diagnosis of exclusion when a thorough work-up yields no evidence of other pathology.Anger
Some chronically ill patients become angry, asking, “Why me?” Healthcare providers often become easy targets for this displaced anger. In the medical office and emergency department, the nurses and technicians frequently bear the brunt of angry or impatient patients who use anger and yelling to intimidate their caregivers and to try to get their own way. Some people become incensed when they have to wait their turn. Acknowledging people’s feelings and apologizing for their inconvenience often can ease the unpleasantness.Sadness
Sadness is a common reaction to an illness or diagnosis. Extreme sadness can color every aspect of a person’s relationship with those around them. Normal sadness allows the anticipation and expectation of pleasurable activities over time. Prolonged sadness with dysphoria actually may be undiagnosed depression, and, of course, these patients should be evaluated for major depression and observed for indications of self-harm or suicide.
Reference
Blumenfield M, Thompson TL. The psychological reaction to physical illness. In: Simons RC, Pardes H (eds). Understanding Human Behavior in Health and Illness, 2nd ed. Baltimore, MD: Williams & Wilkins; 1981.
Excerpted from Changing How We Think About Difficult Patients by Joan Naidorf, DO