Ten Practical Psychiatric Perspectives
A Presentation for SOMC Medical Education
Kendall L. Stewart, MD, MBA, DFAPA
October 15, 2010
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These are among the most frustrating patients you will encounter.
Contrary to the conventional wisdom, they can also be among your most grateful and gratifying patients.

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• This is a huge medical problem.
• Chronic pain is among the most common reasons patients visit physicians.
• This is the third largest health care problem in the world.
• More than 60 million Americans suffer from chronic pain.
• And its treatment leads to all kinds of other problems.
• You will see many of these patients, and they will frustrate you enormously.
• After listening to this presentation, you will be able to answer the following questions:
– Why is this issue so important?
– What practical psychiatric perspectives will assist you in managing these challenging patients?
– How can you implement these perspectives in your clinical practice?
– What are some of the treatment challenges?
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• Your ability to integrate these practical perspectives in your clinical practice will enhance your effectiveness.
1 Click on the hyperlinks in the presentation for additional information.

1. Ask whether the patient is confident that nothing has been missed.
2. Remember the “soma to psyche” connection.
3. Leave the drug management to the experts—unless you are one.
4. Suggest regular visits.
5. Monitor drug usage carefully.
6. Recommend appropriate daily exercise.
7. Encourage healthy distractions.
8. Teach progressive relaxation.
9. Suggest sensory override techniques
10. Encourage positive addictions.

• So long as your patient believes something has been missed, you cannot begin working on the goal of living with the pain .
• Many of our patients like to go to the Cleveland Clinic for a second opinion.
• You will be humbled by the number of times consultants will find something significant that you have missed.
• New findings rarely produce a cure.
• But a comprehensive examination often provides an enabling sense of closure.
1 A local surgeon diagnosed diverticulitis and recommended surgery.

• Begin with the genuine acknowledgement that the patient is suffering.
• Remind them that you are there to help them “live with” their pain.
• After you have convinced the patient that you believe the pain is real, begin to tentatively explore the painful emotions that may be contributing to the pain experience.
• When your conversations are confined mostly to the psychic pain, avoid going back to the physical symptoms except to briefly document the intensity of the pain.
1 An elderly woman came in with the complaint that her head was burning.

• This complex medical management is best left to one physician.
• Clarify your role up front.
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• Invite the patient to make an informed decision.
• Make a commitment to the prescribing physician that you will not prescribe.
• Then inform the patient of your commitment.
• When they test you—and they will— remind them of this commitment and their previous agreement.
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Do this before you get frustrated and resentful.
A colleague of mine promised to call his patient every evening.
Then he moved away and left the patient to me.

• These patients often feel their physicians don’t take them seriously .
• They feel shunted to other specialists.
• They want a physicians they can depend on.
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• Seeing the doctor too frequently often becomes their positive addiction.
• Their visits to the doctor are often their principal social outlets.
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I routinely now ask my patients when they would like to return.
They change the frequency depending on what is going on in their lives.
I reassure them that they can always call.

• Ask your patients to keep a medication diary .
• Ask to see this at every visit.
• Inquire about side effects.
• Communication about what you learn and observe with the other physicians on the team.
• This patients will sometimes ask you not to communicate with their other physicians.
• Don’t agree to this condition.
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Never, ever agree to confidentiality beforehand.
A borderline patient once asked me to keep her pill stash for her.

• This remains a hard sell, but we must keep selling it.
• Those physicians who exercise regularly themselves are more likely to recommend exercise to their patients, and they are more credible persuaders.
• People with chronic back pain are very likely to overdo exercise at times.
• Daily exercise works best.
• Combining exercise with some other enjoyable activity is critical.
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I exercise two hours every day.
I combine exercise with thinking, classical music, reading my Kindle, and watching the news.

• Healthy distractions
– Television 1
– Reading
– Music
– Facebook™
– Productive activities
• Unhealthy distractions
– Alcohol
– Pain medications
– Rumination
– Complaining
– Eating
– Consumptive activities
1 When my mother’s television went off, her pain increased dramatically.

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1 This is also a great way to put yourself to sleep.

• Heating pad
• Heating rubs
• Local cold compresses
• Hot bath
• Loud music 1
• Vigorous exercise
• Sex
• Deep tissue massage
• Other strong sensory experiences
1 My schizophrenic patients often drown out the voices this way.

• Self-help groups can be very helpful— especially for recovering patients.
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• Religious people who worship regularly clearly lead more healthy, satisfying lives.
• A consuming passion for serving others is the best positive addiction.
• Some demanding hobbies such as coupon clipping, scrapbooking and genealogy can serve as positive addictions.
• Passions that produce strong negative emotions such as spectator sports or politics are not as helpful.
1 Those who become consumed with helping others are most likely to succeed.

A Patient-Centered, Evidence-Based Diagnostic and Therapeutic Process
• Introduce yourself using AIDET 1 .
• Sit down.
• Make me comfortable by asking some routine demographic questions.
• Ask me to list all of problems and concerns.
• Using my problem list as a guide, ask me clarifying questions about my current illness(es).
• Using evidence-based diagnostic criteria, make accurate preliminary diagnoses.
• Ask about my past psychiatric history.
• Ask about my family and social histories.
• Clarify my pertinent medical history.
• Perform an appropriate mental status examination.
• Review my laboratory data and other available records.
• Tell me what diagnoses you have made.
• Reassure me.
• Outline your recommended treatment plan while making sure that I understand.
• Repeatedly invite my clarifying questions.
• Be patient with me.
• Provide me with the appropriate educational resources.
• Invite me to call you with any additional questions I may have.
• Make a follow up appointment.
• Communicate with my other physicians.
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A cknowledge the patient. I ntroduce yourself. Inform the patient about the D uration of tests or treatment.
E xplain what is going to happen next. T hank your patients for the opportunity to serve them.

• American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision , 2000
• Sadock, B. J. and Sadock V. A., Concise Textbook of Clinical
Psychiatry, Third Edition, 2008 1
• Flaherty, AH, and Rost, NS, The
Neurology , April 2007 2
Massachusetts Handbook of
• Stead, L, Stead, SM and Kaufman, M,
Clerkship, Second Edition, March 2005
First Aid© for the Psychiatry
• Klamen, D, and Pan, P, Psychiatry Pre Test Self-Assessment and
Review, Twelfth Edition, March 2009 3
• Oransky, I, and Blitzstein, S, Lange Q&A: Psychiatry, March 2007
• Ratey, JJ, Spark: The Revolutionary New Science of Exercise and the
Brain, January 2008
• Median, John, Brain Rules: 12 Principles for Surviving and Thriving at Home, Work and School, February 2008
• Stewart KL, “Dealing With Anxiety: A Practical Approach to Nervous
Patients,” 2000
• Jacobson and Jacobson, Psychiatric Secrets, 2 nd Edition, 2001

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• Explore the site maintained by the organization where evidence-based medicine began at McMaster University here .
• Sign up for the Medscape Best Evidence Newsletters of your choice here . in the specialties
• Subscribe to the
Evidence-Based Mental Health and search a database at
National Registry of Evidence-Based Programs and Practices maintained by the Substance Abuse and Mental Health Services
Administration here .
• Explore a limited but useful database of mental health practices that have been "blessed" as evidence-based by various academic, administrative and advocacy groups collected by the Iowa Consortium for Mental Health here .
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Download this presentation and related presentations and white papers at www.KendallLStewartMD.com
.
• Learn more about Southern Ohio Medical Center and the job opportunities there at www.SOMC.org
.

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Kendall L. Stewart, M.D.
VPMA and Chief Medical Officer
Southern Ohio Medical Center
Chairman & CEO
The SOMC Medical Care Foundation, Inc.
1805 27th Street
Waller Building
Suite B01
Portsmouth, Ohio 45662
740.356.8153
StewartK@somc.org
KendallLStewartMD@yahoo.com
www.somc.org
www.KendallLStewartMD.com
1 Speaking and consultation fees benefit the SOMC Endowment Fund.

Sarah Porter, DO
SOMC FP 2006
Kevin Kammler, DO
OUCOM 1993 www.somc.org
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