The old-fashioned doctor, whose departure from the modem medical scene is so greatly lamented, was amply aware of each patient's personality, family, work, and way of life. Today, we often blame a doctor's absence of that awareness on moral or ethical deficiency either in medical education or in the character of people who become physicians. An alternative explanation, however, is that doctors are just as moral, ethical, and concerned as ever before, but that a vast amount of additional new information has won the competition for attention. The data available to the old-fashioned doctor were a patient's history, physical examination, and "per- sonal profile," together with a limited number of generally ineffectual therapeu- tic agents. A doctor today deals with an enormous array of additional new information, which comes from X rays, biopsies, cytology, electrographic tracings, and the phantasmagoria of contemporary laboratory tests; and the doctor must also be aware of a list of therapeutic possibilities that are both far more effective and far more extensive than ever before.

Contenuti

I. On Becoming a Patient: Psychosocial Considerations.- 1. Illness and Help-Seeking Behavior.- Concepts and Definitions: Help-Seeking Behavior and Illness Behavior.- Factors Influencing Help-Seeking Behavior.- Factors Affecting Perception of a Symptom.- Demographic Factors.- The Role of Stress.- The Role of Previous Experience (“Priming Factors”).- Taxonomy of Medical Help-Seeking Behavior.- Summary.- Implications.- For the Patient.- For the Physician.- For the Community and Health Care System.- Recommended Reading.- References.- 2. The Sick Role.- Sick Role Expectations.- Sick Role Performance by Patients.- Summary.- Implications.- For the Patient.- For the Physician.- For the Community and Health Care System.- Recommended Reading.- References.- 3. Expectations in the Consulting Room.- Relief from Distress.- Communication of Information.- Effect of Priming Factors on Expectations.- The Physician’s Covert Expectations.- Society’s Expectations about the Physician—The “Doctor Role”.- Technical Competence.- Universalism of the Medical Role.- Functional Specificity.- Affective Neutrality.- The Physician’s Collectivity Orientation.- Summary.- Implications.- For the Patient.- For the Physician.- For the Community and Health Care System.- Recommended Reading.- References.- II. On Being a Patient: Psychophysiologic Considerations.- 4. Anxiety.- Phenomenology of Anxiety.- Theories of Anxiety and Emotions.- Learning Theory Model.- Psychoanalytic Signal Theory of Anxiety.- Physiology of Anxiety.- Brain Mechanisms of Anxiety.- Central Neurochemistry of Anxiety.- Function of Anxiety.- Disregulation of Anxiety.- Fainting.- Hyperventilation Syndrome.- Stress-Related Disorders.- Classification of Anxiety Disregulation Syndromes.- Evaluation of Anxiety.- Contexts of Anxiety.- Differential Diagnosis of Anxiety States.- Management of Anxiety.- Summary.- Implications.- For the Patient.- For the Physician.- For the Community and Health Care System.- Recommended Reading.- References.- 5. Psychological Defense Mechanisms.- Distress, Anxiety, and Defense Mechanisms.- Classification of Defense Mechanisms.- Defenses Listed According to Their Main Subsystem Effects.- Illustrations of Defense Mechanisms as They May Be Encountered in Medical Practice.- Defense Mechanisms That Manifest Their Main Effects in the Input Subsystem.- Defense Mechanisms That Manifest Their Main Effects in the Internal Processing Subsystem.- Defense Mechanisms That Manifest Their Main Effects in the Output (Action) Subsystem.- Defense Mechanisms Whose Main Effects Are More Evenly Distributed in All the Subsystems by Affecting the Decider or Executive Subsystem Itself.- Defense Mechanisms, Anxiety, Character, and Coping Styles.- Summary.- Implications.- For the Patient.- For the Physician.- For the Community and Health Care System.- Recommended Reading.- References.- 6. Depression.- Affect, Mood, and Depression.- Phenomenology of Depression and the Depressive and Manic Syndromes.- Separation, Bereavement, and Grief.- Phenomenology.- Course.- Pathological Grief Reactions.- Separation in Children.- Separation in Infant Monkeys.- Significance of Bereavement and Depression.- Function of Depression.- Brain Mechanisms of Depression.- Biogenic Amines.- Acetylcholine.- Other Putative Neurotransmitters and Neuromodulators.- Intracellular Sodium.- Psychological Aspects.- A Hypothetical Integrated Model.- Physiology and Endocrinology of Depression.- Neuroendocrinology.- Physiologic Signs of Depression (Depressive Syndrome).- Evaluation of Depression.- Physical Symptoms in Depressive Syndrome Associated with Major Affective Disorders.- Evaluation of Suicidal Potential.- Risk Factors.- Suicidal Attempt.- Evaluation of Suicidal Attempt.- Management of Depression.- Summary.- Implications.- For the Patient.- For the Physician.- For the Community and Health Care System.- Recommended Reading.- References.- 7. Pain.- Definitions and Functions of Pain.- Qualities of Pain.- Nature of Pain.- Neurophysiology of Pain.- Historical Neurophysiologic Theories of Pain Perception.- Descending Influences from the Brain.- Role of Endorphins in Pain Mechanism.- Central Neuropharmacology of Pain.- Psychosocial Factors Influencing Pain Experience.- Placebo Effect.- Use of Placebos in Medical Practice.- Psychological Meanings of Pain.- “Psychogenic” Pain.- Management of Pain.- Summary.- Implications.- For the Patient.- For the Physician.- For the Community and Health Care System.- Recommended Reading.- References.- 8. Sleep and Dreaming.- Stages of Sleep.- NREM Sleep.- REM Sleep.- Basic Rest-Activity Cycle.- Biological Rhythms.- Brain Mechanisms of Sleep.- Dreams.- Functions of Sleep and Dreaming.- Sleep Needs.- Environmental Factors Affecting Sleep.- Sleep Disorders.- Insomnia.- Hypersomnia.- Narcolepsy.- Somnambulism (Sleepwalking).- Enuresis (Bed-Wetting).- Night Terrors.- Nightmares.- Sleep Apnea.- Medical Conditions Affected by REM Sleep.- Hyperthyroidism and Hypothyroidism.- Summary.- Implications.- For the Patient.- For the Physician.- For the Community and Health Care System.- Recommended Reading.- References.- III. On Assessing a Patient: A Clinical Systems Approach.- 9. Approach to Patients: The Systems-Contextual Framework and the Patient Evaluation Grid.- The Patient, His Components, and the Environment.- Disease, Illness, and Distress.- The Systems- Contextual Approach.- The Patient Evaluation Grid (PEG).- What Goes into the PEG.- The Significance of Contexts.- The Significance of Dimensions.- Rational Patient Management.- Summary.- Implications.- For the Patient.- For the Physician.- For the Community and Health Care System.- Recommended Reading.- References.- 10. The Current Context of Help-Seeking Behavior.- The Current Context in the Biological Dimension.- The Current Context in the Personal Dimension.- Outline of the Mental-Status Examination.- The Current Context in the Environmental Dimension.- Interaction among the Current Context Dimensions.- Summary.- Implications.- For the Patient.- For the Physician.- For the Community and Health Care System.- Recommended Reading.- References.- 11. The Recent Context of Help-Seeking Behavior.- The Recent Context in the Biological Dimension.- The Recent Context in the Personal Dimension.- The Recent Context in the Environmental Dimension.- Summary.- Implications.- For the Patient.- For the Physician.- For the Community and Health Care System.- Recommended Reading.- References.- 12. The Background Context of Help-Seeking Behavior.- The Background Context in the Biological Dimension.- The Background Context in the Personal Dimension.- Personality as a Factor in Pathogenesis of Disease.- The Background Context in the Environmental Dimension.- Intersystems Interaction in the Background Context-Development.- Freud.- Erikson.- Piaget.- Summary.- Implications.- For the Patient.- For the Physician.- For the Community and Health Care System.- Recommended Reading.- References.- IV. On Managing a Patient.- 13. The Case of the “Sick Tarzan”: A Challenging Case History.- 14. The Doctor-Patient Relationship.- Summary.- Implications.- For the Patient.- For the Physician.- For the Community and Health Care System.- Recommended Reading.- References.- 15. The Patient’s Personality.- Personality and Character.- The Concept of Personality Types in Patients.- Personality Types and the Sick Role.- Dependent, Demanding Patients.- Orderly, Controlling Patients.- Dramatizing, Emotional Patients.- Long-Suffering, Self-Sacrificing Patients.- Guarded, Suspicious Patients.- Superior and Special Patients.- Seclusive, Aloof (Schizoid) Patients.- Impulsive Patients with a Tendency to Act Out.- Patients with Mood Swings.- Patients with Chronic Memory Deficits and a Tendency to Confusion (Chronic Organic Brain Syndrome).- From Types to Individuals.- Summary.- Implications.- For the Patient.- For the Physician.- For the Community and Health Care System.- Recommended Reading.- References.- 16. The Hospitalized Patient.- The Hospital as a Social System.- Kinds of Hospitals.- The People in a Hospital.- The Organization of an Inpatient Unit.- The Hospital and Outside Organizations.- The Hospital Environment.- Summary.- Implications.- For the Patient.- For the Physician.- For the Community and Health Care System.- Recommended Reading.- References.- 17. Therapeutic Dimensions.- Approaches in the Biological Dimension.- Approaches in the Personal Dimension.- Psychotherapy in Medical Settings.- Formal Psychotherapy.- Approaches in the Environmental Dimension.- Summary.- Implications.- For the Patient.- For the Physician.- For the Community and Health Care System.- Recommended Reading.- References.- 18. Drugs Affecting Behavior.- Drugs Affect All Dimensions of the Patient.- Psychotropic Drugs.- Antianxiety Drugs (Minor Tranquilizers).- Drugs Affecting Mood.- Antipsychotic Drugs (Major Tranquilizers, Neuroleptics).- Summary.- Implications.- For the Patient.- For the Physician.- For the Community and Health Care System.- Recommended Reading.- References.- 19. Some Illustrative Patients.- The Management of the Sick Tarzan.- Biological Dimension.- Personal Dimension.- Environmental— Interpersonal Dimension.- The Case of the Catatonic Patient with Enlarged Ventricles.- History and Course.- Comments.- The Case of the Suicidal Terminal Cancer Patient.- History.- Evaluation.- Course of Management.- Comments.- 20. Summary and Perspectives.

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