Improving the Capacity to Test Reality

Difficult patients often have distorted views of realty. Stressed patients with cluster A and B personality disorders may transiently hear voices, hallucinate, have brief episodes of delusional thinking, or have other severe distortions in perception of reality (e.g., paranoia). This can occur with paranoid, schizotypal, and borderline personality disorders. If psychotic disturbances in reality are present, assess and treat these first before providing the requested medical care. Mobilizing external supports, using medications, or placing the patient in a safe and calm environment is often sufficient.

A stressed or somatic patient can also present with a tenuous or disturbed relationship to reality. Some hypochondriac patients appear delusional in their belief that they have a serious medical condition, even when medical testing contradicts this. Patients with body dysmorphic disorder are certain that a part of their body is defective, even when no visual evidence confirms this. Difficult patients may have a disturbance in the sense of reality, such as derealization (watching own life as if it were a movie), depersonalization (not feeling a part of one's own life), dramatic distortions of what has been said, transient misper-ceptions of real events (interpreted according to core beliefs or irrational thoughts), or misunderstanding the physician or patient role. Such reality distortions are not usually dangerous but can lead to severe problems in the physician-patient relationship if they are not recognized and addressed. Verbal techniques include uncovering and clarifying the patient's irrational thoughts or core beliefs and using confrontation, clarification, and interpretation to improve the patient's reality testing.

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