The Psychotic Patient

Psychotic patients have an impairment of their reality-testing abilities. They have a gross inability to communicate effectively. They may also suffer from hallucinations, delusions, or feelings of persecution. Psychotic patients cannot deal with their fear. They are constantly struggling with the ever-changing demands of their environment. It is most important to recognize the psychotic patient early and remain as calm as possible. If the patient has had violent episodes, make sure assistance is standing by.

In general, interviewing psychotic patients presents a difficult task for the inexperienced interviewer. Some of these patients tend to be inarticulate and preoccupied with fantasies, whereas others are reasonably lucid. The symptoms and signs of their psychosis are not usually evident at first assessment. There are several clues to the existence of a psychosis. Interviewers should pay particular attention to the speech pattern and its organization. Is there a jumble of ideas? Psychotic patients are easily distracted, and the interviewer must constantly remind them of the subject. These patients fail to complete any chain of thought and cannot follow any idea to completion. They can have bizarre impressions about their bodies. They may complain that they have noticed that one arm has recently shortened or that their external genitalia have suddenly shrunk or enlarged. In addition, they may have evidence of an inappropriate affect; for example, a patient may laugh while telling about the death of a friend or relative.

A special type of psychotic personality disorder is found in patients with Munchausen's syndrome. Such patients are the classic hospital malingerers. They are pathologic liars and travel from clinician to clinician, from hospital to hospital. They complain of a wide variety of symptoms and, in fact, create signs of illness to seek an advantage. Their histories are well rehearsed, and they have a masochistic perpetuation of self-injury. For example, the patient with Munchausen's syndrome may actually prick the skin under a fingernail so that it will not be obvious, drop some blood into the urine, and call the clinician, stating that there is blood in the urine. These patients frequently seek out painful diagnostic and therapeutic procedures. At times, they may even undergo unnecessary surgical procedures.

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