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DIAGNOSTIC CATEGORIES

A. Acute Problems

  1. Delirium with psychotic features secondary to the medical or surgical problem, or compounded by effect of treatment.

  2. Acute anxiety, often related to ignorance and fear of the immediate problem as well as uncertainty about the future.

  3. Anxiety as an intrinsic aspect of the medical problem (eg, hyperthyroidism).

  4. Denial of illness, which may present during acute or intermediate phases of illness.

B. Intermediate Problems

  1. Depression as a function of the illness or acceptance of the illness, often associated with realistic or fantasied hopelessness about the future.

  2. Behavioral problems, often related to denial of illness and, in extreme cases, causing the patient to leave the hospital against medical advice.

C. Recuperative Problems

  1. Decreasing cooperation as the patient sees that improvement and compliance are not compelled.

  2. Readjustment problems with family, job, and society.

GENERAL CONSIDERATIONS

A. Acute Problems

1. “Intensive care unit psychosis”

The ICU environment may contribute to the etiology of delirium. Critical care unit factors include sleep deprivation, increased arousal, mechanical ventilation, and social isolation. Other causes include those common to delirium and require vigorous investigation (see Delirium).

2. Presurgical and postsurgical anxiety states

Anxiety before or after surgery is common and commonly ignored. Presurgical anxiety is very common and is principally a fear of death (many surgical patients make out their wills). Patients may be fearful of anesthesia (improved by the preoperative anesthesia interview), the mysterious operating room, and the disease processes that might be uncovered by the surgeon. Such fears frequently cause people to delay examinations that might result in earlier surgery and a greater chance of cure.

The opposite of this is surgery proneness, the quest for surgery to escape from overwhelming life stresses. Some polysurgery patients may be classified as having factitious disorders. Dynamic motivations include the need to get medical care as a way of getting dependency needs met, the desire to outwit authority figures, unconscious guilt, or a masochistic need to suffer. Frequent surgery may also be related to a somatic symptom disorder, particularly body dysmorphic disorder (an obsession that a body part is disfigured). More apparent reasons may include an attempt to get relief from pain and a lifestyle that has become almost exclusively medically oriented, with all of the risks entailed in such an endeavor.

Postsurgical anxiety states are usually related to pain, procedures, and loss of body image. Acute pain problems are quite different from chronic pain disorders (see Chronic Pain Disorders, this chapter); the former are readily handled with adequate analgesic medication (see Chapter 5-06). Alterations in body image, as with amputations, ostomies, and mastectomies, often raise concerns about relationships with others.

3. Iatrogenic problems

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