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December 14, 1994, Vol 272, No. 22 >
ARTICLE | December 14, 1994

Denial in the Medical Interview: Title and subTitle BreakRecognition and Management FREE

David E. Ness, MD; Jack Ende, MD
[+] Author Affiliations

Reprint requests to Department of Psychiatry, Medical College of Pennsylvania and Hahnemann University, Allegheny Campus, Allegheny General Hospital, 320 E North Ave, Pittsburgh, PA 15212-4772 (Dr Ness).


JAMA. 1994;272(22):1777-1781. doi:10.1001/jama.1994.03520220071033
Text Size: A A A
Published online
Article
References

Denial is a psychological defense in which the individual repudiates some or all of the meanings of an illness, thereby warding off an awareness of painful thoughts and feelings such as fear, grief, depression, and anger. Although it is often viewed as a problem, denial may at times be a healthy and adaptive response to illness. In the medical interview, denial may be exhibited by the patient, the physician, or both. Not all instances of denial can or should be addressed within the interview. The decision to address denial can be made based on how adaptive the denial is, what kind of psychosocial support is available to the patient, and how well prepared the patient is to deal with the fears that underlie denial. In those instances when denial should be addressed, the interviewer can use techniques of clarification, confrontation, and interpretation.

(JAMA. 1994;272:1777-1781)

REFERENCES

1 +
Cohen-Cole S. The Medical Interview: The Three-Function Approach . St Louis, Mo: Mosby-Year Book; 1991;:151-152.
2 +
Moore EB, Fine BD. Psychoanalytic Terms and Concepts . New Haven, Conn: Yale University Press; 1990;.
3 +
Quill TE.  Recognizing and adjusting to barriers in doctor-patient communication. Ann Intern Med . 1989;;111:51-57.
4 +
Fowers BJ.  The cardiac denial of impact scale: a brief, self-report research measure. J Psychosom Res . 1992;;36:469-475.
5 +
Jacobsen BS, Lowery BJ.  Further analysis of the psychometric properties of the Levine Denial of Illness Scale. Psychosom Med . 1992;;54:372-381.
6 +
Moses R, Cividali N.  Differential levels of awareness of illness: their relation to some salient features in cancer patients. Ann N Y Acad Sci . 1966;; 125:984-994.
7 +
Moses R.  Denial in political process.  In: Breznitz S, ed. The Denial of Stress . New York, NY: International Universities Press; 1983;:287-297.
8 +
Freud A. The Ego and the Mechanisms of Defense . Revised edition. New York, NY: International Universities Press; 1966;:79.
9 +
Freud A. Normality and Pathology in Childhood . New York, NY: International Universities Press; 1965;:177.
10 +
Strauss DH, Spitzer RL, Muskin PR.  Maladaptive denial of physical illness: a proposal for DSM-IV. Am J Psychiatry . 1990;;147:1168-1172.
11 +
Yellowlees PM, Ruffin RE.  Psychological defenses and coping styles in patients following a life-threatening attack of asthma. Chest . 1989;;95: 1298-1303.
12 +
Barsky AJ, Hochstrasser B, Coles A, Zisfein J, O'Donnell C, Eagle K.  Silent myocardial ischemia: is the person or the event silent? JAMA . 1990;;264: 1132-1135.
13 +
Phelan M, Dobbs J, David AS.  'I thought it would go away': patient denial in breast cancer. J R Soc Med . 1992;;85:206-207.
14 +
Hackett TP, Cassem NH, Raker JW.  Patient delay in cancer. N Engl J Med . 1973;;289:14-20.
15 +
Douglas CJ, Druss RG.  Denial of illness: a reappraisal. Gen Hosp Psychiatry . 1987;;9:53-57.
16 +
Miller LJ.  Psychotic denial of pregnancy: phenomenology and clinical management. Hosp Community Psychiatry . 1990;;41:1233-1237.
17 +
Druss RG, O'Connor JF, Stern LO.  Psychologic response to colectomy. Arch Gen Psychiatry . 1969;; 20:419-427.
18 +
Ellis SJ, Small M.  Denial of illness in stroke. Stroke . 1993;;24:757-759.
19 +
Goldsmith RJ, Green BL.  A rating scale for alcoholic denial. J Nerv Ment Dis . 1988;;176:614-620.
20 +
Watson M, Greer S, Blake S, Shrapnell K.  Reaction to a diagnosis of breast cancer: relationship between denial, delay, and rates of psychological morbidity. Cancer . 1984;;53:2008-2012.
21 +
Perry JC.  Appendix IV: Perry's clinical defense mechanism ratings scales, and glossary of defenses.  In: Vaillant GE, ed. Empirical Studies of Ego Mechanisms of Defense . Washington, DC: APA Press; 1986;:124-125.
22 +
Carsky M, Selzer MA, Terkelsen K, Hurt SW.  The PEH: a questionnaire to assess acknowledgment of psychiatric illness. J Nerv Ment Dis . 1992;; 180:458-464.
23 +
Hackett TP, Cassem NH.  Development of a quantitative rating scale to assess denial. J Psychosom Res . 1974;;18:93-100.
24 +
Druss RG, Douglas CJ.  Adaptive responses to illness and disability: healthy denial. Gen Hosp Psychiatry . 1988;;10:163-168.
25 +
Wool MS.  Understanding denial in cancer patients. Adv Psychosom Med . 1988;;18:37-53.
26 +
Kubler-Ross E. On Death and Dying . New York, NY: Macmillan Publishing Co Inc; 1969;:39.
27 +
Lowery BJ, Jacobsen BS, Cera MA, Mclndoe D, Kleman M, Menapace F.  Attention versus avoidance: attributional search and denial after myocardial infarction. Heart Lung . 1992;;21:523-528.
28 +
Levenson JL, Mishra A, Hamer RM, Hastillo A.  Denial and medical outcome in unstable angina. Psychosom Med . 1989;;51:27-35.
29 +
Levine J, Warrenburg S, Kerns R, et al.  The role of denial in recovery from coronary heart disease. Psychosom Med . 1987;;49:109-117.
30 +
Dean C, Surtees PG.  Do psychological factors predict survival in breast cancer? J Psychosom Res . 1989;;33:561-569.
31 +
Greer S, Morris T, Pettingale KW, Haybittle JL.  Psychological response to breast cancer and 15-year outcome. Lancet . 1990;;335:49-50.
32 +
Martin AR.  Exploring patient beliefs: steps to enhancing physician-patient interaction. Arch Intern Med . 1983;;143:1773-1775.
33 +
Ewing JA.  Detecting alcoholism: the CAGE questionnaire. JAMA . 1984;;252:1905-1907.
34 +
Cyr MG, Wartman SA.  The effectiveness of routine screening questions in the detection of alcoholism. JAMA . 1988;;259:51-54.
35 +
Moore RD, Bone LR, Geller G, Mamon JA, Stokes EJ, Levine DM.  Prevalence, detection, and treatment of alcoholism in hospitalized patients. JAMA . 1989;;261:403-407.
36 +
Skinner HA, Hold MB, Schuller R, Roy J, Israel Y.  Identification of alcohol abuse using laboratory tests and a history of trauma. Ann Intern Med . 1984;;101:847-851.
37 +
Greenstein RA, Ness DE.  Psychiatric emergencies in the elderly. Emerg Med Clin North Am . 1990;;8:429-441.
38 +
Folstein MF, Folstein SE, McHugh PR.  Mini-Mental State: a practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res . 1975;;12:189-198.
39 +
Ende J, Rockwell S, Glasgow M.  The sexual history in general medicine practice. Arch Intern Med . 1984;;144:558-561.
40 +
Bush B, Shaw S, Cleary P, Delbanco TL, Aronson MD.  Screening for alcohol abuse using the CAGE questionnaire. Am J Med . 1987;;82:231-235.
41 +
Mishler EG. The Discourse of Medicine: Dialectics of Medical Interviews . Norwood, NJ: Ablex Publishing Co; 1984;.
42 +
West C.  'Ask me no questions... ': an analysis of queries and replies in physician-patient dialogues.  In: Fisher S, Todd AD, eds. The Social Organization of Doctor-Patient Communication . Washington, DC: Center for Applied Linguistics; 1983;:75-106.
43 +
Shuy RW.  Three types of interference to an effective exchange of information in the medical interview.  In: Fisher S, Todd AD, eds. The Social Organization of Doctor-Patient Communication . Washington, DC: Center for Applied Linguistics; 1983;:189-202.
44 +
Crouch MA, McCauley J.  Interviewing style and response to family information by family practice residents. Fam Med . 1986;;18:15-18.
45 +
Gorlin R, Zucker HD.  Physicians' reactions to patients: a key to teaching humanistic medicine. N Engl J Med . 1983;;308:1059-1063.
46 +
Cox A, Hopkinson K, Rutter M.  Psychiatric interviewing techniques II: naturalistic study: eliciting factual information. Br J Psychiatry . 1981;; 138:406-415.
47 +
Cox A, Holbrook D, Rutter M.  Psychiatric interviewing techniques VI: experimental study: eliciting feelings. Br J Psychiatry . 1981;;139:144-152.
48 +
Beisser AR.  Denial and affirmation in illness and health. Am J Psychiatry . 1979;;136:1026-1030.
49 +
Shelp EE, Perl M.  Denial in clinical medicine: a reexamination of the concept and its significance. Arch Intern Med . 1985;;145:697-699.
50 +
Strauss DH, Spitzer RL, Muskin PR.  Maladaptive denial of physical illness: a proposal for DSM-IV. Am J Psychiatry . 1990;;147:1168-1172.
51 +
Hauser ST, Jacobson AM, Bliss R, et al.  The family and the onset of its youngster's insulin-de-pendent diabetes: ways of coping.  In: Cole RE, Reiss D, eds. How Do Families Cope With Chronic Illness? Hillsdale, NJ: Lawrence Erlbaum Association; 1993;:26.
52 +
Janne P, Reynaert C, Decoster P.  Denial and silent ischemia: which comes first? JAMA . 1991;; 265:213.
53 +
Billings JA, Stoeckle JD. The Clinical Encounter: A Guide to the Medical Interview and Case Presentation . Chicago, Ill: Year Book Medical Publishers Inc; 1989;:180-181.
54 +
Reiser DE, Schroder AK, Liebgott AR, Shmock CL. Patient Interviewing: The Human Dimension . Baltimore, Md: Williams & Wilkins; 1980;:62-64.
55 +
Gabbard GO. Psychodynamic Psychiatry in Clinical Practice . Washington, DC: American Psychiatric Press; 1990;:79-80.
56 +
Kernberg OF, Selzer MA, Koenigsberg HW, Carr AC, Appelbaum AH. Psychodynamic Psychotherapy of Borderline Patients . New York, NY: Basic Books Inc Publishers; 1989;:11.

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Country-Specific Mortality and Growth Failure in Infancy and Yound Children and Association With Material Stature

Use interactive graphics and maps to view and sort country-specific infant and early dhildhood mortality and growth failure data and their association with maternal

1 +
Cohen-Cole S. The Medical Interview: The Three-Function Approach . St Louis, Mo: Mosby-Year Book; 1991;:151-152.
2 +
Moore EB, Fine BD. Psychoanalytic Terms and Concepts . New Haven, Conn: Yale University Press; 1990;.
3 +
Quill TE.  Recognizing and adjusting to barriers in doctor-patient communication. Ann Intern Med . 1989;;111:51-57.
4 +
Fowers BJ.  The cardiac denial of impact scale: a brief, self-report research measure. J Psychosom Res . 1992;;36:469-475.
5 +
Jacobsen BS, Lowery BJ.  Further analysis of the psychometric properties of the Levine Denial of Illness Scale. Psychosom Med . 1992;;54:372-381.
6 +
Moses R, Cividali N.  Differential levels of awareness of illness: their relation to some salient features in cancer patients. Ann N Y Acad Sci . 1966;; 125:984-994.
7 +
Moses R.  Denial in political process.  In: Breznitz S, ed. The Denial of Stress . New York, NY: International Universities Press; 1983;:287-297.
8 +
Freud A. The Ego and the Mechanisms of Defense . Revised edition. New York, NY: International Universities Press; 1966;:79.
9 +
Freud A. Normality and Pathology in Childhood . New York, NY: International Universities Press; 1965;:177.
10 +
Strauss DH, Spitzer RL, Muskin PR.  Maladaptive denial of physical illness: a proposal for DSM-IV. Am J Psychiatry . 1990;;147:1168-1172.
11 +
Yellowlees PM, Ruffin RE.  Psychological defenses and coping styles in patients following a life-threatening attack of asthma. Chest . 1989;;95: 1298-1303.
12 +
Barsky AJ, Hochstrasser B, Coles A, Zisfein J, O'Donnell C, Eagle K.  Silent myocardial ischemia: is the person or the event silent? JAMA . 1990;;264: 1132-1135.
13 +
Phelan M, Dobbs J, David AS.  'I thought it would go away': patient denial in breast cancer. J R Soc Med . 1992;;85:206-207.
14 +
Hackett TP, Cassem NH, Raker JW.  Patient delay in cancer. N Engl J Med . 1973;;289:14-20.
15 +
Douglas CJ, Druss RG.  Denial of illness: a reappraisal. Gen Hosp Psychiatry . 1987;;9:53-57.
16 +
Miller LJ.  Psychotic denial of pregnancy: phenomenology and clinical management. Hosp Community Psychiatry . 1990;;41:1233-1237.
17 +
Druss RG, O'Connor JF, Stern LO.  Psychologic response to colectomy. Arch Gen Psychiatry . 1969;; 20:419-427.
18 +
Ellis SJ, Small M.  Denial of illness in stroke. Stroke . 1993;;24:757-759.
19 +
Goldsmith RJ, Green BL.  A rating scale for alcoholic denial. J Nerv Ment Dis . 1988;;176:614-620.
20 +
Watson M, Greer S, Blake S, Shrapnell K.  Reaction to a diagnosis of breast cancer: relationship between denial, delay, and rates of psychological morbidity. Cancer . 1984;;53:2008-2012.
21 +
Perry JC.  Appendix IV: Perry's clinical defense mechanism ratings scales, and glossary of defenses.  In: Vaillant GE, ed. Empirical Studies of Ego Mechanisms of Defense . Washington, DC: APA Press; 1986;:124-125.
22 +
Carsky M, Selzer MA, Terkelsen K, Hurt SW.  The PEH: a questionnaire to assess acknowledgment of psychiatric illness. J Nerv Ment Dis . 1992;; 180:458-464.
23 +
Hackett TP, Cassem NH.  Development of a quantitative rating scale to assess denial. J Psychosom Res . 1974;;18:93-100.
24 +
Druss RG, Douglas CJ.  Adaptive responses to illness and disability: healthy denial. Gen Hosp Psychiatry . 1988;;10:163-168.
25 +
Wool MS.  Understanding denial in cancer patients. Adv Psychosom Med . 1988;;18:37-53.
26 +
Kubler-Ross E. On Death and Dying . New York, NY: Macmillan Publishing Co Inc; 1969;:39.
27 +
Lowery BJ, Jacobsen BS, Cera MA, Mclndoe D, Kleman M, Menapace F.  Attention versus avoidance: attributional search and denial after myocardial infarction. Heart Lung . 1992;;21:523-528.
28 +
Levenson JL, Mishra A, Hamer RM, Hastillo A.  Denial and medical outcome in unstable angina. Psychosom Med . 1989;;51:27-35.
29 +
Levine J, Warrenburg S, Kerns R, et al.  The role of denial in recovery from coronary heart disease. Psychosom Med . 1987;;49:109-117.
30 +
Dean C, Surtees PG.  Do psychological factors predict survival in breast cancer? J Psychosom Res . 1989;;33:561-569.
31 +
Greer S, Morris T, Pettingale KW, Haybittle JL.  Psychological response to breast cancer and 15-year outcome. Lancet . 1990;;335:49-50.
32 +
Martin AR.  Exploring patient beliefs: steps to enhancing physician-patient interaction. Arch Intern Med . 1983;;143:1773-1775.
33 +
Ewing JA.  Detecting alcoholism: the CAGE questionnaire. JAMA . 1984;;252:1905-1907.
34 +
Cyr MG, Wartman SA.  The effectiveness of routine screening questions in the detection of alcoholism. JAMA . 1988;;259:51-54.
35 +
Moore RD, Bone LR, Geller G, Mamon JA, Stokes EJ, Levine DM.  Prevalence, detection, and treatment of alcoholism in hospitalized patients. JAMA . 1989;;261:403-407.
36 +
Skinner HA, Hold MB, Schuller R, Roy J, Israel Y.  Identification of alcohol abuse using laboratory tests and a history of trauma. Ann Intern Med . 1984;;101:847-851.
37 +
Greenstein RA, Ness DE.  Psychiatric emergencies in the elderly. Emerg Med Clin North Am . 1990;;8:429-441.
38 +
Folstein MF, Folstein SE, McHugh PR.  Mini-Mental State: a practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res . 1975;;12:189-198.
39 +
Ende J, Rockwell S, Glasgow M.  The sexual history in general medicine practice. Arch Intern Med . 1984;;144:558-561.
40 +
Bush B, Shaw S, Cleary P, Delbanco TL, Aronson MD.  Screening for alcohol abuse using the CAGE questionnaire. Am J Med . 1987;;82:231-235.
41 +
Mishler EG. The Discourse of Medicine: Dialectics of Medical Interviews . Norwood, NJ: Ablex Publishing Co; 1984;.
42 +
West C.  'Ask me no questions... ': an analysis of queries and replies in physician-patient dialogues.  In: Fisher S, Todd AD, eds. The Social Organization of Doctor-Patient Communication . Washington, DC: Center for Applied Linguistics; 1983;:75-106.
43 +
Shuy RW.  Three types of interference to an effective exchange of information in the medical interview.  In: Fisher S, Todd AD, eds. The Social Organization of Doctor-Patient Communication . Washington, DC: Center for Applied Linguistics; 1983;:189-202.
44 +
Crouch MA, McCauley J.  Interviewing style and response to family information by family practice residents. Fam Med . 1986;;18:15-18.
45 +
Gorlin R, Zucker HD.  Physicians' reactions to patients: a key to teaching humanistic medicine. N Engl J Med . 1983;;308:1059-1063.
46 +
Cox A, Hopkinson K, Rutter M.  Psychiatric interviewing techniques II: naturalistic study: eliciting factual information. Br J Psychiatry . 1981;; 138:406-415.
47 +
Cox A, Holbrook D, Rutter M.  Psychiatric interviewing techniques VI: experimental study: eliciting feelings. Br J Psychiatry . 1981;;139:144-152.
48 +
Beisser AR.  Denial and affirmation in illness and health. Am J Psychiatry . 1979;;136:1026-1030.
49 +
Shelp EE, Perl M.  Denial in clinical medicine: a reexamination of the concept and its significance. Arch Intern Med . 1985;;145:697-699.
50 +
Strauss DH, Spitzer RL, Muskin PR.  Maladaptive denial of physical illness: a proposal for DSM-IV. Am J Psychiatry . 1990;;147:1168-1172.
51 +
Hauser ST, Jacobson AM, Bliss R, et al.  The family and the onset of its youngster's insulin-de-pendent diabetes: ways of coping.  In: Cole RE, Reiss D, eds. How Do Families Cope With Chronic Illness? Hillsdale, NJ: Lawrence Erlbaum Association; 1993;:26.
52 +
Janne P, Reynaert C, Decoster P.  Denial and silent ischemia: which comes first? JAMA . 1991;; 265:213.
53 +
Billings JA, Stoeckle JD. The Clinical Encounter: A Guide to the Medical Interview and Case Presentation . Chicago, Ill: Year Book Medical Publishers Inc; 1989;:180-181.
54 +
Reiser DE, Schroder AK, Liebgott AR, Shmock CL. Patient Interviewing: The Human Dimension . Baltimore, Md: Williams & Wilkins; 1980;:62-64.
55 +
Gabbard GO. Psychodynamic Psychiatry in Clinical Practice . Washington, DC: American Psychiatric Press; 1990;:79-80.
56 +
Kernberg OF, Selzer MA, Koenigsberg HW, Carr AC, Appelbaum AH. Psychodynamic Psychotherapy of Borderline Patients . New York, NY: Basic Books Inc Publishers; 1989;:11.

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