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This chapter discusses a composite case illustrating a man's alarming resistance to his underlying medical acuity, and to his physician. The medical condition can be diagnosed by routine history and physical examination, but it is termed occult because the patient's psychological defenses are protean, and exceptional finesse and focus are required to overcome them. Another case with a primary psychiatric diagnosis is considered in which an assessment of risk by a physician assistant (PA) is indeterminate, but an attending physician's brief, focused interview elicits the acute precipitant and accurately identifies the underlying crisis state of mind. The emergency department environment is often sub-optimal for mental health cases, making interview skill all the more necessary. The objective of the chapter, to add to the emergency practitioner's psychiatric skill set, should not draw attention away from the equally important longer term goal of reducing psychiatric visits to emergency departments.
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