Psychosomatics 47:486-490, December 2006
doi: 10.1176/appi.psy.47.6.486
© 2006 Academy of Psychosomatic Medicine
Naked Patients in the General Hospital: Differential Diagnosis and Management Strategies
Guy Maytal, M.D.,
Felicia A. Smith, M.D., and
Theodore A. Stern, M.D.
Received September 25, 2005; revised December 21, 2005; accepted January 4, 2006. From the Psychiatric Consultation Service, Massachusetts General Hospital; McLean Hospital, Belmont, MA; and Harvard Medical School, Boston, MA. Address correspondence and reprint requests to Dr. Maytal, Massachusetts General Hospital, Fruit St., Warren Building, Rm. 605, Boston, MA 02114. e-mail: GMaytal{at}Partners.org
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ABSTRACT
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Physicians and patients are frequently concerned, and, at times, distressed, by nakedness during clinical encounters. When nakedness appears, clinicians should attempt to establish the reason for it and determine whether it is appropriate for the situation. Establishing the etiology of nudity can facilitate care by hospital staff and help to modulate their countertransference reactions and behavior. The authors present and discuss three cases involving nudity at times other than during the physical examination, within the context of differential diagnosis and treatment alternatives.
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INTRODUCTION
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Physicians and patients have long been concerned about how undressed a patient should be during a physical examination and whether a chaperone is needed for the examination. However, we often underappreciate the distress experienced by visitors and hospital staff when a patient lies nude in bed or walks around nude in patient-care areas (apart from an examination). When such behavior occurs, clinicians should attempt to determine the reason for the behavior, which is often inappropriate. Knowing the etiology of the nudity may facilitate care provided by hospital staff and help modify their affective and behavioral reactions to the aberrant behavior.
We present three cases where non–examination-related nakedness among medical-surgical inpatients created some distress among visitors and staff and led to requests for psychiatric consultation. We will discuss the nature of the staff distress, the differential diagnosis, and treatment alternatives for the behavior.
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Case Series
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"Mr. A" Mr. A is a 53-year-old man with a history of right-heart failure, chronic obstructive pulmonary disease (COPD), obesity, and medication noncompliance. He was admitted to the medical service for an exacerbation of COPD.
From the outset of his admission, Mr. A refused to wear traditional hospital gowns or other clothing (despite the insistence by nursing and medical staff that he do so); he was naked each time staff entered the room. Furthermore, because of the difficulty he had walking to the bathroom, he would occasionally wear an adult diaper; this was also disturbing to staff. Nurses and house officers tended to avoid Mr. A’s room, and they failed to attend to all of his needs. Psychiatric consultation was requested to help deal with his persistent nudity.
Although the consultant’s initial assumption was that he suffered from delirium, this hypothesis was rejected. Mr. A was alert, oriented, and did not manifest changes in consciousness over time. Air hunger was also raised as a possible cause of his behavior, but his breathing had improved since his hospital admission, and his respiratory complaints had disappeared. When his old medical record was reviewed, we learned that Mr. A had spent many of his previous hospitalizations and much of his time at home naked. Ultimately, medical and primary psychiatric causes were ruled out. In further conversations with Mr. A, the psychiatric consultant learned that Mr. A felt trapped by his respiratory illness and his obesity and that he longed for more independence but was frustrated by his inability to attain it. The consultant concluded that Mr. A felt needy and dependent on others and that he was shamed and angered by both his physical condition and these feelings. Mr. A therefore expressed his aggressive feelings by being naked in front of others. His behavior was ultimately due to regression in the hospital, in the context of an Axis II disorder (with features of both dependent and narcissistic personality disorders).
Mr. A’s constant nakedness caused staff discomfort and led to the patient’s premature discharge from the hospital and to frequent readmissions for much-needed medical care. Working with the staff and the patient, the psychiatric consultant devised a behavioral treatment plan whereby the patient was explicitly told that he would be ignored as long as he was naked (unless a medically urgent situation arose) and that he would have his needs met only if he kept his clothes or a hospital gown on.
The plan was effective. Mr. A remained clothed more often than not; staff avoided his room less, and he received more comprehensive care.
"Ms. B" Ms. B, a 20-year-old woman with no history of medical problems, was removed from a plane for disruptive behavior and was brought to the hospital’s emergency department in an agitated state. Despite multiple efforts by the emergency department staff, she refused to keep her hospital gown on or to cover herself with a blanket. She either sat bolt upright on her stretcher or paced around her room completely naked. Her temperature was 99.0°F; her pulse was 110 beats per minute; and her blood pressure was 136/86 mm Hg. Physical examination revealed an agitated woman with dry skin and mucous membranes, dilated pupils (to 8 mm), and choreoathetoid movements of her fingers.
According to her husband, she had recently been hospitalized in another state for schizoaffective disorder. She was discharged on amitriptyline and benztropine. Ms. B’s husband further reported that he and Ms. B were airborne when she impulsively took 70 mg of benztropine and 2,100 mg of amitriptyline. She became disruptive, and the pilot diverted the aircraft to the airport. In the emergency department, she was diagnosed with anticholinergic toxicity, placed on a cardiac monitor, and treated with intravenous physostigmine. Within 1 minute, her agitation resolved, and she became immediately aware of (and embarrassed by) her nakedness; Ms. B quickly covered herself. However, after 30 minutes (consistent with the expected duration of action of intravenous physostigmine) her agitation recurred, and she rapidly disrobed. Another dose of physostigmine was administered, and her agitation once again disappeared; again she became embarrassed and clothed herself. Ms. B subsequently responded well to a continuous intravenous infusion of physostigmine, and she was transferred to a psychiatric facility after several days.
"Mr. C" Mr. C, an 80-year-old man with progressive dementia (manifested by cognitive and language impairment and memory problems), seemed less able to care for himself at home. His relatives found him on the floor of his apartment after a fall; he was malnourished, confused, and disheveled, and they brought him to the hospital. On arrival, Mr. C had no signs of infection. A CT scan of the head was negative for intracranial blood or mass shift. A poor historian, Mr. C could not adequately explain the circumstances that led to his fall. He therefore underwent a syncope evaluation, which included an electrocardiogram, 24-hour Holter monitoring, an echocardiogram, and carotid artery ultrasound, all of which yielded no diagnostic information. An EEG was unremarkable, as well.
However, from the beginning of his hospitalization, Mr. C would wander the halls of the medical service either completely naked or with his hospital gown draped over his shoulder. Notably, the medical team and other staff frequently joked about Mr. C’s behavior. Nonetheless, psychiatric consultation was requested in order to assist with his behavioral management.
A mental status examination revealed significant frontal dysfunction (e.g., with poor planning, impulsivity, and immodesty (that is, the patient was completely nude when the examiner first entered the room). Mr. C had moderate-to-severe dementia and was unable to discuss his behavior in a meaningful way. His daughter was contacted; it appeared that Mr. C’s mental status was close to his baseline. She also reported that he wandered away on occasion and once had been found naked in the street in the middle of the night. Mr. C’s family and the medical team agreed that he was not safe at home. A search for a bed in a nursing home was begun.
In the hospital, Mr. C was treated with a low dose of quetiapine (to help with his behavior and erratic sleep cycle). Given his cognitive problems, staff was encouraged (as much as possible in a busy medical unit) to create a predictable environment for Mr. C. This included putting him in a single room with a window (to both avoid the confusion of frequently changing roommates and to allow him to orient to the day/night cycle). The psychiatric consultant also suggested that, as much as possible, one nurse should care for Mr. C and perform the frequent reorientation that he required. With these interventions, Mr. C’s naked wanderings diminished substantially. Furthermore, once his caregivers had specific ways to help Mr. C, their discomfort abated and so did the jokes that had been made at his expense.
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DISCUSSION
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Differential Diagnosis and Management Strategies
Our cases raise a number of important issues regarding the management of the naked inpatient. First, one must create a differential diagnosis and a management plan for an inpatient who remains unclothed. In doing so, one should consider whether the behavior is new or recurrent, because an understanding of its causes facilitates its management. Second, it is useful to explore how the patient understands his or her nakedness. A naked patient (for instance, a patient with hyperesthesia who disrobes to avoid stimulation of pain receptors, a dementia patient who wanders naked without explanation, and a manic patient who sits naked on the windowsill because she wants God to see her body) will require different treatment approaches depending on the meaning that is ascribed to the nakedness. If this behavior is new, potentially dangerous medical conditions associated with being naked should be ruled out.
Creation of a differential diagnosis is a priority for the clinician who cares for a naked patient. In the case of Mr. A, delirium was suspected, given his multiple medical conditions. The presence of pulmonary or cardiac disease, obesity, and immobility (which could have set the stage for pulmonary emboli), and the use of steroids (prescribed for his COPD flare-up) all could have caused an alteration of mental status and unusual behavior. Fortunately, each of these was ruled out. Also, other causes (including air hunger due to poor pulmonary function and difficult undressing and dressing) associated with aberrant behavior were considered. Mr. A did not suffer from air hunger, although he did have difficulty dressing because of his obesity. Although the possibility of a primary psychotic illness or mania was raised, it was discounted. Lastly, Mr. A had some insight into the manipulative and aggressive intent behind his nakedness. Although the psychiatric consultant considered a diagnosis of paraphilia because he wore only a diaper much of the time (the so-called "adult babies" fetish), it became clear that the patient’s behavior stemmed from a regressed state, and it was not linked to sexual arousal. These data were helpful in formulating a behavioral treatment plan that allowed Mr. A to get the care he needed and the staff to be less disturbed by him.
For Ms. B, the diagnosis was anticholinergic delirium cause by anticholinergic toxicity. She had no insight into her nakedness. In fact, when she became aware of it, she was embarrassed by it and quickly covered herself. The new onset of such behavior in a patient without a long-term psychiatric history is always suggestive of a medical cause. As is often the case with a naked medically ill patient, once the medical issue is treated, the behavior resolves.
Mr. C’s case generated several concerns. Given that his primary diagnosis of dementia was already known, once other sources of delirium or traumatic injury were ruled out, the etiology of his wandering while inadequately dressed became clear. His family’s confirmation that this behavior was not new was consistent with progressive dementia. Nonetheless, staff was unsure as to how to manage his behavior. They kept their distance from him, literally and figuratively, in part through the use of inappropriate humor. However, once a practical and effective plan was implemented, his caregivers were able to experience a renewed sense of effectiveness. An element to underscore in this treatment is that the management of inappropriate behavior in the dementia patient usually consists of both pharmacological and behavioral interventions.
In these three cases, the presence of nakedness led the psychiatric consultant to generate a differential diagnosis. Ultimately, a specific diagnosis was reached for each case, and a treatment plan was implemented specific to that etiology. These cases illustrate three possible causes for nakedness in the inpatient setting; however, there are many causes for this behavior. In generating a differential diagnosis, the clinician should consider multiple etiological categories (including primary medical causes, Axis I disorders, Axis II disorders, as well as psychodynamic causes; see Appendix 1 for a list of the common causes of nakedness in the hospitalized patient).
Once a differential diagnosis is generated, an appropriate clinical evaluation should be performed to reach a diagnosis and to develop an appropriate management plan. It should be noted that an integral part of the evaluation of the naked patient is the attempt to understand the meaning of the nakedness to the patient.
Practically every clinician has encountered a naked patient in the general hospital. Nonetheless, few if any medical texts discuss an approach to the naked patient. Just as rare are reports of nudity or its differential diagnosis and management. Unfortunately, clinicians, as well as patients, visitors, and ancillary staff, are often dismayed by such behavior. Although it is true that not all clinicians from all practice settings or cultures react in the same way to a naked inpatient, nudity in a general hospital often elicits a mixture of strong reactions, ranging from titillation to rage.
Awareness and Management of Countertransference
A wide variety of patient attributes and behaviors can lead to physician distress and discomfort. In its broadest sense, this emotional response to patients (often a potent combination of negative and positive emotions) is termed countertransference.1 Although physicians and nurses rarely examine their positive reactions (for example, the affection felt by staff toward a child dying of cancer), they are usually aware of, and troubled by, their negative reactions. Problematic or difficult patients can fall into several categories (for instance, dependent clingers, "entitled" demanders, manipulative help-rejecters, and self-destructive deniers).2,3 Each of these types of patient interacts with their caregivers and their treatment in ways that leave caregivers feeling angry, devalued, manipulated, or helpless. Often, these emotional reactions make it difficult for caregivers to interact with and treat their patients appropriately.
Also, a patient can be viewed or experienced as difficult as a result of the personal characteristics of the physician, not just those of the patient. For example, a doctor who ignores his or her own need for dependency may encourage a patient to be dependent on his or her caregiver, whereas a seemingly independent physician may dismiss all psychosocial components of illness and label a patient with these complaints as a malingerer.4
Furthermore, a communication failure on the part of the physician (apart from any personal characteristics) can lead to a difficult interaction with a patient. Not understanding what a patient’s goals are, what the meaning of the illness is to the patient, or which coping mechanisms will work best for the patient, all can lead to noncompliance or counterproductive behavior by the patient.5
Both nurses and physicians should be aware of their reactions to patients because some responses may lead to substandard care and to worse outcomes (under the guise of lowering treatment expectations because one labels a patient as "difficult").6 The naked inpatient elicits a variety of (often negative) emotional reactions. It is important that medical staff note their own level of disgust, irritation, or frustration with such a patient in order to prevent staff from reaching a level of distress that interferes with their patient’s care.
In such instances, inappropriate nakedness of the patient has the potential to remove him or her from the confines of the sick role. As originally defined by Talcott Parsons,7 the "sick role" is a (usually temporary) dysfunctional social role that requires reintegration into the social organism. In this role, a person is exempt from normal social responsibilities, is not responsible for his or her illness, has an obligation to want to get well, has an obligation to seek professional help, and an obligation to cooperate in treatment. The physician has a reciprocal role, wherein he or she is expected to represent and communicate these norms to patients to control their "social deviance."
Guided by training in scientific medicine and by professional socialization, physicians are expected to act in the interests of the patient, rather than their own material interests, and to be guided by egalitarian universalism, rather than particular personal interests. To do so, physicians must take an affectively neutral stance with their patients as a means of protecting themselves and their patients from overly involved emotional reactions that could disrupt their respective roles.
Although Parson’s approach has been criticized in recent decades, his fundamental idea of a "sick role" and its usefulness in the larger social organization remains one of the cornerstones of medical sociology.8 When a patient is inappropriately naked, this behavior elicits strong reactions on the part of medical staff by virtue of the behavior’s deviance from accepted social norms. In these situations, the medical staff may begin to behave toward this person on the basis of their own emotional reactions, instead of on what is medically indicated. By recalling the role of this individual in this particular context (that is, a sick person) and their own roles as medical caregivers, physicians, and nurses will be better able to treat the patient appropriately. Being affectively neutral vis-à-vis the patient allows clinicians to preserve the boundaries of "patient" and "caregiver" as a means of ensuring that the patient receives appropriate care despite physicians’ emotional reactions to disturbing behavior.
One common reaction by staff to a naked patient is the use of humor. Although humor is a necessary and often helpful tool that allows physicians and nurses alike to tolerate difficult and disturbing situations, it can be inappropriate when used in a way that is demeaning or leads to poor patient care. Furthermore, the naked patient may elicit other reactions, including (but not limited to) disgust, anger, and avoidance. Negative countertransference inevitably leads staff to avoid contact with the patient, and may even lead them to stop thinking about the patient’s care. Furthermore, being around a patient who is disturbing or despairing may lead medical staff to feel despair without knowing why.
In these situations, it is important that the culture of the inpatient unit be accepting, to facilitate an atmosphere where staff are able to discuss their reactions and feelings in an open and nonjudgmental manner. By airing their concerns and having colleagues point out when their reactions interfere with patient care, staff can deal with such situations more effectively, professionally, and in a manner that allows doctors and nurses to better understand their patients.9
Impact of Culture
Modern medicine is a field of great cultural and religious diversity—both among medical staff and patient populations. Diverse cultural backgrounds have an impact on how medical staff respond to a naked patient. European staff, for example, may be more comfortable with naked patients and may examine patients completely naked, unlike American physicians, who may only examine the undraped area of a patient.
Furthermore, staff who come from more traditional cultural or religious backgrounds may become more uncomfortable around the persistently naked patient. A physician’s cultural and ethnic background plays an important role in how he or she reacts to a patient’s nudity.10 Therefore, supervisors and colleagues must make efforts to be aware of these complicating factors and find ways to address these particular concerns in a nonjudgmental and supportive manner.
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CONCLUSIONS
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Caring for a naked patient in the hospital setting is a common problem for most physicians and nurses. The naked patient elicits strong reactions in both seasoned medical staff and hospital visitors. When confronting such a patient, the physician has two essential and equally important tasks:
First, he or she must generate a differential diagnosis for the behavior (for example, personality disorder, the interplay of interpersonal dynamics, cognitive impairment, the result of impaired judgment, or sensory accommodation) and pursue the appropriate work-up to rule out life-threatening and reversible causes.
The second task is to better understand his or her own reactions (and those of other staff) to the patient. Negative reactions by medical and nursing staff (a component of countertransference) often prevent patients from receiving appropriate care. By understanding the source of these reactions and formulating strategies to combat them, staff can provide patients the care they require in a more satisfying and professional manner.
Last, given the growing cultural and ethnic diversity of both medical staff and patient populations, it is important for caregivers to be cognizant of the way in which their colleagues and patients relate to nakedness; we need to foster an atmosphere where everyone can feel comfortable providing and receiving care.
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REFERENCES
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- Goldberg PE: The physician-patient relationship: three psychodynamic concepts that can be applied to primary care. Arch Fam Med 2000; 9:1164–1168[Abstract/Free Full Text]
- Groves JE: Taking care of the hateful patient. N Engl J Med 1978; 298:883–887[Abstract]
- Smith S: Dealing with the difficult patient. Postgrad Med J 1995; 71:653–657[Abstract]
- Anstett R: The difficult patient and the physician-patient relationship. Fam Pract 1980; 11:281–286
- Dilks P: There are no difficult patients. Aust J Adv Nurs 1996; 13:4[Medline]
- O’Kelly G: Countertransference in the nurse-patient relationship: a review of the literature. J Adv Nurs 1998; 2:391–397
- Parsons T: Social structure and dynamic process: the case of modern medical practice, in The Social System. Glencoe, IL, Free Press, 1951, pp 428-479
- Hughes J: Organization and Information at the Bed-Side: The Experience of the Medical Division of Labor by University Hospitals’ Inpatients. Chicago, IL, University of Chicago Press, 1994
- Stern TA, Prager LM, Cremens MC: Autognosis rounds for medical house staff. Psychosomatics 1993; 34:1–7[Medline]
- Gawande A: Naked. N Engl J Med 2005; 353:645–648[Free Full Text]
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ABSTRACT
INTRODUCTION
