Commenting on patient's appearance

[PsyDr]

When describing behavioral observations: how in depth are you willing to comment on patient's appearances?

Do you comment on weight? Unusual or out of date dress? Mannerisms?


(it's been dead here. Thought this would stimulate some discussion)

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[Sanman]

I usually will mention grooming, clothing, and ambulation as standard. I did see an old note from psychiatry on one my former patients that went very in depth on the number and themes of his tattoos (many and with death themes; think skulls, snakes, there may have been one of the devil) and well as his general size (big guy, looks intimidating).

 

[cara susanna]

Hygiene and grooming (usually adequate or disheveled, no more detail than that), and weight. But I really don't like commenting on weight and will always write "WNL," lol

 

[WisNeuro]

Broad brush strokes unless there is something fairly notable. As for weight, in my population, the medical history usually encapsulates assumptions on weight (e.g., Type II DM, hyperlipidemia, high cholesterol, etc). Mannerisms-wise, pretty much only things that are neurologically notable.

 

[RxPsych]

I've been taught to describe physical characteristics in a way that, if somebody were to read the report before they saw the patient, they wouldn't be surprised with what walked in the door. Obviously not getting too specific, but mentioning notable characteristics (face tattoos, poor hygiene, dressing like a furry).

 

[tr]

My default for the 'Appearance' entry in the MSE is "appropriately dressed and groomed". If there is a notable departure that is clinically relevant, I will remark it. E.g. sometimes I will say "attentively," "professionally," "casually," "very casually," or in the extreme case, "disheveled" if that's true.

If they have a facial tattoo I would probably note it, if it's on the body probably not (unless it covers a large proportion of their exposed skin and is therefore obviously remarkable, like I might put 'with bilateral full sleeve tattoos' if that were true).

If they seem like they could be underweight to the point of medical or psychiatric relevance I will note "slender." I would rarely comment on overweight since it's so common in the US as to be unremarkable.

Mannerisms, if relevant, I think would usually go under psychomotor.

 

[Sanman]

My default for the 'Appearance' entry in the MSE is "appropriately dressed and groomed". If there is a notable departure that is clinically relevant, I will remark it. E.g. sometimes I will say "attentively," "professionally," "casually," "very casually," or in the extreme case, "disheveled" if that's true.

If they have a facial tattoo I would probably note it, if it's on the body probably not (unless it covers a large proportion of their exposed skin and is therefore obviously remarkable, like I might put 'with bilateral full sleeve tattoos' if that were true).

If they seem like they could be underweight to the point of medical or psychiatric relevance I will note "slender." I would rarely comment on overweight since it's so common in the US as to be unremarkable.

Mannerisms, if relevant, I think would usually go under psychomotor.

With the advent of telehealth and my general background in home care and nursing home care, I often chuckle at that term. I often see folks in pajamas or underwear, which can be appropriately dressed if they are at home (often having forgotten my appt).

 

[PsyDr]

On occasion I have seen older psychologists/psychiatrists say the patient "good looking" or "attractive". 9/10, that patient has been very very attractive and their appearance affected how people interacted with them.

If they seem like they could be underweight to the point of medical or psychiatric relevance I will note "slender." I would rarely comment on overweight since it's so common in the US as to be unremarkable.

What if the patient is complaining that their spouse no longer initiates sex with them, and they have gained 100lbs in recent history? I mean... you kinda understand something there, and it does speak to their insight.

 

[Peacemaker36]

Yes I've noticed older clinicians writing things like "very attractive." I would feel quite anxious if I wrote something like that and the patient ever saw the note.

In some AMCs and other institutional settings patients have the ability to log in to their medical record and read their entire thing online. They can see a note as soon as it's filed. I used to write notes imagining a lawyer reading it, but now I also include the patient in my mental peanut gallery.

 

[Ollie123]

A scale of 1-5 chili peppers in homage to "RateMyProfessors".

On a more serious note, as with tr, my default was "appropriately dressed and groomed". In my last gig, that was where it ended for probably 98% of patients. I would comment if there was something very, very apparent and relevant to treatment (e.g., meaningful disfiguration that was a source of distress, a clinically-meaningful level of dishevelment suggestive of depression, SMI, homelessness, etc.). We inevitably have BMI from primary care so I wouldn't comment on weight unless relevant to treatment. I do health psych and SUD work so sometimes weight or other more specific appearance-related things may be (e.g., an obviously distended upper abdomen in someone with a long history of severe alcohol abuse). For instance, when running weight management groups back in the day, obviously weight and body type were more of a focal point.

That said, I always viewed this as checking boxes for pencil-pushers and almost never give this section of a report more than 2 seconds of thought. History/diagnostics/plan is where my focus goes.

 

[cara susanna]

On occasion I have seen older psychologists/psychiatrists say the patient "good looking" or "attractive". 9/10, that patient has been very very attractive and their appearance affected how people interacted with them.


What if the patient is complaining that their spouse no longer initiates sex with them, and they have gained 100lbs in recent history? I mean... you kinda understand something there, and it does speak to their insight.

Wouldn't that be in the subjective section where you're documenting the session content?

 

[ClinicalABA]

"Client was wearing super cute Oshkosh B'gosh overalls, though about half way through the session I noted a distinct odor of poo poo emanating from his general direction. Also had a Cheerio stuck behind his ear."

 

[chicandtoughness]

“Appears stated age, well groomed” or some appropriate variation

If there’s something significant I will call it out. Having worked the overnight shift at inpatient psych, I have written some fun descriptors

 

[Sanman]

"Client was wearing super cute Oshkosh B'gosh overalls, though about half way through the session I noted a distinct odor of poo poo emanating from his general direction. Also had a Cheerio stuck behind his ear."

Actually, that can be helpful in differentiating my patients from yours. You could arguably mention that the patient is unable to state their age, the current date or time and only oriented to self and partially to situation (doctor). Then we can play the game of toddler or dementia patient from the chart.

 

[ClinicalABA]

My grad school research and dissertation was about alzheimers/dementia. Not a random occurrence that I now do what I do!

 

[AcronymAllergy]

Usually just grooming and dress (e.g., casually/professionally dressed, adequately/neatly groomed). I'm similar RE: weight in that I might comment if they're exceedingly underweight, but it's not usually something I mention otherwise. If there are things that stand out about their interaction style, I have an interaction component (e.g., presented as pleasant and respectful) where I might include it, unless it relates to things like speech oddities (e.g., paraphasias, word-finding difficulty). I may also just discuss some of it in my summary and conclusions.

 

[futureapppsy2]

My grad school research and dissertation was about alzheimers/dementia. Not a random occurrence that I know do what I do!

I know a lot of people who have moved between gerontology and kids and vice versa!

 

[Sanman]

I know a lot of people who have moved between gerontology and kids and vice versa!

Yeah, my old company used to recruit kids folks for similar reasons. Experience with minimally or non-verbal patients and behavior managment. I did some kid work as well in my younger years for similar reasons.

 

[PsyDWannabe]

On occasion I have seen older psychologists/psychiatrists say the patient "good looking" or "attractive". 9/10, that patient has been very very attractive and their appearance affected how people interacted with them.


What if the patient is complaining that their spouse no longer initiates sex with them, and they have gained 100lbs in recent history? I mean... you kinda understand something there, and it does speak to their insight.

Then I would comment on their insight into their current circumstances, and I wouldn’t necessarily give specific examples unless it was part of some sort of therapy progress note addressing that specific issue.

I find it very creepy when mental health professionals comment on patients’ attractiveness. Very creepy. Isn’t inappropriate romantic/sexual relationships the number one reason for revocation/suspension of license/board complaints? If you can’t resist the urge to comment on the attractiveness of your patient, then you need therapy of your own because it speaks to a deeper psychological complex. Unless it’s directly tied into the reason the individual is in therapy which again would belong in progress notes, but certainly not as part of a mental status assessment or similar.

But this opinion is informed by my biased anecdotal experiences of knowing super creepy psychologists who either initiated relationships with their patients or pawned the patient unto another psychologist, just so they could date them. We can all guess how well that ended. And to be fair, the individuals in question were very sexually creepy and inappropriate losers to begin with.

 

[PsyDr]

Then I would comment on their insight into their current circumstances, and I wouldn’t necessarily give specific examples unless it was part of some sort of therapy progress note addressing that specific issue.

I find it very creepy when mental health professionals comment on patients’ attractiveness. Very creepy. Isn’t inappropriate romantic/sexual relationships the number one reason for revocation/suspension of license/board complaints? If you can’t resist the urge to comment on the attractiveness of your patient, then you need therapy of your own because it speaks to a deeper psychological complex. Unless it’s directly tied into the reason the individual is in therapy which again would belong in progress notes, but certainly not as part of a mental status assessment or similar.

But this opinion is informed by my biased anecdotal experiences of knowing super creepy psychologists who either initiated relationships with their patients or pawned the patient unto another psychologist, just so they could date them. We can all guess how well that ended. And to be fair, the individuals in question were very sexually creepy and inappropriate losers to begin with.

Eh. I’ve seen some patients that were professional models. Their looks affected how people interacted with them. They knew their looks were much better than average. I don’t see a problem with saying, “this person is in the upper percentile of looks, and it’s a factor in their life”.

Average looking person to decent looking, I’m on your side. Crazy good looking (including dudes)? Yeah, I’ll say something.

Same for if someone is wearing a $7k suit or Japanese vintage denim, vs off the rack stuff.

 

[MCParent]

Eh. I’ve seen some patients that were professional models. Their looks affected how people interacted with them. They knew their looks were much better than average. I don’t see a problem with saying, “this person is in the upper percentile of looks, and it’s a factor in their life”.

Average looking person to decent looking, I’m on your side. Crazy good looking (including dudes)? Yeah, I’ll say something.

Same for if someone is wearing a $7k suit or Japanese vintage denim, vs off the rack stuff.

The upper and lower 10% of people, in terms of looks, live in different worlds.

 

[The Cinnabon]

The upper and lower 10% of people, in terms of looks, live in different worlds.

It's very interesting to see!

One of my friends who is very conventionally attractive gets free coffee about a quarter of the time we go to any cafe or w/e. Always is wild how normalized it is for him.

 

[clausewitz2]

It's very interesting to see!

One of my friends who is very conventionally attractive gets free coffee about a quarter of the time we go to any cafe or w/e. Always is wild how normalized it is for him.

Mandatory:

 

[AcronymAllergy]

Mandatory:

Exactly what I thought of as well

 

[tr]

Eh. I’ve seen some patients that were professional models. Their looks affected how people interacted with them. They knew their looks were much better than average. I don’t see a problem with saying, “this person is in the upper percentile of looks, and it’s a factor in their life”.

Average looking person to decent looking, I’m on your side. Crazy good looking (including dudes)? Yeah, I’ll say something.

I don't know, I think this would be weird to put in someone's medical chart. At the very least, extreme attractiveness is pretty subjective. There's general agreement on which people are 'attractive' but 'crazy good looking' seems to be highly dependent on the observer. So I think this type of note would say more about the writer than the patient.

Same for if someone is wearing a $7k suit or Japanese vintage denim, vs off the rack stuff.

I definitely would not recognize a $7K suit if I saw one. Nor the Japanese vintage denim. If they're wearing a suit of any type, they are 'attentively dressed'. If they are wearing jeans of any type, they are 'casually dressed'. If the jeans are ripped, they are 'very casually dressed.'

I have used 'revealingly dressed' too, especially for manic patients who were hypersexual.

 

[borne_before]

I feel like I really suck at behavioral observations.


"He/she dressed appropriately for the weather and occasion."

I recently wrote this: "he/she wore the same Megadeath x Simpsons across the three days of testing. Their interest in metal music was discussed several other times, often without discussing other topics that are expected for some of his/her age. Although X responded appropriately conversational leads about other topics from the psychologist, he/she tended to direct the conversation back to their interest in metal music. Although interest in metal is not uncommon in firstname's age group, the frequency of metal music was evidence of restricted or repetitive interest."

It drives me bonkers when someone makes a behavioral observation, but then fails to interpret it within the context of their report.

 

[cara susanna]

I didn't even know Japanese vintage denim was a thing.

 

[borne_before]

I didn't even know Japanese vintage denim was a thing.

google the tokyo tuck.

 

[Sanman]

I didn't even know Japanese vintage denim was a thing.

Check out selvage or selvedge denim

 

[Sanman]

Eh. I’ve seen some patients that were professional models. Their looks affected how people interacted with them. They knew their looks were much better than average. I don’t see a problem with saying, “this person is in the upper percentile of looks, and it’s a factor in their life”.

Average looking person to decent looking, I’m on your side. Crazy good looking (including dudes)? Yeah, I’ll say something.

Same for if someone is wearing a $7k suit or Japanese vintage denim, vs off the rack stuff.

 

[cara susanna]

Like, I dunno, helping people.

Helping who?

I DON'T KNOW, PEOPLE WHO NEED HELP.

 

[The Cinnabon]

I didn't even know Japanese vintage denim was a thing.

Japanese Raw denim is super cool and will last someone an entire lifetime. I'm thinking about splurging and finally getting a pair.


Oni Denim specifically has a pair or three that looks phenomenal

 

[borne_before]

Japanese Raw denim is super cool and will last someone an entire lifetime. I'm thinking about splurging and finally getting a pair.


Oni Denim specifically has a pair or three that looks phenomenal

I like bravestar selvedge

 

[Sanman]

Japanese Raw denim is super cool and will last someone an entire lifetime. I'm thinking about splurging and finally getting a pair.


Oni Denim specifically has a pair or three that looks phenomenal

If I ever spent the money on such a thing, my child would be like:

 

[PsyDWannabe]

I feel like I really suck at behavioral observations.


"He/she dressed appropriately for the weather and occasion."

I recently wrote this: "he/she wore the same Megadeath x Simpsons across the three days of testing. Their interest in metal music was discussed several other times, often without discussing other topics that are expected for some of his/her age. Although X responded appropriately conversational leads about other topics from the psychologist, he/she tended to direct the conversation back to their interest in metal music. Although interest in metal is not uncommon in firstname's age group, the frequency of metal music was evidence of restricted or repetitive interest."

It drives me bonkers when someone makes a behavioral observation, but then fails to interpret it within the context of their report.

That makes sense because that’s not commenting on attractiveness, that’s commenting on grooming/dressing which has way more to do with one’s acute mental status than their attractiveness ever will. It’s also directly clinically relevant to differential diagnosis. There are few ways that attractiveness can be diagnostically significant (narcissistic personality disorder etc)

 

[Ollie123]

I didn't even know Japanese vintage denim was a thing.

I also learned something today. And now I'm wondering...can they be mistaken for a $30 pair from Target if you are >= 3 feet away? Because my last pair are still going strong after 8ish years.

I'm all for spending more on high-quality clothing, but jeans never stood out to me as something worth investing in.

 

[WisNeuro]

I also learned something today. And now I'm wondering...can they be mistaken for a $30 pair from Target if you are >= 3 feet away? Because my last pair are still going strong after 8ish years.

I'm all for spending more on high-quality clothing, but jeans never stood out to me as something worth investing in.

Aside from sporting apparel, outdoor gear, and business apparel, I am very frugal with clothes. My wife occasionally sneaks my stuff into the trash because it's falling apart.

 

[PsyDr]

I also learned something today. And now I'm wondering...can they be mistaken for a $30 pair from Target if you are >= 3 feet away? Because my last pair are still going strong after 8ish years.

I'm all for spending more on high-quality clothing, but jeans never stood out to me as something worth investing in.

Like most signifiers: it only means something to people in the know. It’s the same for:

Phillip Patelk watches… most people can’t tell a $1MM watch from a fossil watch.

Cars like a Land Cruiser… a sequoia is like $60k, a badged Land Cruiser starts at $120k+

An off the rack suit or a pair of shoes costs like $400, but a bespoke one from a tailor or cordwainer is much more.

Everyone has these things. It’s like a PsyD vs phd. No one cares except the people who want to signify something to a small group of people who likely are intolerable.

 

[WisNeuro]

Like most signifiers: it only means something to people in the know. It’s the same for:

Phillip Patelk watches… most people can’t tell a $1MM watch from a fossil watch.

Cars like a Land Cruiser… a sequoia is like $60k, a badged Land Cruiser starts at $120k+

An off the rack suit or a pair of shoes costs like $400, but a bespoke one from a tailor or cordwainer is much more.

Everyone has these things. It’s like a PsyD vs phd. No one cares except the people who want to signify something to a small group of people who likely are intolerable.

Bourbon and scotch. And a family member has recently gotten me into quality tequilas.

 

[The Cinnabon]

I also learned something today. And now I'm wondering...can they be mistaken for a $30 pair from Target if you are >= 3 feet away? Because my last pair are still going strong after 8ish years.

I'm all for spending more on high-quality clothing, but jeans never stood out to me as something worth investing in.

Raw Denim is less about "look at this, it's so expensive"

It does have some serious practical utility. The first being that it's untreated denim which allows for far more control in how it fades, how it's broken in, etc.

The TL;DR is that is lasts a while, and can be customized to a much greater degree (fit, fade, etc.). My uniqlo raw denim has broken in and offers a fit that's hard to replicate from off the shelf treated denim.

 

[borne_before]

Raw Denim is less about "look at this, it's so expensive"

It does have some serious practical utility. The first being that it's untreated denim which allows for far more control in how it fades, how it's broken in, etc.

The TL;DR is that is lasts a while, and can be customized to a much greater degree (fit, fade, etc.). My uniqlo raw denim has broken in and offers a fit that's hard to replicate from off the shelf treated denim.

It's all about those custom fades... I love it.

 

[smalltownpsych]

I only comment on attractiveness when it’s completely inappropriate to do so. I like to see how people react to middle aged white men making rude sexist comments these days. It’s my own sadistic psychological experiment so it would be a complete waste of time to put it in the chart where no one gets to read it.

Seriously have never put it in the chart and I have had some patients who were very attractive. It just never seemed that relevant even when it was part of their experience in life. I tend to not document my thoughts and opinions and treatment conceptualizations and just stick to basic diagnostic data in the intake and even less in the notes. The exception is with any legal risk types of things like suicide or homicide risk or mandated reporting. In these case I carefully document my thought processes as it both helps me to cya and also to manage these situations better and not miss key things.

 

[Sanman]

I only comment on attractiveness when it’s completely inappropriate to do so. I like to see how people react to middle aged white men making rude sexist comments these days. It’s my own sadistic psychological experiment so it would be a complete waste of time to put it in the chart where no one gets to read it.

Are you limiting this to just patients or are we talking in the grocery store as well?

 

[borne_before]

I've heard women love being told to smile.

 

[smalltownpsych]

Are you limiting this to just patients or are we talking in the grocery store as well?

This discussion of inappropriate things to say reminds me of when my daughter was getting married and posted a picture wearing her wedding dress on Facebook and an old “friend” from high school said, “wow! She looks hot!” My wife said I needed to unfriend him. lol

 

[borne_before]

This discussion of inappropriate things to say reminds me of when my daughter was getting married and posted a picture wearing her wedding dress on Facebook and an old “friend” from high school said, “wow! She looks hot!” My wife said I needed to unfriend him. lol

I used to listen a radio show on XM. They had a reoccurring discussion about how some dudes just have a pervert button they can't stop of hitting...

 

[PsyDr]

Since the literature, to include meta-analysis, says that attractiveness affects:

1) Perception of personality
2) Perceptions of competence
3) Perceptions of intelligence
4) Income


I don't know how "inappropriate" it is to comment on a clinically meaningful thing.

And before anyone says anything about gender, the literature says it works for both genders.

And before anyone says anything about subjectivity, the literature does not support that position.

Come on. I'm a lot of things, and have a lot of flaws, but this is not motivated by sexism.

There are similar lines of literature for rich people.

Noncomprehensive Sources:

Budesheim, T. L. and S. J. DePaola (1994). "Beauty or the Beast? The Effects of Appearance, Personality, and Issue Information on Evaluations of Political Candidates." Personality and Social Psychology Bulletin 20(4): 339-348.

Doorley, K. and E. Sierminska (2015). "Myth or fact? The beauty premium across the wage distribution in Germany." Economics Letters 129: 29-34.

Feingold, A. (1992). "Good-looking people are not what we think." Psychological Bulletin 111(2): 304-341.

Langlois, J. H., et al. (2000). "Maxims or myths of beauty? A meta-analytic and theoretical review." Psychol Bull 126(3): 390-423.

Ramsey, J. L. and J. H. Langlois (2002). "Effects of the “Beauty Is Good” Stereotype on Children's Information Processing." Journal of Experimental Child Psychology 81(3): 320-340.

Scholz, J. K. and K. Sicinski (2015). "Facial Attractiveness and Lifetime Earnings: Evidence from a Cohort Study." The Review of Economics and Statistics 97(1): 14-28.

Zebrowitz, L. A., et al. (2002). "Looking Smart and Looking Good: Facial Cues to Intelligence and their Origins." Personality and Social Psychology Bulletin 28(2): 238-249.

 

[Shiori]

I don't think I've ever documented attractiveness because I can't think of a time when it's been relevant to anything I would do in therapy. My notes tend to be very treatment focused, and it's never been important to treatment. My observational documentation is almost exclusively to note any big changes in presentation. Is my normally well-dressed client suddenly dressing very casually? I will ask about it. I'm also at a stage where I remember all of my clients pretty thoroughly so I notice their changes without my notes.

Weight is similar. I don't document my personal assessment of their weight. If they have disorder eating, I'll note that.

I will document how a client describes themselves though, depending on the context and its relevance to our treatment goals.

 

[Sanman]

I don't think I've ever documented attractiveness because I can't think of a time when it's been relevant to anything I would do in therapy. My notes tend to be very treatment focused, and it's never been important to treatment. My observational documentation is almost exclusively to note any big changes in presentation. Is my normally well-dressed client suddenly dressing very casually? I will ask about it. I'm also at a stage where I remember all of my clients pretty thoroughly so I notice their changes without my notes.

Weight is similar. I don't document my personal assessment of their weight. If they have disorder eating, I'll note that.

I will document how a client describes themselves though, depending on the context and its relevance to our treatment goals.

I can agree about the changes in appearance. It reminded me of a chronic pain patient I treated many years ago as an intern. Guy disappeared for a few weeks after a long course of therapy and showed up to our last session looking like a new man. I did not initially recognize him when he was at the office door. Well dressed, neatly groomed, moving better, and using a cane instead of a walker. Amazing turnaround.

 

[AcronymAllergy]

I used to listen a radio show on XM. They had a reoccurring discussion about how some dudes just have a pervert button they can't stop of hitting...

Can confirm.