The “Difficult” Patient

1. The “Difficult” Patient Revised 2019: Carrie L. Ernst, MD, Associate Professor of Psychiatry, Icahn School of Medicine at Mount Sinai Revised 2013: Carrie L. Ernst, MD, Associate Professor of Psychiatry, Icahn School of Medicine at Mount Sinai Ann Schwartz, MD, FACLP, Professor, Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine Revised 2011: Ann Schwartz, MD, FAPM, Professor, Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine Original version: Mary Jo Fitz-Gerald, MD, Professor of Clinical Psychiatry, La. State University Health Sciences Center, Shreveport, LA Version of March 15, 2019 APM Resident Education Curriculum

2. Objectives Discuss characteristics of difficult patients Develop a differential diagnosis for the difficult patient Describe the effect of medical illness on normal personality styles and defense mechanisms Provide behavioral strategies for managing the difficult patient.

3. The Consult • 53 year old male, self-employed business owner, history of cocaine and alcohol use disorders, hospitalized with osteomyelitis. Assess capacity to leave AMA. • 25 year old female with sickle cell anemia and longstanding opioid use disorder becomes agitated after medical team refuses to give her IV hydromorphone. Need recommendations for med-seeking behavior • 40 year old male admitted with myocardial infarction calls office of the hospital CEO to complain about his care. Assess for psychiatric disorder.

4. What Makes a Patient Difficult? • Drug-seeking behavior • Excessive requests for attention • Physically or verbally aggressive behavior • Sabotaging care • Wandering/pulling out lines Multiple somatic complaints Anger or irritability Frequent doctor visits/calls Noncompliance Depression Anxiety Agitation

5. Approach to the Difficult Patient Step 1: Initial diagnosis Step 2: Gauge distress of the treating team Step 3: Develop a management plan

6. Step 1: Initial Diagnosis

7. Assessment of the Difficult Patient Awake and Alert? Yes No Confused? Reassess when awake Search for cause of impaired arousal Hold sedating meds for evaluation Manage agitation if recurs No Yes Intoxicated? Mood, Psychotic, or Anxiety Disorder? Yes No No Yes Supportive Care Monitor for withdrawal Manage agitation Delirium or Dementia Assess acuity Search for cause Manage agitation Personality Disorder? Psychiatric tx Educate & help staff No Yes Scared?  reassure Angry?  Explore; patient rep In Pain/discomfort?  treat Miscommunication  communicate Poor patient/team fit  collaborative approach Jerk/Criminal?  security, police Reassure Explore patient’s experience Educate & help staff Set limits; Prn meds

8. Another Way to Assess the Difficult Patient Non-Deliberate Behaviors • Delirium • Dementia • Psychosis/Depression/Mania • Somatic Symptom Disorders Patient Isn’t the Problem • MD fatigue/stress/burnout • Failure to communicate • Countertransference • Poor patient/team style fit Boland R. R I Med J 2014; Jun 2;97(6):29-32. Deliberate Behaviors Factitious Disorder & Malingering Personality Disorders

9. Differential Diagnosis of the Difficult Patient Neurocognitive Disorder: Delirium, Dementia Mood, Anxiety or Psychotic Disorder Substance Use Disorder: intoxication, withdrawal, dependence Somatic Symptom or Related Disorder Developmental Disorder Personality Disorder Maladaptive coping; regression due to stress “Jerk”

10. Psychological Challenges for the Medically Ill Patient Reaction to and coping with illness Illness as personal weakness or punishment Fear: of unknown, of loss, of separation Hospitalization means separation from others and normal life; lack of privacy Communication difficulties between caretakers and patients Differences in expectations between patients and caretakers Loss of control/helplessness Role change

11. Types of Coping Responses • Problem-focused: • Definition: efforts to alter the stressful situation • Examples: gathering information, making arrangements for care, planning, taking action • Emotion-focused: • Definition: efforts to regulate the emotional distress associated with the situation • Examples: focusing on positive aspects of the situation, mental or behavioral disengagement, seeking emotional support from others • Both types of responses can reduce distress Reviewed in: Penley JA et al, J Behav Med. 2002;25:551-603

12. Healthy Coping Styles Healthy copers generally use both problem- and emotion-focused styles Healthy copers are optimistic, flexible, consider outcomes, and focus on specific problems Problem coping can lead to passivity, denial, and rigid behavior

13. Emotional Response to Illness: Use of Defense Mechanisms • Immature defense mechanisms • Denial • Splitting • Regression • Projective identification • Omnipotence and devaluation • Healthy defense mechanisms • Humor • Altruism • Sublimation

14. Personality Style Versus Personality Disorder Personality style is a lifelong habitual way one thinks, feels, behaves and copes; partially biologically determined (temperament) Personality disorder is an enduring pattern of inner experience and behavior that is inflexible, pervasive and causes impairment Under stress (such as with medical illness), personality style may become more rigid and maladaptive to the point where it is difficult to differentiate from personality disorder

15. “The Hateful Patient” Groves JE. N Engl J Med 1978; 298:883-887 • Groves described 4 types of patients who invoke “helplessness in the helper” • Dependent Clingers • Entitled Demanders • Manipulative Help-Rejecters • Self-Destructive Deniers

16. Dependent Clingers Helplessness and needy, want attention Utilize regression, passive-aggression and idealization Physician may initially feel special, and then later feel depleted Resemble those with dependent or histrionic personalities

17. Entitled Demanders “Narcissistic” Arrogant, demanding, and devaluing others Have baseline low self-esteem and the illness is a further insult May be confrontational and unable to problem solve

18. Manipulative Help-Rejecters Appear to want treatment and keep returning Yet will reject treatment solutions Root cause is that the illness is more important to the patient than the treatment May have borderline personality disorder or traits Utilize splitting, projective identification, idealizing/devaluing

19. Self-Destructive Deniers Often exhibit Cluster B, especially antisocial, characteristics Lying, deceitful, and acting out behaviors Arouse hatred, then guilt, and finally despair in the providers

20. Illness Behaviors of “Hateful Patients” Groves JE. N Engl J Med 1978; 298:883-887

21. DSM-5 Personality Disorders American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA: American Psychiatric Publishing. Cluster A—odd and eccentric Cluster B—dramatic, emotional, or erratic Cluster C—anxious or fearful

22. Features of DSM-5 Personality Disorders: Cluster A

23. Features of DSM-5 Personality Disorders: Cluster B

24. Features of DSM-5 Personality Disorders: Cluster C

25. Impact of Medical Illness on Personality Disorders Dependent: need to be cared for Obsessive Compulsive: fear loss of control; may become controlling Histrionic: may be dramatic, emotionally changeable, act sexually inappropriate Narcissistic: may feel that the perfect self-image is threatened by illness Paranoid: blame doctors for the illness; supersensitive to a perceived lack of attention or caring Schizoid: become anxious and even more withdrawn

26. Step 2: Gauge Distress of the Treating Team

27. Behaviors Seen in Staff Caring for Difficult Patients Regression to helpless or vengeful position Sadistic behavior towards patient Staff disagreement about care of patient Inappropriate confrontation of patient Avoid or abandon patient Neglect medical work-up Feel inadequate, angry, frustrated Ask vague consult questions Sexual arousal or rescue fantasies Extra time or tests with patient Boundary violations

28. Step 3: Develop a Management Plan

29. Order of Priorities Ensure safety of staff and patient Rapidly diagnose and evaluate most pressing psychiatric issues Identify and implicitly address staff-patient dissonance/miscommunication Explicitly address patient’s conflicts Educate consultee and staff Assist with follow-up and disposition plan Ensure that recommendations are carried out

30. General Strategies for Dealing with the Difficult Patient Ensure that the basic needs of the patient are met, communication of difficulties, privacy, etc Facilitate consistent staff presence to help control any attempts at staff splitting Attempt to understand meaning of illness for the patient Attempt to understand, empathize, and acknowledge the patient’s stressors Incorporate understanding of potential contribution of team dynamics

31. Rules for Confrontation of the Difficult Patient Set limits Acknowledge the real stressors Avoid breaking down needed defenses Avoid overstimulation of patient’s wish for closeness Avoid overstimulation of patient’s rage Avoid confrontation of narcissistic entitlement (= hope/faith) Appeal to sense of entitlement

32. Helping the Staff Prevent splitting Permit limit setting Explain patient’s reality to staff Reinforce staff strengths Model non-sadistic interactions Reassure that such patients stir up negative feelings in the best of caregivers Write clear behavior management strategy and safety plan in chart Ally with staff- do not interpret staff’s pathology

33. Strategies for Management of 4 Types of “Hateful Patients” Groves JE. N Engl J Med 1978; 298:883-887

34. Strategies for Managing Specific Personality Disorders in the Medical Setting

35. Management of Cluster A Personality Disorders Blumenfield M, Strain JJ (eds). Psychosomatic Medicine, LWW, 2006

36. Management of Cluster B Personality Disorders Blumenfield M, Strain JJ (eds). Psychosomatic Medicine, LWW, 2006

37. Management of Cluster C Personality Disorders Blumenfield M, Strain JJ (eds). Psychosomatic Medicine, LWW, 2006

38. References American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing. Blumenfield M, Strain JJ (eds). (2006). Psychosomatic Medicine. Philadelphia, PA : Lippincott Williams &​ Wilkins Boland R. The problem patient: modest advice for frustrated clinicians. R I Med J.2014; Jun 2;97(6):29-32. Groves JE. Taking Care of the Hateful Patient. N Engl J Med 1978; 298:883-887 Penley JA, Tomaka J, Wiebe JS., The association of coping to physical and psychological health outcomes: a meta-analytic review. J Behav Med. 2002;25:551-603