The “Difficult” Patient

1. The “Difficult” Patient APM Resident Education Curriculum Mary Jo Fitz-Gerald, MD Professor of Clinical Psychiatry La. State University Health Sciences Center Shreveport, LA Revised Summer 2011 Ann Schwartz, MD, FAPM Fall 2013 Carrie Ernst, MD Ann Schwartz, MD, FAPM

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 Discuss behavioral strategies for managing the difficult patient.

3. The Consult • 53 year old male, self-employed business owner, history of cocaine and alcohol abuse, hospitalized with osteomyelitis. Assess capacity to leave AMA. • 25 year old female with sickle cell anemia and longstanding opiate dependence becomes agitated after medical team refuses to give her IV Dilaudid. 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 eval 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? Psych tx Educate & help staff No Yes Scared?  reassure Angry?  Explore; patient rep In Pain/discomfort?  meds Jerk/Criminal?  security, police Reassure Explore patient’s experience Educate & help staff Set limits; Prn meds

8. 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 Poor coping style/challenging personality style and regression due to stress “Jerk”

9. 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

10. Coping Responses Problem-focused or emotion-focused Problem-focused refers to gathering information, making arrangements for care Emotion-focused refers to seeking emotional support, mental or behavioral disengagement (Penley et al, 2002)

11. Healthy Coping Styles Generally use both problem- and emotion-focused “Health copers” are optimistic, flexible, consider outcomes, and focus on specific problems Problem coping leads to passivity, denial, and rigid behavior (Sclozman et al, 2004)

12. Emotional Response to Illness • Immature defense mechanisms • Denial • Splitting • Regression • Projective identification • Omnipotence and devaluation • Healthy defense mechanisms • Humor • Altruism • Delay self-gratification

13. Personality Style Versus Personality Disorder Personality style is lifelong habitual way one thinks, feels, behaves and copes; often genetically 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

14. “The Hateful Patient” • Groves (NEJM, 1978) described 4 personality characteristics which invoke “helplessness in the helper” • Dependent Clingers • Entitled Demanders • Manipulative Help-Rejecters • Self-Destructive Deniers

15. 4 Types of Hateful Patients Groves, NEJM, 1978

16. Dependent Clingers These patients are completely 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 perhaps histrionic personalities

17. Entitled Demanders “Narcissistic” Arrogant, demanding, and devaluing others 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 Often borderline personality disorders Utilize splitting, projective identification, idealizing/devaluing

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

20. DSM-5 Personality Disorders Cluster A—odd and eccentric Cluster B—dramatic, emotional, or erratic Cluster C—anxious or fearful

21. Cluster A: Paranoid Blumenfield M, Strain JJ (eds). Psychosomatic Medicine, LW&W, 2006 • Characterized by suspiciousness and projection of negativity onto others; attribution of damaging motivation onto others; fear exploitation and humiliation • Management recommendations • Empathize with the patient’s fear of being hurt • Acknowledge complaints without arguing or ignoring • Openly and honestly explain medical illness • Correct reality distortions and unreasonable explanations • If the patient refuses care out of mistrust, rather than insist, ask, if it acceptable that you disagree about the need of the test

22. Cluster A: Schizoid Blumenfield M, Strain JJ (eds). Psychosomatic Medicine, LW&W, 2006 • Characterized by indifference to social relationships, as well as a very limited range of emotional experience and expression • Management recommendations • Empathize with the patient’s need for both privacy and contact • Accept the patient’s unsociability • Reduce the patient’s isolation as tolerated • Neutrally impart medical information • Don’t demand involvement or permit total withdrawal • Correct reality distortions and unreasonable patient expectations • Gently question irrational thoughts and suggest more rationale ones

23. Cluster A: Schizotypal Blumenfield M, Strain JJ (eds). Psychosomatic Medicine, LW&W, 2006 • Characterized by peculiarities and eccentricities of thought, behavior, appearance, and interpersonal style • Management recommendations • Empathize with the patient’s idiosyncratic style/magical thinking and perceptions without directly confronting them • Accept the patient’s unsociability • Reduce the patient’s isolation as tolerated • Neutrally impart medical information • Don’t demand involvement or permit total withdrawal • Correct reality distortions and unreasonable patient expectations • Gently question irrational thoughts and suggest more rationale ones

24. Cluster B: Antisocial Blumenfield M, Strain JJ (eds). Psychosomatic Medicine, LW&W, 2006 • Characterized by pervasive pattern of disregard and violation of the rights of others; may be impulsive, irritable, deceitful; fear exploitation • Management recommendations • Empathize with the patient’s fear of exploitation and low self-esteem • Determine if there is secondary gain; • Avoid moralizing; explain that deception results in your giving patient poor care • Correct reality distortions and unreasonable patient expectations • Gently question irrational thoughts and suggest more rational ones

25. Cluster B: Histrionic Blumenfield M, Strain JJ (eds). Psychosomatic Medicine, LW&W, 2006 • Characterized by exaggerated emotional reactions, approaching theatricality, in everyday behavior; fear loss of love, attention and admiration • Management recommendations • Empathize with the patient’s fear of losing love or care • Interact in a friendly way, not too reserved, not too warm • Discuss the patient’s fears, reassure when possible • Use logic to counteract an emotional style of thinking • Set limits if the patient regresses • Correct reality distortions and unreasonable patient expectations • Gently question irrational thoughts and suggest more rationale ones

26. Cluster B: Borderline Blumenfield M, Strain JJ (eds). Psychosomatic Medicine, LW&W, 2006 • Characterized by pervasive instability, with a pattern of poor impulse control; fears separations, loss, or emotional abandonment • Management recommendations • Empathize with the patient’s fear of abandonment/separation and plan for absences by arranging coverage • Express a wish to help and satisfy reasonable needs • Ask the patient to monitor impulsive behaviors with a diary • Set firm limits and do not punish • Correct reality distortions and unreasonable patient expectations • Gently question irrational thoughts and suggest more rationale ones

27. Cluster B: Narcissistic Blumenfield M, Strain JJ (eds). Psychosomatic Medicine, LW&W, 2006 • Characterized by unrealistic, inflated sense of self-importance and lack of sensitivity to other people’s needs; fear loss of prestige, power, image, esteem • Management recommendations • Empathize with the patient’s vulnerability and low self-esteem • Don’t mistake the patient’s superior attitude for real confidence and don’t confront the entitlement • When you are devalued or attacked, acknowledge the patient’s hurt and your mistakes and expresses your continued wish to help • Correct reality distortions and unreasonable patient expectations • Gently question irrational thoughts and suggest more rationale ones

28. Cluster C: Dependent Blumenfield M, Strain JJ (eds). Psychosomatic Medicine, LW&W, 2006 • Characterized by passivity, tendency to cling to others to the point of being unable to make any decisions or to take independent action; fear separation, independence, decision-making; need to be cared for • Management recommendations • Empathize with the patient’s need for care • Discourage total dependence • Be careful to avoid telling the patient what to do • Encourage independent thinking and action • Realize that what the patient says he or she wants is not necessarily what they need • Don’t abandon or threaten termination • Correct reality distortions and unreasonable patient expectations • Gently question irrational thoughts and suggest more rationale ones

29. Cluster C: Obsessive-Compulsive Blumenfield M, Strain JJ (eds). Psychosomatic Medicine, LW&W, 2006 • Characterized by perfectionism, overwhelmed with concern for neatness and minor details, trouble making decisions or getting things accomplished; fear imperfection, loss of control • Management recommendations • Empathize with the patient’s logical, detailed, unemotional style of thinking • If obsessive thoughts are interfering with medical care, ask about the patient’s feelings • Don’t struggle with the patient’s over control and critical judgments • Avoid abandoning the patient • Correct reality distortions and unreasonable patient expectations • Gently question irrational thoughts and suggest more rationale ones

30. Cluster C: Avoidant Blumenfield M, Strain JJ (eds). Psychosomatic Medicine, LW&W, 2006 • Characterized by desire for, but fear of any involvement with other people; fears rejection, humiliation, embarrassment • Management recommendations • Empathize with the patient’s social fears, shame, shyness, and fears of revealing inadequacies, rejection, embarrassment, humiliation, and anger • Help the patient describe in detail the feared situation • Encourage and support the patient to gradually face the fears and stop the tendency to avoid; if this seems overwhelming, chose smaller fears to confront • Gently elicit irrational thoughts and suggest more rational ones • Correct reality distortions

31. Personality Disorders and Medical Illness Dependent: need to be cared for Obsessive Compulsive: fear loss of control; may become controlling Histrionic personalities may be dramatic, emotionally changeable, and act sexually inappropriate

32. Personality Disorders and Medical Illness (continued) Narcissistic: may feel that the perfect self-image is threatened by illness Paranoid: blames doctors for the illness and is supersensitive to a perceived lack of attention or caring Schizoid: becomes anxious and even more withdrawn with illness

33. Step 2: Gauge Distress of the Treating Team

34. 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

35. Step 3: Develop a Management Plan

36. Dealing with the Difficult Patient Ensure that the basic needs of the patient are met, communication of difficulties, privacy, etc Consistent staff helps 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

37. Dealing with the Patient (continued) Accept patient; don’t directly confront immature defenses Set appropriate boundaries and limits Avoid confrontation of entitlement; appeal to entitlement and redirect entitlement to expectation for best possible medical care Accept reasonable requests Discuss any irrational fears or treatment Use appropriate psychopharmacology

38. Dealing with the Difficult Patient Groves, NEJM, 1978 Dependent Clingers  Schedule appointments, consistent interactions Entitled Demanders  Accept entitlement & redirect it to an expectation of appropriate medical attention Manipulative Help Rejecters  Help patient limit demands & hostility; encourage team to help patient maintain sense of autonomy Self-Destructive Deniers: Be compassionate & deligent; treat underlying depression; accept the limits set by patient but don’t abandon patient

39. Psychopharmacology May be of benefit in treating Axis I Disorders such as mood, anxiety, or psychotic disorders Impulsivity and anger may respond to mood stabilizers and antipsychotics Avoid agents with addictive potential due to the propensity for substance abuse in these patients

40. Helping the Treatment Team Acknowledge the reactions of the treaters and empathize with their countertransferences Acknowledge universality of their feelings Model non-sadistic behavior and appropriate limit setting Arrange team meetings to prevent splitting Develop clear behavioral management strategy Ally with staff- DO NOT interpret staff’s pathology Explain patient’s reality to staff Give permission to say no to excessive demands Recommend interventions needed for safety

41. References Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision, DSM-IV-TR, American Psychiatric Association, 2000. Feinstein, RE and Vanderburg, S. Personality Disorders in Family Practice, In Textbook of Family Practice, ed. Rakel, RE. Philadelphia. W.B. Saunders Co. 1994 Feinstein, RE. Personality Traits and Disorders, In Psychosomatic Medicine, ed. Blumenfield M, Strain JJ. Philadelphia. Lippincott. 2006 Groves, JE. Taking Care of the Hateful Patient. NEJM. 1978; 298:883-887. Groves JE. Difficult Patients. In” Stern TA, Fricchione GL, Cassem NH et al eds. Handbook of General Hospital Psychiatry. Philadelphia. Mosby. 2004; 293-312.

42. References (continued) Jackson JL, Kroenke K. Difficult Patient Encounters in the Ambulatory Clinic. Archives of Internal Medicine 1999; 159: 1069-1074. Penley JA, Tomaka J, Wiebe JS. The Association of Coping to Physical and Psychological Health Outcomes: A Meta-Analytic Review. Journal of Behavioral Medicine 2002; 25. 551-603. Sclozman SC, Groves JE, Weisman AD. Coping with Illness and Psychotherapy of the Medically Ill. In: Stern TA, Fricchione GL, Cassem NH et al eds. Handbook of General Hospital Psychiatry. Philadelphia. Mosby 2004; 61-68.