Dealing with Difficult Patients

1. Dealing with Difficult Patients Phil Antunes M.D. Scott & White Department of Psychiatry

2. Narcissistic/Entitled Patient • Pattern of having a grandiose sense of self-importance (exaggerates achievements and talents) • Expects to be recognize as superior without accomplishments to substantiate such recognition • Feels special and unique, and can only be understood by, or should associate with other high-status people • Arrogant, condescending, and haughty

3. Narcissistic Personality Think of the letter “E” • Enamored with fantasies of power, unlimited success, brilliance, or ideal love • Has a sense of Entitlement • Interpersonally Exploitative • Requires Excessive admiration • Lacks Empathy (“Empathy-less”) • Often Envious, or believes others are Envious of him or her

4. Narcissistic Personality---Teaching Points • Find out what the agenda is in seeking treatment • Acknowledge errors, but do not be overly self-critical • Be cautious about making remarks that may be seen as critical • Monitor for signs of depression following a narcissistic injury, and treat judiciously

5. Narcissistic Personality---Treatment • Encourage the patient to openly express his or her needs, and to ask others what their needs are • Monitor countertransference; avoid gratification or punishment • Vulnerable to hypochondriacal preoccupation---these patients are adept at getting doctors to prescribe medication

6. Borderline Personality Disorder • Pervasive pattern of unstable interpersonal relationships • Marked impulsivity • Alteration between idealization and devaluation • Recurrent suicidal behavior, threats, or thoughts, or self-mutilation • Affective instability/lability

7. Borderline Personality • Chronic feelings of emptiness • Inappropriate, intense anger • Transient, stress related dissociation or paranoid ideations • Identity disturbance, unstable self-image or sense of self

8. Borderline PersonalityTeaching Points • Monitor countertransference feelings closely; avoid falling into the trap of projective identification Pt MD Pt MD Pt MD

9. Borderline PersonalityTeaching Points • Be consistent, set and maintain firm boundaries • Be aware of possible substance abuse • Avoid prescribing large amounts of potentially lethal medications • Antidepressants may be beneficial, especially SSRIs, to decrease impulsivity • Antipsychotic medications may be helpful (“ego glue”)

10. Borderline PersonalityTeaching Points • Focus on the “here and now”, rather than exploring past traumatic experiences, such as abuse • Be active; discuss splitting and strong affects as they happen • Overtime, help the patient see a connection between actions and feelings • Explore healthy alternatives/outlets instead of self-destructive behaviors

11. Dealing with Angry Patients • May invoke the “flight or fight” response in you • Underlying meaning of patient’s anger may not be apparent or ambiguous (previous trauma, chronic illness, acute pain) • May be angry over something someone else did • Empathize without blaming • Could be your staff or your colleague • Avoid “jousting” or agreeing with patient • If angry over a systems issue, don’t explain that things probable will never change

12. Dealing with Angry Patients • Let patient ventilate feelings in a private setting, usually with a second staff present, if possible • Show compassion and humane respect • Stay calm, don’t raise your voice, be aware of body language • You don’t have to endure frank abuse • Don’ttake it personal! • Have an open dialogue with your staff about difficult patients • Have a secure online communication option available to angry patients---doesn’t tie up you or staff’s time unreasonably

13. Histrionic Personality • From hystera, (“hysterical”) meaning uterus • Excessive emotionality and attention-seeking • Uncomfortable if not the center of attention • Provocative, seductive, flirtatious • Uses physical appearance to draw attention

14. Histrionic Personality • Dramatic, animated in speech and behavior • Suggestible • Often feels relationships are more intimate than they actually are

15. Histrionic Personality Teaching Points • Be careful of the patient’s eroticized transference (acting out); this is more about the patient’s defenses, not about you; Sexualizing/flirtatious behavior is a smokescreen to deeper feelings of inferiority and powerlessness; Avoid the following pitfalls: • Contributing to the eroticized transference • Narcissistic needs being met by an adoring patient • Voyeuristic enjoyment of the patient’s fantasies • Sense of disgust at the patient’s disclosures • Sadistic enjoyment of being “unavailable” to your patient • Closely monitor your reactions to and interactions with the patient • Resist too much self-disclosure

16. Histrionic Personality Teaching Points • Help the patient build self-esteem in areas other than attractiveness • These patients are very sensitive about aging • Be aware of help-rejecting complaining

17. References • Hickson, GB., Dealing with Angry Patients • Robinson, D. Disordered Personalities, Rapid Psychling Press • Scherger, J., Dealing with Angry Patients

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