Strategies for Dealing With the Difficult Patient

1. Strategies for Dealing With the Difficult Patient Family Medicine Forum Annual Meeting Vancouver, British Columbia October 14 – 16, 2010 Jon Davine, MD, CCFP, FRCP(C) Associate Professor, McMaster University

2. Objectives • Be aware of the different personality styles • Be aware of some of the treatment approaches for these patients • Understand transference and countertransference issues, and how they can enhance work with these patients

3. PERSONALITY DISORDERS • can be ego-dystonic, and lead to significant distress • can be treatable • Weissman (‘90) concluded that overall lifetime prevalence for Axis II Disorders ranged from 10 - 13%

4. Personality Disorder • “A personality disordered patient is one who gives the physician that “uh-oh” feeling in the gut, on hearing, reading, or thinking of the patient’s name.” • Also called the “heartsink patient”

5. CLUSTER A • The hallmark of cluster A are odd or eccentric personalities. • These are often seen as bizarre, and are often isolated. • These people often do not present looking for psychotherapy.

6. 1. Paranoid Personality • Pervasive distrust and suspiciousness of others. • These people usually alienate others, are often isolated. • By definitions, suspicious thoughts are not delusional.

7. 2. Schizoid Personality • Detachment from social relationships, and a restricted range of expression of emotions in interpersonal settings. • These people are isolated but are not looking to change this. They rarely present for psychotherapy.

8. 3. Schizotypal Personality • They may have magical thinking and odd beliefs such as telepathy, predicting the future. • Though unusual, these are not felt to be delusional, but rather pushing the envelope of our cultural beliefs. • Social and interpersonal deficits marked by acute discomfort and reduced capacity for close relationships cognitive or perceptual distortions and eccentricities of behaviour.

9. CLUSTER B This group often includes labile affect and poor impulse control.

10. 1. BORDERLINE PERSONALITY • Problems with self identity and problems with self-other boundaries in interpersonal relationships. • Mood lability, often including depression and anger. • Unstable interpersonal relationships, often marked by a pattern of part-object relationships with “good” objects and “bad” objects. • “Splitting” may occur with caregivers. • Abandonment sensitivity. • Recurrent suicidal or self-mutilating behaviour. • Chronic feelings of emptiness. • Under stress, may have micropsychotic” episodes.

11. In therapy: the therapeutic limit setting may promote self-other differentiation, and whole object vs part object relationships. S S S O O O

12. Self Identity Obj Relations Depression Anger

13. SYMPTOMS OF BORDERLINE PERSONALITY DISORDER Paranoid ideation or dissociative symptoms Relationships - intense and unstable Abandonment - fear of Anger - inappropriate and intense Affect - unstable Impulsivity Identity disturbance Suicidal behaviour Emptiness - chronic feelings From: Berber, Mark J; The Canadian Journal of Diagnosis, May, 1997.

14. Borderline Personality Disorder • Do you feel you are still searching for your self identity? • By self-identity, I mean that the things that you consider to be important about yourself and the world, do you find they stay relatively constant or do you find they are always changing dramatically for you? • Do you have long term or chronic feelings of sadness? • Do you have long term or chronic feelings of anger? • Do you find that your relationships usually get very difficult and end abruptly?

15. Borderline Personality Disorder • Do you find that you have had chronic suicidal ideation on and off over the years? • Have you had suicidal attempts in the past? • Have you had episodes in the past where you tried to hurt yourself, not kill yourself, but simply cause yourself pain? • How do you feel after these episodes of self harm? (often feel sense of release or relief). • Do you have chronic feelings of emptiness?

16. Borderline Personality Disorder • Do you find that your moods bounce around a lot so that you can be feeling okay then suddenly feel angry or you can be feeling okay and suddenly feel sad and does this happen a lot during the course of the day? • Do you find that when your mood does change quickly, you may do things on impulse and then regret it afterwards?

17. Borderline • Typically have poor boundaries, and may be seductive • Idealized transference?erotic transference • Vulnerable M.D.: remember, it’s not you they are falling for, but their idealized version of you

18. Borderline • Issues of dependency and closeness can be problematic • Schopenhauer: Universal dilemma of emotional closeness like the predicament of two porcupines in the cold • Close enough for warmth--prick each other with quills • Avoid quills--become too cold--constant tension • With borderlines, if complain about too much distance, probably just right

19. Borderline • Little sense of self, poor boundaries • ‘I’m feeling suicidal today, what are you going to do about it?’ • Important therapeutically to set limits; e.g. “it’s important for you to use your internal resources to deal with this issue. I’ll see you on Friday at our usual time”

20. 2.0 NARCISSISTIC PERSONALITY • Actually an inner, low sense of self esteem, which is then “covered” up with an external grandiosity. • “True self” vs “false self”. • As grandiosity can be seen as fragile, sensitive to external opinion “narcissistic wounding”. • With grandiosity comes “narcissistic entitlement”. Needs admiration “narcissistic fuelling”. Can be interpersonally exploitative, lacks empathy, difficulty with intimacy. In therapy: drop the “big guy” as unnecessary. See the “little guy” as acceptable. TS FS

21. Narcissistic • If they are not able to be insightful, you can use their entitlement; e.g. “you deserve the best treatment, and this is what the best treatment is.” • Go along with them somewhat, without compromising yourself • You can lose some of the smaller battles, to win the war

22. Transference and Countertransference • Transference: the patient transfers feelings onto you which really reflect what they felt toward early caregivers, e.g. anger, fear. You’re left wondering where it comes from. • Don’t take it personally!! • Countertransference: the therapist’s emotional reactions to the patient • People have written about ‘countertransference hatred’

23. Countertransference • We all have patients who arouse ‘negative countertransference” • This is psych-speak for “I can’t stand you” • Important to acknowledge and not deny these feelings • Check to see if it’s based on patient behaviour, or some of your own issues

24. Countertransference • Important to not “act out in the countertransference”, e.g. strangle a patient, yell at a patient, or more subtly, shorten a visit or not ask certain questions • Remember, we are human, and this is a constant task • I often still “reel myself in” mid interview

25. Countertransference • It may even help a patient encounter • If you are feeling something in a room, you can ‘label’ it for the patient, e.g. “Mr. Smith, tell me if I’m off base, but…..” • This may open up a useful dialogue • Don’t label your emotion, simply label the behaviour

26. Countertransference Am J. of Psych ’05; May 2005, Betan et al. Using countertransference to help with dx, and thus tx • Factor 1- overwhelming, inadequate - B, high • Factor 2-helpless, inadequate - B • Factor 3-positive - C • Factor 4-special/overinvolved - C

27. Countertransference • Factor 5- sexualized - B • Factor 6- disengaged - B • Factor 7- parental/protective - C • Factor 8-criticized/mistreated - B, high

28. Countertransference Factors most associated with narcissistic personality: • I feel annoyed in sessions with him/her • I feel used or manipulated by him/her • I lose my temper with him/her • I feel mistreated or abused by him/her • I feel resentful working with him/her

29. Countertransference Factors most associated with narcissistic personality: • I talk about him/her with my spouse or significant other more than my other patients • I feel I am “walking on eggshells” around him/her, afraid that if I say the wrong thing, he/she will explode, fall apart or walk out. • When checking my phone messages, I feel anxiety or dread that there will be one from him/her

30. Countertransference Factors least associated with narcissistic personality: • I feel compassion for him/her • I am very hopeful about the gains she/he is making or will likely make in treatment • I look forward to sessions with him/her • She/he is one of my favorite patients

31. Interviewing Tips • Watch body language and label it • Label emotions--”You seem angry” • Sounds hokey, but it works

32. Interviewing Tips • If you have done something in the interview you regret, it’s ok to say you’re sorry

33. 3. HISTRIONIC PERSONALITY • Excessive emotionality and attention seeking. • Can be inappropriately sexually seductive, flamboyant, provocative. • Can be dramatic, exaggerated expression of emotion.

34. 4. ANTISOCIAL PERSONALITY • Disregard for and violation of the rights of others occurring since age 15 years. • Includes activities such as breaking the law, lots of fighting, difficult work history. • Often has history of trouble in school with suspensions or expulsions. • Deceitful; often shows lack of remorse. • Must be at least age 18. Prior to age 18, called Conduct Disorder.

35. CLUSTER C Hallmark is low self esteem. Often feels anxious, fearful.

36. 1. Avoidant Personality • Social inhibition, feelings of inadequacy, and hypersensitivity to negative evaluation. • Avoids closer interpersonal contact for fear of rejection. • Distinct therefore, from schizoid personality who is more comfortable with lack of closeness. • Avoids occupational activities that may involve significant interpersonal contact because of fears of rejection. • Very sensitive in social situations for fear of criticism or rejection.

37. 1. Avoidant Personality TAPE: “I’m not good enough, therefore, I’ll avoid closeness because I’ll only get rejected.” Price to pay is loneliness, low mood. THERAPY: If doing CBT (Cognitive Behavioural Therapy), could connect cognitive distortions regarding self esteem and interpersonal relationships. Could give behavioural homeworks involving contact with other people.

38. Avoidant Personality vs. Social Phobia • Avoidant can be ‘the life of the party’, can give presentations, but no one gets close to them • Social phobics can’t go to parties or social gatherings, but may have very close friends they have maintained for years. Good with 1:1 • These two may often co-exist, as self esteem issues are a common denominator

39. 2. Dependent Personality • Excessive need to be taken care of that leads to submissive and clinging behaviour, and fears of separation. • Need others to assume responsibility for most major areas of life. • Lacks self confidence, feels unable to care for oneself.

40. 2. Dependent Personality TAPE: “I’m not good enough to take care of myself, therefore, I must have someone (or something) to take care of me. Even if a relationship is not good, I’ll put up with it because it’s all I’m worth, and I need someone there in any case.” THERAPY: Can do CBT. Correct cognitive distortion regarding low sense of self, excessive need for others. May try homeworks which involve independent activities to help encourage better sense of self.

41. 3. OBSESSIVE-COMPULSIVE PERSONALITY DISORDER • Preoccupation with orderliness, perfectionism, and mental and interpersonal control, at the expense of flexibility, openness, and efficiency. • Can get preoccupied with details “lose the forest for the tress.” • Perfectionism gets in the way of completing tasks. • Excessively devoted to work, as the expense of leisure and friendships - “too many eggs in the work basket”. • Hypermoral, very conscientious. • Controlling in interactions with others. • May hoard things, including money. • Rigid, stubborn.

42. 3. Obsessive-Compulsive Personality Disorder TAPE: “I’m not good as the next person, but if I do things perfectly, I will be acceptable.” THERAPY: Help someone accept themselves as good enough, and thus lesson the need for perfectionism. Can use CBT approach here as well.

43. OCD vs.OCPD • If you have obsessions and/or compulsions, that is OCD • OCPD is the perfectionistic, workaholic personality style • They may co-exist

44. Personal History • Where were you born and raised? • Happy home or not such a happy home to grow up in? What made it not so happy? • Describe your mother (father). Now did you get along with her (him) growing up and now? • How many sibs do you have? How did you get along with them growing up and now? • Were you ever physically abused growing up? Sexually abused?

45. Personal History • How far did you go in school? How did it go academically? How did it go socially? • What has your work experience been like since school? • Can you tell me about significant romantic relationships you have had in your life? • Are you in a current relationship (marriage)? How is it going? If you have children, how is it going with them? • Do you have friends? • Who do you turn to for support?

46. Personal History • In general, how is your self esteem? • In general, can you get close to people, or do you tend to keep a distance?

48. JON DAVINE’S EMAIL jdavine@cogeco.ca