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Dealing with the difficult patients in the medical setting
- 1. Dealing with Difficult Patients in the Medical Settings Ahmad Alzahrani MBBS, ABHS-Psychiatry University of Toronto psychosomatic medicine fellowship
- 2. Content – Who are the difficult patients? – Do All patients become difficult? – The emotions of the treating team – The Hateful Patients – How to assess a difficult patient? – How to manage?
- 3. The consult – “A 40 year old male admitted with myocardial infarction calls office of the hospital CEO to complain about his care. Assess for psychiatric disorder.” – “A 35 year old female patient with AML refuses the second time of bone marrow aspiration. She looks less motivated. Is she depressed?” – “We need help with a 64 year old professional male with ESRD on hemodialysis. He has been kicked out of all other dialysis centers due to his obnoxious behavior. He screams at and berates the staff and may be banned from our state operated unit. Is there anything that can be done to manage his behavior?”
- 4. Who are the difficult patients?
- 5. The Difficult Patients – Anxiety – Agitation – Depression – Multiple somatic complaints – Anger or irritability – Excessive demands – Noncompliance – Wandering, pulling out lines – Drug-seeking behavior – Excessive requests for attention – Physically or verbally aggressive behavior - Up to 15% of patients are labelled difficult by their physicians.
- 6. A stressful Situations – Narcissistic Injury – Reexamine their own self-views and address any feelings of invulnerability to illness – Confronting the impermanence of life. – These lead to Patient to feel “defective, weak, and less desirable”. – Being in a hospital – Forcing a patient to endure both body exposure, in thin flimsy gowns, and constant personal and bodily intrusions. – Separation – From their normal comfortable environment and social support.
- 7. Do All patients become difficult?
- 8. Psychological Responses to illness Behavioral ResponsesAffective Responses Meaning of illness Character Style Life history/experience Temperament Psychological Defenses Coping Strategies Stresses of illness Lazarus RS: Stress and Emotion: A New Synthesis, Textbook of Psychosomatic Medicine, 2nd edition, 2011
- 9. Coping Styles – A conscious effort to alter a stressful situation. – Hundreds of coping strategies have been identified. – Problem-focused coping – Seeking information, planning, and taking action. – Emotion-focused coping – Involve focusing on positive aspects of the situation, mental or behavioral disengagement, and seeking emotional support from others.
- 10. Coping Styles Coping Style Description Confrontative Hostile or aggressive efforts to alter a situation. Distancing Efforts to mentally detach self from a situation. Self-controlling Attempting to regulate one’s feelings or actions. Seeking social support Attempting to seek emotional support or information from others. Accepting responsibility Accepting a personal role in the problem. Escape-avoidance Efforts to escape/avoid a problem or situation, both cognitively and behaviorally. Planful problem solving Attempting to come up with solutions to alter a situation. Positive re-appraisal Re-framing a situation in a more positive light.
- 11. Coping Styles Healthy copers - Use a combination of problem & emotion focused coping. - Optimistic, practical, flexible, and composed - Consider possible outcomes and emphasize immediate problems. Poor copers - Often are unable to make decisions. - Hold rigid and narrow views. - Passive and deny excessively. - Moments of impulsivity and unexpected compliance.
- 12. Defense Mechanisms – Mental operations that remove some component(s) of unpleasurable affects (emotions) from conscious awareness—the thought, the sensation, or both. – Largely unconscious. – A coping strategy or defense mechanism may be relatively maladaptive or ineffective in one context but adaptive and effective in another.
- 13. Levels of Defense Mechanisms based on Maturity Primitive (Psychotic, Pathological) •Delusional Projection •Conversion •Denial •Distortion •Splitting •Extreme Projection Immature •Acting out •Idealization •Fantasy •Passive aggression •Projection •Projective Identification Neurotic •Displacement •Dissociation •Hypochondriasis •Intellectualization •Isolation •Rationalization •Reaction formation •Regression •Repression •Undoing Mature •Humor •Sublimation •Suppression •Altruism •Anticipation •Identification •Introjection
- 14. Defense Mechanisms – Defenses most often used by “difficult patients” – fall under the immature category. – characteristic of the cluster B personality disorders. – Often are irritating to others as this defense style transmits patients’ “shame, impulses, and anxiety to those around them” – Neurotic defenses, which can also be maladaptive – experienced more privately and usually do not annoy others because they do not distort reality as much.
- 15. Meaning of Illness Personality Type Characteristics Meaning of Illness Dependent Need, demanding, unable to reassure self Seeks reassurance from others Threat of abandonment Obsessional Meticulous, orderly, likes to feel in control, dichotomous Loss of control over body/emotions/impulses Histrionic Entertaining, dramatic, seductive Loss of love or attractiveness Masochistic “Perpetual victim” Ego-syntonic, conscious or unconscious punishment Paranoid Guarded, distrustful, sensitive to slights Proof that world is against patient Medical care is invasive and exploitative Narcissistic Arrogant, devaluing, vain, demanding Threat to self-concept of perfection and invulnerability, shame evoking Schizoid Aloof, distant Fear of intrusion Adapted from: James Levenson, Textbook of Psychosomatic Medicine, 2nd edition, 2011
- 16. The emotions of the treating team
- 17. Countertransference – Classically reactions to a patient that represent the past life experiences of the clinician. – For example, – A frail elderly woman is given extra attention by a physician because she reminds him of his mother. – A young diabetic patient is scolded for non-compliance because the nurse’s own child is diabetic and non-compliant. – Recently, countertransference has come to encompass all feelings and attitudes of clinicians towards the patient, both physician- and patient-originated.
- 18. Countertransference – Often result in negative reactions (aversion, fear, despair, or even malice). – Positive reactions should be watched also. – May predict later devaluation. – May Potentially lead to significant boundary violations on the part of the clinician, in an effort “to do everything possible” for the patient.
- 20. The Hateful Patients The Hateful Patient Associated Personality Defense Mechanisms Coping Styles Countertransference Dependent Clingers Dependent Histrionic Regression Passive aggression Idealization Excessively seeking social support Power and special Depleted, exhausted Wish to escape Entitled Demanders Narcissistic Self-idealization Devaluing Projection, Splitting Confrontational Fearful of reputation Enraged about demands Ashamed, inferior Manipulative Help-Rejecters Borderline Splitting Projective identifying Idealizing/devaluing Escape-avoidance Seek social supports Anxiety overlooking illness Irritation/frustration Depression/self-doubt Self-Destructive Deniers Antisocial (or any cluster B) Primitive denial Acting out, Devaluing Distancing Escape-avoidance Enraged/malice Wish the patient were dead
- 21. Dependent Clinger – A forty-five year old male with a history of peripheral vascular disease who recently underwent a below the knee amputation is now crying and sobbing on the unit. He becomes highly anxious and despondent when there is not somebody in the room with him, calling for the nurses unnecessarly. When family is present, he requires their constant attention, requesting they feed him, help him drink liquids, and even blow his nose, despite full upper extremity mobility.
- 22. Entitled Demander – “A fifty-six year old male is admitted to the hospital secondary to AIDS complications. Through out the hospitalization, he is belligerent and belittling to the staff and physicians, including the junior members of the psychosomatic service. He is pleased to hear that his case is ‘unique,’ requiring the director of the psychosomatic service to meet him personally. Upon arrival of the director, the patient immediately comments, ‘you have a lot of guts wearing that outfit. How much is it worth? $100? $1000? You could feed a hundred starving children in Africa for your one outfit. I hope you can live with yourself.’”
- 23. Manipulative Help-Rejecters – A sixty-eight year old female who recently left AMA from another hospital presents to the emergency department for worsening edema of her lower extremities. Upon further evaluation, she is found to have significant congestive heart failure and is admitted. During her admission, she is initially cooperative with the primary team, but as her condition improves, she becomes belligerent and hostile with the staff, complaining that her water has too much ice in it, the coffee is not served on time, and the nurses are not looking at her properly. Indignant, she demands to leave the hospital AMA, stating that she will get better care elsewhere. When records are obtained from the other hospital, it is discovered that a similar scenario occurred there.
- 24. Self-Destructive Deniers – A thirty-six year old male with end-stage liver disease has frequent re- admissions to the hospital for altered mental status. Despite his worsening status, he continues to drink heavily and uses other illicit substances. With each admission, he requests a liver transplant but then angrily reacts when he is advised that abstinence is a requirement for transplant consideration. He is hostile and belligerent with the staff, threatening them on multiple occasions.
- 25. How to assess a difficult patient?
- 26. Assessment of the Difficult Patient Awake and Alert? Yes NoYes Yes Yes Yes No No NoNo Confused? Mood, Psychotic, or Anxiety Disorder? Intoxicated? Supportive Care Monitor for withdrawal Manage agitation Delirium or Dementia Assess acuity Search for cause Manage agitation Personality Disorder? Psych tx Educate & help staff 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 Reassess when awake Search for cause of impaired arousal Hold sedating meds for evaluation Manage agitation if recurs Mary Jo Fitz-Gerald, MD, The “Difficult” Patient, Academy of Psychosomatic Medicine 2013
- 27. How to Manage?
- 29. Behavioral Management – Ensure that the basic needs of the patient (privacy, food, etc.) are being met. – Attempt to maintain consistent staff. – Attempt to understand and empathize with the patient. – Acknowledge the real stresses in the current situation. – Accept the patient’s limitations by not directly confronting immature defenses or poor coping styles.
- 30. Behavioral Management – Set firm limits on unreasonable expectations by consistently declaring that “in order to provide the best medical care possible ...” However, reasonable requests, or approximations thereof, should not be refused. – Gently discuss any irrational fears about the illness or treatment that the patient may have, and assess his ability for reality testing (i.e., ensure that a transient psychosis is not occurring).
- 31. Helping the treating 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
- 32. Pharmacotherapy – 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
- 33. Pharmacotherapy 1st line 2nd line 3rd line Depression SSRIs SNRIs Mirtazapine Bupropion Hydroxyzine Lithium Aripiprazole Bipolar depression: Quetiapine Lamotrigine Stimulants TCAs and MAOIs (lethal in OD) Benzodiazepines Insomnia Mirtazapine Trazodone Melatonin/ramelteon Hydroxyzine Zolpidem Eszopiclone Quetiapine Benzodiazepines Opiates Irritability/impulsivity Divalproex Quetiapine Olanzapine Risperidone Lamotrigine Aripiprazole Ziprasidone Typical antipsychotics Carbamazepine Lithium Benzodiazepines Opiates
- 34. References – James Amos, Psychosomatic Medicine an Introduction to Consultation-Liaison Psychiatry 2010. – James Levenson, Textbook of Psychosomatic Medicine, second edition 2011 – Mary Jo Fitz-Gerald, MD, The “Difficult” Patient, Academy of Psychosomatic Medicine 2013 – Jerome S. Blackman, 101 Defenses, 2004.
Hinweis der Redaktion
- When students are asked why they enter medicine, a common answer will be helping others and contribute to the welfare of humanity. However, after even a few years of clinical practice, many physicians will readily admit to experiences of anger, frustration, inadequacy, and, occasionally, strong negative reactions towards patients. (James Amos, Psychosomatic Medicine)
- Narcissistic Injury self view injury… self concept injury. Separation from family and their comfortable environment may lead to conscious or unconscious feeling of abandonment (not only in children.. It can occur in adults…). E.g. of separation newly diagnosed AIDS pt may fear rejection from community and abandonment by family. An advanced cancer pt may elect to undergo another course of chemotherapy despite the low likelihood of success rather than seek palliative and end of life care because the latter would signify giving up. The pt might fear that his oncologist who had worked with him for a decade would abandon him. (Textbook of Psychosomatic Medicine).
- Character style develops from both life experience and temperament (inborn). The 3 factors: coping strategies, meaning of illness and psychological defenses affects the psychological responses to illness and these appear in the form of mood and behavior. Does the flowchart stop here?... One important factor is the psychodynamic interaction with the treating team and their countertransference toward the patient. The ongoing psychodynamic interaction between the patient and the team is an important period of time to manage the patient condition.
- For example Maladaptive denial A lung cancer patient continue smoking thinking he has a mild lung condition. Adaptive denial Use of denial in an advanced pancreatic cancer patient might enable him to maximize his quality of life in the months before his death. Healthy individuals usually use different defenses throughout their lives, whereas pathological use occurs when persistent use of certain defenses leads to maladaptive behavior that affects one’s physical and/or mental health. (James Amos, Psychosomatic Medicine)
- * Simply stated, immature defenses make others suffer, while neurotic defenses cause the self to suffer. (James Amos, Psychosomatic Medicine)
- A central task of the psychiatrist working with the medically ill is to understand patients’ subjective experience s of illness. (ask questions like: what do you know about your condition? What was your first response when hearing about it? Any current symptoms and how do you manage? How did it affect your life? What do you know about the prognosis and future plans?)
- It is important for the consultant to understand not only the underlying causes of the patient’s behavior, but also the emotions generated in the treating staff, if a successful resolution is to be achieved. (James Amos, Psychosomatic Medicine, 2010).
- Being aware of these emotions allows the clinician to attain better understanding to and provide better care for the patient.
- Will need to speak with nursing staff and family; get thorough medical, psych and substance hx, thorough physical exam, incl neuro/cognitive exam Nature of precipitants, envt in which agitation occurs. * Keeping in mind that comorbidity often present but we have to treat the most serious condition/s first.