Dealing with Difficult Patients in the Medical

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Ahmad AlzahraniMBBS, ABHS-Psychiatry

University of Toronto psychosomatic medicine fellowship

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?

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?”

Who are the difficult patients?

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.

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.

Do All patients become difficult?

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

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.

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.

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.

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.

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

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.

Meaning of Illness

Personality Type Characteristics Meaning of Illness

Dependent Need, demanding, unable to reassure selfSeeks 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 patientMedical 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

The emotions of the treating team

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 remindshim 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.

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.

The Hateful Patients

The Hateful PatientsThe Hateful

PatientAssociatedPersonality

DefenseMechanisms Coping Styles Countertransference

DependentClingers

DependentHistrionic

RegressionPassive aggressionIdealization

Excessivelyseeking socialsupport

Power and specialDepleted, exhaustedWish to escape

EntitledDemanders

Narcissistic Self-idealizationDevaluingProjection, Splitting

Confrontational Fearful of reputationEnraged about demandsAshamed, inferior

ManipulativeHelp-Rejecters

Borderline SplittingProjective identifyingIdealizing/devaluing

Escape-avoidanceSeek socialsupports

Anxiety overlooking illnessIrritation/frustrationDepression/self-doubt

Self-DestructiveDeniers

Antisocial(or any cluster B)

Primitive denialActing out, Devaluing

DistancingEscape-avoidance

Enraged/maliceWish the patient were dead

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.

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.’”

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.

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.

How to assess a difficult patient?

Assessment of the Difficult Patient

Awake and Alert?

Yes

No Yes

Yes

Yes

Yes

No

No

No No

Confused?

Mood, Psychotic, orAnxiety Disorder?

Intoxicated?

Supportive CareMonitor for withdrawalManage agitation

Delirium or Dementia Assess acuity Search for cause Manage agitation

Personality Disorder? Psych tx Educate & help staff

Scared? reassureAngry? Explore; patient repIn Pain/discomfort? medsJerk/Criminal? security, police

ReassureExplore patient’s experienceEducate & help staffSet limits; Prn meds

Reassess when awakeSearch for cause of impaired arousalHold sedating meds for evaluationManage agitation if recurs

Mary Jo Fitz-Gerald, MD, The “Difficult” Patient, Academy of Psychosomatic Medicine 2013

How to Manage?

Behavioral Management

Pharmacotherapy

Helping the Treating Team

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.

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).

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

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

Pharmacotherapy1st line 2nd line 3rd line

Depression SSRIsSNRIsMirtazapineBupropionHydroxyzine

LithiumAripiprazoleBipolar depression:QuetiapineLamotrigine

StimulantsTCAs and MAOIs(lethal in OD)Benzodiazepines

Insomnia MirtazapineTrazodoneMelatonin/ramelteonHydroxyzine

ZolpidemEszopicloneQuetiapine

BenzodiazepinesOpiates

Irritability/impulsivity DivalproexQuetiapineOlanzapineRisperidone

LamotrigineAripiprazoleZiprasidoneTypical antipsychoticsCarbamazepineLithium

BenzodiazepinesOpiates

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.

Thank you for listening