Dealing with Difficult Patients: Strategies and Approaches in Psychiatry
This resource provides valuable insights into managing difficult patients in psychiatry, addressing characteristics, differential diagnosis, and behavioral strategies. It outlines common challenges such as substance use disorders, medical illness impact on personality, and difficult behaviors. The approach emphasizes initial diagnosis, team distress evaluation, and management plan development for effective patient care.
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The Difficult Patient APM Resident Education Curriculum Revised 2019: Carrie L. Ernst, MD, Associate Professor of Psychiatry, Icahn School of Medicine at Mount Sinai Revised 2013: Carrie L. Ernst, MD, Associate Professor of Psychiatry, Icahn School of Medicine at Mount Sinai Ann Schwartz, MD, FACLP, Professor, Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine Revised 2011: Ann Schwartz, MD, FAPM, Professor, Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine Original version: Mary Jo Fitz-Gerald, MD, Professor of Clinical Psychiatry, La. State University Health Sciences Center, Shreveport, LA Version of March 15, 2019 ACADEMY OF CONSULTATION-LIAISON PSYCHIATRY Psychiatrists Providing Collaborative Care Bridging Physical and Mental Health
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 Provide behavioral strategies for managing the difficult patient. Academy of Consultation-Liaison Psychiatry 2
The Consult 53 year old male, self-employed business owner, history of cocaine and alcohol use disorders, hospitalized with osteomyelitis. Assess capacity to leave AMA. 25 year old female with sickle cell anemia and longstanding opioid use disorder becomes agitated after medical team refuses to give her IV hydromorphone. 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. Academy of Consultation-Liaison Psychiatry 3
What Makes a Patient Difficult? Multiple somatic complaints Anger or irritability Frequent doctor visits/calls Noncompliance Depression Anxiety Agitation Drug-seeking behavior Excessive requests for attention Physically or verbally aggressive behavior Sabotaging care Wandering/pulling out lines 4 Academy of Consultation-Liaison Psychiatry
Approach to the Difficult Patient Step 1: Initial diagnosis Step 2: Gauge distress of the treating team Step 3: Develop a management plan Academy of Consultation-Liaison Psychiatry
Step 1: Initial Diagnosis ACADEMY OF CONSULTATION-LIAISON PSYCHIATRY Psychiatrists Providing Collaborative Care Bridging Physical and Mental Health
Assessment of the Difficult Patient Awake and Alert? Yes No Confused? Reassess when awake Search for cause of impaired arousal Hold sedating meds for evaluation 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? Psychiatric tx Educate & help staff No Yes Scared? reassure Angry? Explore; patient rep In Pain/discomfort? treat Miscommunication communicate Poor patient/team fit collaborative approach Jerk/Criminal? security, police Reassure Explore patient s experience Educate & help staff Set limits; Prn meds
Another Way to Assess the Difficult Patient Deliberate Behaviors Factitious Disorder & Malingering Personality Disorders Non-Deliberate Behaviors Delirium Dementia Psychosis/Depression/Mania Somatic Symptom Disorders Patient Isn t the Problem MD fatigue/stress/burnout Failure to communicate Countertransference Poor patient/team style fit Boland R. R I Med J 2014; Jun 2;97(6):29-32. Academy of Consultation-Liaison Psychiatry 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 Maladaptive coping; regression due to stress Jerk Academy of Consultation-Liaison Psychiatry
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 Academy of Consultation-Liaison Psychiatry 10
Types of Coping Responses Problem-focused: Definition: efforts to alter the stressful situation Examples: gathering information, making arrangements for care, planning, taking action Emotion-focused: Definition: efforts to regulate the emotional distress associated with the situation Examples: focusing on positive aspects of the situation, mental or behavioral disengagement, seeking emotional support from others Both types of responses can reduce distress Reviewed in: Penley JA et al, J Behav Med. 2002;25:551-603 Academy of Consultation-Liaison Psychiatry 11
Healthy Coping Styles Healthy copers generally use both problem- and emotion-focused styles Healthy copers are optimistic, flexible, consider outcomes, and focus on specific problems Problem coping can lead to passivity, denial, and rigid behavior Academy of Consultation-Liaison Psychiatry 12
Emotional Response to Illness: Use of Defense Mechanisms Immature defense mechanisms Denial Splitting Regression Projective identification Omnipotence and devaluation Healthy defense mechanisms Humor Altruism Sublimation Academy of Consultation-Liaison Psychiatry 13
Personality Style Versus Personality Disorder Personality style is a lifelong habitual way one thinks, feels, behaves and copes; partially biologically 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 Academy of Consultation-Liaison Psychiatry 14
The Hateful Patient Groves described 4 types of patients who invoke helplessness in the helper Dependent Clingers Entitled Demanders Manipulative Help-Rejecters Self-Destructive Deniers Groves JE. N Engl J Med 1978; 298:883-887 Academy of Consultation-Liaison Psychiatry 15
Dependent Clingers 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 histrionic personalities Academy of Consultation-Liaison Psychiatry 16
Entitled Demanders Narcissistic Arrogant, demanding, and devaluing others Have baseline low self-esteem and the illness is a further insult May be confrontational and unable to problem solve Academy of Consultation-Liaison Psychiatry 17
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 May have borderline personality disorder or traits Utilize splitting, projective identification, idealizing/devaluing Academy of Consultation-Liaison Psychiatry 18
Self-Destructive Deniers Often exhibit Cluster B, especially antisocial, characteristics Lying, deceitful, and acting out behaviors Arouse hatred, then guilt, and finally despair in the providers Academy of Consultation-Liaison Psychiatry 19
Illness Behaviors of Hateful Patients Type of Patient Illness Behavior Dependent Clingers Demanding, sticky, constantly ask for reassurance, rejection sensitive Entitled Demanders Needy, hostile, belittling Manipulative Help Rejecters Pessimistic, undermine treatment, yet demanding Self-destructive Deniers Hopeless, uncooperative + dependent, may continue self injurious behavior despite medical complications Groves JE. N Engl J Med 1978; 298:883-887 Academy of Consultation-Liaison Psychiatry 20
DSM-5 Personality Disorders Cluster A odd and eccentric Cluster B dramatic, emotional, or erratic Cluster C anxious or fearful American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA: American Psychiatric Publishing. Academy of Consultation-Liaison Psychiatry 21
Features of DSM-5 Personality Disorders: Cluster A Disorder Features Paranoid Suspiciousness and projection of negativity onto others; attribution of damaging motivation onto others; fear exploitation and humiliation Schizoid Indifference to social relationships, as well as a very limited range of emotional experience and expression Schizotypal Peculiarities and eccentricities of thought, behavior, appearance, and interpersonal style Academy of Consultation-Liaison Psychiatry 22
Features of DSM-5 Personality Disorders: Cluster B Disorder Features Antisocial Pervasive pattern of disregard and violation of the rights of others; may be impulsive, irritable, deceitful; fear exploitation Histrionic Exaggerated emotional reactions, approaching theatricality, in everyday behavior; fear loss of love, attention and admiration Borderline Pervasive instability, with a pattern of poor impulse control; fears separations, loss, or emotional abandonment Narcissistic Unrealistic, inflated sense of self-importance and lack of sensitivity to other people s needs; fear loss of prestige, power, image, esteem Academy of Consultation-Liaison Psychiatry 23
Features of DSM-5 Personality Disorders: Cluster C Disorder Features Dependent Passivity, tendency to cling to others; fear separation, independence, decision-making; need to be cared for Obsessive- Compulsive Perfectionism, overwhelmed with concern for neatness and minor details, trouble making decisions or getting things accomplished; fear imperfection, loss of control Desire for, but fear of any involvement with other people; fears rejection, humiliation, embarrassment Avoidant Academy of Consultation-Liaison Psychiatry 24
Impact of Medical Illness on Personality Disorders Dependent: need to be cared for Obsessive Compulsive: fear loss of control; may become controlling Histrionic: may be dramatic, emotionally changeable, act sexually inappropriate Narcissistic: may feel that the perfect self-image is threatened by illness Paranoid: blame doctors for the illness; supersensitive to a perceived lack of attention or caring Schizoid: become anxious and even more withdrawn Academy of Consultation-Liaison Psychiatry 25
Step 2: Gauge Distress of the Treating Team ACADEMY OF CONSULTATION-LIAISON PSYCHIATRY Psychiatrists Providing Collaborative Care Bridging Physical and Mental Health
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 Academy of Consultation-Liaison Psychiatry
Step 3: Develop a Management Plan ACADEMY OF CONSULTATION-LIAISON PSYCHIATRY Psychiatrists Providing Collaborative Care Bridging Physical and Mental Health
Order of Priorities Ensure safety of staff and patient Rapidly diagnose and evaluate most pressing psychiatric issues Identify and implicitly address staff-patient dissonance/miscommunication Explicitly address patient s conflicts Educate consultee and staff Assist with follow-up and disposition plan Ensure that recommendations are carried out Academy of Consultation-Liaison Psychiatry 29
General Strategies for Dealing with the Difficult Patient Ensure that the basic needs of the patient are met, communication of difficulties, privacy, etc Facilitate consistent staff presence to help 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 Incorporate understanding of potential contribution of team dynamics Academy of Consultation-Liaison Psychiatry 30
Rules for Confrontation of the Difficult Patient Set limits Acknowledge the real stressors Avoid breaking down needed defenses Avoid overstimulation of patient s wish for closeness Avoid overstimulation of patient s rage Avoid confrontation of narcissistic entitlement (= hope/faith) Appeal to sense of entitlement Academy of Consultation-Liaison Psychiatry 31
Helping the Staff Prevent splitting Permit limit setting Explain patient s reality to staff Reinforce staff strengths Model non-sadistic interactions Reassure that such patients stir up negative feelings in the best of caregivers Write clear behavior management strategy and safety plan in chart Ally with staff- do not interpret staff s pathology Academy of Consultation-Liaison Psychiatry 32
Strategies for Management of 4 Types of Hateful Patients Type of Patient Illness Behavior Dependent Clingers Schedule appointments, consistent interactions Entitled Demanders Accept entitlement and redirect it to expectation of appropriate medical attention Manipulative Help Rejecters Help patient limit demands and hostility; encourage team to help patient maintain sense of autonomy Be compassionate and diligent; treat underlying depression; accept limits set by patient but don t abandon patient Self-destructive Deniers Groves JE. N Engl J Med 1978; 298:883-887 Academy of Consultation-Liaison Psychiatry 33
Strategies for Managing Specific Personality Disorders in the Medical Setting Academy of Consultation-Liaison Psychiatry 34
Management of Cluster A Personality Disorders Disorder Strategies Paranoid Empathize with fear of being hurt Acknowledge complaints without arguing Honestly explain medical illness Correct distortions, unreasonable explanations If the patient refuses care out of mistrust, ask if it acceptable that you disagree Schizoid Empathize with & accept need for privacy and contact Reduce patient s isolation as tolerated Neutrally impart information Correct distortions, unreasonable expectations Gently question irrational thoughts Schizotypal Empathize with idiosyncratic style/magical thinking and perceptions but don t directly confront Similar strategies to above Blumenfield M, Strain JJ (eds). Psychosomatic Medicine, LWW, 2006 Academy of Consultation-Liaison Psychiatry 35
Management of Cluster B Personality Disorders Disorder Strategies Empathize with fear of exploitation, low self-esteem Determine if secondary gain Avoid moralizing Explain that deception results in poor care Correct distortions, unreasonable expectations Antisocial Empathize with fear of losing love or care Interact in a neutral, friendly way; set limits Discuss the patient s fears, reassure Use logic to counteract emotional style of thinking Correct distortions, unreasonable expectations Histrionic Empathize with fear of abandonment and plan for absences Use consistent staff to avoid splitting Express a wish to help and satisfy reasonable needs Set firm limits but don t punish Correct distortions, unreasonable expectations Borderline Empathize with vulnerability , low self-esteem Don t mistake superior attitude confidence; don t confront the entitlement Acknowledge patient s hurt and your mistakes and expresses wish to help Correct distortions, unreasonable expectations Narcissistic Blumenfield M, Strain JJ (eds). Psychosomatic Medicine, LWW, 2006 Academy of Consultation-Liaison Psychiatry 36
Management of Cluster C Personality Disorders Disorder Strategies Dependent Empathize with need for care Discourage total dependence; avoid telling patient what to do Encourage independent thinking and action Don t abandon Correct distortions, unreasonable expectations Obsessive- Compulsive Empathize with patient s detailed, unemotional style of thinking If obsessive thoughts are interfering with care, ask about feelings Don t struggle over control and critical judgments Avoid abandoning the patient Correct distortions, unreasonable expectations Avoidant Empathize with fears, shame, shyness Help the patient describe the feared situation Encourage and support the patient to face the fears Gently elicit irrational thoughts and suggest more rational ones Correct reality distortions Blumenfield M, Strain JJ (eds). Psychosomatic Medicine, LWW, 2006 Academy of Consultation-Liaison Psychiatry 37
References American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing. Blumenfield M, Strain JJ (eds). (2006). Psychosomatic Medicine. Philadelphia, PA : Lippincott Williams & Wilkins Boland R. The problem patient: modest advice for frustrated clinicians. R I Med J.2014; Jun 2;97(6):29-32. Groves JE. Taking Care of the Hateful Patient. N Engl J Med 1978; 298:883-887 Penley JA, Tomaka J, Wiebe JS., The association of coping to physical and psychological health outcomes: a meta-analytic review. J Behav Med. 2002;25:551- 603 Academy of Consultation-Liaison Psychiatry 38
