Strategies for Dealing With the Difficult Patient

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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

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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

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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

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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
  patients name.
• Also called the heartsink patient

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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.

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1. Paranoid Personality

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

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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.

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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.

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CLUSTER B

• This group often includes labile affect and poor
  impulse control.

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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.

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

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O
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• Self Identity
• Obj Relations
• Depression
• Anger

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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.

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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?

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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?

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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?

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Borderline

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

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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

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Borderline

• Little sense of self, poor boundaries
• Im feeling suicidal today, what are you going
  to do about it?
• Important therapeutically to set limits e.g.
  its important for you to use your internal
  resources to deal with this issue. Ill see you
  on Friday at our usual time

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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
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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

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Transference and Countertransference

• Transference the patient transfers feelings onto
  you which really reflect what they felt toward
  early caregivers, e.g. anger, fear. Youre left
  wondering where it comes from.
• Dont take it personally!!
• Countertransference the therapists emotional
  reactions to the patient
• People have written about countertransference
  hatred

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Countertransference

• We all have patients who arouse negative
  countertransference
• This is psych-speak for I cant stand you
• Important to acknowledge and not deny these
  feelings
• Check to see if its based on patient behaviour,
  or some of your own issues

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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

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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 Im off base, but..
• This may open up a useful dialogue
• Dont label your emotion, simply label the
  behaviour

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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

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Countertransference

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

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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

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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

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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

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Interviewing Tips

• Watch body language and label it
• Label emotions--You seem angry
• Sounds hokey, but it works

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Interviewing Tips

• If you have done something in the interview you
  regret, its ok to say youre sorry

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3. HISTRIONIC PERSONALITY

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

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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.

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CLUSTER C

• Hallmark is low self esteem. Often feels
  anxious, fearful.

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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.

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1. Avoidant Personality

• TAPE
• Im not good enough, therefore, Ill avoid
  closeness because Ill 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.

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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 cant go to parties or social
  gatherings, but may have very close friends they
  have maintained for years. Good with 11
• These two may often co-exist, as self esteem
  issues are a common denominator

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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.

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2. Dependent Personality

• TAPE
• Im 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, Ill put up with it because its all Im
  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.

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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.

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3. Obsessive-Compulsive Personality Disorder

• TAPE
• Im 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.

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OCD vs.OCPD

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

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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?

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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?

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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?

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• JON DAVINES EMAIL
• jdavine_at_cogeco.ca