Managing the difficult patient Stan Bennett MS, OTR/L CDR USPHS Therapist Category Day USPHS Scientific and Training Symposium June 12, 2014
OBJECTIVES 1. Distinguish between a “psychotic” disorder and a “personality” disorder. 2. Identify unique characteristics of personality disorders 3. Describe the faulty problem-solving process identified with personality disorders 4. List 5 proactive techniques to utilize with managing difficult behaviors in your practice setting
Managing the difficult patient Between 10 and 60% perceived as being “difficult” (Wasan et al, 2005) Perceived “difficult” patients often evoke feelings of: Anger / frustration / emotionally drained / incompetency / confusion / upset / anxiety / guilt / manipulation / decreased productivity / retaliation / fear Healthcare provider characteristics / perceptions / attitudes also contribute to difficult patient encounters. Jackson and Kroenke (1999) noted that healthcare providers with decreased empathy and poor attitudes towards patient psychosocial issues perceived more patient-encounters as difficult.
Managing the difficult patient Jackson and Kroenke (1999) also noted difficult patients tended to have and/or elicit greater depression/anxiety disorder, poor functional status, unmet expectations, reduced satisfaction and a greater utilization of health care services. Hahn (2001) reported that difficult patients tend to have psychosomatic symptoms, abrasive personality styles and meet the diagnostic criteria for personality disorder.
Personality Disorder An enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individual’s culture, is pervasive and inflexible, has an onset in adolescence or early adulthood, is stable over time, and leads to distress or impairment (Diagnostic and Statistical Manual of Mental Disorders Fifth Edition, 2013)
“Social Screening” for Personality Disorder By other Professionals’ Reactions: Referrals preceded by an apology By Your Internal Experience: When relating to them you feel as though you are the “crazy one” By your Emotional Response: Consistent feelings of annoyance or irritation By “Everyday-Language” Diagnosis: jerk / idiot / weirdo / creep / &%@$# However, is there any legitimacy to defining patients by your responses?
“Social screening” For personality disorder Colli et al (2014) found a “significant and consistent relationship between therapist reactions and specific personality disorders”. Cluster B personality disorders evoked more negative and decreased emotional control from their treating therapists as compared to clusters A and C personality disorders. If you and no one else has a problem with a patient then you probably have a personality conflict However, if you and other healthcare providers share the same negative emotional responses about a specific client then that person likely has a very strong personality trait or undiagnosed personality disorder.
Characteristics of personality disorder Only one pervasive “way to be” Only one tool in their behavioral toolbox Unable to observe their behavior “Sense of Agency” / “Observational Ego” Drama pattern instead of problem-solving pattern (identity validation motive rather than problem solving motive)
What causes personality disorder Psychoanalytic Theory (Freud) – Disruptions in the relationship of a young child to significant others resulting in the creation of distorted experiences and dysfunctional behaviors. Current data does not support this theory Genetic Theory – Hereditary transmission of neurological abnormalities. Identical twins do not have 100% concordance rates (average: 58%). No reliable genetic markers have yet to be found Biopsychosocial Theory (Current prevailing theory) - Temperament factors (heredity/neurology) and character factors (psychological, environmental/experiential) combine to create a pattern of distorted experiences and dysfunctional behavior.
DSM-V Personality Disorder Diagnoses Cluster A – “Mature” Type (odd, eccentric) Paranoid Schizoid Schizotypal Cluster B – “Immature” Type (dramatic, emotional, erratic) Antisocial Borderline Histrionic Narcissistic Cluster C – “Anxious” Type (anxious, fearful) Avoidant Dependent Obsessive-Compulsive
Psychotic Disorders / Personality Disorders Psychotic Disorders Personality Disorders Disorder of feelings/behavior Exhibit traits (Parkinson’s Disease) Frequently does not respond to medication / behavioral therapy Disorder of thought/perception Exhibit symptoms (ex: cold / flu) Frequently responds to medication
Problem-solving process Normal vs Disordered Personality Normal Personality Abnormal Personality Difficulties in life lead to survival-based pattern of validating their position called “identity” Identity-validation process: Problem is defined “personally” Reactions/behaviors justified Original problem is amplified More problems are created The goal is to validate their position by creating DRAMA. Difficulties in life lead to survival-based pattern of problem solving Problem-solving process: Problem defined operationally Possible actions are considered Actions are selected Outcomes are evaluated The goal is to produce solutions
Managing the difficult patient Your goal is to avoid the DRAMA! Rescuer I’m helping / I’m special Persecutor I’m correcting / I’m right (powerful) Victim I’m wounded / I’m blameless
Primary Characteristics of Drama Overt purpose is to make their behavior seem justifiable and reasonable Covert purpose is to validate their identity rather than produce a workable outcome Involves unexpected switch in identity Creates stimulation (confused/upset) in service of validating their identity Produces new problems, intensifies problems or leaves problems unaddressed Survival-based and resistive to both exposure and intervention. Designed to propagate itself (survive) and to get others to participate
Proactive techniques to manage difficult patient behaviors Be Active and Responsive: Stay out of their DRAMA: They will try to make you feel bad for not participating in their problems Anticipate the “Drama Switch” Maintain Empathetic Neutrality Refuse to take assigned position in the drama Refuse to take things personally Maintain a Position of Freedom and Power “NEED” less than the individual Have lower intensity of personal drama Stick to the issue and not the person/personality
Proactive techniques to manage difficult patient behaviors Have Consultation Team Available: Talk to your colleagues or supervisor. They will convince you that you are not crazy Be Comfortable Using Silence; Go Slowly Have the Willingness to Disavow Responsibility for Success or Failure: Be willing to succeed or fail WITH POWER! Have an ability to make mistakes Be comfortable with Reality-Based Confrontations Be comfortable with Saying NO Be willing to Break the “rules” of the Drama; to be defined as “wrong”
References American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Arlington, VA, American Psychiatric Association, 2013. Colli, A., Tanzili, A., Dimaggio, G. & Lingiardi, V. (2014). Patient personality and therapist response: An empirical investigation. American Journal of Psychiatry, 171, 102-108. Hahn, S. R. (2001). Physical symptoms and physician-experienced difficulty in the physician- patient relationship. Annals of Internal Medicine, 134, 897-904. Hahn, S. R., Kroenke, K., Spitzer, R. L., Brody, D., Williams, J. B., Linzer, M., & deGruy, F. V. (1996). The difficult patient: Prevalence, psychopathology, and functional impairment. Journal of General Internal Medicine, 11, 1-8. Jackson, J. L., & Kroenke, K. (1999). Difficult patient encounters in the ambulatory clinic. Archives of Internal Medicine, 159, 1069-1075. Lester, G. (2003). Personality disorders in social work and health care(3rd ed.). Cross Country Education Wasan, A. D., Wootton, J., & Jamison, R. N. (2005). Dealing with difficult patients in your pain practice. Regional Anesthesia and Pain Medicine, 30, 184-192.