Transcript Dealing with Difficult Patients

Dealing with Difficult
Patients
Phil Antunes M.D.
Scott & White
Department of Psychiatry
Narcissistic/Entitled Patient
• Pattern of having a grandiose sense of selfimportance (exaggerates achievements and
talents)
• Expects to be recognize as superior without
accomplishments to substantiate such recognition
• Feels special and unique, and can only be
understood by, or should associate with other
high-status people
• Arrogant, condescending, and haughty
Narcissistic Personality
Think of the letter “E”
• Enamored with fantasies of power, unlimited
success, brilliance, or ideal love
• Has a sense of Entitlement
• Interpersonally Exploitative
• Requires Excessive admiration
• Lacks Empathy (“Empathy-less”)
• Often Envious, or believes others are Envious
of him or her
Narcissistic Personality---Teaching
Points
• Find out what the agenda is in seeking
treatment
• Acknowledge errors, but do not be overly selfcritical
• Be cautious about making remarks that may
be seen as critical
• Monitor for signs of depression following a
narcissistic injury, and treat judiciously
Narcissistic Personality---Treatment
• Encourage the patient to openly express his or
her needs, and to ask others what their needs
are
• Monitor countertransference; avoid
gratification or punishment
• Vulnerable to hypochondriacal preoccupation--these patients are adept at getting doctors
to prescribe medication
Borderline Personality Disorder
• Pervasive pattern of unstable interpersonal
relationships
• Marked impulsivity
• Alteration between idealization and devaluation
• Recurrent suicidal behavior, threats, or thoughts,
or self-mutilation
• Affective instability/lability
Borderline Personality
• Chronic feelings of emptiness
• Inappropriate, intense anger
• Transient, stress related dissociation or
paranoid ideations
• Identity disturbance, unstable self-image or
sense of self
Borderline Personality
Teaching Points
• Monitor countertransference feelings closely;
avoid falling into the trap of projective
identification
Pt
MD
Pt
MD
Pt
MD
Borderline Personality
Teaching Points
• Be consistent, set and maintain firm
boundaries
• Be aware of possible substance abuse
• Avoid prescribing large amounts of potentially
lethal medications
• Antidepressants may be beneficial, especially
SSRIs, to decrease impulsivity
• Antipsychotic medications may be helpful
(“ego glue”)
Borderline Personality
Teaching Points
• Focus on the “here and now”, rather than
exploring past traumatic experiences, such as
abuse
• Be active; discuss splitting and strong affects
as they happen
• Overtime, help the patient see a connection
between actions and feelings
• Explore healthy alternatives/outlets instead of
self-destructive behaviors
Dealing with Angry Patients
• May invoke the “flight or fight” response in you
• Underlying meaning of patient’s anger may not be
apparent or ambiguous (previous trauma, chronic
illness, acute pain)
• May be angry over something someone else did
– Empathize without blaming
– Could be your staff or your colleague
– Avoid “jousting” or agreeing with patient
• If angry over a systems issue, don’t explain that
things probable will never change
Dealing with Angry Patients
• Let patient ventilate feelings in a private setting,
usually with a second staff present, if possible
• Show compassion and humane respect
• Stay calm, don’t raise your voice, be aware of
body language
• You don’t have to endure frank abuse
• Don’t take it personal!
• Have an open dialogue with your staff about
difficult patients
• Have a secure online communication option
available to angry patients---doesn’t tie up you or
staff’s time unreasonably
Histrionic Personality
•
•
•
•
•
From hystera, (“hysterical”) meaning uterus
Excessive emotionality and attention-seeking
Uncomfortable if not the center of attention
Provocative, seductive, flirtatious
Uses physical appearance to draw attention
Histrionic Personality
• Dramatic, animated in speech and behavior
• Suggestible
• Often feels relationships are more intimate
than they actually are
Histrionic Personality
Teaching Points
• Be careful of the patient’s eroticized transference (acting out);
this is more about the patient’s defenses, not about you;
Sexualizing/flirtatious behavior is a smokescreen to deeper
feelings of inferiority and powerlessness; Avoid the following
pitfalls:
–
–
–
–
–
Contributing to the eroticized transference
Narcissistic needs being met by an adoring patient
Voyeuristic enjoyment of the patient’s fantasies
Sense of disgust at the patient’s disclosures
Sadistic enjoyment of being “unavailable” to your patient
• Closely monitor your reactions to and interactions with the
patient
• Resist too much self-disclosure
Histrionic Personality
Teaching Points
• Help the patient build self-esteem in areas
other than attractiveness
• These patients are very sensitive about aging
• Be aware of help-rejecting complaining
References
• Hickson, GB., Dealing with Angry Patients
• Robinson, D. Disordered Personalities, Rapid
Psychling Press
• Scherger, J., Dealing with Angry Patients
???????????????????