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.
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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.
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What Makes a Patient Difficult?
 Multiple somatic complaints
 Anger or irritability
 Frequent doctor visits/calls
 Noncompliance
 Depression
 Anxiety
 Agitation
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 Drug-seeking behavior
 Excessive requests for attention
 Physically or verbally aggressive
behavior
 Sabotaging care
 Wandering/pulling out lines
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Approach to the Difficult Patient
 Step 1: Initial diagnosis
 Step 2: Gauge distress of the treating team
 Step 3: Develop a management plan
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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?
No
Yes
Intoxicated?
Mood, Psychotic, or
Anxiety Disorder?
No
Personality Disorder?
Yes
Yes
Psychiatric tx
Educate & help staff
No
Scared?  reassure
Angry?  Explore; patient rep
In Pain/discomfort?  treat
Miscommunication  communicate
Poor patient/team fit  collaborative approach
Jerk/Criminal?  security, police
Supportive Care
Monitor for withdrawal
Manage agitation
Yes
Reassure
Explore patient’s experience
Educate & help staff
Set limits; Prn meds
Reassess when awake
Search for cause of impaired arousal
Hold sedating meds for evaluation
Manage agitation if recurs
No
Delirium or Dementia
Assess acuity
Search for cause
Manage agitation
Another Way to Assess the Difficult Patient
Deliberate Behaviors
 Factitious Disorder &
Malingering
 Personality Disorders
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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.
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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”
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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
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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
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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
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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
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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
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“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
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Groves JE. N Engl J Med 1978; 298:883-887
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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
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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
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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
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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
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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
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Groves JE. N Engl J Med 1978; 298:883-887
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DSM-5 Personality Disorders
 Cluster A—odd and eccentric
 Cluster B—dramatic, emotional, or erratic
 Cluster C—anxious or fearful
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American Psychiatric Association. (2013). Diagnostic and
Statistical Manual of Mental Disorders (5th ed.). Arlington, VA:
American Psychiatric Publishing.
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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
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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
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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
ObsessiveCompulsive
Perfectionism, overwhelmed with concern for neatness and minor
details, trouble making decisions or getting things accomplished; fear
imperfection, loss of control
Avoidant
Desire for, but fear of any involvement with other people; fears
rejection, humiliation, embarrassment
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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
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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
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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
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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
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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
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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
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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
Self-destructive Deniers
Be compassionate and diligent; treat
underlying depression; accept limits set by
patient but don’t abandon patient
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Groves JE. N Engl J Med 1978; 298:883-887
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Strategies for Managing Specific Personality Disorders
in the Medical Setting
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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
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Blumenfield M, Strain JJ (eds). Psychosomatic Medicine, LWW, 2006
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Management of Cluster B Personality Disorders
Disorder
Strategies
Antisocial
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
Histrionic
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
Borderline
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
Narcissistic
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
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Blumenfield M, Strain JJ (eds). Psychosomatic Medicine, LWW, 2006
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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
ObsessiveCompulsive
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
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Blumenfield M, Strain JJ (eds). Psychosomatic Medicine, LWW, 2006
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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;25:551603
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