Managing the disruptive patient
51st Annual Scientific Assembly
Ontario College of Family Physicians November 2013
Jon Hunter MD FRCPC
[Bob Maunder MD FRCPC]
Faculty/Presenter Disclosure
• Faculty: Jon Hunter
• Program: 51st Annual Scientific Assembly
• Relationships with commercial interests:
– NONE
Disclosure of Commercial
Support
• This program has received NO financial support
• This program has received NO in-kind support
• Potential for conflict(s) of interest:
– NONE
Mitigating Potential Bias
• N/A
Objectives
1) participants will be able to recognize
attachment styles
2) participants will learn how the attachment
style of an individual influences their
interaction with HCW’s
3) participants will derive techniques for
managing disruptive attachment behaviors
Sarah Difficult
Call from FP unit:
• “Jon, you’ve got to help me with Sarah…she
calls all day, overwhelming the secretary, and
demands lots of attention, about all these flaky
symptoms… when she’s here she’s so loud she’s
putting other patients off…She seems to hate
my suggestions, but when I try and end the
appt. she’s hard to get out of the unit...I’m
ready to strangle her…”
Literature Review
N = 500 outpatients -- 15% rated as difficult
More likely to have:
•
•
•
•
•
•
•
Mental disorder
> 5 somatic symptoms
> severe symptom
Poorer function
More unmet expectations
Less satisfaction with care
Higher use of services
Hahn, Kroenke,J. of Gen Int Med 1996
Jackson,Kroenke, Archives Int Med 1999
Literature Review
• 21 patients described by 9 FP’s as ‘difficult’
• 7/21 difficult patients vs.1/21 controls
had (at least one) personality disorder
• 5/21 had dependent (‘wimpy’) personality
Schafer, Nowlis Archives Fam Med 1998
Literature Review
• Interview of 15 randomly sampled FP.’s in
Israel
• >5 years in practice
• Structured I/V + Questionnaire…
Steinmetz, Tabenkin, Family Practice, 2001
Literature Review
•
•
•
•
•
•
•
•
Difficult Patient:
‘Everything hurts’
High anxiety
‘Pain in the neck’
Demanding, exploiting
Angry at doctor
Uncooperative
Difficult psychiatric patient
Drug Addict
Literature Review
• James E Groves
• Taking Care of the Hateful Patient
• New England Journal of Medicine, 1978
• Hateful patients… “induce feelings which their
caregivers find difficult to tolerate”
Attachment and disruptive behavior…
• How does understanding attachment style
help you with Sarah Difficult?
• Let’s classify her:
Preoccupied/anxious attachment:
• I find that others are reluctant to get as close
as I would like. I often worry that my partner
doesn’t really love me or won’t want to stay
with me. I want to merge completely with
another person, and this desire sometimes
scares people away.
Dismissing attachment:
• I am somewhat uncomfortable being close to
others; I find it difficult to trust them,
difficult to allow myself to depend on them. I
am nervous when anyone gets too close, and
often, [love] partners want me to be more
intimate than I feel comfortable being.
Disorganized/fearful attachment:
• I am constantly frustrated by partners, I feel
the need to be really close, but then they
screw me over, and I get so angry I blow up.
They can’t understand me, and when they back
off, I get really scared of being alone, but even
angrier that they’re leaving....
The attachment system…
Explore until
it’s
dangerous
Stay close until
it’s safe
Dimension of Attachment Avoidance
Fearful
or Disorganized
Dismissing
Preoccupied
Secure
Dimension of Attachment Anxiety
University of Toronto Consultation-Liaison Psychiatry Division
Adult attachment styles:
•
•
•
•
Secure (55%)
Anxious (Compulsively care-seeking) (20%)
Dismissive (Compulsively self-reliant) (15%)
Disorganized (Fearful) (10%)
Why you see insecure people as
patients:
“we have a baby, . . .
someone close to us
departs or dies, a limb is
lost or sight fails”
Bowlby J. Attachment and Loss, Vol. 1:
Attachment. New York: Basic Books,
1969 , pg. 82
Why you see insecure people as patients:
Tertile of
attachment
insecurity →
“trying to make
myself feel better by
eating,
smoking, drinking,
using drugs or
medications”
low
middle
high
8%
8%
33%
(Maunder, Lancee, Balderson et al., 2006)
What changes with different A/S’s?
1) Healthcare Utilization
Mean Annual
Primary Care Costs
(US$)
(Ciechanowski, 2000): Primary Care Costs
in 701 People with Diabetes
550
500
450
400
350
300
Secure
Preoccupied Dismissing
Interpersonal Style
Fearful
Proportion of medical
patients
who report symptoms
that
What changes
with
different
A/S’s?
cannot be explained
2) proportion of unexplained symptoms
80
Percentage
60
40
20
0
Secure
Preoccupied Dismissing
Fearful
Anxious attachment:
• Preoccupied with fear
• Can’t cope by self, need to keep other
attached via constant distress signal
• Experienced as needy, or clingy
Anxious attachment
Management guidelines:
• HCW as External Modulator of patient
• Attentive, supportive attitude
• Preemptive contact to decrease “distress
signals”
• Frequent, regular, time-limited contact:
- not contingent on distress
Anxious attachment
Management guidelines:
• Present team as an integrated whole
• Enhance internal regulation of distress:
– reminders of previous coping
– relaxation techniques
– benzodiazepines
(ie night before and morning of chemo.)
A post-operative phone call & pain
p < .001
18
16
14
12
10
8
phone call
no call
p < .001
6
4
2
0
Pain score
# pain pills
Percent of patients
What changes with different A/S’s?
Proportion of diabetic patients with poorly
3) adherencecontrolled disease
80
60
40
20
0
1
2
3
Patient's Interpersonal Style
4
Adherence domain
Dismissing style
(N=1463; 35.7%)
Odds Ratio†
General diet non-adherence
1.41
Exercise non-adherence
1.36
Foot care non-adherence
1.21
Current smoker
1.42
Oral hypoglycemic agents
(<80% adherent)
1.23
† Reference group = Secure style (N=1806; 44.1%)
Dismissing attachment:
• Dislike dependence
• Necessary lack of control may provoke crisis
– e.g. anaesthetic, sedation
• Noncompliance or poor sense of alliance
Dismissing attachment
Management guidelines:
• Respect need for independence
• Allow patient to set interpersonal distance Don’t crowd!
• Re-frame investigations/treatments as
expediting return to self-reliance
• Model identification and expression of affect
• Model flexibility
What changes with different A/S’s?
4) symptom reportage
6
5
4
3
2
Colonic Mucosa
1
normal
0
friable
Repressive
Coping
Dismissing
Standard
Adaptable
HighAnxious
Health Anxiety
Style of expressing worry and symptoms
Maunder &
Greenberg,
IBD, 2004
What
changes
withindifferent
A/S’s?
"Difficult"
encounters
the emergency
room
(according to MD)
5) Md-pt. interpersonal
difficulty
50
Percentage
40
30
20
10
0
Secure
Preoccupied
Dismissing
Patient' s Interpersonal Style
Fearful
Disorganized/fearful attachment
•
•
•
•
Unstable approach and withdrawal
Help-seeking + help-rejecting
Complaining + dismissive
Demanding + angry
Disorganized/fearful attachment
• lowest frequency of scheduled preventive
care
• highest frequency of missed visits
BUT….
• highest frequency of same day (crisis)
appointments
Paul Ciechanowski, Gen Hosp Psychiatry, 2006
Disorganized/fearful attachment
• Experienced as needy +++, frustrating.
• No reliable strategy for relating
– oscillations, mixed messages
• +++ difficult to reliably engage or comfort
Disorganized/fearful attachment
Management guidelines:
•
•
•
•
Appreciate extent of patient’s fear
Assess suicidality
Attend to needs of staff
Deliver uniform messages, so as to prevent
abandonment, over-investigation and...
• Use an independent guide to treatment:
“Usual high standard of care”
Summary
Adult attachment and CL:
1. provides a useful shorthand for practical
individualization of management strategies
2. is an evidence-based approach to
optimizing adaptation to med/surg. illness
3. complements diagnosis-based approaches
4. Generates patient-specific management
plans
Resources
• Attachment insecurity as a disease risk factor
– Maunder R.G., Hunter J.J., Attachment and psychosomatic medicine:
Developmental contributions to stress and disease. Psychosom Med, 63
(4), 2001, 556-567
– Maunder RG, Hunter JJ Attachment relationships as determinants of
physical health. Journal of the American Academy of Psychoanalysis
and Dynamic Psychiatry, 36: 11-32, 2008
– L McWilliams, S.J. Bailey, Associations between adult attachment
ratings and health conditions: Evidence from the National Comorbidity
Survey replication. Health Psychology, 29 (4), 446-453, 2010
• Measuring attachment insecurity
– Ravitz P, Maunder RG, Hunter JJ, Sthankiya B, Lancee, WJ. Adult
Attachment Measures – a 25 year review. J Psychosom Res, , 69: 41932, 2010.
Resources
• Identifying attachment prototypes
– Maunder RG, Hunter JJ. Assessing patterns of adult
attachment in medical patients. Gen Hosp Psychiatry
31:123-130, 2009
• Attachment-influenced management
– Hunter J., Maunder R.G. Using attachment theory to
understand illness behavior. Gen Hosp Psychiatry, 23
(4), 2001, 177-182
• Youtubes:
- Search “Maunder and attachment”