The difficult patient
Psychodynamics:
Coping styles, defense mechanisms and
countertransference
Suicide: Assessment of suicide risk and management
Consult question
• „Sixty-five year old male with end-stage renal
disease on hemodialysis. He has been kicked
out of all other dialysis centers due to his
obnoxious behaviour. He hollers and berates
the staff. How to manage his behaviour?“
Difficult patient presents with
Vague and generalized somatic symptoms
Depression
15% of patients
labeled as
Anxiety
difficult
Medication non-adherence
A personality disorder
Excessive demands and repeated visits
Difficult patients evoke strong emotional
reactions
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•
•
•
Aversion
Fear
Despair
Malice
Remember!
Medical illness and hospitalization is stressful
• Experiencing a medical illness requiring admission is a
narcissistic injury: a threat to self-worth or self-esteem
• Patient re-examines his self-view while confronting the
impermanence of life
• Patient feels defective, weak and less desirable
• Being in a hospital is very uncomfortable, body exposure,
personal and bodily intrusions
• Patients are separated from their comfortable environment
and have to accept dependency on their caregivers
Understand psychodynamic factors
Personality structure of the patient:
• coping styles: consciously applied behavioral
actions
• defense mechanisms: unconscious,
psychological processes used by patients to
deal with reality and to maintaint self-image
Emotions experienced by the team:
countertransference
Personality
• Personality types
• Personality disorders
Continuum
Personality types
• Personality: a combination of characteristics
that predisposes them to think, feel and
behave
• Inborn: temperament
• Environmentally influenced: character
Identify
personality types
Sanguine
Melancholic
Phlegmatic
Choleric
Quizz:
Have you seen this
picture before?
a) Yes
b) No
c) Do not know
Personality disorder
Individual uses a personality style:
• Rigid
• Extreme
• Maladaptive
• Damaging to self or others
• Result: impairment in interpersonal, social or
occupational domains
Coping styles and illness behavior
• How an individual manages and attempts to alter
stressful situation: consciously applied behavioral
actions
• Problem-focused: Seeking information, planning,
taking action
• Emotion-focused: Focusing on positive aspects of
the situation, mental or behavioral disengagement
and seeking emotional support from others
Name positive aspect of
the illness and treatment
Healthy and adaptive copers
• Use combination of problem and emotionfocused copingto deal with a stressor and use
different strategies for varied situations
• Are optimistic, practical, flexible and
composed
• View illness as a challenge, strategy, value
Poor copers
•
•
•
•
•
Are passive,
Deny excessively
Hold rigid and narrow views
Unable to make decisions
Paradoxically they have moments of
impulsivity and unexpected compliance
• View illness as an enemy, punishment,
weakness, relief or irreparable loss
Coping style
Description
Confrontative
Hostile or aggressive efforts to alter a situation
Distancing
Efforts to mentaly detach self from a situation
Self-controlling
Attempting to regulate one´s feelings or actions
Seeking social support
Atempting to seek emotional support or information
from others
Accepting responsibility Accepting a personal role in the problem
Escape-avoidance
Efforts to escape/avoid a problem or situation, both
cognitively and behavioraly
Planful problem solving Attempting to come up with solutions to alter a situation
Positive re-appraisal
Re-framing a situation in more positive light
Defense mechanisms
• Defenses: used by all individuals to protect
the self from anxiety
• To provide refuge from a situation with which
one cannot currently cope
• Psychotic, immature, neurotic and mature
What defenses are used
by „difficult patients?“
Defense
mechanism
Mature
Humor
Description
Sublimation
Channeling unacceptable impulses into more constructive activities
Suppression
Intentional exclusion of material from conscioussness
Neurotic
Displacement
Transfer of unacceptable thoughts, feelings or desires from one object to a less threatening substitute
Emphasizing the amusing or ironic aspect of the conflict or stressors
Isolation of
affect
Rationalization
Separation of painful idea /event from feelings associated with it
Reaction
formation
Repression
Immature
Acting out
Going to the opposit extreme to overcompensate for unacceptable impulses
Devaluation
Idealization
Exagerating negative qualities of others
Overestimating the desirable qualities of self or others
Passive
aggression
Projection
Indirect and passive expression of anger towards others
Regression
Reversion of personality to a lower level of expression
Splitting
Separating people and actions into categories of all good and all bad
Psychotic
Projective
identification
Projecting a negative aspect of the self onto another and then coercing the other into identifying with the projected emotion
Inventing a socially acceptable and logical reason why one is not bothered
Involuntary forgetting of a painful event
Performing an action to express unconscious emotional conflicts usually antisocial in nature
Attribution of own unaccpetable desires /imulses to another person
Psychotic denial Failing to recognize obvious implications or consequences of a thought, act or situation
Immature
defenses
Acting out
Description
Performing an action to express unconscious
emotional conflicts usually antisocial in nature
Devaluation
Exagerating negative qualities of others
Idealization
Overestimating the desirable qualities of self
or others
Passive aggression Indirect and passive expression of anger
towards others
Projection
Attribution of own unaccpetable desires
/imulses to another person
Regression
Reversion of personality to a lower level of
expression
Splitting
Separating people and actions into categories
of all good and all bad
Immature defenses
• Characteristic of the cluster B personality disorders:
antisocial, borderline, histrionic, narcissistic
• Irritating to others as this defense style transmits
patients „shame, impulses and anxiety to those
around them“
• Make others suffer (x neurotic defenses cause the
self to suffer)
Do not confront the patient directly, as defenses are
unconscious!
Risk of further escalation of oppositional behavior!
Identify defenses and understand
behaviors
• Awareness of the potential for
eidealizing/devaluing: Glowing praises follow
by harsh criticizing
• Awareness of splitting: The patient tend to
divide the medical staff as „all good“ or „all
bad“ caregivers
Physician´s factors and
countertransference
• Doctor – vs. Patient centered approach?
• Strict bio-medical model – vs. Psychosocial
approach?
• Countertransference: reactions to a patient
that represents the past life experiences of
the clinician
Examples?
Management
Understand them,
recognize the defense
mechanisms and
coping styles
• Ensure that the basic needs of the patient (privacy,
food, etc.) including maintaining consistent staff are
met.
• Attempt to understand and empathize with the
patient and acknowledge the real stresses in the
current situation (OARS!!!)
• Accept the patient´s limitations by not directly
confronting immature defenses or poor coping styles
• Set firm limits on unreasonable expectations by
consistently declaring „in order to provide the best
medical care possible….“Reasonable requests should
not be refused.
Management
• Do not directly confront the patient´s
entitlement or rage
• Gently discuss any irrational fears about the
illness or treatment and assess ability for reality
testing (transient psychosis?)
• Acknowledge and empathize with the primary
team´s countertransference. Discuss with them
the universality of these emotions.
• Use psychopharmacology when appropritate
Psychopharmacology
• depression and anxiety: SSRI, bupropion,
avoid benzodiazepines
• insomnia: mirtazapine, trazodone, melatonin
• irritability/impulsivity: divalproex,
quetiapine, olazapine, risperidone
JZ
Suicide
„There are only two kinds of psychiatrists:
those who have had patients commit
suicide, and those who will.“
Suicide
• No treatment outcome is more devastating
than suicide.
• Coping with the devastating aftermath – both
in MDs and psychotherapists and families:
shock, guilt and shame, isolation, grief,
dissociation, crises of faith about
psychotherapy and other treatments
Suicide
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•
•
•
11th leading cause of death in te USA
30 000 suicide attempts are reported annually in the USA
5-6% of attempts occur in hospitals
Study of 76 patients who commited suicide on an inpatient
psychiatric unit, 78% denied suicide ideation or intent as
their last communication
• Severe agitation or anxiety was found in 79% of the patients
during the week before their suicide
Do not rely only on oral reports of patients denying
suicidal ideas, but pay closer attention
to psychic and motor anxiety as a risk factor.
Medical conditions as predictors of
suicide
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•
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Severe pain
Congestive heart failure
Seizure disorder
Chronic lung disease
AS
Suicide: Questions
• Have you ever felt that life was not worth living?
• Did you ever wish you could go to sleep and just not
wake up?
• Have things ever reached the point where you ´ve
thought about harming yourself?
• When did you first notice such thoughts?
• Have you made a specific plan to harm or kill
yourself?
• If so, what does the plan include?
Source: APA Practice Guidelines for Assessment of Patients with Suicidal behaviors
Suicide risk assessment
• The presenting suicide ideation and
behaviors
• Recent suicide ideation and behavior over
the preceding 8 weeks
• Past suicide ideation and behaviors
• Immediate suicide ideation and future
suicide plans
Suicide risk assessment
S sex: male
A age: >45, <19
D depression
P previous attempts
E ethanol abuse
R rational thinking loss (psychosis?)
S social suppot lacking
O organized plan
N no spouse
S sickness (somatic illness with pain)
Management
Each positive answer = 1 point
Write it to the
medical record!
• 0-2: low risk
• 3-4: medium risk; outpatient treatment,
observation
• 5-6: high risk; hospitalization, especially in cases
without social support
• 7-10: very high risk; hospitalization
Literature
• Amos JJ. And Robinson RG. Psychosomatic
Medicine. An introduction to consultationliaison psychiatry. Cambridge, 2010