1. What diagnoses might this patient have that would explain this behavior?
2. What communication techniques would you use in approaching this patient?
All patients bring aspects of themselves into clinical encounters—and so do you. A distinction can be made between healthy or adaptive traits and dysfunctional or maladaptive traits. Adaptive traits include sound judgment, adequate frustration tolerance, delayed gratification, an ability to cooperate, and emotional control, whereas Mr. Downey exhibits a number of maladaptive traits. He experiences emotion dysregulation, moving quickly from irritability to anger to sadness. He also shows low frustration tolerance and an inability to delay gratification, as evidenced by his outbursts when not given what he requests. In addition, he overtly attacks and devalues members of the clinical team, with little, if any, regard for their concerns. His history of polysubstance dependence and requests for numerous medications also suggest generally poor coping mechanisms for managing stress or pain. Globally, Mr. Downey lacks impulse control, sound judgment, and insight into his maladaptive traits.
Clinicians also carry aspects of their own identities and personalities into clinical encounters, and at times they can feel strong emotional reactions to their patients. This is particularly the case in difficult patients, especially those who devalue others or malinger symptoms. As such, Mr. Downey likely inspires negative feelings in clinicians involved with him, including discomfort, fear, anxiety, or anger. This can lead to avoidance or neglect of the patient by the clinician, contributing further to the patient’s emotional and behavioral outbursts, which in turn leads to ever-more clinician resentment. In an effort to break this cycle, it is important to identify these reactions, and to discuss them openly with team members and supervisors.
Psychiatry can be consulted to assist in management with difficult patients. For instance, certain symptoms may be amenable to pharmacological management. Mr. Downey exhibits a labile mood and poor impulse control, suggesting the possible role for a dopamine antagonist if his outbursts cannot be otherwise managed. In the event of severe agitation or violence, patients may benefit from a dopamine antagonist as needed for behavioral control. This may reduce the incidence of agitation and violence along with decreasing the need for physical restraints. Benzodiazepines may need to be used in conjunction with dopamine antagonists to control extrapyramidal side effects and to potentiate the antipsychotic’s effect, but must be used with caution in any patient with a history of substance abuse, as Mr. Downey has. Ultimately, very close or constant observation may be necessary in order to prevent further ingestion of items that will prolong his stay. This is particularly important as a patient improves medically and surgically as disposition out of a structured setting, such as a hospital, causes some patients to regress psychologically with resulting behavioral dysregulation. Other indications for consulting psychiatry include instances in which a patient may lack the capacity to accept or refuse treatments based on poor judgment or insight, as well as general breakdowns in communication or cooperation with the treatment team.
It is important to rule out any conditions (medical and psychiatric) that contribute to maladaptive expressions or behaviors. This includes mood disorders (eg, bipolar illness), anxiety disorders (eg, PTSD), psychotic disorders, delirium, factitious disorder, malingering, or substance-induced states. When traits appear in the absence of other conditions and are pervasive, fixed, and severely maladaptive, it is important to seriously consider a personality disorder, although generally it requires a longitudinal history of this behavior before labeling a difficult patient with this kind of diagnosis. Personality disorders must be diagnosed with caution, as once a patient is labeled as such, it may make it difficult for the surgical team to treat the patient objectively without their own emotions interfering. Table 49-1 describes the various personality disorders. Mr. Downey has normal laboratory values and vitals, has not recently used mood-altering substances, is otherwise physically healthy, and has been admitted in the past for similar reasons. He very well might, therefore, have a personality disorder. However, he is clearly attempting to obtain secondary gain (remaining out of prison) by his behavior, and so malingering would be high on the differential list in this case too.
Given his maladaptive traits (lack of remorse for others, poor impulse control, emotional dysregulation, limited coping, etc), a history of incarceration, and the deliberate creation of medical problems with specific aims, Mr. Downey most likely is demonstrating malingering. He may also fit within Cluster “B” pathology and may fit the diagnosis of antisocial personality disorder.
Communicating with Mr. Downey may be difficult, but there are general techniques that can be used. First and foremost, a united, clear, and consistent message must be utilized when communicating with all difficult patients. Although most common in borderline personality disorder, all patients are capable of unintentionally splitting treatment teams so as to cause disagreements and difficulties that lead to disrupted care and poor outcomes. In addition, it is paramount that certain boundaries be clearly defined and maintained with all patients utilizing maladaptive traits.
A common technique equally useful for difficult, demanding, hostile, or dependent patients is scheduling specific, time-limited sessions that are entirely and solely treatment based (eg, seeing hospitalized patients twice at 8 am and 1 pm daily for 15 minutes each, going over very specific treatment agendas). Informing the patient of the schedule up front and then enforcing it is crucial. One will need to cater the content of these sessions depending on the person’s traits. For example, obsessive–compulsive personalities often dwell on details and minutiae; it may be helpful to enlist them in keeping track of their own recovery (vital signs, labs, medication regimen) while keeping them informed when small fluctuations and insignificant changes are not to be worried about to minimize anxiety.
Considerable anxiety, worry, and stress related to medical conditions, immobility, loss of function, or pain are each very real experiences. Empathizing with such an experience can be challenging due to a patient’s toxic demeanor and attitude but also very powerful in creating an alliance. The principal mechanism of empathy is validation or acknowledgment of a patient’s concerns. Empathy is a direct recognition of what the patient is experiencing and reflection of it back in a clear, simple, and nonjudgmental language. In Mr. Downey’s example, one might recognize his concerns and confirm them with empathic statements (eg, “It must be terrifying to think about going to prison.”) rather than with less empathic questions (eg, “What are you so worried about?”). Additionally, one may attempt to normalize concerns expressed by a patient (“Your reaction to a prison sentence is natural.”), paving the road to a shared understanding. A patient who is validated in this manner may sense genuine concern and engage in a more cooperative dialogue, leading to shared clinical goals. Finally, depending on the patient’s values, it is important to identify others who may assist in enhancing communication, including but not limited to family members, friends, intimate partners, social work, or clergy. In some instances, consultation with a psychiatric service may be indicated.
Table 49-1. Personality Disorder Diagnoses |Favorite Table|Download (.pdf)
Table 49-1. Personality Disorder Diagnoses
|Cluster A (“MAD” and “WEIRD”): odd, poor sense of reality with distorted thinking|
|Paranoid personality d/o||Excessively suspicious, holds grudges, distrusts|
|Schizoid personality d/o||Disengaged, apathetic, uninterested in interaction|
|Schizotypal personality d/o||Eccentric, odd, holding strange or magical beliefs|
|Cluster B (“BAD” and “WILD”): labile, unstable, impulsive, and behaviorally difficult|
|Histrionic personality d/o||Theatrical, exaggerated, flirtatious, seductive|
|Antisocial personality d/o||Lacking remorse, associated with criminality|
|Borderline personality d/o||Moody, self-injurious, impulsive, unstable relations|
|Narcissistic personality d/o||Grandiose sense of self, judgmental, dismissive|
|Cluster C (“SAD” and “WORRIED”): passive, preoccupied, anxious, and afraid|
|Avoidant personality d/o||Excessively shy, feels awkward, afraid of rejection|
|Dependent personality d/o||Passive, lacking self-confidence, relying on others|
|Obsessive–compulsive personality d/o||Perfectionistic, rigid, preoccupied with detail|