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Mr. Downey is a 35-year-old gentleman with a history of heroin dependence, alcohol abuse, and cocaine abuse, transferred from the county jail and admitted for observation after deliberately ingesting a razor blade in order to prevent being transferred to prison. He had a similar episode two months prior to this admission in which the razor blade was removed via EGD in the emergency room. On this presentation, however, he declined an EGD, demanding instead that he be operated upon. As there was no indication of an acute abdomen, he was instead admitted for observation with the plan for him to pass the razor blade on his own, and to surgically intervene only if he developed signs of peritonitis or perforation. In the emergency department, all vitals and laboratory results are unremarkable. The patient’s last use of heroin, alcohol, and cocaine was approximately six months ago, prior to his incarceration.

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On admission, the patient is accompanied by two guards and is shackled at all times. On the floor he begins demanding clonazepam for the treatment of his anxiety disorder and hydromorphone intravenously for acute pain complaints. His affect ranges from irritable to angry to bouts of tearfulness. He intermittently swears at nursing staff as well as at you and your senior resident. Whenever his requests are denied or perceived to not be met, he begins to kick his bedside stand, yell, or bang his head on the bed or the floor until he is restrained by his guards and hospital security. On the second hospital day, an abdominal KUB shows the presence of not only the razor blade but also two batteries that the patient apparently ingested from the television remote in his room. When asked why he ingested the batteries, the patient again states his fear of returning to jail and his strong desire to avoid going back to prison “at all costs.” He then blames the surgical team for not treating his pain and anxiety causing him to “act out,” and threatens that if “no one listens” to him, he will do it again.

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1. What diagnoses might this patient have that would explain this behavior?

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2. What communication techniques would you use in approaching this patient?

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Difficult Patients

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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 ...

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