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 symptomsDepressionAnxietyMedication non-adherenceA personality disorderExcessive demands and repeated visits

15% of patients labeled as

difficult

Difficult patients evoke strong emotional reactions

• 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

Quizz:Have you seen this

picture before?a) Yesb) No

c) Do not know

SanguineMelancholicPhlegmatic

Choleric

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 ofthe illness and treatment

Healthy and adaptive copers

• Use combination of problem and emotion-focused 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

Description

MatureHumor Emphasizing the amusing or ironic aspect of the conflict or stressors

Sublimation Channeling unacceptable impulses into more constructive activities

Suppression Intentional exclusion of material from conscioussness

NeuroticDisplacement Transfer of unacceptable thoughts, feelings or desires from one object to a less threatening substitute

Isolation of affect

Separation of painful idea /event from feelings associated with it

Rationalization Inventing a socially acceptable and logical reason why one is not bothered

Reaction formation

Going to the opposit extreme to overcompensate for unacceptable impulses

Repression Involuntary forgetting of a painful eventImmatureActing out Performing an action to express unconscious emotional conflicts usually antisocial in nature

Devaluation Exagerating negative qualities of othersIdealization 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

PsychoticProjective identification

Projecting a negative aspect of the self onto another and then coercing the other into identifying with the projected emotion

Psychotic denial Failing to recognize obvious implications or consequences of a thought, act or situation

Immature defenses

Description

Acting out Performing an action to express unconscious emotional conflicts usually antisocial in nature

Devaluation Exagerating negative qualities of othersIdealization 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

• 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.

Understand them, recognize the defense

mechanisms and coping styles

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

Suicide

„There are only two kinds of psychiatrists: those who have had patients commit

suicide, and those who will.“

JZ

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

• 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

• Severe pain • Congestive heart failure• Seizure disorder• Chronic lung disease

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

AS

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 assessmentS sex: maleA age: >45, <19D depression

P previous attemptsE ethanol abuseR rational thinking loss (psychosis?)S social suppot lackingO organized planN no spouseS sickness (somatic illness with pain)

Management

Each positive answer = 1 point

• 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

Write it to the medical record!

Literature

• Amos JJ. And Robinson RG. Psychosomatic Medicine. An introduction to consultation-liaison psychiatry. Cambridge, 2010