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Dealing with Difficult Patients Phil Antunes M.D. Scott & White Department of Psychiatry Narcissistic/Entitled Patient • Pattern of having a grandiose sense of selfimportance (exaggerates achievements and talents) • Expects to be recognize as superior without accomplishments to substantiate such recognition • Feels special and unique, and can only be understood by, or should associate with other high-status people • Arrogant, condescending, and haughty Narcissistic Personality Think of the letter “E” • Enamored with fantasies of power, unlimited success, brilliance, or ideal love • Has a sense of Entitlement • Interpersonally Exploitative • Requires Excessive admiration • Lacks Empathy (“Empathy-less”) • Often Envious, or believes others are Envious of him or her Narcissistic Personality---Teaching Points • Find out what the agenda is in seeking treatment • Acknowledge errors, but do not be overly selfcritical • Be cautious about making remarks that may be seen as critical • Monitor for signs of depression following a narcissistic injury, and treat judiciously Narcissistic Personality---Treatment • Encourage the patient to openly express his or her needs, and to ask others what their needs are • Monitor countertransference; avoid gratification or punishment • Vulnerable to hypochondriacal preoccupation--these patients are adept at getting doctors to prescribe medication Borderline Personality Disorder • Pervasive pattern of unstable interpersonal relationships • Marked impulsivity • Alteration between idealization and devaluation • Recurrent suicidal behavior, threats, or thoughts, or self-mutilation • Affective instability/lability Borderline Personality • Chronic feelings of emptiness • Inappropriate, intense anger • Transient, stress related dissociation or paranoid ideations • Identity disturbance, unstable self-image or sense of self Borderline Personality Teaching Points • Monitor countertransference feelings closely; avoid falling into the trap of projective identification Pt MD Pt MD Pt MD Borderline Personality Teaching Points • Be consistent, set and maintain firm boundaries • Be aware of possible substance abuse • Avoid prescribing large amounts of potentially lethal medications • Antidepressants may be beneficial, especially SSRIs, to decrease impulsivity • Antipsychotic medications may be helpful (“ego glue”) Borderline Personality Teaching Points • Focus on the “here and now”, rather than exploring past traumatic experiences, such as abuse • Be active; discuss splitting and strong affects as they happen • Overtime, help the patient see a connection between actions and feelings • Explore healthy alternatives/outlets instead of self-destructive behaviors Dealing with Angry Patients • May invoke the “flight or fight” response in you • Underlying meaning of patient’s anger may not be apparent or ambiguous (previous trauma, chronic illness, acute pain) • May be angry over something someone else did – Empathize without blaming – Could be your staff or your colleague – Avoid “jousting” or agreeing with patient • If angry over a systems issue, don’t explain that things probable will never change Dealing with Angry Patients • Let patient ventilate feelings in a private setting, usually with a second staff present, if possible • Show compassion and humane respect • Stay calm, don’t raise your voice, be aware of body language • You don’t have to endure frank abuse • Don’t take it personal! • Have an open dialogue with your staff about difficult patients • Have a secure online communication option available to angry patients---doesn’t tie up you or staff’s time unreasonably Histrionic Personality • • • • • From hystera, (“hysterical”) meaning uterus Excessive emotionality and attention-seeking Uncomfortable if not the center of attention Provocative, seductive, flirtatious Uses physical appearance to draw attention Histrionic Personality • Dramatic, animated in speech and behavior • Suggestible • Often feels relationships are more intimate than they actually are Histrionic Personality Teaching Points • Be careful of the patient’s eroticized transference (acting out); this is more about the patient’s defenses, not about you; Sexualizing/flirtatious behavior is a smokescreen to deeper feelings of inferiority and powerlessness; Avoid the following pitfalls: – – – – – Contributing to the eroticized transference Narcissistic needs being met by an adoring patient Voyeuristic enjoyment of the patient’s fantasies Sense of disgust at the patient’s disclosures Sadistic enjoyment of being “unavailable” to your patient • Closely monitor your reactions to and interactions with the patient • Resist too much self-disclosure Histrionic Personality Teaching Points • Help the patient build self-esteem in areas other than attractiveness • These patients are very sensitive about aging • Be aware of help-rejecting complaining References • Hickson, GB., Dealing with Angry Patients • Robinson, D. Disordered Personalities, Rapid Psychling Press • Scherger, J., Dealing with Angry Patients ???????????????????