When students are asked why they enter medicine, a common answer will be helping others and contribute to the welfare of humanity. However, after even a few years of clinical practice, many physicians will readily admit to experiences of anger, frustration, inadequacy, and, occasionally, strong negative reactions towards patients. (James Amos, Psychosomatic Medicine)
Narcissistic Injury self view injury… self concept injury. Separation from family and their comfortable environment may lead to conscious or unconscious feeling of abandonment (not only in children.. It can occur in adults…). E.g. of separation newly diagnosed AIDS pt may fear rejection from community and abandonment by family. An advanced cancer pt may elect to undergo another course of chemotherapy despite the low likelihood of success rather than seek palliative and end of life care because the latter would signify giving up. The pt might fear that his oncologist who had worked with him for a decade would abandon him. (Textbook of Psychosomatic Medicine).
Character style develops from both life experience and temperament (inborn). The 3 factors: coping strategies, meaning of illness and psychological defenses affects the psychological responses to illness and these appear in the form of mood and behavior. Does the flowchart stop here?... One important factor is the psychodynamic interaction with the treating team and their countertransference toward the patient. The ongoing psychodynamic interaction between the patient and the team is an important period of time to manage the patient condition.
For example Maladaptive denial A lung cancer patient continue smoking thinking he has a mild lung condition. Adaptive denial Use of denial in an advanced pancreatic cancer patient might enable him to maximize his quality of life in the months before his death. Healthy individuals usually use different defenses throughout their lives, whereas pathological use occurs when persistent use of certain defenses leads to maladaptive behavior that affects one’sphysical and/or mental health. (James Amos, Psychosomatic Medicine)
* Simply stated, immature defenses make others suffer, while neurotic defenses cause the self to suffer. (James Amos, Psychosomatic Medicine)
A central task of the psychiatrist working with the medically ill is to understand patients’ subjective experience s of illness. (ask questions like: what do you know about your condition? What was your first response when hearing about it? Any current symptoms and how do you manage? How did it affect your life? What do you know about the prognosis and future plans?)
It is important for the consultant to understand not only the underlying causes of the patient’s behavior, but also the emotions generated in the treating staff, if a successful resolution is to be achieved. (James Amos, Psychosomatic Medicine, 2010).
Being aware of these emotions allows the clinician to attain better understanding to and provide better care for the patient.
Will need to speak with nursing staff and family; get thorough medical, psych and substance hx, thorough physical exam, incl neuro/cognitive exam Nature of precipitants, envt in which agitation occurs. * Keeping in mind that comorbidity often present but we have to treat the most serious condition/s first.
Dealing with the difficult patients in the medical setting
Dealing with Difficult
Patients in the Medical
University of Toronto psychosomatic medicine fellowship
– Who are the difficult patients?
– Do All patients become difficult?
– The emotions of the treating team
– The Hateful Patients
– How to assess a difficult patient?
– How to manage?
– “A 40 year old male admitted with myocardial infarction calls office of the
hospital CEO to complain about his care. Assess for psychiatric disorder.”
– “A 35 year old female patient with AML refuses the second time of bone marrow
aspiration. She looks less motivated. Is she depressed?”
– “We need help with a 64 year old professional male with ESRD on hemodialysis.
He has been kicked out of all other dialysis centers due to his obnoxious
behavior. He screams at and berates the staff and may be banned from our state
operated unit. Is there anything that can be done to manage his behavior?”
The Difficult Patients
– Multiple somatic complaints
– Anger or irritability
– Excessive demands
– Wandering, pulling out lines
– Drug-seeking behavior
– Excessive requests for attention
– Physically or verbally aggressive
- Up to 15% of patients are labelled difficult by their physicians.
A stressful Situations
– Narcissistic Injury
– Reexamine their own self-views and address any feelings of invulnerability to illness
– Confronting the impermanence of life.
– These lead to Patient to feel “defective, weak, and less desirable”.
– Being in a hospital
– Forcing a patient to endure both body exposure, in thin flimsy gowns, and constant
personal and bodily intrusions.
– From their normal comfortable environment and social support.
Psychological Responses to
Behavioral ResponsesAffective Responses
Life history/experience Temperament
Stresses of illness
Lazarus RS: Stress and Emotion: A New Synthesis, Textbook of Psychosomatic Medicine, 2nd edition, 2011
– A conscious effort to alter a stressful situation.
– Hundreds of coping strategies have been identified.
– Problem-focused coping
– Seeking information, planning, and taking action.
– Emotion-focused coping
– Involve focusing on positive aspects of the situation, mental or behavioral
disengagement, and seeking emotional support from others.
Coping Style Description
Confrontative Hostile or aggressive efforts to alter a situation.
Distancing Efforts to mentally detach self from a situation.
Self-controlling Attempting to regulate one’s feelings or actions.
Seeking social support Attempting 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 behaviorally.
Planful problem solving Attempting to come up with solutions to alter a situation.
Positive re-appraisal Re-framing a situation in a more positive light.
- Use a combination of problem & emotion
- Optimistic, practical, flexible, and composed
- Consider possible outcomes and emphasize
- Often are unable to make decisions.
- Hold rigid and narrow views.
- Passive and deny excessively.
- Moments of impulsivity and unexpected
– Mental operations that remove some component(s) of unpleasurable affects
(emotions) from conscious awareness—the thought, the sensation, or both.
– Largely unconscious.
– A coping strategy or defense mechanism may be relatively maladaptive or
ineffective in one context but adaptive and effective in another.
– Defenses most often used by “difficult patients”
– fall under the immature category.
– characteristic of the cluster B personality disorders.
– Often are irritating to others as this defense style transmits patients’
“shame, impulses, and anxiety to those around them”
– Neurotic defenses, which can also be maladaptive
– experienced more privately and usually do not annoy others because they do
not distort reality as much.
Meaning of Illness
Personality Type Characteristics Meaning of Illness
Dependent Need, demanding, unable to reassure self
Seeks reassurance from others
Threat of abandonment
Obsessional Meticulous, orderly, likes to feel in control, dichotomous Loss of control over body/emotions/impulses
Histrionic Entertaining, dramatic, seductive Loss of love or attractiveness
Masochistic “Perpetual victim” Ego-syntonic, conscious or unconscious
Paranoid Guarded, distrustful, sensitive to slights Proof that world is against patient
Medical care is invasive and exploitative
Narcissistic Arrogant, devaluing, vain, demanding Threat to self-concept of perfection and
invulnerability, shame evoking
Schizoid Aloof, distant Fear of intrusion
Adapted from: James Levenson, Textbook of Psychosomatic Medicine, 2nd edition, 2011
– Classically reactions to a patient that represent the past life experiences of
– For example,
– A frail elderly woman is given extra attention by a physician because she reminds
him of his mother.
– A young diabetic patient is scolded for non-compliance because the nurse’s own child
is diabetic and non-compliant.
– Recently, countertransference has come to encompass all feelings and attitudes
of clinicians towards the patient, both physician- and patient-originated.
– Often result in negative reactions (aversion, fear, despair, or even malice).
– Positive reactions should be watched also.
– May predict later devaluation.
– May Potentially lead to significant boundary violations on the part of the
clinician, in an effort “to do everything possible” for the patient.
The Hateful Patients
Coping Styles Countertransference
Power and special
Wish to escape
Confrontational Fearful of reputation
Enraged about demands
Anxiety overlooking illness
(or any cluster B)
Acting out, Devaluing
Wish the patient were dead
– A forty-five year old male with a history of peripheral vascular disease who
recently underwent a below the knee amputation is now crying and sobbing on
the unit. He becomes highly anxious and despondent when there is not
somebody in the room with him, calling for the nurses unnecessarly. When
family is present, he requires their constant attention, requesting they feed him,
help him drink liquids, and even blow his nose, despite full upper extremity
– “A fifty-six year old male is admitted to the hospital secondary to AIDS
Through out the hospitalization, he is belligerent and belittling to the staff and
physicians, including the junior members of the psychosomatic service. He is
pleased to hear that his case is ‘unique,’ requiring the director of the
psychosomatic service to meet him personally. Upon arrival of the director, the
patient immediately comments, ‘you have a lot of guts wearing that outfit. How
much is it worth? $100? $1000? You could feed a hundred starving children in
Africa for your one outfit. I hope you can live with yourself.’”
– A sixty-eight year old female who recently left AMA from another hospital
presents to the emergency department for worsening edema of her lower
extremities. Upon further evaluation, she is found to have significant congestive
heart failure and is admitted. During her admission, she is initially cooperative
with the primary team, but as her condition improves, she becomes belligerent
and hostile with the staff, complaining that her water has too much ice in it, the
coffee is not served on time, and the nurses are not looking at her properly.
Indignant, she demands to leave the hospital AMA, stating that she will get
better care elsewhere. When records are obtained from the other hospital, it is
discovered that a similar scenario occurred there.
– A thirty-six year old male with end-stage liver disease has frequent re-
admissions to the hospital for altered mental status. Despite his worsening
status, he continues to drink heavily and uses other illicit substances. With each
admission, he requests a liver transplant but then angrily reacts when he is
advised that abstinence is a requirement for transplant consideration.
He is hostile and belligerent with the staff, threatening them on multiple
Assessment of the Difficult Patient
Awake and Alert?
Mood, Psychotic, or
Monitor for withdrawal
Delirium or Dementia
Search for cause
Personality Disorder? Psych tx
Educate & help staff
Angry? Explore; patient rep
In Pain/discomfort? meds
Jerk/Criminal? security, police
Explore patient’s experience
Educate & help staff
Set limits; Prn meds
Reassess when awake
Search for cause of impaired arousal
Hold sedating meds for evaluation
Manage agitation if recurs
Mary Jo Fitz-Gerald, MD, The “Difficult” Patient, Academy of Psychosomatic Medicine 2013
– Ensure that the basic needs of the patient (privacy, food, etc.) are being met.
– Attempt to maintain consistent staff.
– Attempt to understand and empathize with the patient.
– Acknowledge the real stresses in the current situation.
– Accept the patient’s limitations by not directly confronting immature defenses
or poor coping styles.
– Set firm limits on unreasonable expectations by consistently declaring that “in
order to provide the best medical care possible ...” However, reasonable
requests, or approximations thereof, should not be refused.
– Gently discuss any irrational fears about the illness or treatment that the
patient may have, and assess his ability for reality testing (i.e., ensure that a
transient psychosis is not occurring).
Helping the treating team
– Acknowledge the reactions of the treaters and empathize with their
– Acknowledge universality of their feelings
– Model non-sadistic behavior and appropriate limit setting
– Arrange team meetings to prevent splitting
– Develop clear behavioral management strategy
– Ally with staff- DO NOT interpret staff’s pathology
– Explain patient’s reality to staff
– Give permission to say no to excessive demands
– Recommend interventions needed for safety
– May be of benefit in treating Axis I Disorders such as mood, anxiety, or
– Impulsivity and anger may respond to mood stabilizers and antipsychotics
– Avoid agents with addictive potential due to the propensity for substance
abuse in these patients
– James Amos, Psychosomatic Medicine an Introduction to Consultation-Liaison
– James Levenson, Textbook of Psychosomatic Medicine, second edition 2011
– Mary Jo Fitz-Gerald, MD, The “Difficult” Patient, Academy of Psychosomatic
– Jerome S. Blackman, 101 Defenses, 2004.