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Difficult Patients
Overview
The medical equivalent of war is the care of the difficult patient. Doctors soldier steadily on through all kinds of clinical chores, arduous schedules, and “administrivia,” but when they get to the types of patients variously called “obnoxious,” “needy,” “crocky,” “malignant,” and even “hateful,” they fight the worst battles of their careers, become prone to clinical blunders, mess up their personal lives, violate boundaries, and get sued. The good news is that—almost without exception—the “difficult patient” situation makes the consulting psychiatrist more useful to treating physician and patient alike than in any other medical encounter. Harrowing though such situations may temporarily be, it is just this kind of consultation that earns the trust and respect of the physician consultee and generates more consultation requests later on (and, really, there are few better ways for a psychiatrist starting out to build a practice than by becoming a specialist on the care of the difficult patient). Before turning to management strategies, it is worth reviewing the presentations of difficult patients.
Case 1
Ms. A, a 38-year-old woman with a history reported in the chart as being significant for obesity, lower back pain, systemic lupus erythematosus, chronic tinnitus, fibromyalgia, and bipolar disorder, was admitted to the hospital for fever and cough. Pneumonia was initially diagnosed, and her medical symptoms had been improving with antibiotics. However, care had been increasingly complicated by her escalating demands and seemingly endless physical complaints: she had been complaining of back pain, “because of my lupus flare” (despite any objective evidence of autoimmune exacerbation), with repeated requests for oxycodone as the only medication that will help; urinary symptoms, despite a normal exam and laboratory findings; and insomnia and anxiety. In addition, Ms. A continued to leave the hospital to smoke cigarettes and at times, went off the unit for hours at a time, and lashed out at the physician team when they told her that she needed to be present for morning rounds. Conflict broke out among staff; some nurses had excellent rapport with her and viewed her as a sympathetic character, who was at the mercy of a cold and indifferent attending physician and senior resident, as well as their apparently heartless colleagues on the night shift—who just didn't seem to understand how much Ms. A was suffering. On his first nightfloat shift on this service, the junior resident prescribed lorazepam for insomnia, despite the daytime team's instructions to withhold benzodiazepines. This error was corrected the following night, but the next morning, Ms. A told the junior resident, “I need to sleep because of my bipolar. If you don't give me my lorazepam, I'm gonna kill myself”. An argument ensued between the patient and the junior resident, which escalated and resulted in a loud verbal conflict between the resident, the nurse, and the charge nurse. By the time the consultant received the consult request (delivered in an indignant, angry tone by the rotating subintern), the entire staff was in an uproar.
Types of Difficult Patients
Delirious patients may be assaultive. Guilty, bereaved spouses can be litigious. Temporal lobe epileptic patients are often clingy and viscous. Manic patients are emotional cyclones. Celebrities at times generate anxiety in their caregivers. Patients with schizophrenia can be non-compliant. Anyone when ill can regress and become angry, dependent, and hypochondriacal—yet none of these difficult situations necessarily produces “difficult patient” scenarios.
Difficult patients are almost always persons with personality disorders, or at least those who, in the face of medical illness, severe psychosocial stress, alcohol and substance use disorders (SUDs), regressively display the maladaptive traits so characteristic of the personality-disordered patient. This highlights the importance of differentiating state versus trait: true personality disorders lie closer to trait because they are relatively durable over time, while SUDs and eating disorders lie closer to state because change, when it occurs, can be dramatic. In the Diagnostic and Statistical Manual of Mental Disorders , 5th edition (DSM-5), personality disorders are defined by clusters of traits, while SUDs are associated with maladaptive behaviors that the substance gives rise to. However, the consultant will do well to remember that patients encountered on inpatient units are often at their worst—and as personality disorders are diagnosed based on traits observed over time, the patient with “borderline traits” may not meet criteria for the actual personality disorder despite seeming to exhibit evidence during an acute medical illness. Despite their reputation of being intractable and chronic conditions, even the stability of full-fledged personality disorders over time has come under scrutiny in recent years, as prognosis, change, and recovery now appear perhaps more favorable for some disorders than previously thought.
Not all patients with personality disorders are difficult patients or necessitate psychiatric consultation. Looking at pure types through the lens of DSM-5, those not necessarily belonging to the difficult patient paradigm are paranoid, schizoid, and schizotypal personality disorders (cluster A), and avoidant, dependent, and obsessive–compulsive personality disorders (cluster C), which do not necessarily belong to the difficult patient paradigm. Patients with a paranoid personality disorder deserve brief mention, however, as the nearly boundless suspiciousness, hostility towards others, and extreme employment of projection often render them problematic to the primary clinical team when they must—always reluctantly—seek medical care.
Nonetheless, although some of these may be difficult patients, it is really when we look into Cluster B disorders that a pit of despair opens: antisocial, borderline, and narcissistic (for the sake of this discussion, histrionic patients are grouped with borderline patients because, as difficult patients, they are almost indistinguishable). With these three diagnoses, comprising the dramatic-emotional-erratic cluster, there is almost a complete overlap between difficult patients and personality disorders. DSM-5 defines them as the following:
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Antisocial personality disorder involves a pattern of disregard for, and violation of, the rights of others.
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Borderline personality disorder is characterized by a pattern of instability in interpersonal relationships, poor self-image, labile and dysphoric affects, and marked impulsivity.
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Narcissistic personality disorder is embodied by a pattern of grandiosity, a need for admiration, and a lack of empathy.
The key word here is pattern . Personality traits lead to personality disorder when they are “inflexible and pervasive across a broad range of personal and social situations,” leading to significant distress or impairment in multiple domains of functioning. These traits are enduring for most of the life span, and deviate markedly from the expectations of the patient's culture. Finally, they do not result from another mental or physical disorder, such as depression or head trauma.
Antisocial and Narcissistic Personality Disorders
Patients with antisocial personality disorder display the defining trait of disregard for the rights of others. The disorder satisfies the general criteria for the other personality disorders and consistently manifests at least three of the following traits: rule-breaking; deceitfulness (e.g., lying, conning others); impulsivity or poor planning (resulting in a parasitic lifestyle that is sustained by manipulating others); aggressiveness (with repeated assaults and fights); irresponsibility (failing to sustain a job or uphold financial obligations); and a lack of conscience, remorse or empathy.
Narcissistic personality disorder defines itself in the grandiosity and lack of empathy shown by at least five of the following traits: arrogance; a preoccupation with fantasies of power, beauty, love, brilliance, or money; convictions of “specialness”; a hunger for admiration; entitlement; exploitation and manipulativeness; stunted empathy (an inability to “feel into” the other person); envy; and displays of contemptuousness.
Antisocial personality disorder and narcissistic personality disorder are similar in terms of selfishness but different in terms of social destructiveness. One could think of the difference as that between criminality and shabby ethics. Whether these two entities differ more in degree or in kind is a question perhaps better left to religion or philosophy, yet in psychiatry one view has been that the personality disorders have similar ego defects (except in degree) and similar underlying psychic organizations or even a common borderline personality organization . If it is true that a change in social context (e.g., incarceration) brings out borderline personality in persons who otherwise look antisocial, as some have claimed, there may be some utility to the notion of a core personality disorder called borderline with several variant presentations . At any rate, the management strategies discussed subsequently work for borderline and for other personality disorders alike, given a rigorous application and a sufficiently strong social structure.
The concept of an underlying or core borderline personality organization is a metaphor that has considerable utility in the discussion of the difficult patient. In the medical setting, antisocial and narcissistic patients are difficult only when they are acting like borderlines. The idea is that the underlying good–bad split or fragmented borderline personality organization is held together by the self-promoting program of the antisocial person and the grandiosity of the narcissist. Antisocial and narcissistic patients who believe their physicians' interests parallel their own are unctuous and un-difficult (“prison sincerity”). When the psychopathy and grandiosity are punctured by illness or injury and thwarted by medical treatment, the underlying fragmented, rageful, splitting, attacking borderline comes out. In the discussion that follows, therefore, borderline personality is the referent paradigm of difficulty, to be discussed more at length and used interchangeably with difficult patient .
Borderline Personality Disorder
“Borderline personality” was originally named because it seemed to psychoanalysts to lie between the psychoses and the neuroses. Borderline patients are dreaded for their impulsivity, swings from love to hate, and maddening irrationality. They split the world into exaggerated dichotomies of good and evil. An interpersonal middle ground does not exist. These patients, by some combination of innate rage and inept parenting, cannot find a moderate position in any aspect of mental life.
Borderline patients have a multi-faceted personality disorder that goes beyond the repeated self-injurious behavior once referred to as the “behavioral specialty” of the disorder, with characteristics grouped into four broad domains of affective, interpersonal, behavioral, and cognitive features. Symptoms range from bordering on psychosis, in which the patient is chaotic or irrational, to bordering on neurosis, in which the patient desperately clings to others to feel real—reflective of historical assumptions that the disorder represented a “border” state between psychosis and neurosis. The borderline patient exhibits five or more of the following traits: frantic efforts to avoid or prevent (usually perceived) abandonment, a pattern of intense interpersonal relationships characterized by unstable alternations between idealization and devaluation; unstable sense of self or identity; impulsive behaviors that may be self-damaging; recurrent suicidal ideation, attempts, threats, or self-mutilation; marked mood reactivity and affective instability; inappropriate, intense anger and poor self-control of anger; chronic feelings of emptiness, and transient paranoid ideation and dissociative symptoms.
In the past, borderline personality was sometimes held to be a sub-set of biological depressive illness or a variant of traditional diagnoses, such as hysteria, sociopathy, or alcoholism. This is likely reflective of the high rates of co-morbid psychiatric disorders found in this population: one of the more rigorously conducted studies to date followed 290 borderline personality patients, and found that even at 6-year follow-up, 75% of these patients surveyed met criteria for a mood disorder (61% for major depression), 35% for post-traumatic stress disorder (PTSD), 34% for an eating disorder, 29% for panic disorder, and 19% for a substance use disorder (SUD). More striking is the fact that this represented a decline from initial surveys, and that even in patients whose borderline personality remitted, psychiatric co-morbidity remained high. Rates of remission of symptoms of both borderline personality and affective disorders have similarly been shown to reciprocally delay the time to recovery of each other, suggesting an interplay of related, but separate, etiologies. Unfortunately, borderline personality disorder remains both underdiagnosed as well as misdiagnosed (often as bipolar disorder). The consultant would therefore do well to thoroughly review the diagnostic criteria and differential diagnosis of this disorder.
Regardless of sub-type or co-morbid diagnosis, however, borderline patients can abruptly flee treatment or develop psychotic transference and delusions about their caregivers. Short, circumscribed episodes of delusional thinking in unstructured situations and when under stress are almost pathognomonic. Borderlines display a signature trait, poor observing ego, which is a dense denial of vital aspects of reality and irrationality to a degree that almost has to be seen to be believed. Although the relation of borderline personality to schizophrenia was long debated, it is likely that if there is a “border” with a biological illness, it is closer to affective illness without being completely tangential to it.
Heredity plays a crucial role in the cause of borderline personality, with 42% to 68% of the variance found to be associated with genetic factors. Innate intolerance to anxiety and a constitutional tendency toward rage have long been accepted even by psychoanalytic theorists regarding borderline personality. Individual features of borderline personality disorder have also been found to run in families. Many studies have examined the co-aggregation of borderline personality and other psychiatric disorders in families; however, a recent review found that while evidence was suggestive of a familial relationship of borderline personality with major depressive disorder (MDD) and SUDs, conclusions are limited by methodologic problems in most studies and more evidence is needed.
Psychologically based theories also focus on the family of origin. Psychoanalysts view borderline personality as arising from failure by the patient's mother to foster coherent differentiation between self and object in the first 18 months of life, leading to the development of pathologic ego defenses. The patient does not learn to tolerate negative affect associated with separation; this continues the child's clinging into adulthood, as if others were desperately needed parts of the self. The borderline's adult relationships are called transitional after the transitional object. The patient's mother (possibly borderline herself ) apparently feared fusion with (and destruction of or by) the child. She could not let the child separate because of her own fears of being alone. On rapprochement, she tended to reject the child for “deserting” her. She mostly saw the child as her own transitional object and—used as the imaginary playmate of the mother—the child never grew into an emotionally separate human being.
In borderline personality, the boundaries between the self and others are blurred, so that closeness seems to threaten fusion. Sexuality and dependency are confused with aggression. Needs are experienced as rage. Long-term relationships disintegrate because of an inability to find optimal interpersonal distance. Because of inadequate ego mechanisms of defense, there is little ability to master painful feelings or to channel needs or aggression into creative outlets. Ambivalence is poorly tolerated. Impulse control is dismal. The patient has a fragmented mental picture of the self and views others as all bad and simultaneously all potent, a chaotic mixture of shameful and grandiose images.
In addition to the literature on inadequate parenting, borderline personality is linked with parental neglect and abuse, particularly severe or sexual abuse. The analytically based theory put forth is that the child victim of sexual abuse (especially of chronic abuse ) used dissociation as a defense against massive psychic trauma, and the dissociation became habitual, undermining ego integration. This association with abuse is seen as variously explaining phenomena ranging from a propensity toward dissociative psychotic-like episodes, rage, sexual disorders, psychotic–erotic transferences in psychotherapy, and self-mutilation. The literature on abuse has the important effect of spotlighting the relationship between borderline phenomena and dissociation, something the older literature under-emphasized. Although the exact role that abuse plays in the development of borderline personality is still being worked out, it is clear that a significant number of borderline patients, when asked to give a history of such abuse, do so; this has to be taken into account in management.
Borderline personality occurs in perhaps 2% of the population. Despite its small size, the borderline cohort stands out in the general hospital because of its florid presentation, notoriety for frequent utilization of both psychiatric and medical services, and because of the feelings of anger and helplessness stirred up in the caregivers.
These patients often make themselves medical outcasts because they ruthlessly destroy the care they crave. However, because of this, the diagnosis of borderline personality has unfortunately attracted a considerable amount of bad press, both within the lay public, the medical community at large, and even among psychiatrists and other mental health clinicians. This fact begs the question of how this affects psychiatric, medical, and nursing care, as clinicians who seek to avoid the difficult patient may overlook important clinical signs and under-diagnose disease, in an unconscious effort to limit patient interaction. Medical co-morbidity in borderline patients is significant, at least partly due its association with obesity; a 10-year longitudinal study found that compared ever-recovered to never-recovered borderline patients, the latter had significantly higher rates of chronic health conditions—notably obesity, diabetes, urinary incontinence, and osteoarthritis—as well as poorly defined illnesses, such as chronic fatigue syndrome and fibromyalgia. They also had higher rates of poor health-related life-style choices, financial burdens related to medical illness, and higher rates of utilization of costly medical services. Appropriate medical care is thus sorely lacking in this population, shunned as it is by the medical community—and thus adroit management of the inpatient medical team is of paramount importance in effecting sound patient care, as is discussed later in the chapter.
Difficult Behavior and the Consultee
The previous discussion about the DSM-5 diagnoses of difficult patients must be leavened with a simple fact: it is not the diagnosis of these patients that makes them difficult for the consultee—it is their behavior. The relationship of the behavior to other aspects of mental life is schematized in Figure 43-1 .
Such patients have abnormally intense affects, poorer-than-average neutralizers of affect, or both. In any case, raw rage, naked dependency, and ontologic shame are present and are often found on the surface. The cognitive structures that ordinarily temper intense affects are distorted and primitive. The ego weakness of the patient is shown by the absence of higher-level defenses and by the primitive nature of the ones that are present.
Under pressure of intense affect (rage, terror, shame), the patient uses dissociation to a greater or lesser extent and enters the dream-like state that persons ordinarily enter only in extreme emergencies. In this dissociated state (which is probably present much of the time to some degree), the patient is distracted, numb, and difficult to reach. The pervasiveness of dissociation is one feature of borderline personality that is insufficiently discussed in the literature; however, it can contribute drastically to the pathologic cognitions of borderline patients and place a distorting lens of unreality between them and the real world.
Besides dissociation, the borderline patient uses denial of major aspects of reality to cope. This mythification of the external, threatening world is displayed in defenses called primitive idealization, omnipotence , and devaluation . As the names imply, these are metaphors for the dreamy, wishful, mythified world the difficult patient inhabits, a world of black and white and good and evil. These maladaptive defenses may be all too visible in the medical setting, but even more troubling are two others with which such patients unsuccessfully try to manage their extreme negative affects: splitting and projective identification.
Splitting is by definition a rigid separation of positive and negative thoughts or feelings. Normal persons are ambivalent and can experience two contradictory feeling states at one time; the borderline personality characteristically shifts back and forth, entirely unaware of one feeling state while in another. Sometimes one state is rigidly held while its opposite is projected onto the environment. Splitting may protect the patient from the anxiety of reconciling contradictory extremes (at the expense of the already unstable personality). In social systems, borderline patients can split the staff into warring “good” and “bad” factions that unwittingly act out the patient's internal world.
Projective identification is said to consist of taking an unwanted aspect of the self, such as cruelty or envy, and wholly ascribing it to (“projecting it into”) another. The patient then unconsciously pressures that person to own the projected attribute. Unaware that a self-fulfilling prophecy is being set-up, the recipient complies with the projection and acts it out. These two mechanisms can complement each other, with projective identification being used to “confirm” one side of a polarized, split view of the world.
Although the long-term psychotherapy of the borderline patient can involve therapeutic undoing of these defenses, it is inadvisable—even dangerous—to confront such defenses in brief encounters in the medical setting. It is crucial, however, to be aware of their presence. For example, awareness of borderline splitting prepares the consultant to deal with the division of the medical staff into “good ones” and “bad ones.” Recognition of the patient's primitive idealization, of a physician for instance, can help the consultant prepare for the furious devaluing that is to follow.
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