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The difficult patient Psychodynamics: Coping styles, defense mechanisms and countertransference Suicide: Assessment of suicide risk and management.

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Presentation on theme: "The difficult patient Psychodynamics: Coping styles, defense mechanisms and countertransference Suicide: Assessment of suicide risk and management."— Presentation transcript:

1 The difficult patient Psychodynamics: Coping styles, defense mechanisms and countertransference Suicide: Assessment of suicide risk and management

2 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?“

3 Difficult patient presents with Vague and generalized somatic symptoms Depression Anxiety Medication non-adherence A personality disorder Excessive demands and repeated visits 15% of patients labeled as difficult

4 Difficult patients evoke strong emotional reactions Aversion Fear Despair Malice

5 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

6 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

7 Personality Personality types Personality disorders Continuum

8 Personality types Personality: a combination of characteristics that predisposes them to think, feel and behave Inborn: temperament Environmentally influenced: character

9 Identify personality types Quizz: Have you seen this picture before? a)Yes b)No c) Do not know Sanguine Melancholic Phlegmatic Choleric

10 Personality disorder Individual uses a personality style: Rigid Extreme Maladaptive Damaging to self or others Result: impairment in interpersonal, social or occupational domains

11 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 of the illness and treatment

12 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

13 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

14 Coping styleDescription ConfrontativeHostile or aggressive efforts to alter a situation DistancingEfforts to mentaly detach self from a situation Self-controllingAttempting to regulate one´s feelings or actions Seeking social support Atempting to seek emotional support or information from others Accepting responsibilityAccepting a personal role in the problem Escape-avoidance Efforts to escape/avoid a problem or situation, both cognitively and behavioraly Planful problem solvingAttempting to come up with solutions to alter a situation Positive re-appraisalRe-framing a situation in more positive light

15 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?“

16 Defense mechanism Description Mature HumorEmphasizing the amusing or ironic aspect of the conflict or stressors SublimationChanneling unacceptable impulses into more constructive activities SuppressionIntentional exclusion of material from conscioussness Neurotic DisplacementTransfer 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 RationalizationInventing a socially acceptable and logical reason why one is not bothered Reaction formation Going to the opposit extreme to overcompensate for unacceptable impulses RepressionInvoluntary forgetting of a painful event Immature Acting outPerforming an action to express unconscious emotional conflicts usually antisocial in nature DevaluationExagerating negative qualities of others IdealizationOverestimating the desirable qualities of self or others Passive aggression Indirect and passive expression of anger towards others ProjectionAttribution of own unaccpetable desires /imulses to another person RegressionReversion of personality to a lower level of expression SplittingSeparating people and actions into categories of all good and all bad Psychotic Projective identification Projecting a negative aspect of the self onto another and then coercing the other into identifying with the projected emotion Psychotic denialFailing to recognize obvious implications or consequences of a thought, act or situation

17 Immature defenses Description Acting out Performing an action to express unconscious emotional conflicts usually antisocial in nature DevaluationExagerating negative qualities of others Idealization 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 SplittingSeparating people and actions into categories of all good and all bad

18 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!

19 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

20 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?

21 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

22 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

23 Psychopharmacology depression and anxiety: SSRI, bupropion, avoid benzodiazepines insomnia: mirtazapine, trazodone, melatonin irritability/impulsivity: divalproex, quetiapine, olazapine, risperidone

24 Suicide „There are only two kinds of psychiatrists: those who have had patients commit suicide, and those who will.“ JZ

25 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

26 Suicide 11th leading cause of death in te USA 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.

27 Medical conditions as predictors of suicide Severe pain Congestive heart failure Seizure disorder Chronic lung disease

28 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

29 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

30 Suicide risk assessment S sex: male A age: >45, <19 D depression P previous attempts E ethanol abuse R rational thinking loss (psychosis?) S social suppot lacking O organized plan N no spouse S sickness (somatic illness with pain)

31 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!

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


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