1. Dealing with Difficult Patients Phil Antunes M.D. Scott & White Department of Psychiatry

2. Narcissistic/Entitled Patient Pattern of having a grandiose sense of self- importance (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

3. 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

4. Narcissistic Personality---Teaching Points Find out what the agenda is in seeking treatment Acknowledge errors, but do not be overly self- critical Be cautious about making remarks that may be seen as critical Monitor for signs of depression following a narcissistic injury, and treat judiciously

5. 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

6. 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

7. 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

8. Borderline Personality Teaching Points Monitor countertransference feelings closely; avoid falling into the trap of projective identification Pt MD

9. 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)

10. 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

11. Dealing with Angry Patients May invoke the flight or fight response in you Underlying meaning of patients 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, dont explain that things probable will never change

12. 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, dont raise your voice, be aware of body language You dont have to endure frank abuse Dont take it personal! Have an open dialogue with your staff about difficult patients Have a secure online communication option available to angry patients---doesnt tie up you or staffs time unreasonably

13. 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

14. Histrionic Personality Dramatic, animated in speech and behavior Suggestible Often feels relationships are more intimate than they actually are

15. Histrionic Personality Teaching Points Be careful of the patients eroticized transference (acting out); this is more about the patients 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 patients fantasies – Sense of disgust at the patients disclosures – Sadistic enjoyment of being unavailable to your patient Closely monitor your reactions to and interactions with the patient Resist too much self-disclosure

16. 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

17. References Hickson, GB., Dealing with Angry Patients Robinson, D. Disordered Personalities, Rapid Psychling Press Scherger, J., Dealing with Angry Patients

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