Partners in Care:
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thinking, functioning and behaving. Typically, they have trouble decoding situations, thus difficulty in relating to people. They have limitations in relationships, social activities, work and school, and will project and blame others for their challenges, including their medical providers. They are also excessive consumers of medical services. In a 2021 Canadian study of primary medical patients, those with comorbid personality disorders had five times the rate of emergency department visits, more frequent hospitalizations and higher overall health services use. 1 In a systematic case review, impairment of the brain’ s prefrontal cortex( PFC) seems to be common in many aggressive personalities, as well as variations in brain chemistry and structure. 2
Studies have been done in primary care settings in hopes of isolating some of the most salient factors for patients presenting with demanding behaviors. Major psychological factors include:
• Insecurity or low self esteem
• Seeking attention from medical authorities
• Sense of entitlement
• Difficult communication styles
• Cultural differences
It is helpful to identify the main personality styles in medical patients. The most common are:
1. The“ easily triggered” who are generally impulsive and overly reactive to life stressors.
2. The“ somatic complainer” who expresses emotions through physical symptoms rather than make the connection with feelings or sentiment. They also present as unhappy and easily frustrated. They also feel they are not treated fairly and not understood.
3. Those with“ negative threat bias,” who always see the negative and will process life stresses as,“ The glass is always empty.”
4. The“ compulsive perfectionist” finds that whatever is offered is never good enough, and when you try to help, they can appear quite condescending. They annoy others with their obsessiveness.
Why are some patients such a challenge? We are all human and have our own traumas, losses and childhood experiences. It is appropriate to ask about an individual’ s upbringing and what their adolescence and early adulthood were like. Once you know what they have experienced and why they overreact, it is easier to deal with demanding behaviors. Those with trauma often feel bad and can’ t manage their emotions, which then spill over on others. They will distract you with drug seeking or dramatizing medical complaints. They seem to take little personal responsibility and want a quick fix or more medicine to ease their worry or obsessions. It is important to stay calm and professional and focus on the real problem. Communicate with clear information that is easy to understand which will avoid misinterpretation. You should never tell such patients that there is nothing medically wrong and their problem is psychiatric. Rather, your pain or symptom is real, just very difficult to treat.
Consider these strategies to manage your reaction to difficult personalities:
• Listen, don’ t just react.
• Avoid taking it personally. You are not the only person they treat this way.
• Don’ t judge; this patient may be in real pain and cannot manage due to their trauma history.
• Remain calm: don’ t let them control your emotions.
And remember, it’ s not about you! They are reacting to their environment and situation and are not intentionally ruining your day.
We all must learn to respond with compassion and not just react negatively to challenging behaviors. And remember to take care of your own needs:
• Recognize your own challenges and traumas, and how these negative experiences impact your transference / countertransference with patients.
• Make sure and get sufficient rest( remember to take breaks during the day).
• Balance your life with family, friendships and social diversion.
• Low carb, adequate protein and plant-based diets will give you more energy.
• Eighty ounces of water per day and minimize caffeine and soda.
• Faith life or spiritual practices can really help.
• Yoga, stretching and cardio exercise will help you relax.
Remember, these are some of our most challenging patients, yet they can have a good prognosis if cared for with patience and understanding. It is OK to ask for help or“ share” responsibilities with other team members. Medication will only provide symptomatic relief so be careful of polypharmacy. It is also helpful to have a family member or significant other who can assist with holding limits, and is willing to stick it out with their demanding partner. Professional burnout can be minimized when you employ common sense approaches to challenging communications with these most difficult patients.
References:
1
Psychiatric Services, 2021 Vol 72, Number 12
2 https:// www. sciencedirect. com, Cruz-Ausejo 2024
Dr. Wernert is the Executive Medical Director of Norton Medical Group and practices with Norton Behavioral Medicine.
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