Difficult Patient – UpToDate

1 When physician-patient interaction is deemed difficult, diagnose personality disorder when it is present in patients.

RECOGNIZING PERSONALITY DISORDERS — The clinician may feel angry, threatened, defensive, or incompetent, or may find it difficult to feel any emotional connection with the patient. Alternatively, the clinician may find him or herself preoccupied with the patient without any specific event or attribute that would reasonably induce such involvement. These clinician reactions may provide some evidence toward the consideration of a personality disorder, although they are certainly not pathognomonic for this diagnosis.

The consistent presence of certain behaviors and traits, with onset in middle to late adolescence and continuing throughout adult life, are particularly suggestive of a personality disorder:

  • Frequent mood swings
  • Angry outbursts
  • Anxiety sufficient to cause difficulty making friends
  • Need to be the center of attention
  • Feeling of being widely cheated or taken advantage of
  • Difficulty delaying gratification
  • Not feeling there is anything wrong with their behavior (ego-syntonic symptoms)
  • Externalizing and blaming the world for their behaviors and feelings

2 When confronted with difficult patient interactions, seek out and update, when necessary, information about the patient’s life circumstances, current context, and functional status.

3 In a patient with chronic illness, expect difficult interactions from time to time. Be especially compassionate and sensitive at those times.

4 With difficult patients remain vigilant for new symptoms and physical findings to be sure they receive adequate attention (e.g., psychiatric patients, patients with chronic pain).

People with schizotypal, schizoid, and paranoid personality disorders (Cluster A) often do not readily seek treatment unless dealing with acute problems such as a substance use disorder. For those who do seek treatment, there is evidence that these patients have great difficulty establishing a therapeutic relationship.

5 When confronted with difficult patient interactions, identify your own attitudes and your contribution to the situation.

6 When dealing with difficult patients, set clear boundaries.

Borderline, narcissistic, histrionic, and antisocial personality disorders (Cluster B) are each associated with testing and pushing the limits of the treatment relationship. Clinicians need to take great care to avoid crossing appropriate boundaries in a quest to build a relationship. Many Cluster B patients present the most daunting challenges to maintaining a therapeutic relationship.

7 Take steps to end the physician-patient relationship when it is in the patient’s best interests.

8 With a difficult patient, safely establish common ground to determine the patient’s needs (eg. threatening or demanding patients).

Building a therapeutic relationship with patients with dependent, avoidant, and obsessive-compulsive personality disorders (Cluster C) is facilitated because these patients are willing to take responsibility for their problems and more readily engage in a dialogue with the therapist to try to solve them in comparison to patients with more severe Cluster A or B disorders.


Reference: UpToDate 2014

Posted in 27 Difficult Patient, 99 Priority Topics, FM 99 priority topics, Others

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