Shawn B Hersevoort MD MPH UCSF Fresno Psychiatry
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What defines personality and personality disorder? What are the different clusters of personality disorders and how do they relate to patient care? Who do we describe as a “difficult patient” and why? What is countertranference? How can we understand personality styles through attachment theory?
A person’s individual patterns of: Thought, emotion, and behavior
Tends to be stable over time and based primarily on temperament and early development Usually comes with unique advantages and disadvantages – which work better at some times than others
Trait approach includes dimensional measurement
Biological approach seen on functional MRI, neurochemistry, etc.
Psychoanalytic approach “defenses” to resolve internal conflict
Behavioristic approach product of rewards and punishments)
Experience and behavior that deviates markedly from the expectations of the individual's culture.
This pattern is manifested in two (or more) of the following areas: 1. cognition (perception and interpretation of self, others
and events) 2. affect (the range, intensity, lability, and appropriateness of emotional response) 3. interpersonal functioning 4. impulse control
The enduring pattern is inflexible and pervasive across a broad range of personal and social situations The enduring pattern leads to clinically significant distress or impairment in social, occupational, or other important areas of functioning The pattern is stable and of long duration … and its onset can be traced back at least to adolescence or early adulthood
The enduring pattern is not better accounted for as a manifestation or consequence of another mental disorder The enduring pattern is not due to the direct physiological effects of a substance or a general medical condition such as head injury People under 18 years old who fit the criteria of a personality disorder are usually not diagnosed with such a disorder, although they may be diagnosed with a related disorder. Antisocial personality disorder cannot be diagnosed at all in persons under 18
Cluster A: “weird” Paranoid Schizoid Schizotypal
Cluster B: “wild”
Antisocial Borderline Histrionic Narcissistic
Cluster C: “worried” Avoidant Dependent
Paranoid personality disorder Suspicious, holds grudges, interprets motives as
evil
Schizoid personality disorder Loner and likes it that way (vs. avoidant PD)
Schizotypal personality disorder Odd beliefs, awkward socially, mild psychotic
symptoms
Antisocial personality disorder reckless, cruel, and criminal
Borderline personality disorder Impulsive and unstable
Histrionic personality disorder Emotional and attention seeking
Narcissistic personality disorder Grandiose, lacking in empathy
Avoidant personality disorder Inhibited, sensitive, anxious
Dependent personality disorder Fears separation, need to be taken care of
Obsessive-compulsive personality disorder Rigid, detail oriented, “trees for forest”
Personality disorder
Population
Psychiatry Clinic
Any
(7) 0.9-15.7
45.5
A/Paranoid
(3) 0.7-5.1 (3)
4.2
A/Schizoid
(1.5) 0.8-1.7
1.4
A/Schizotypal
(1) 0.06-1.6
0.6
B/Antisocial
(2.5) 0.6-4.1
3.6
B/Borderline
(2) 0.5-3.9
9.3
B/Histrionic
(1.5) 0.2-2.9
1
B/Narcissistic
(1.5) 0.03-2.7
2.3
C/Avoidant
(3.5) 0.8-6.4
14.7
C/Dependent
(1) 0.1-1.5
1.4
C/Obsessive-compulsive
(3) 1.3-4.7
8.7
The prevalence/percentage of PDs in 6 nonclinical community studies using structured interviews Frequency of DSM-IV PDs in 859 psychiatric outpatients
Cluster A: “weird” Association with psychotic disorders May benefit from low dose neuroleptics
Cluster B: “wild” Associated with bipolar May benefit from low dose mood stabilizers
Cluster C: “worried” Associated with anxiety disorders May benefit from SSRIs
Cluster A and C: “weird” and “worried” Do not want to talk to, or are worried about other people … THEY ARE AFRAID OF YOU
Cluster B: “wild” They might want to talk to you, but maybe not vice-versa … YOU ARE AFRAID OF THEM
Cluster A: “weird” Paranoid Schizoid Schizotypal
They are afraid you will try to get to know them, so they avoid contact Do NOT: spend too much time developing rapport Do NOT: let them go without asking questions Do: be concrete and brief (for their benefit)
Cluster B: “wild” Antisocial They are afraid you will try to control them, so they create chaos DON’T control but also don’t give in
Borderline They are afraid you will try to abandon them, so they seduce/attack DON’T abandon them but don’t bend over backward
Histrionic They are afraid you will try to ignore them, so they perform DON’T ignore them but also don’t give them all of your time
Narcissistic They are afraid you will try to disrespect them, so they boast/insult DON’T disrespect them but also don’t let them disrespect you
Cluster B: “wild”
Antisocial Borderline Histrionic Narcissistic
Do NOT: confront the behaviors directly if possible Do: be calm, clear, friendly, and brief (for your benefit) Do: set reasonable boundaries on contact and behavior
Cluster C: “worried” Avoidant They are afraid you will be critical of them, so they hide DON’T be critical but also don’t over praise
Dependent They are afraid you will abandon them , so they cling DON’T abandon them but don’t bend over backward either
Obsessive-Compulsive They are afraid you will take away their control, so they try to control by having all the information/influence DON’T totally takeover but also don’t let them make all the decisions
Cluster C: “worried” Avoidant Dependent Obsessive-Compulsive
Do NOT: confront the behaviors directly if possible Do: be calm, clear, friendly, and brief (for their benefit) Do: set reasonable boundaries or contact and behavior
~15% of encounters in a primary care walk-in clinic were experienced as “difficult” by the provider
“difficult” patients are more likely to : 1) have a mental disorder 2) have more than 5 somatic sxs 3) have poorer functional status
Multiple unexplained symptoms Refractoriness and chronicity Differences in expectations of care Poor adherence to prescribed treatment Disproportionate physical and social disability Affective and behavioral dysregulation Primitive (unhealthy) defense mechanisms Evoke strong negative countertransference But remember…usually the “problem” isn’t just the patient, but rather a mismatch between the patient’s needs and expectations and the provider and system’s ability or willingness to take care of them
Transference: patient’s feelings about doctor Countertransference: how we feel about the pt Fueled by two processes: - The feelings/behaviors of the patient - Caregiver’s own unconscious baggage Use your reactions as clinical data to understand the psychology and behavior of the patient The better you understand your personal reactions, the less likely it will influence your response to the patient
Research over the last two decades has demonstrated the contribution of other nonpatient factors that make patients “difficult”: Physicians with less empathy and poorer psychosocial attitude scores Overworked physicians Physician anxiety and depression Physicians with larger numbers of patients with psychosocial problems or substance abuse
Attachment theory explores the impact of early attachment experiences on subsequent interpersonal behavior and perceptions
Based on work of John Bowlby (WHO study post WWII), Mary Ainsworth (“strange situation”), Donald Winnicott, etc.
“I’m OK, You’re OK” – value self / trust you
much less likely to have a “difficult” encounter likely experienced relatively consistent early caregiving comfortable depending on, and are readily comforted by, others (positive view of self and others) generally able to express emotional stress without somatizing
“I’m OK, You’re NOT OK” – value self / DON’T trust you early caregiving may have been consistently emotionally unresponsive more likely to underreport symptoms, misrepresent adherence May need more proactive contacts by clinics, like telephone calls or
home visits by nurses or caseworkers are less likely to use medical care appropriately because of their relative inability to collaborate with clinicians Clinician needs a higher index of suspicion with regard to the possibility of worsening medical illness or complications, given their possible tendency to underreport symptoms
“I’m NOT OK, You’re OK” – DON’T value self / trust you May have experienced early caregiving that was
inconsistently responsive more likely to somatize, exaggerate symptoms may benefit from more traditional approaches, such as regularly scheduled appointments with a consistent caregiver
“I’m NOT OK, You’re NOT OK” – DON’T value self / DON’T trust you May have had overly critical or harsh rejecting caregiving (negative
view of self and others) more likely to demonstrate interpersonal patterns in which they flee once a certain level of closeness is attained, i.e., engage in approachavoidance behavior patterns that stem from a fear of intimacy may somatize to avoid discussing feelings, etc. may benefit from regular attention to their problems by several providers in a clinic, without an emphasis on care by a single provider, although they may eventually learn to trust a single provider
Patients with fearful attachment report significantly more medically unexplained symptoms than patients with secure attachment
Number of lifetime medically unexplained symptoms is positively correlated with continuous ratings of fearful and preoccupied attachment
More missed scheduled office visits among those with dismissing compared to secure attachment style
Among patients with a dismissing attachment style, those who rated their patient-provider communication as good Had clinically significant lower HbA1C scores Increased adherence to medications and glucose
monitoring
Think about the problem as “bilateral” and talk about “difficult situations”, rather than “difficult patients”. Treat patients with respect and offer decision-making power appropriately. Be curious about the underlying reason for the “difficult” behavior. Notice unusual reactions in yourself. Take care of yourself and your colleagues. Treat the treatable (depression, anxiety, neurologic sx, medical illness, etc.) Set clear expectations Create a safe, calm environment for problem-solving Consider psychiatry consult, ethics consult, and/or mediator
Develop a “third story” A version of events that both disputing parties can agree upon Make concession, when possible Share control Five A’s for Dealing with Hostile Patients: Acknowledge the problem Allow the patient to vent uninterrupted Agree on what the problem is Affirm what can be done Assure follow-through
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What defines personality and personality disorder? Consistent patterns, level of adaptation What are the different clusters of personality disorders and how do they relate to patient care? Weird, wild, worried – each with it’s own attack and counter Who do we describe as a “difficult patient” and why? Makes us feel bad about ourselves – transference/counter What is countertranference? How we see the patient based on who they are and who we are How can we understand personality styles through attachment theory? Attitude towards self vs. other based partly on early childhood experiences – trusting/untrusting of them/you
Personality Disorders in Medical Care Settings. Robert Oldham MD MSHA, Director Fresno County Department of Behavioral Health. 2013.
Fiester E. The “difficult: patient reconceived: An expanded moral mandate for clinical ethics. American Journal of Bioethics 2012; 12(5): 2-7. Groves JE. Taking care of the hateful patient. New England Journal of Medicine 1978; 298:883-887. Hahn S. Physical symptoms and physician-experienced difficulty in the physicianpatient relationship. Annals of Internal Medicine 2001; 134: 897-904. Howe EG. Throwing Jello: A primer on helping patients. Journal of Clinical Ethics 2006; 17: 3-14. Jackson JL and Kroenke K. Difficult patient encounters in the ambulatory clinic: Clinical predictors and outcomes. Archives of Internal Medicine 1999; 159: 10691075. Krebs EE, Garrett JM, and Konrad TR. The difficult doctor? Characteristics of physicians who report frustration with patients: An analysis of survey data. BMC Health Services Research 2006; 6: 128-136. Stone D, Patton B, and Heen S. Difficult conversations: How to discuss what matters most. 1999; New York: Penguin Books. Wasan AD, Wootton J, and Jamison RN. Dealing with difficult patients in your pain practice. Regional Anesthesia and Pain Medicine 2005; 30: 184-192.
Questions?
