Most challenging patient population(s) to treat? (aside from cluster B's)

[Ceke2002]

Yeah, didn't want to make it too easy for you so I've excluded the cluster B types

From the literature I've read it would seem that the chronically eating disordered population ranks as one of the most difficult to treat in terms of therapist frustration, potential burn out, risks of countertransference, and so on. I'm just curious what patient population or populations different practitioners here find most challenging to work with?

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[heyjack70]

Psychotic patients without insight. Or basically anyone who is struggling but refuses recommended treatment options and is unable to rationally discuss their refusal.

 

[WingedOx]

Insomnia patients... hands down.

 

[masterofmonkeys]

Patients with psych/pain or psych/somatic stuff. Partially because their doctors have managed to medicalize them before they ever end up in our offices.

 

[Ceke2002]

Psychotic patients without insight. Or basically anyone who is struggling but refuses recommended treatment options and is unable to rationally discuss their refusal.

Been through the bolded section a number of times with a few friends over the years - 'You have a BMI of 10, your liver is shutting down, your latest blood and cardiac tests are predicting a high risk of sudden heart failure, you've basically just been given 48 hours to live without emergency medical stabilisation, and you can't understand why you've just been carried into hospital under a section order because clearly you're just fine and dandy and you could stand to lose another 10 pounds at least'

Yeah, it's frustrating. I suppose at least you have the training and tools to perhaps better handle those sorts of situations, but then I guess you'd still experience the same frustration from a different point of view. Definitely not a situation I envy anyone being in (and they think all Psychiatrist's do is sit around all day, pushing pills in the name of Big Pharma and living the life of Riley )

 

[Ceke2002]

Insomnia patients... hands down.

Just regular garden variety type insomnia, or specific sleep disorders?

 

[WingedOx]

Just regular garden variety type insomnia, or specific sleep disorders?

if insomnia is bad enough to be in my office it's usually comorbid with an anxiety disorder. They usually want me to polypharmacy them into submission or something like, "2 mg xanax is the only thing that works, doc!"

I'm somewhat thankful my state's medicaid only permitted like 10 ambien tabs per month.

 

[Ceke2002]

if insomnia is bad enough to be in my office it's usually comorbid with an anxiety disorder. They usually want me to polypharmacy them into submission or something like, "2 mg xanax is the only thing that works, doc!"

I'm somewhat thankful my state's medicaid only permitted like 10 ambien tabs per month.

Ah I see, *those* types of insomniacs.

I have sleep delay onset disorder (or whatever it's called now, I seem to remember they changed the name for some reason) - my 'treatment' of it basically consists of me glancing at the clock and going 'Oh look it's 5.20 am and I'm wide awake, eh whatever I'll sleep at some point'

 

[F0nzie]

I want to say Bipolar disorder because of the irritability. Although recent I have been working with a lady with a history of Bipolar disorder and I have come to the realization that it's not Bipolar disorder it's just that she is super mean.

 

[Ceke2002]

Patients with psych/pain or psych/somatic stuff. Partially because their doctors have managed to medicalize them before they ever end up in our offices.

The medicalised somatoform patients I could definitely see as being a handful to deal with. I can understand a Psychiatrist being bought in as part of an over all treatment management plan for legitimate pain issues (legitimate as in there is something physically diagnostic going on), from the point of view of perhaps using different therapy techniques to help the patient better manage their response to pain via stress relief, relaxation exercises, etc. What I don't understand though is why a patient would expect a Psychiatrist to co-currently treat them for both their mental health issues and their physical pain issues? You're not a pain management specialist, so unless you're working as part of a treatment team, why would these patients even think you could manage both things at the same time - do they think you're like some one stop doctor shop or something? Hmm, that is a bit odd.

 

[Ceke2002]

I want to say Bipolar disorder because of the irritability. Although recent I have been working with a lady with a history of Bipolar disorder and I have come to the realization that it's not Bipolar disorder it's just that she is super mean.

OMG, you mean someone with a diagnosed mental illness is also just a downright unlikeable person? Surely you jest, I mean obviously she's just super mean because it's 'her' bipolar disorder playing up, it couldn't possibly be any sort of actual character fault - don't you know having a mental illness absolves us of all wrong doing.

 

[shan564]

I actually don't mind the somatoform patients as much if there's nothing along Cluster B. At least they're invested in their care.

Eating disorders are frustrating for the obvious reasons.

Fickle psychosis with poor insight can be frustrating, but most of them don't end up following up in clinic, so it's hard to get burned out on them just because there's less exposure to them. I actually like seeing those patients in the ER or on the inpatient unit, since they get better relatively quickly.

 

[silas2642]

Yeah, didn't want to make it too easy for you so I've excluded the cluster B types

From the literature I've read it would seem that the chronically eating disordered population ranks as one of the most difficult to treat in terms of therapist frustration, potential burn out, risks of countertransference, and so on. I'm just curious what patient population or populations different practitioners here find most challenging to work with?

For me I think it would be patients who struggle with anorexia because the goals of the clinician and the patient are completely opposed-- you want them to gain weight and they want to keep losing.

 

[Doctor Bagel]

I'm super surprised that nobody has said addicted patients, although I guess you might be getting at that with the pain patients.

 

[Ceke2002]

Eating disorders are frustrating for the obvious reasons.

For me I think it would be patients who struggle with anorexia because the goals of the clinician and the patient are completely opposed-- you want them to gain weight and they want to keep losing.

If it's any consolation your eating disorder patients are probably right there with you in terms of frustration, even if they won't necessarily admit it (at least not in the early stages of treatment). Unless someone has starved themselves to the point that they've completely lost all capacity to see any reason, I think a large majority of those with eating disorders do retain at least some spark of knowledge that what they're doing/thinking/feeling isn't exactly normal.

 

[shan564]

If it's any consolation your eating disorder patients are probably right there with you in terms of frustration, even if they won't necessarily admit it (at least not in the early stages of treatment). Unless someone has starved themselves to the point that they've completely lost all capacity to see any reason, I think a large majority of those with eating disorders do retain at least some spark of knowledge that what they're doing/thinking/feeling isn't exactly normal.

Yeah, one reason why psychiatrists tend to get frustrated with eating disorders is because we often only see the severe ones in the inpatient/consults setting. Also because they take a long time to get better, so unless you're subspecialized in treating eating disorder patients, you might not notice the improvement. I definitely had a much better experience rotating through a specialized eating disorders treatment center than what I had when I was just doing general inpatient or consults.

 

[Ceke2002]

Yeah, one reason why psychiatrists tend to get frustrated with eating disorders is because we often only see the severe ones in the inpatient/consults setting. Also because they take a long time to get better, so unless you're subspecialized in treating eating disorder patients, you might not notice the improvement. I definitely had a much better experience rotating through a specialized eating disorders treatment center than what I had when I was just doing general inpatient or consults.

Even at my worse, when I was basically being given 6 months to live if I continued on the path I was on at the time, although there was the part of me that still dug my heels in and went 'fine, I'll die then, but I am NOT gaining weight!' there was another part that was going 'I don't want to die, I want to get better, if I have to eat and gain weight then I guess I just have to bite the bullet and do what needs to be done'. I managed to get medically stable, for a while at least, after that, but it still took me another 15 or so years before I achieved any sort of remission. And that was after I'd already been sick for 9 years, so 24 years of an active eating disorder, which started at the age of 8, all up. It was frustrating at the time when I really wanted help to try and fully recover (instead of just constantly being stabilised when I was in medical crisis) and no Doctor or Therapist would touch me with a barge pole, or those that did were only willing to assist up to a point (as in 'I can help you live with it, but you'll never recover'), but I do understand now that they actually would have been doing me a disservice to try and take on a chronic case of anorexia if they didn't have the specialty training to deal with such a case.

I know a lot of people find it difficult to understand how someone can refuse to eat, or not feel as if they are able to eat normally - to the point that they're endangering their lives - and I can understand that. Eating is like one of the most basic needs of human survival, it's almost inconceivable that someone who has food available to them would reject something that is so fundamental to life. And most of the time a lot of us also struggle to understand why we can't just eat and be normal like everyone else as well. I know in my situation a lot of the time when I was insisting that it was 'my choice' and 'my body' and 'you can't tell me what to do', inside I was banging my head against a metaphorical brick wall and going 'FFS, why can't I just eat and be normal, everyone else can do it what the hell is so wrong with me?!' Sometimes it's just easier to convince yourself that you have a choice in what you're doing rather than face the idea that things inside your head really are that screwed up and you need help.

 

[shan564]

I know a lot of people find it difficult to understand how someone can refuse to eat, or not feel as if they are able to eat normally - to the point that they're endangering their lives - and I can understand that. Eating is like one of the most basic needs of human survival, it's almost inconceivable that someone who has food available to them would reject something that is so fundamental to life.

Mental illness is mental illness. Eating may be a basic need of human survival, but few people debate the same point about suicidality, which flies in the face of basic human survival. I think that people find eating disorders difficult to understand for the same reason why people may find delusions (or other symptoms of psychiatric illness) difficult to understand - it's easy to comprehend "your heart isn't pumping hard enough" or "your airways are damaged from years of smoking," but it's harder to explain "something in your brain isn't sending the right signals."

 

[Ceke2002]

Mental illness is mental illness. Eating may be a basic need of human survival, but few people debate the same point about suicidality, which flies in the face of basic human survival. I think that people find eating disorders difficult to understand for the same reason why people may find delusions (or other symptoms of psychiatric illness) difficult to understand - it's easy to comprehend "your heart isn't pumping hard enough" or "your airways are damaged from years of smoking," but it's harder to explain "something in your brain isn't sending the right signals."

Good point, I suppose this is where the role of more education in society at large comes into play. And mental health education is definitely one reason that whilst I might not exactly go around shouting about my various diagnoses from the rooftops I don't hide the fact I have them either.

Edited to add: And I suppose my previous sentiments were more aimed at those sections of society whose response to someone with an eating disorder tends to be along the lines of 'Geez, I love my food, how could you not eat? Just go to McDonald's and grab a Big Mac, it's not that hard'.

 

[WingedOx]

I'm super surprised that nobody has said addicted patients, although I guess you might be getting at that with the pain patients.

Depends on the setting. Inpatient is irritating since half the time the substance-users are basically using the unit as a shelter.

Outpatient I have more enjoyment as long as the patient very clearly understands that I'm not going to be a "dealer" for him.

 

[Psychobabbling]

The most challenging patient population to treat is a really unique sub population....it's called...The Staff

"This patient is soooo borderline."

"Oh my gawd they are such a malingerer"

"Doc-torrrrr, the patient refused a PO GIVE them an IM....you're JUST writing for Ativan? (Muttering under their breath...when my nurse gets hurt because you didn't add Haldol....)

 

[Ceke2002]

The most challenging patient population to treat is a really unique sub population....it's called...The Staff

"This patient is soooo borderline."

"Oh my gawd they are such a malingerer"

"Doc-torrrrr, the patient refused a PO GIVE them an IM....you're JUST writing for Ativan? (Muttering under their breath...when my nurse gets hurt because you didn't add Haldol....)

I think you just won this thread