most difficult psych patients

[ClinPsycMasters]

I did a quick search and came across a thread that was closed so I am opening this one.

In my very limited clinical experience, it's folks with somatic complaints of elusive nature that are most frustrating, and people with personality disorders that are most difficult to handle.

In terms of personality disorders, it's PPD, Cluster B, and DPD. Some Cluster B patients are amazingly intelligent and I end up getting manipulated in response to their seductive behavior, fits of rage, etc, at some point. It's almost inevitable. Presently I work with psychiatrists, neurologists, and neuropsychologists, and I do assessments mostly. However, I do come across these patients at times (two in particular stand out) and it can be a terrifying experience at times. I find it very difficult to remain compassionate towards these patients as I instinctively react in self-defense, shutting down and going into a survival mode of sorts, as if I'm in jungle and facing a smart predator who is looking for smallest sign of weakness on my part. Suddenly I want to hurt them, to save them, feel guilty, feel victimized, all within the same session. So it takes tremendous effort to deal with some of these patients, specially some who seem to have life long training in manipulation and a superior intelligence. Perhaps those who deal with them often enough can handle things much better. When you come across them on occasion, it's harder.

A funny thing though. One time I was assessing a narcissistic patient who would shake his head at me constantly throughout the assessment, sighing, and being sarcastic throughout. You see, he used to be a psychology professor and made it very clear to me that I was beneath him, so I had to deal with countertransference and my own anxieties towards authority figures.

At the end he told me that he hoped I learned something. I told him it was an honor to test him and that I felt humbled. He smiled smugly.

I don't deal with psych emergencies but I figure there must be difficult patients there all the time. Patients with all types of psychoses, addictions, armed and dangerous. A psych student once told me he saw a patient in ER who looked very much like Lindsay Lohan. She had BPD (like Lindsay?) and the cuts were so deep and grotesque, he threw up right there!

---

Members don't see this ad.

 

[whopper]

I used to find borderline PD patients extremely frustrating. I still do, but nowhere near as much, and a large part of the reason why is because I'm actually learning DBT, though not enough to be a good therapist utilizing DBT.

The more I've learned about it, the more I've come to realize that much of our frustrations as psychaitrists with these patients are because 1) we don't have a medication that treats this disorder, 2) we aren't taught DBT well if at all, 3) we get several borderline PD patients without having the training to deal with them, and 4) we usually don't have anyone we know who has DBT training where we can refer these patients.

I have yet to find just one psychiatrist who knows how to use DBT. Not one. Yet we get patients with this disorder all the time. I have, however, seen dozens of psychiatrists attempt to treat borderline while writing a diagnosis that the psychiatrist doesn't even believe in (e.g. mood do nos, psychosis nos, bipolar nos). The borderline patient a few years later is no better, and is 100 lbs heavier thanks to (insert psychotropic medication here).

And the irony of this situation is that we are taught that we are supposed to use DBT on borderlines. If we know that why don't we use it or at least refer to someone who does? Where I did residency, no one in the area knew how to use DBT so there was no one we could refer our borderline patients.

Where I'm currently working, there are actually people who know how to utilize DBT. I can actually refer a borderline patient to a DBT therapist, and after a few months, I actually see a difference. It's become much less frustrating to have a borderline patient when I can actually do something with these patients other than throw a medication that I'm not expecting to even work.

 

[Psych Doctor]

I used to find borderline PD patients extremely frustrating. I still do, but nowhere near as much, and a large part of the reason why is because I'm actually learning DBT, though not enough to be a good therapist utilizing DBT.

The more I've learned about it, the more I've come to realize that much of our frustrations as psychaitrists with these patients are because 1) we don't have a medication that treats this disorder, 2) we aren't taught DBT well if at all, 3) we get several borderline PD patients without having the training to deal with them, and 4) we usually don't have anyone we know who has DBT training where we can refer these patients.

I have yet to find just one psychiatrist who knows how to use DBT. Not one. Yet we get patients with this disorder all the time. I have, however, seen dozens of psychiatrists attempt to treat borderline while writing a diagnosis that the psychiatrist doesn't even believe in (e.g. mood do nos, psychosis nos, bipolar nos). The borderline patient a few years later is no better, and is 100 lbs heavier thanks to (insert psychotropic medication here).

And the irony of this situation is that we are taught that we are supposed to use DBT on borderlines. If we know that why don't we use it or at least refer to someone who does? Where I did residency, no one in the area knew how to use DBT so there was no one we could refer our borderline patients.

Where I'm currently working, there are actually people who know how to utilize DBT. I can actually refer a borderline patient to a DBT therapist, and after a few months, I actually see a difference. It's become much less frustrating to have a borderline patient when I can actually do something with these patients other than throw a medication that I'm not expecting to even work.

This is excellent post.

I am in private practice and I am amazed to see the number of people walking to my office who have Personality disorders, especially BPD ( Majority of them are carrying the diagnosis of Bipolar Mood Disorders instead of Borderline Personality Disorder).

Unfortunate thing is, we have been trained for 4 years ( instead of 3 years like Internal Medicine), and still not given training to deal with patients with BPD. It would be nice if 6 months would have been focused on dealing with personality disorders especially for the Borderline Personality Disorder ( BPD). We were given a choice of elective ( which most of us wasted for hanging out), it should be a must training like inpatient or outpatient rotations.

I stick to this formula, if patient is not getting better with any medication, either patient is doing drugs, he has some medical issues, or he has personality disorder.

 

[sunlioness]

There's one DBT program in this area that I have referred patients to and it's really helped them a lot (except for this one woman who claimed to have severe DID and didn't like DBT because she felt it invalidated her alters. She didn't last long in treatment with me though because she kept testing my boundaries every day and eventually I told her she needed DBT and then she told me I was invalidating her alters who deserved to be taken care of by a provider who "really cared" and didn't "clock out every day at 5" and well, I made the referral. She refused and that was the end of that. She probably didn't like it because she adamantly refused to take any personal responsibiliy for regulating her own affect, but I digress). I personally would love more training in DBT. I read Linehan (on my own), but that was several years ago now and I don't really remember it. And yes, I learned as well that BPDs need DBT, but I was never taught DBT either and DBT was not utilized in my training programs IOP. What is up with that?

I would actually love to get training in DBT, but so far I haven't really looked into how to go about doing that. And the patient above was probably the most challenging patient I've ever had. She would call me and leave voice mail messages of her self-injuring and then alternately say how it was my fault she did that because I didn't care or say how it wasn't her responsibility because [alter] did it and therefore I shouldn't hold her accountable.

 

[ClinPsycMasters]

Perhaps by redefining BDP as C-PTSD or something, we will see more programs interested in teaching DBT. Face it, when you call something a personality disorder, it sounds fatalistic enough to scare people away. We need a more optimistic label. Nobody seems to like to diagnose them with BPD. I don't know if all this emphasis on clinical as opposed to personality disorders is simply a matter of what can be changed or simply avoiding the consequences of diganosing someone with BPD.

 

[Therapist4Chnge]

Perhaps by redefining BDP as C-PTSD or something, we will see more programs interested in teaching DBT. Face it, when you call something a personality disorder, it sounds fatalistic enough to scare people away. We need a more optimistic label. Nobody seems to like to diagnose them with BPD. I don't know if all this emphasis on clinical as opposed to personality disorders is simply a matter of what can be changed or simply avoiding the consequences of diganosing someone with BPD.

The solution is to train more providers in DBT and related skills. BPD make up a small % of the overall population and a LARGE % of the frequent flyers that get seen in hospitals. As whopper said, you can't throw pills at a BPD patient and expect them to get better. There may be a reduction in symptoms because they are a half-step above being a zombie, but it does nothing for their actual treatment. I've seen many of the same pts. pop back in a couple weeks later when they go off their meds, and it is like being in my own personal "Groundhog Day".

I think the two biggest psych-related shortcomings in your generic hospital are a poor understanding of how to handle BPD and how/when to use motivational interviewing (chronic pain pts would be a close 3rd). I'm glad to see increased visability of MI training, but there is still woefully insufficient training at most hospitals.

 

[whopper]

Perhaps by redefining BDP as C-PTSD or something, we will see more programs interested in teaching DBT

I fear that classifying it as a form of PTSD (and yes they do share some characteristics) may cause some doctors to simply treat it as PTSD and give an SSRI as if it's solving the problem.

I do think BPD may have some PTSD similarities, though the trauma goes much beyond an anxiety disorder. The patient has problems on an emotional developmental level.

But whatever we do, if it pushes us in the right direction, then I'll back it. If reclassifying it as a form of PTSD does that, so be it. I don't know.

IMHO, as a profession, I think this is something we need to fix up. This is to the degree where I've seen dozens of borderlines misdiagnosed on paper by doctors that even believed the patient had bpd--which is ridiculous. It reminds me of the Emperor's New Clothes.

 

[ClinPsycMasters]

I think insurers are going to be looking for some solid evidence, if they are going to cover DBT. The few RCTs conducted have shown DBT to be somewhat effective but it falls way short of a magic bullet. It does seem to reduce parasuicidal and some of the more extreme impulsive behavior, and that is important. We need more long-term studies.

I don't want to stray off topic too much but I'm also interested in other therapeutic approaches such as mentalization based therapies though I have less confidence in transference focused therapy.

 

[pingouin]

I think insurers are going to be looking for some solid evidence, if they are going to cover DBT. The few RCTs conducted have shown DBT to be somewhat effective but it falls way short of a magic bullet. It does seem to reduce parasuicidal and some of the more extreme impulsive behavior, and that is important. We need more long-term studies.

I don't want to stray off topic too much but I'm also interested in other therapeutic approaches such as mentalization based therapies though I have less confidence in transference focused therapy.

There is already plenty of evidence that DBT is helpful and cost-effective in many populations (not just BPD), and insurance is already covering it. I entered authorizations for individual and group DBT treatment back in 2004.

 

[ClinPsycMasters]

There is already plenty of evidence that DBT is helpful and cost-effective in many populations (not just BPD), and insurance is already covering it. I entered authorizations for individual and group DBT treatment back in 2004.

I live in Canada so not much is covered here. What are the details of the insurance coverage? Is it a particular length of time (or number of sessions)? And can you get it covered only if there are particular Axis I disorders present as well?

 

[Wednesday]

This is one reason to live in Seattle! Lots of psychiatrists and psychologists trained in DBT and places to refer patients to, including full programs with weekly groups and everything. I am at UW and we have a resident training program in DBT. The nurses teach DBT skills on most of our inpatient units. It's nice. And effective. And really, many people can benefit from the skills, not only BPD pts.

 

[ClinPsycMasters]

That's it, I'm moving to Seattle then.

Back to the topic: Other "difficult patients" of another sort, are the ones who don't speak English. With the translator in the room, you still have difficulty with clear communication, and on top of that you lose the privacy and one on one rapport...and the whole thing takes much longer than anticipated.

 

[whopper]

IMHO, an institution could make big money if they started DBT treatment teams. This is something I've rarely seen. I did not see any in all of NJ. Yeah, there may have been a few, but if there were, I didn't see or hear of any.

 

[pingouin]

IMHO, an institution could make big money if they started DBT treatment teams. This is something I've rarely seen. I did not see any in all of NJ. Yeah, there may have been a few, but if there were, I didn't see or hear of any.

Minnesota (the state in general, not just U MN) is actually an excellent model for provision of mental health treatment. They have fully embraced DBT and it's widely available as compared to other places. My LCSW supervisor had trained up there before moving to our state, and was constantly lamenting what she gave up regarding the state's respect for funding mental health services.

Regarding insurance reimbursement as discussed above, what is authorized will vary depending on the company and the member's benefits. However, if they're going to cover "DBT", then they need to authorize for individual AND group therapy, and (likely) psychiatric management.

 

[whopper]

Lots of psychiatrists and psychologists trained in DBT and places to refer patients to, including full programs with weekly groups and everything. I am at UW and we have a resident training program in DBT.

Not surprising. Linehan is at U.W.

Where I am, in southern Ohio, there are DBT teams and therapists, though I believe there should be more. Several treatment agencies and county mental health boards that don't have them are incorporating them and offering incentives for therapists to learn it if they don't already know it.

 

[OldPsychDoc]

Minnesota (the state in general, not just U MN) is actually an excellent model for provision of mental health treatment. They have fully embraced DBT and it's widely available as compared to other places. My LCSW supervisor had trained up there before moving to our state, and was constantly lamenting what she gave up regarding the state's respect for funding mental health services.
.

She obviously left before the Pawlenty administration took over...

 

[pingouin]

She obviously left before the Pawlenty administration took over...

well shoot. apparently.

there goes my hope that some state, somewhere, might actually adequately fund mental health treatment. because mine sure doesn't.

 

[Faebinder]

We need to address the misdiagnosis of "BPD" as bipolar disorder. This has got to stop.

Unfortunately, psychiatrists doing DBT in the office is not possible. No insurance will pay a fair compensation for these sessions. The only way to survive and do them is to privately or if an institution wants to take the hit... and most dont because they can admit the patient, make money off government and send the patient out once the 2-day crisis of the borderline patient is over. To them, the patient is a perfect recycling income... when census is low, call them bipolar and admit them, when census is high, quote articles that show borderline treatment is better as outpatient and dont admit them.

I am again unsure how to make this better. Wiser folks thought about it and got no where. The ones who should be addressing this is the government/state insurance agencies that pay for re-admissions, but hey, since when did they care about the opinions of doctors on how to improve costs and care. The idea of spending money (pay for DBT centers and therapy) to save a lot more money (multiple readmissions) is beyond their scope of thinking.

 

[whopper]

Unfortunately, psychiatrists doing DBT in the office is not possible. No insurance will pay a fair compensation for these sessions. The only way to survive and do them is to privately or if an institution wants to take the hit..

To them, the patient is a perfect recycling income... when census is low, call them bipolar and admit them, when census is high, quote articles that show borderline treatment is better as outpatient and dont admit them.

Agree, and I think I know what you're talking about....with the misdiagnosis...after all you are training where I trained.

A psychiatrist need not, however, actually use the DBT, but instead make a referral. It may not be cost-effective for a psychiatrist to do DBT, but it can be cost-effective to get other therapists such as counselors, social workers, or psychologists to do so.

IMHO we still need to know DBT because the borderline patient may have other issues we should keep tabs on. E.g. frequent flyers to the ER or inpatient, substance abuse issues that we can treat with medication, a comorbid disorder such as PTSD which is highly associated with borderline PD. If we know DBT, we can interact well with the therapists who administer it.

In fact, most DBT teams I've seen aren't headed by psychiatrists, but are headed by other mental health professionals.

But administratively, the people at the top should be putting in place some DBT people in their system for referrals.

Where I am now, and where I did training, things are very different. The city I'm in, for example, will actually pay a psychologist to see if someone in the hospital is malingering. In most hospitals, if they find the person malingering, they will not get reimbursed, thus killing the financial incentive for a hospital to confront the issue. If the person is malingering, the city will reimburse the hospital. The city came to the realization that it is cost-effective to cut off malingerers than to allow them to continue to stay in the hospital at a cost of thousands of dollars/day for what could be several days/year.

I don't know what the state has in place for borderlines, but I do know there is more DBT treatment in this area thanks to intervention of those who are looking more at cost-saving that profiteering.

This is just further evidence that if you're only after the profit, the target of good care is not always congruent with profitting.

 

[Regnvejr]

I fear that classifying it as a form of PTSD (and yes they do share some characteristics) may cause some doctors to simply treat it as PTSD and give an SSRI as if it's solving the problem.

I do think BPD may have some PTSD similarities, though the trauma goes much beyond an anxiety disorder. The patient has problems on an emotional developmental level.

But whatever we do, if it pushes us in the right direction, then I'll back it. If reclassifying it as a form of PTSD does that, so be it. I don't know.

IMHO, as a profession, I think this is something we need to fix up. This is to the degree where I've seen dozens of borderlines misdiagnosed on paper by doctors that even believed the patient had bpd--which is ridiculous. It reminds me of the Emperor's New Clothes.

We started a DBT program in our clinic in cooperation with another clinic in town, did the training etc. The only one in the state. Doing great with it. It also helps to "re-program" your thinking about BPD. We are taught to think in the direction of "difficult" patients, which doesn't help on the unconditional positive regard, and clearly shows our main relation with BPD to be fear. Linehan's model of the 5 areas of dysregulation (I can post details tomorrow) gives much better handle on it and also takes it more into an Axis I direction, where it really needs to be. But just like PTSD, the diagnosis needs to be careful. I have seen a boatload of BPD diagnoses based mainly on the patient being "difficult."

But it really is part of a "rotten childhood" syndrome and the person's reaction to this. As such, it does look to me very much as a person's reaction to others not stepping in and helping when they should have. I see a continuum of responses from anxiety disorder to depressive disorders, to PTSD, to BPD, to DID, in various mixes. I have personally never seen a BPD patient without significant abuse background and strong PTSD traits when I really take a close look at the diagnoses.

I have learned to really loathe other psychiatrists' diagnoses of trauma patients. I have also become frustrated with what patients have been told about the diagnosis, and found that if you discuss causes and reasons for the diagnosis with patients, and discuss the DBT, the theory behind it and why I think it is a good idea, patients will embrace it and do very well. Blaming patients for our past inability to treat them really sucks. Our ineptitude is not the patient's fault. It is not as much that they are "difficult" as that we have not bothered to really help them in a way that works.



That aside, in answer to the OP, I don't find BPD my most challenging patients. Asperger patients with ADHD and unexplained loss of function and memory, now THAT is what keeps me awake. I'll take any help I can on that. The region's child neurologist and multiple scans have been unable to help me, and so far only above-normal doses of carbamazepine and risperidone have helped.

 

[ClinPsycMasters]

That can happen in Asperger's? I thought they were high functioning. Sounds more autistic.

 

[Regnvejr]

That can happen in Asperger's? I thought they were high functioning. Sounds more autistic.

Nah, its Asperger's, IQ was normal, communication was normal. But there is other stuff going on. Almost like CDD, but in a 12-year-old.

 

[Manicsleep]

I would like to say to the OP.
It is good that you are experiencing all these personality disorders. We had an 8 bed ward that was staffed by 2 residents and an attending all devoted to personality disorders.
It was grueling work, we worked long hours (short call every other night to help the residents on call) but I learned a lot. They closed it because it didnt make money but I think you can forge similar experiences out of any encounter with personality disorders.

I actually find the dependent personality disorder most difficult BTW. A severe one is rare but they can literally suck the life out of you.

 

[whopper]

My most difficult patients (this is what you can see in a long term care facility)...

1) psychotic/manic patient who is dangerous (e.g. punching people everyday, multiple times a day) and refuses meds. Even with emergency meds the person is still very dangerous. When I request the court for court-ordered medications, the court does not listen to the case for weeks. During those 1-3 weeks, my treatment team is screwed.

(In a long term facility, this actually occurs about once every few weeks).

2) Pregnant patient who is dangerous, and is in the first trimester and Haldol does not work.

3) Patient with entitled parents who call me up and want me to treat them over their frustration with having a mentally ill child. (I'm talking on the order of 5 hrs a week, just talking to them). I had one parent try to convince me that one-nostril breathing treats psychosis. I went through the trouble of going through the medical literature and a pubmed search where I actually looked into it to see if there was any possibility the mother could've been right. Nope. She wasn't, and she wasn't happy with my response even though I tried to present this to her in the friendliest manner I could. She was treating the situation as if the hospital was a restaurant and I was the maitre d. She came over to the treatment team, and during the meeting, a violent incident occurred where a patient attacked another patient, and the mother expected me not to react to that situation only focus my time on her.

The mother a few days later insisted I serve her daughter gourmet cheeses for lunch because she did not like the quality of the hospital food. I told her if she really wants gourmet cheeses, she's going to have to talk to the patient advocate. Ahem, I actually eat the hospital food, and yes, it's from the same kitchen.

4) A county mental health board who is demanding I discharge a patient that I believe is dangerous, and very very very apparently dangerous (e.g. 10/10 mental health professionals saw the person and even agreed), and then a doctor from the MHB comes over, sees the patient for ten minutes and writes down in the chart the patient is fine. The MHB's discharge plan is to let the person go home, on her own.

(That was the closest I ever came to walking up to another doctor's face and calling that person a liar to their face. The patient was drooling, had flat affect, and every few minutes tried to pull objects out of the air with her hands, and no the doctor didn't happen to catch the patient at the wrong moment. I saw the patient while the other doctor was seeing her too.)

But the MHB does not want the liability of forcing a discharge (which is in their power), so during the meantime, they come over and actually write in the chart several entries that are in complete contradiction to what everyone in my treatment team is seeing, and gave me several calls demanding I discharge the patient. My response, "It is in your power to overrride me and discharge the patient. If you feel this strongly, do it. Otherwise, let me treat this patient in the manner that I and her family believes is appropriate." (Her family never agreed with the MHB.)

 

[ClinPsycMasters]

Whopper, how about disturbed but extremely bright folks with significant training in/knowledge of psychology/psychiatry? They know what they want and they know how the system works. They can outsmart me for sure.

 

[whopper]

True.

In general the better the insight, the better the patient. To date, as far as I know, I haven't had a medical professional as a patient on a long term basis. I do though recall seeing an IM doctor on consult service.

Most of my patients, against my recommendation, also don't do much research on their disorder. Of the few that do, some of them start using their knowledge in an inappropriate manner. E.g. one guy claims to be allergic to everything. Since he's done his medical homework, he starts telling me the right symptoms for an allergy. I actually had to have this guy seen by an allergist, who after several tests confirmed the guy is allergic to nothing we know of so far!

On occasion, I get a patient who is psychotic, but their memory and concentration are intact. (The old schizophrenia, chronic paranoid type). When I inform the judge that the patient needs to be kept in the hospital. If that patient has a lawyer willing to put up a battle, during the cross-examination, they'll ask me exactly what the patient needs to do to get out. When a psychotic patient with an intact concentration gets a hold of this, well, it's almost giving them a free pass to get out so long as they can "play the part." E.g. a psychotic patient who wants to kill someone else, but now all he has to do is say he does not want to do this for the next few weeks.

It's not hard for someone with an intact concentration and memory to play the part when they know what the part is.

Every type of clinical setting brings it's own set of difficult patients. In outpatient there's a different group that I consider difficult, that actually in an inpatient setting I would find easy. E.g. a substance abuser who wants a medication of abuse. I have no problem saying no to these people in an inpatient setting because if the person may actually be in need for one of these medications, I can observe them and judge for myself. In outpatient, you really can't tell (at least IMHO) with a degree of overwhelming confidence, and much of what you rely on is what the patient tells you, not by what you see in your 1/2 hour with the patient.

So, when I deny Ativan to someone claiming to have panic attacks, that person may in fact be having them. I really can't tell since they're not having the panic attack in my office.

 

[Cruzinman]

Dissociative Identity Disorder, misdiagnosed with False Memory Syndrome.

 

[ClinPsycMasters]

Dissociative Identity Disorder, misdiagnosed with False Memory Syndrome.

wow, have you had a patient like that? I've never seen a true DID patient nor have psychiatrists I work with (the two I've asked).

 

[Manicsleep]

I used to work at a medical school in a mental health capacity. Never had any significant problems until I started my fellowship.

Suddenly there were a few very persistent people asking for modafinil.

 

[Regnvejr]

wow, have you had a patient like that? I've never seen a true DID patient nor have psychiatrists I work with (the two I've asked).

When PTSD gets bad enough, that's what you end up with. If you get a serious case of PTSD, you need to screen for it. True DID patients may not be aware that they have it.

 

[Therapist4Chnge]

When PTSD gets bad enough, that's what you end up with. If you get a serious case of PTSD, you need to screen for it. True DID patients may not be aware that they have it.

I've seen it twice with severe trauma cases. Both were very bizarre presentations and I was skeptical at first, but eventually it became clear they both were legitimate cases. Very sad cases, but they were invaluable for learning.

 

[ClinPsycMasters]

PTSD, mostly childhood sexual abuse, right? Did these patients have more than one alter personalities?

 

[Manicsleep]

Doesnt have to be sexual abuse.

I have seen it with a kid coming back from war.
Extended flashback, DID whatever. He did some scary things.

 

[Therapist4Chnge]

Both of my cases were related to childhood sexual trauma, but I can definitely see significant combat related trauma being a factor.

 

[Doc Samson]

Regardless of pathology, the most difficult psych patients are:

1) Psychiatrists
2) Other physicians
3) Nurses

 

[Regnvejr]

PTSD, mostly childhood sexual abuse, right? Did these patients have more than one alter personalities?

It's not so much alters as past personalities. When the memories are bad enough, you don't just hide them, you hide everything. So when they come back, you check out till the're gone again.

Not entirely accurate, but good enough for conceptualization.

Sexual abuse, bad neglect, severe emotional abuse, crime victims, messy accidents, war experiences etc.

 

[ClinPsycMasters]

It's not so much alters as past personalities. When the memories are bad enough, you don't just hide them, you hide everything. So when they come back, you check out till the're gone again.

Not entirely accurate, but good enough for conceptualization.

Sexual abuse, bad neglect, severe emotional abuse, crime victims, messy accidents, war experiences etc.

I see. Would you say these past personalities/states are physiologically distinct from each other and the present/mature one?

 

[ClinPsycMasters]

Regardless of pathology, the most difficult psych patients are:

1) Psychiatrists
2) Other physicians
3) Nurses

No way! I mean sure, there are a few who have tempers or feel entitled, but I also know quite a number of psychiatrists who are gentle and friendly, quite unassuming.

 

[Regnvejr]

I see. Would you say these past personalities/states are physiologically distinct from each other and the present/mature one?

In my experience with childhood trauma survivors, they are emotionally different, certainly. But it is not like "Hi, I'm Jane Doe and I'm 12 years old and goes to XYZ school. Nothing that clear.

The 'alters' are typically not fully functional, they're only there to take the brunt of the memories, until it clears up again. I had one patient with a couple distinct dissociative stages, of which one's sole "job" was to curl up under the chair and cry and plead for "daddy, please stop," (these people do not have good lives before coming to us). Once it cleared, she was a bit confused and hazy, but had no memories of it,and was generally clear and functional without any memories of the even or that past. It clearly is a defense that allows you to function the rest of the time.

 

[ClinPsycMasters]

I don't intend to digress too much but DID continues to mystify me. Etiology is still unclear. There is no history of severe trauma in some cases. Yet there is the overlap with PTSD and also BPD. We all dissociate when it comes to severe trauma but why do some develop DID and some don't? I'm brainstorming here of course, but DID also reminds me of human body's natural and automatic reaction (defense mechanisms, dissociation, etc) to stressors which provides short-term relief but often enough is damaging in the long-term. Yet, a helpless child subjected to the trauma of sexual abuse may not have a more proactive option other than dissociation.

Returning to the topic of the thread, I can not imagine having to work with such a patient, both because of the complexity of diagnosis/treatment, but also due to my own emotional reaction to horrors of child abuse.

 

[sunlioness]

I'm brainstorming here of course, but DID also reminds me of human body's natural and automatic reaction (defense mechanisms, dissociation, etc) to stressors which provides short-term relief but often enough is damaging in the long-term. Yet, a helpless child subjected to the trauma of sexual abuse may not have a more proactive option other than dissociation.

This is exactly true. Children don't have a lot of options. So they do dissociate, often to great extremes, which is life saving in the short term and devastating in the long term.

Returning to the topic of the thread, I can not imagine having to work with such a patient, both because of the complexity of diagnosis/treatment, but also due to my own emotional reaction to horrors of child abuse.

They're some of the most challenging patients out there. I'm actually okay hearing things that are pretty awful. What gets me with DID patients is how some of them continually test you. It can be like borderline PD to the nth degree and it gets scary at times. For some reason, this seems to happen more often with people who have been in the system for a while and come to me already carrying the diagnosis. I diagnosed one person with DID in residency whom I saw for therapy and whom I still see and this hasn't really been a problem with her. (She was previously diagnosed as schizoaffective bipolar, but even so hadn't been in the system for too too long)

 

[Manicsleep]

Regardless of pathology, the most difficult psych patients are:

1) Psychiatrists
2) Other physicians
3) Nurses

Really?

I have not come across this at all with the psychiatrist part. Even with the other physician or nurses, it is the exception and not the norm for me. I did have a really bad case of factitious disorder with a nurse...actually a few now that I think about it, but one was just horrible (for me and him).

Once or twice I have come across an LVN or CNA who wants to dictate terms with their kids treatment. I have had a lot of success with turning the situation around on them. I ask them to research, do homework and report, praise them for their knowledge and hold them accountable etc. The nonsense stops quickly.

 

[Manicsleep]

When it comes to my worst patients I usually think along the lines of personality disorders.

I agree with whopper as I have worked in a long term institution where violence happened that some cases can be quite dangerous.
But for some reason, when I look back on those cases, I don't see myself doing anything different. For the most part, I tend to "embrace the suck."

With the personality disorders cases, I often wish I had never had several of those patients on my case load. Especially in the forensics setting where I saw so much severe ASPD.

 

[whopper]

l. What gets me with DID patients is how some of them continually test you. It can be like borderline PD to the nth degree and it gets scary at times

I evaluated someone with borderline who appeared to have a strong disturbance of identity. Makes sense. Borderlines are often abused or abandoned. DID, in theory, is the product of severe abuse.

I always approach people with DID with extreme suspicion. I've known good psychiatrists who don't believe it's a valid diagnosis. This one particular person IMHO tilted my own belief toward thinking DID is valid.

She didn't have DID, but her level of identity disturbance was to a degree where I believed if this is a spectrum, she's close to DID. She dramatically changed her hairstyle every few days. Everytime someone interviewed her, she gave a very different story regarding her background. Her background, no matter how she presented it, however, was always consistent with one thing--extreme abuse or neglect by her family. She had no stable friends or family that she could rely on, and every few months she'd move to a completely new location several states away. She also denied several of her behaviors she was seen doing on the unit, but she had nothing to gain from the denial.

She appeared to have no gains we could identify by this behavior. For example, she was in the hospital for restoration of her competency to stand trial. She cooperated with my testing that clearly showed she met the criteria to be held competent for trial. If she was malingering, well she just passed the test with flying colors for her to stand trial. I also administered a few tests for malingering and they were all strong negatives.

DID is hard to dx, several psychiatrists do not think it's a valid dx, and the therapies are also in an area of debate. Since very few people are diagnosed with DID, most psychiatrists, if thrust into a position where they want to treat it, have little experience with it.

 

[sunlioness]

I always approach people with DID with extreme suspicion. I've known good psychiatrists who don't believe it's a valid diagnosis. This one particular person IMHO tilted my own belief toward thinking DID is valid.

I believe it's valid and actually tend to approach the "true believers" from both sides of the controversy with an equal amount of skepticism. It just seems to me that people who spend a lot of time vehemently arguing for either side are oftentimes invested in something other than Truth and what's best for patients.

I'm also skeptical when patients present to me telling me they have DID. The very nature of DID is to hide, even from the person who has it, so many folks don't even necessarily realize what's going on until they have someone outside recognize it and screen for it. That's what happened with my patient from residency. And well, even then, while I had DID in the back of my head from the beginning given her sx and complex trauma history, I actually didn't definitively make the diagnosis until about 9 months into treatment. In someone who is presenting with the diagnosis of DID, I like to see a hstory of previous treatment from knowledgable people. Otherwise, I start to worry about secondary gain/factitious issues. Some people do hit upon DID as the perfect way to both get a lot of attention for having an "exotic" diagnosis or as a way to avoid personal responsibility for their actions. (ie. "I didn't do it. My alter did.")

 

[ClinPsycMasters]

I don't know how valid DID diagnosis is. I have no problem with dissociation but it's the "identity" part that gets me. It sounds too philosophical. We could use a dissociation continuum instead. Sure, they're severely disturbed, but multiple identities/personalities? The overlap with PTSD, BPD, and various psychotic illnesses makes it even more confusing.

 

[Doc Samson]

No way! I mean sure, there are a few who have tempers or feel entitled, but I also know quite a number of psychiatrists who are gentle and friendly, quite unassuming.

I'm not passing judgment on entire professions, but the worst case scenario for an involuntary psychiatric patient (especially if manic) is if they're a psychiatrist/physician/nurse. Attempts to engage in treatment typically end up with the patient challenging diagnosis/procedure/med choice.

 

[sunlioness]

I don't know how valid DID diagnosis is. I have no problem with dissociation but it's the "identity" part that gets me. It sounds too philosophical. We could use a dissociation continuum instead. Sure, they're severely disturbed, but multiple identities/personalities? The overlap with PTSD, BPD, and various psychotic illnesses makes it even more confusing.

Dissociation is a continuum actually. It goes from the common stuff that everyone does (like getting really absorbed in a good book) all the way up to the fragmentation with amnesia barriers that is DID. The alters in DID aren't really separate people or personalities, but they can act like it to a large degree. I think the process of dissociaton can play a large role in BPD, PTSD, etc, but that DID is a valid, if very extreme, manifestation.

 

[Faebinder]

Regardless of pathology, the most difficult psych patients are:

1) Psychiatrists
2) Other physicians
3) Nurses

Only seen 1 psychiatrist as a psych patient, and one pediatrician but never was directly in charge of treatment. I managed lotsa nurses though.... i think it really depends on the diagnosis. So far nurses have proven to me to be the most NON-COMPLIANT human beings on earth.. I can't convince them of anything.

 

[sunlioness]

LOL. I'm pretty non-compliant myself even though I know better. I'm borderline diabetic and my PCP wants me on Zocor. I understand completely why this is a good idea. I just keep forgetting to take it. So maybe doctors do make bad patients.