Which patients do you find most difficult to deal with?

[Ypo.]

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So, ER has their own stress-coping thread, and I figured psych ought to have one, too.

I'm just a lowly third year student, and I really like psychiatry. However I've noticed that certain types of patients are more difficult for me than others.

Like many people, borderline patients can drive me up the wall. If I don't figure out quickly who is a borderline patient sometimes I find myself with the wind knocked out of me. However, most borderline patients (once I've figured out they are borderline) I can manage pretty decently. I just have a set of tools that I use. I feel I understand these patients pretty well. Unless they are super malignant, I can usually do a decent job with them.

But the ones that I really seem to have difficulty finding compassion for are the ones who pathologically somaticize. Conversion disorder, somatoform disorder, etc...and I have no set of tools. I don't understand what type of therapy to use with them. I don't understand how they come to be the way they are. So most of the time I just get so irritated. And not just with them; with the medical establishment who suckers into all their physical complaints, thus perpetuating the cycle.

 

[erg923]

I actually find somaticizing very easy to understand for me. I mean we all do it to some degree, jut not at the diagnosable level. I myself tend to manifest anxiety as headaches and stomach upset, rather than always realizing "hey, I feel anxious or upset about something." Chronic somaticizers are likely "internalizing" their problems, and have had a history of doing so throughout their lives. In cases where patients are high internalizers, a non-directive, insight oriented therapy that allows them to actually experience their emotions should be employed. Get them aware of themselves. Some may even be borderline Alexithymic, so working on emotional insight is key. After some time, and assuming a strong therapeutic alliance, the therapist may even use "challenging." That is, addressing the client is semi-confrontational ways so they can not escape and must confront the situation and their feelings.

And I take it you haven't read much Charcot or Freud if you don't understand Conversion D/O. These diagnoses can be tricky to understand or work with if one doesn't buy into unconscious motivations and drives. I find med school students have a harder time with these than their psychologist counterparts. The recommended therapy for Conversion disorders is very similar to the Somatoform D/Os i previously discussed.

 

[Ypo.]

I'm not talking about stress HA or IBS. I'm talking about patients who cannot be on any medication because they will exhibit every side effect known to man (and some not).

I don't care how much theory you read. Some patients will just get under your skin and some you will be better dealing with than the average. It's just human nature.

 

[Ypo.]

And I take it you haven't read much Charcot or Freud if you don't understand Conversion D/O. These diagnoses can be tricky to understand or work with if one doesn't buy into unconscious motivations and drives. I find med school students have a harder time with these than their psychologist counterparts.

I would also add that anybody with a DSM-IV in hand can diagnose conversion disorder. You could also argue that psychologists have a harder time than med students understanding when the symptoms aren't due to medical reasons. 😉

 

[erg923]

I'm not talking about stress HA or IBS. I'm talking about patients who cannot be on any medication because they will exhibit every side effect known to man (and some not).

I would argue that this is really the same D/O, only at different degrees of severity. What does the patient gain by complaining of side-effects for himself? and what does it allow him to avoid? I might argue, if he creates side effects and cant take the medication, it represents a coping mechanism and an unconscious resistance to the sick role? What do you think? If he is doing it strictly for attention, or sympathy, then you have a whole different D/O...Factitious D/O.
And yes, you really only need a DSM to do the diagnosis, but I would like to think that mental health professionals like to have somewhat of a deeper understanding of psychopathology than whats available in the DSM, and don't hold the DSM as "the truth" necessarily. I was just making the point of reading the historical nomenclature in order to really understand the disorder and what lies under it.

 

[Ypo.]

I would argue that this is really the same D/O, only at different degrees of severity. What does the patient gain by complaining of side-ffects for himself? and what does it allow him to avoid? I might argue, if he creates side effects and cant take the medication, it represents a coping mechanism and an unconscious resistance to the sick role? What do you think? If he us doing it strictly for attention, or sympathy, then you have a whole different D/O...Factitious D/O.

yeah...like I said, DSM-IV, but...

I don't think it's always so clear cut. I think most patients get at least some level of secondary emotional gain out of somaticizing.

 

[OldPsychDoc]

I usually just complement these patients on how "sensitive" they are, and try to get some homeopathic dose of something appropriate started along with my empathic listening. Mirtazipine can work wonders in these folks, BTW.

 

[sunlioness]

yeah...like I said, DSM-IV, but...

I don't think it's always so clear cut. I think most patients get at least some level of secondary emotional gain out of somaticizing.

Sure they do. But the need to do that also comes from psychic pain and that's what we're in business to help alleviate. 🙂 I really like borderlines and somatic stuff, but I recognize that this makes me somewhat of an oddball.

What I really don't like are MR, dementia, and TBI. If your brain is actually physically scrambled, I'm at somewhat of a loss.

 

[nitemagi]

Sure they do. But the need to do that also comes from psychic pain and that's what we're in business to help alleviate. 🙂 I really like borderlines and somatic stuff, but I recognize that this makes me somewhat of an oddball.

What I really don't like are MR, dementia, and TBI. If your brain is actually physically scrambled, I'm at somewhat of a loss.

I find the somaticizing people with actual findings, to be more interesting than those that just complain. If a pt. has IBS, technically it's not a somatization d/o. That's a physical illness by DSM standards, even though we all know how much of IBS/migraine/etc is d/t physical expression of emotional distress. I feel like these people are on an extreme end of the spectrum, including those with rash to 50 meds, unlike those that like AE's with all meds because their stomach got a little upset.

My hardest are the in-between patients, those that don't absolutely have to be in the hospital, and don't have good outpatient care, but you know could do really well if they saw someone on a regular basis. Tough to see in the ED at least because they're just slipping through the cracks, just like those that have just enough money to not be on welfare, but are still dirt poor.

 

[Ypo.]

What I really don't like are MR, dementia, and TBI. If your brain is actually physically scrambled, I'm at somewhat of a loss.

At least it's clear cut (ie-there's not much you can do).


Maybe I've just had bad luck. But we've had a bunch of pts with somatoform disorder that all of the psychiatrists are sick of seeing (because they present so frequently and basically aren't willing to entertain any possibility other than expensive tests to find out the "cause.").

 

[whopper]

I used to find Cluster B patients often time causing counter-transference.

However by PGY-II, I had this under control. Actually now they don't bother me much if at all unless they do something that'll cause actual physical difference such as fling a cup of red kool aid on the white painted wall, and it hardly ever gets to that point, and if it did, getting mad at the patient will not accomplish anything positive.

Only things that seem to bother me the most in the field right now are when patients are turfed around inappropriately, or when its up to 2 or more docs (or teams) to work on the patient, and the other doctor or team tries to dump stuff on you that really is their responsibility. This however is usually not the patient's fault, but the fault of the system & lazy schmoes in it.

E.g. police drop a guy to emergency psyche who robbed a store because the guy claimed he was suicidal in the police car. So now he's in the emergency psyche unit and he admits to you he only said that because he didn't want to go to jail, and shows no psychiatric symptoms or problems other than antisocial PD which is not justification for inpatient treatment. So you call the cops to pick him back up to bring the guy to jail and they tell you he's your problem, not theirs becuase he's obviously "psychotic". The police in this case IMHO are simply playing the system because they don't want to handle this mess and do more paperwork. (Anyone on the board with police experience, correct me if I'm wrong).

So if you discharge the guy and he does something like beat someone up a few days later, you might be held liable. But if you put him on inpatient, you're going to get the inpatient doctor mad at you for not discharging in the first place.

Another example--patient lost 100 lbs in the past few months and has a number of GI problems. The IM doc wanted me to fish the cause of the weight loss. I told him that standard of care demands that medical causes of weight loss be ruled out before psyche causes and he doesnt' seem to understand that and still wants me to figure out why the patient is losing weight, when he hasn't investigated it himself, and there's plenty of medical culprits that could be doing it (e.g. the guy's LFTs are all out of whack).

 

[rosette]

Ypo.

Conversion disorder is indeed challenging.
My son's been suffering from it for almost 8yrs but is no "malingerer."
He's 22, has learning difficulties, mild cerebral spacticity, is partially deaf, artistic, musical & generally very creative, intelligent, sensitive & compassionate.

Maybe an adjustment of perspectables 😀 is required to help you extend your very obvious compassion to those you find more challenging. Sometimes a better learning experience can be had from these situations.

I make no apology for stating the obvious as reminders often help. So here goes.

To seperate mind & body & see somatization as pseudo will only increase your frustration & that of your patients.
The mind/brain & body serve & impact each other in ways we've yet to understand. One cannot survive without the other.
Our DNA holds memory. Many heart transplant patients feel & become their donors in varying degrees.
We know stress is responsible for a high percentage of serious illness & disease.
People with Somatoform Disorders & "malingerers" generally remain beyond our understanding because if it's not detectable via CT, MRI scans etc, it doesn't exist, deemed non-organic & therefore psychological & treatment tends towards anti-depressants & psychotherapy.

Conversion/Somatoform Disorders are very real, very painful, can severely disable, sometimes for life, often causing deep depression & very high risk of suicide for its sufferers.
Most, want desperately to get better, to work, be part of society, have meaning, purpose & quality of life.
As for the myth of "secondary gain" in Conversion disorder patients, I'd be interested in others take on this.

Just read what you said about patients who want only to find the "cause."
Consider this. If it were you or someone you loved was suffering, what would you want to happen? What would you expect? Would you, could you just accept the diagnosis or would you want to rule out ANY other possibilities?
Tests, scans, diagnosis are only as good as the person who does them & how many Neurologists ACTUALLY look at the scans themselves?
Don't be jaded Ypo, People are driven by fear & doubt as they're inspired by a beautiful piece of music, art or the beauty of Mother Nature.

I know it's difficult to stay calm, be patient, to rise above it, but those who enter into the medical professions hold great power & as the saying goes: "With great power comes great responsibility"
For now you're a student, come the future you'll be responsible for assessing, diagnosing & treating people like my son & man could I tell you some stories of how he's been treated & how long before he was diagnosed!
That said, My intent is not to criticise or judge, just came across your post by accident & hoped to offer some insight. Also to offer the gift of some Native American wisdom that reminds me how inter-connected we all are. I hope it does the same for others.

Oh Great Spirit, whose voice I hear in the winds & whose breath gives life to all the world, hear me.
I come before you, one of your many children. I am weak & small. I need your strengh & wisdom.
Let me walk in beauty & make my eyes ever behold the red & purple sunset, my ears sharp so I may hear your voice.
Make me wise so i may learn the things you have taught my people, the lessons you have hidden under ebery rock & leaf.
I seek strengh, not to to be superior to my brothers, but to be able to fight my greatest enemy...myself.
Make me ever ready to come to you with clean hands & straight eyes, so whenever life fades, like the fading sunset,
my spirit will come to you without shame.

Jung & Einstein also came up with some beauties that serve to remind us who we are, did they not.

Take care & best luck in your studies.

 

[Ypo.]

Rosette-
thank you for your post and for sharing about your son. I agree that having personal experience with an illness can provide insight which helps us to find compassion. It is good to keep in mind that no one wants to be mentally ill or unhappy.
Sometimes it can be frustrating as a healthcare provider not knowing what to do for these patients. I met one woman in the hospital yesterday who had received over 30 MRIs and CT scans over the past several years (all of them benign) and had multiple laparoscopic surgeries. It almost seems like some in the medical profession are afraid to talk about the underlying psychiatric possibilities. You mention in your post that just because we can't see it doesn't mean it's not real. I understand that for the patient the problem is very real and they are suffering. However there is a difference between a doctor not having found a physical cause yet and there simply not being a physical cause to find. My patient in the hospital the other day was having "strokes" but these had been ruled out by the neurologist. I spent an hour and half talking with her about her horrendous past history of sexual and physical abuse. It was never explicitly stated by her, but apparently the only time she got any attention from her husband was when she was in the hospital. It was very easy for me to find compassion for this woman and to see how this was a coping mechanism for her. However I feel the medical service does her a disservice by choosing to perform invasive surgery, expose her brain to radiation repeatedly. And I do feel it reinforces a vicious cycle, rather than getting to the root of the problem. Addressing the psychological component early on seems to me to give the patient a better chance of returning to a better level of functioning.

 

[rosette]

Deleted

 

[BabyPsychDoc]

Thanks Ypo. Your dilemma is clearer to me now.
I guess you're working outside of the UK.

Hmmm...Rosette, this forum is predominantly populated by physicians practising in the USA, just to make it clear. So, yes, they might have slightly different prospective on things, and they definitely do not work in the NHS.

Getting back to the topic of the thread: I find borderline personalities most challenging to deal with. I dislike being manipulated, and this is kind of a hallmark of borderline behaviour. I have to monitor myself and my feelings very carefully when I am doing an eval on a borderline patient.

I am hoping to do an elective on personality disorder service, to understand these patients better AND to understand myself in relation to these patients.

Conversion disorders on their own do not annoy me. Nor do factitious disorders. I feel very sorry for them, that they have to resort to intentionally making themselves ill in order to satisfy their emotional needs. Malingerers do piss me off, though.

 

[Neurotica]

nm

 

[maybepsych]

What about addicts? It seems to me like it would be hard to be empathetic towards those patients. Especially the ones that aren't making conscious efforts to get better.

Do lots of other people find addicts challenging?

 

[BabyPsychDoc]

What about addicts? It seems to me like it would be hard to be empathetic towards those patients. Especially the ones that aren't making conscious efforts to get better.

Do lots of other people find addicts challenging?

I do not. I feel extremely sorry for them, and a bit scared by the fact that people can be ruled by drugs just like that. I mean, nobody dreams of becoming an addict when they grow up - **** happens, and it happens to the most bright, most hardworking or most priviliged. People get hooked on drugs through different paths; some experiment due to boredom, some try to escape the unpleasant realities of their lives, some just bend to the peer pressure. And they all end up the same way. And when they want to change (because most addicts I have met DO actually want to change, even if they are not very successful in that), they may not be able to overcome the addiction.

Kind of hard not to be empathetic to the addicts, if you think about it this way.

 

[Chimed]

What about addicts? It seems to me like it would be hard to be empathetic towards those patients. Especially the ones that aren't making conscious efforts to get better.

Do lots of other people find addicts challenging?

I think your reaction is very common and reflects the general misunderstanding of addiction. True diagnosed substance dependence as defined in the DSM-IV is a complex disease of the brain. By the time someone has chemical dependence, their disease is often out of that person's conscious control and the concept of "making conscious efforts to get better" no longer applies. (Of course, that isn't true for all patients.) I think that when one approaches patients with substance dependence as someone who has a brain disease, then it is actually pretty easy to feel empathetic toward them. Relapse is often the thing that a lot of clinicians get frustrated by, as do the patients obviously. However, it is also important to understand that relapse is a normal part of recovery and not to treat a relapse as a "moral failure."

Personally, I really enjoy working with this patient population. After all, most addicts can relate to Where the Wild Things Are. 😉

 

[Ypo.]

I'm on addictions right now. I'm working with a wonderful doctor who gave me great advice today. No matter the patient, just think about it in terms of meeting them where they're at in terms of stage of action (precontemplation, contemplation, action, maintenance). There is basically a set of tools you use for each phase (fyi-this is similar to the 5 A's for assessing willingness to quit tobacco). For me it's easier to think of it that way because then I at least know what to do with each patient. Also, it's important realize you can't cure addiction overnight. Another excuse is "oh, the pt is just not trying." But it takes a lot of attempts for most people before they truly quit. The doctor said today that even if patients come in unwillingingly, they can turn around.

I also look at it like diabetes. The pt has a disease that will require monitoring and control their whole life. But just like the average diabetic, they aren't going to do a perfect job. Unlike most diabetics, a lot of them are in hard core denial about their disease.

I must say though, monitoring countertransference can be hard! My props to the therapists and psychiatrists who can deal with this day in and day out.

 

[BabyPsychDoc]

I'm on addictions right now. I'm working with a wonderful doctor who gave me great advice today. No matter the patient, just think about it in terms of meeting them where they're at in terms of stage of action (precontemplation, contemplation, action, maintenance). There is basically a set of tools you use for each phase (fyi-this is similar to the 5 A's for assessing willingness to quit tobacco). For me it's easier to think of it that way because then I at least know what to do with each patient. Also, it's important realize you can't cure addiction overnight. Another excuse is "oh, the pt is just not trying." But it takes a lot of attempts for most people before they truly quit. The doctor said today that even if patients come in unwillingingly, they can turn around.

I also look at it like diabetes. The pt has a disease that will require monitoring and control their whole life. But just like the average diabetic, they aren't going to do a perfect job. Unlike most diabetics, a lot of them are in hard core denial about their disease.

I must say though, monitoring countertransference can be hard! My props to the therapists and psychiatrists who can deal with this day in and day out.

This is a good advice in terms of trying to find your way around management of addicted patients and some of their problems. Unfortunately, it also kind of dehumanizes the addict, as you no longer see them as a person but as a "clinical problem". This can be helpful, as long as you do not overdo it. People are so much more than "abdo pains", "supracondylar fractures", "kidney stones", "crack addicts". Think that each addict is someone's child, someone's brother or sister, someone's lover or parent. They are loved and missed. They yet may be able to return to the "normal" life. Try to see a person, a real living person, behind the substance abuse diagnosis. This approach may make a difference to them, and it will certainly make your job much more rewarding.

As far as countertransference is concerned, I am not sure I understand what sort of countertransference you are experiencing. My main countertransference with these patients is the feeling of profound despair and pain. It IS hard, but not harder than the feeling of helplessness I experienced on geriatrics ward, when I had one death certificate to sign nearly every day; or the anger I had watching kids struggle (and sometimes die) on the paeds haem-onc ward. I guess, these feelings are part and parcel of being a doctor - no matter what your specialty is.

 

[OldPsychDoc]

This is a good advice in terms of trying to find your way around management of addicted patients and some of their problems. Unfortunately, it also kind of dehumanizes the addict, as you no longer see them as a person but as a "clinical problem". This can be helpful, as long as you do not overdo it. People are so much more than "abdo pains", "supracondylar fractures", "kidney stones", "crack addicts". Think that each addict is someone's child, someone's brother or sister, someone's lover or parent. They are loved and missed. They yet may be able to return to the "normal" life. Try to see a person, a real living person, behind the substance abuse diagnosis. This approach may make a difference to them, and it will certainly make your job much more rewarding.

As far as countertransference is concerned, I am not sure I understand what sort of countertransference you are experiencing. My main countertransference with these patients is the feeling of profound despair and pain. It IS hard, but not harder than the feeling of helplessness I experienced on geriatrics ward, when I had one death certificate to sign nearly every day; or the anger I had watching kids struggle (and sometimes die) on the paeds haem-onc ward. I guess, these feelings are part and parcel of being a doctor - no matter what your specialty is.

50, maybe 75% of my patient base is chemically dependent. I think what I find tough is that even when they've decided to sober up, the residue of that lifestyle haunts them for many months--they have legal, financial, relational, social consequences that would be hard for any of us to manage with a sound mind, let alone doing it with a brain that hasn't quite figured out how to function without its favorite chemical. This makes them feel depressed and anxious, and is a strong pull to relapse. I think full psychiatric support is really important in this first year of sobreity, but you also have to add to the list of challenges a lack of access (sometimes as simple as a lack of transportation--many have had their driver's licenses revoked) and insurance. 🙁

 

[alpha62]

50, maybe 75% of my patient base is chemically dependent. I think what I find tough is that even when they've decided to sober up, the residue of that lifestyle haunts them for many months--they have legal, financial, relational, social consequences that would be hard for any of us to manage with a sound mind, let alone doing it with a brain that hasn't quite figured out how to function without its favorite chemical. This makes them feel depressed and anxious, and is a strong pull to relapse. I think full psychiatric support is really important in this first year of sobreity, but you also have to add to the list of challenges a lack of access (sometimes as simple as a lack of transportation--many have had their driver's licenses revoked) and insurance. 🙁

You know what's harder to deal with than a full blown Manic ?

I full blown manic with a net worth of over 5 millon dollars and you would be amazed how many of them there are these days.

Why in the hell should they listen to you ? What did you make last year ?

 

[OldPsychDoc]

You know what's harder to deal with than a full blown Manic ?

I full blown manic with a net worth of over 5 millon dollars and you would be amazed how many of them there are these days.

Why in the hell should they listen to you ? What did you make last year ?

Because if they don't listen to me, they won't HAVE 5 million dollars anymore!

 

[Moki]

Anyone willing to share some pointers on dealing with Borderlines?

 

[erg923]

3 words....DBT

 

[Ypo.]

This is a good advice in terms of trying to find your way around management of addicted patients and some of their problems. Unfortunately, it also kind of dehumanizes the addict, as you no longer see them as a person but as a "clinical problem". This can be helpful, as long as you do not overdo it. People are so much more than "abdo pains", "supracondylar fractures", "kidney stones", "crack addicts". Think that each addict is someone's child, someone's brother or sister, someone's lover or parent. They are loved and missed. They yet may be able to return to the "normal" life. Try to see a person, a real living person, behind the substance abuse diagnosis. This approach may make a difference to them, and it will certainly make your job much more rewarding.

Wow, you sound really compassionate.

If anything, thinking about it in terms of the 5 A's has helped me to remain compassionate, while still being focused and helpful and not wasting effort trying to get someone to make active change who is still in the precontemplative stage. Ultimately what matters most is that you present yourself as compassionate and caring and respectful. If you allow yourself to get so emotionally involved with every patient, you'll burn out in a couple of years. I'm not saying we should be robots, but I do think that adopting a general routine you can use in similar situations is a good idea. My observation is that usually doctors get frustrated when their expectations don't meet those of the patients or when they feel powerless to help. Realizing that people go through different stages of readiness to change helps you to assess how you can best help, as well as saving you from feeling despair when nothing you do seems to work.

As far as countertransference is concerned, I am not sure I understand what sort of countertransference you are experiencing. My main countertransference with these patients is the feeling of profound despair and pain. It IS hard, but not harder than the feeling of helplessness I experienced on geriatrics ward, when I had one death certificate to sign nearly every day; or the anger I had watching kids struggle (and sometimes die) on the paeds haem-onc ward. I guess, these feelings are part and parcel of being a doctor - no matter what your specialty is.

The main one I struggle with is a lack of patience and feeling irritated with some patients.

 

[alpha62]

Because if they don't listen to me, they won't HAVE 5 million dollars anymore!

You do know that when oil is $ 110.00 a barrel in Kuwait, it's also a $ 110.00 in Houston too.

You can stay manic and solvent for a very long time at the rate things are going

 

[willow212]

Interesting discussion.

Personally, I have a hard time with dependent/needy patients, who always want more no matter how much you give, especially the help-rejecting complainer kind of dependent patient. What has helped me manage these folks is knowing where my own boundaries are in terms of how much responsibility I should assume for them and how I handle contact outside of appointments. Even with this, I can't help but feel irritated at times!

 

[BabyPsychDoc]

If anything, thinking about it in terms of the 5 A's has helped me to remain compassionate, while still being focused and helpful and not wasting effort trying to get someone to make active change who is still in the precontemplative stage. Ultimately what matters most is that you present yourself as compassionate and caring and respectful. If you allow yourself to get so emotionally involved with every patient, you'll burn out in a couple of years. I'm not saying we should be robots, but I do think that adopting a general routine you can use in similar situations is a good idea. My observation is that usually doctors get frustrated when their expectations don't meet those of the patients or when they feel powerless to help. Realizing that people go through different stages of readiness to change helps you to assess how you can best help, as well as saving you from feeling despair when nothing you do seems to work.

Once you have acquired a certain amount of experience in medicine, a lot of your working day is spent following some sort of routine. And while you are acquiring the said experience, a lot of your time you are learning the routine to be followed. So, yes, having some general routine to follow is not just a good idea, it is kind of a way of practising medicine.

Knowing what stage the addicted patient is in is important. You would not treat a common cold with broad spectrum antibiotics (not a very good correlation, I know, but can't think of anything better right now); similarly, you would not support the patient who is not ready for an attempt to quit the same way you are supporting the patient who has been sober for a period of time. You will think about different issues concerning your patient through each stage of the process.

So, I agree with what you are saying on both counts above. And, yes, the important thing as far as the patient is concerned is that you present yourself as compassionate and caring and respectful. However, I think you are likely to burn out much sooner if you only present yourself to be compassionate, without the real interest in and empathetic consideration of your patient's problems. Because then you will get bored very quickly with the endless stream of "35 yo white male, 10 year h/o cocaine abuse", "19 yo Hispanic female, 5 year h/o heroin abuse" - and nothing bodes worse for a burnout than boredom in a busy job.

OK, I admit it - I am in the field for secondary gain😉, and I somehow gain much more satisfaction from my work thinking that I am helping Jo to get his life back than thinking I am managing 35 year old white male with cocaine problem.

The main one I struggle with is a lack of patience and feeling irritated with some patients.

[/QUOTE]

I cannot advise regarding your lack of patience and irritability with some patients, but think about what OldPsychDoc said (and addiction is his niche): up to three quarters of the patients he is seeing are chemically dependent on the drugs. Their brains can't work very well without the drug anymore. Try thinking about them as you think about someone with, say, schizophrenia: would you get irritated with a schizophrenic patient? Probably not. We get irritated with addicts because we believe they brought it upon themselves, and to a certain extent it might be right. However, it is actually a much broader issue (ie, was the government to blame because they do not enough to restrict drug trafficking and drug dealing? was the patient's mum to blame, because she was injecting right through the pregnancy? or was it the poppy farmer in Columbia who should be blamed?), which probably should be debated by sociologist and politologists. Off topic.

Good luck!

 

[alpha62]

Anyone willing to share some pointers on dealing with Borderlines?

Yeah, I got some pointers for you:

limit your relationship with them to 3 dates, then change your phone number, get an STD screen, and consider it like a trip to Vegas: fun to vist but you wouldn't want to live there.

 

[Ypo.]

I cannot advise regarding your lack of patience and irritability with some patients, but think about what OldPsychDoc said (and addiction is his niche): up to three quarters of the patients he is seeing are chemically dependent on the drugs. Their brains can't work very well without the drug anymore. Try thinking about them as you think about someone with, say, schizophrenia: would you get irritated with a schizophrenic patient? Probably not. We get irritated with addicts because we believe they brought it upon themselves, and to a certain extent it might be right. However, it is actually a much broader issue (ie, was the government to blame because they do not enough to restrict drug trafficking and drug dealing? was the patient's mum to blame, because she was injecting right through the pregnancy? or was it the poppy farmer in Columbia who should be blamed?), which probably should be debated by sociologist and politologists. Off topic.

Meh. I just think it's human nature to get frustrated and irritated once in awhile. Anybody who says they are always 100% compassionate and never feels exasperated is either lying or has very little insight into their own emotions. As long as you find a healthy way to cope with it, I don't think there is anything wrong with admitting it. 😉

Edit-wait you are a resident in the UK? I'm sure those cushy work hours help you to keep balanced, too.

Anyways, like you say, this is getting off topic from the purpose of the thread.

 

[Moki]

Yeah, I got some pointers for you:

limit your relationship with them to 3 dates, then change your phone number, get an STD screen, and consider it like a trip to Vegas: fun to vist but you wouldn't want to live there.

And don't impregnate them or become impregnated by them? My God, the thought alone. . . . 😱

 

[luft]

I find that I am usually a match for any patient as long as I am well rested. If I am tired, I just don't want to deal with any BS. Like the borderline patient who's mother was paying for all her rent and utilities and took care of her kids while she and her husband used all their money on meth. The patient had some kind of argment with a neighbor and took a few aspirin in an impulsive parasuicidal gesture at about three in the morning. Of course they called me about her just as I had gotten into bed from seeing a bunch of kids in another ER. When I put her on a hold and have her admitted she burst into tears wailing and crying that she never meant to be admitted to a psych facility and she just wanted her mother to understand and to help her. I snapped, but just a little bit and gave her a stern lecture on the seriousness of her gesture and how I didn't care if she didn't want to be admitted and if she wanted her mother to understand, maybe she should try using her words like all the other grown ups. (I'm stretching a bit for dramatic effect, but most of this was all going through my mind at the time) That little lecture was certainly therapeutic, but not so much for the patient. (Yes, I am a little ashamed of myself) Later the nurse told me that while I was talking to the daughter, he was talking to the mother and the mother had been expressing how upset she was with the daughter and had then said, "maybe I should just kill myself!" I just smacked my forehead with my hand and asked him if he had put that in writing anywhere. He hadn't and I confirmed with the mother that she really wasn't going to try to kill herself. On the way home I had a bit of hysterical giggling over the whole situation. The apple does not fall far from the tree my friends. Not far from the tree at all sometimes. Especially not the borderline tree. Oh no.

 

[Anasazi23]

The apple does not fall far from the tree my friends. Not far from the tree at all sometimes. Especially not the borderline tree. Oh no.

Or in the case of borderlines and other PDs, the apple doesn't fall at all. And that's the problem.

Don't feel bad. We all have aggravating days that push our buttons. I think I filled my quota 4 years ago.

 

[whopper]

Anyone willing to share some pointers on dealing with Borderlines?

They used to bug the heck out of me, but by the time I saw my 20th, I got used to it. Doesn't bother me anymore though you still have to be wary of a few things.

1-set limits
2-be honest, don't poo poo things that can't be poo pooed, but when being honest explain it in a manner that'll ease their reaction
3-borderlines & histrionics, some of them are looking for a lawsuit. Document carefully
4-if need be see them with a 3rd party witness. Use another healthcare worker
5-don't let them upset you. If anything just pretend you're watching an episode of Jerry Springer.

From my own experience, if I point out to them that they have a personality disorder & tell them they're their own worst enemy (in a supportive manner) this often times actually breaks the ice and often times gets them to thinking they need to change their impulsive traits.

 

[Moki]

They used to bug the heck out of me, but by the time I saw my 20th, I got used to it. Doesn't bother me anymore though you still have to be wary of a few things.

1-set limits
2-be honest, don't poo poo things that can't be poo pooed, but when being honest explain it in a manner that'll ease their reaction
3-borderlines & histrionics, some of them are looking for a lawsuit. Document carefully
4-if need be see them with a 3rd party witness. Use another healthcare worker
5-don't let them upset you. If anything just pretend you're watching an episode of Jerry Springer.

From my own experience, if I point out to them that they have a personality disorder & tell them they're their own worst enemy (in a supportive manner) this often times actually breaks the ice and often times gets them to thinking they need to change their impulsive traits.

Thank you. It's #5 that needs work for me. I'll try the Jerry route.

 

[alpha62]

Thank you. It's #5 that needs work for me. I'll try the Jerry route.

ha, ha, yeah, make jokes.

I've had a couple of pts that went on to appear the the Jerry Springer show and I spent a couple of months doing time as locum in a clinic behind the chicken joint Anna Nicole used to work in.

 

[whopper]

This may not be the best way to handle it but everytime I see a Borderline or Histrionic patient overreact, I actually get some mild amusement out of it.

Of course I guess its better to not get amusement from the expense of someone else, but I guess that's better than getting mad at the patient.

http://youtube.com/watch?v=3SCJLlSf21Y
Common, as if you don't think that's funny?

I don't know, whenever I see most Cluster Bs overemotionally react, I just see it like its the above or a Jerry Springer classic moment.

I've actually used that Jerry Springer example for the cluster B's I worked with, telling them to try to look at themselves as if they're a 3rd person and compare their overremotionalism & impulsivity to a Jerry Springer episode. Seemed to work well with my patients.

If you get mad at a Cluster B, you're falling into the trap of acting like a Jerry Springer character yourself.

You know? I used to think the Springer show was 100% fake until I worked in psyche. Now I'm thinking its maybe 10% fake. Cluster B people are a dime a dozen!

 

[alpha62]

This may not be the best way to handle it but everytime I see a Borderline or Histrionic patient overreact, I actually get some mild amusement out of it.

Of course I guess its better to not get amusement from the expense of someone else, but I guess that's better than getting mad at the patient.

http://youtube.com/watch?v=3SCJLlSf21Y
Common, as if you don't think that's funny?

I don't know, whenever I see most Cluster Bs overemotionally react, I just see it like its the above or a Jerry Springer classic moment.

I've actually used that Jerry Springer example for the cluster B's I worked with, telling them to try to look at themselves as if they're a 3rd person and compare their overremotionalism & impulsivity to a Jerry Springer episode. Seemed to work well with my patients.

If you get mad at a Cluster B, you're falling into the trap of acting like a Jerry Springer character yourself.

You know? I used to think the Springer show was 100% fake until I worked in psyche. Now I'm thinking its maybe 10% fake. Cluster B people are a dime a dozen!

Cluster B's have made a signifigant contribution to american popular culture.

they've always been with us and it used to be considered Sexy. Think of plays such as
" Cat on a Hot Tin Roof " " A Street Car Named Desire "

I blame the culture of the Southern Male for keeping this crap alive. These Bubbas ought to set up a company called " Oedipus Complex Incorperated " They induldge this crap, they're intimidated by it, they pass it on to their young girls all in the name of "southern virtue" If you are still calling your Mother " Mamma " and your father " Daddy" well into your 50's, you might be part of the problem.

The concept of the " Magnolia Blossom" is funny as hell to me. The reality is probably closer to a movie called
" Black Snake Moan "

Neil Young was so ahead of his time.

 

[Quijotemd]

I'm surprised there's been no mention yet of narcissists, although Axis II in general has been discussed. Sure borderlines can try your patience, especially early in residency, but I still find myself feeling utter grief and frustration when I have to listen to the oblivious type of narcissist. These types talk, talk, talk, and talk about themselves, their problems, and appear to have little regard for anyone else, much less the psychiatrist sitting across the table from them. You try to chime in to add a question or comment and they talk over you. You suggest something to them and they act as if they have their problem figured out (and you say to yourself, WTF? why are you here in my psych ER?!) And perhaps they will question your age, qualifications, etc. to make certain you are good enough to be their doctor. And, in my experience, they often walk in to a psych ER at 3 AM. Just when you can give them your full attention and patience.

Gotta love them!

Q

 

[alpha62]

Oh God, that's what I do is world class malignant narrcies.

It's a good living, the higher oil goes, the more of them trail into my office.

I haven't seen business this good since the dot com bubble.

 

[Chrismander]

Help rejecting complainers. Something just irks me about a patient who shoots down every suggested treatment before it's out of my lips, but still keeps on complaining. i start to want to infantalize them, and regress into a paternalistic doctor of yore: "No, you *will* be trying an SSRI for your chronic anxiety, I don't care if it hurt your tum tum once 4 years ago and didn't work, when you only took it for two weeks.". This is definitely something i'll have to work on during residency. Hope process group helps me get a little more Zen about these poor folks. 🙂

 

[Ritz]

Who Want To 'just Talk'

 

[erg923]

Who Want To 'just Talk'

My goodness how psychiatry has changed over the years.... I can hear the founders rolling over in their graves to that one. Yea, nothing worse than a psych patient who actually wants to talk about his/her problems...right

 

[Chimed]

Help rejecting complainers. Something just irks me about a patient who shoots down every suggested treatment before it's out of my lips, but still keeps on complaining. i start to want to infantalize them, and regress into a paternalistic doctor of yore: "No, you *will* be trying an SSRI for your chronic anxiety, I don't care if it hurt your tum tum once 4 years ago and didn't work, when you only took it for two weeks.". This is definitely something i'll have to work on during residency. Hope process group helps me get a little more Zen about these poor folks. 🙂

Yeah, I agree, these folks can be challenging to deal with. Some people's identity becomes some ingrained in the sick role that they have a hard time letting that go. Some of these patients don't want to get better because they are either scared to face the world without the disease to hide behind or they just simply don't want that responsibility. In a way, you offering them treatment is seen as a threat to their identity. Then again, some people are just plan angry at the world and parental figures, and who better to complain to then the paternalistic doctor who wants to "infantalize" (is that a word?) them? Lord knows we all need to get a little more Zen!

 

[fotolilith]

...cardiology and diabetic patients - for purely psychological reasons. The learned helplessness than caused 90% of those patients' problems is what made me change my mind about doing IM geriatrics.

If a psych patient doesn't want to help themselves, it's easier to not get mad at them when you realize their brains are diseased. When a CHF,COPD or DM type 2 patient doesn't want to help themselves, it's just harder for me to feel sorry for them. I know, I need to go to therapy and deal with my bias against self-destructive people with no "real" psychiatric problems. Or maybe those people need psychiatrists too. 🙂

 

[whopper]

narcissists,

Can't think of one offhand that I had in a clinical case. I've had several with some criterion for narcissism, but not a full blown case of it. I also know people who I think have the disorder but would never seek help for it because they don't think its a problem.

I was thinking that perhaps being narcissistic may prevent one from seeking help about it. Often times people have to hit rock bottom before they seek help, and when you hit bottom, you might lose that narcissism.

 

[Ritz]

Seems I have hit a nerve here 😉, are you one of those willing to 'just talk' and feel pharmacology is just an eye wash and waste ? I want to see you talking and analyzing one of the aggressive patients in your Office - when he is Off his meds and has history of bursting open heads. TALKKKKKKKKKKKKKKK TO MEEEEEEEEEE

My goodness how psychiatry has changed over the years.... I can hear the founders rolling over in their graves to that one. Yea, nothing worse than a psych patient who actually wants to talk about his/her problems...right

 

[Chrismander]

i find it so strange that folks continue to view psychotherapy and psychopharm as an either/or proposition...

Seems I have hit a nerve here 😉, are you one of those willing to 'just talk' and feel pharmacology is just an eye wash and waste ? I want to see you talking and analyzing one of the aggressive patients in your Office - when he is Off his meds and has history of bursting open heads. TALKKKKKKKKKKKKKKK TO MEEEEEEEEEE