Course:PostgradFamilyPractice/ExamPrep/99 Priority Topics/Difficult Patient

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Difficult Patient - Key Features

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

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

The consistent presence of certain behaviors and traits, with onset in middle to late adolescence and continuing throughout adult life, are particularly suggestive of a personality disorder [22]:
• Frequent mood swings
• Angry outbursts
• Anxiety sufficient to cause difficulty making friends
• Need to be the center of attention
• Feeling of being widely cheated or taken advantage of
• Difficulty delaying gratification
• Not feeling there is anything wrong with their behavior (ego-syntonic symptoms)
• Externalizing and blaming the world for their behaviors and feelings

DSM-IV General Diagnostic criteria for personality disorder:

A. An enduring pattern of inner experience and behaviour that deviated markedly from the expectations of the individual’s culture. This pattern is manifested in tow (or more) of the following areas:

a. Cognition (ie. ways of perceiving and interpreting self, other people and events)
b. Affectivity (ie. the range, intensity, lability and appropriateness of emotional response)
c. Interpersonal functioning
d. Impulse Control

B. The enduring pattern is inflexible and pervasive across a broad range of personal and social situations
C. The enduring pattern leads to clinically significant distress or impairment in social, occupational, or other important areas of functioning.
D. The pattern is stable and of long duration and its onset can be traced back at least to adolescence or early adulthood.
E. The enduring pattern is not better accounted for as a manifestation or consequence of another mental disorder.
F. The enduring pattern is not due to the direct physiological effects of a substance (ie. a drug of abuse, a medication) or a general medical condition (ie. head trauma)

Cluster A characteristics: individuals may appear odd and eccentric
• Paranoid
• Schizoid
• Schizotypal

Cluster B characteristics: individuals often appear dramatic, emotional, or erratic in their emotions and behaviour
• Histrionic
• Narcissistic
• Borderline
• Antisocial

Cluster C characteristics: Individuals often appear anxious or fearful
• Avoidant
• Dependent
• Obsessive-compulsive

See DSM-IV, or uptodate article, ‘Personality Disorders’ for full summary of diagnostic criteria for specific personality disorders.

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

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

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

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

6. When dealing with difficult patients, set clear boundaries.

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

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

Study Guide

Difficult Patient


Silk, KR. Personality Disorders. In: UpToDate, Basow, DS (Ed), UpToDate, Waltham, MA, 2012.