working with manipulative behavior primary care conference june 1, 2005 norman jensen md professor...

Working with

Manipulative BehaviorPrimary Care Conference

June 1, 2005

Norman Jensen MDProfessor of Medicine

University of Wisconsin - Madison

nmj@medicine.wisc.edu

I have approved this message.

Intended learning outcomes

• Enhancement of– Concept of manipulative behavior

– Awareness of common contexts

– Awareness of management strategies

– Attitude toward the topic

– Motivation to learn more

Conflicts of interest

• I will mention no pharmaceuticals or medical equipment.

• I will receive no specific pay for this presentation …– in fact,– the more I work, the less I’m paid.

Manipulate Webster’s New Collegiate Dictionary 1980

• 2a. To manage or utilize skillfuly. B. To control or play upon by artful, unfair, or insidious means esp. to one’s own advantage. 3. To change by artful or unfair means so as to serve one’s purpose. Syn. doctor

Machiavellian Webster’s New Collegiate Dictionary 1980.

• NLM MESH heading for manipulation of the psychological type.

• The political theory of Machiavelli that politics is amoral and that any means however unscrupulous can justifiably be used in achieving political power. Characterized by cunning, duplicity, or bad faith.

Manipulation Hamilton JD, et. al. Am J Psychotherapy 1986;40;191.

• “… deliberately influencing or controlling the behavior of others to one’s own advantage by using charm, persuasion, seduction, deceit, guilt induction, or coercion … best restricted to conscious, intentional behavior … and [best] viewed [clinically] as a symptom, like chest pain or fever, with a multitude of causes, some transient, some chronic some more serious than others”.

Manipulative patient behaviors

• Seeking unwarranted “sick” certificates• Seeking Rx for non-Rx drugs• Recurrent lying• Recurrent refusals of care• Recurrent demands for special treatment• Recurrent denials of strong emotion• Recurrent demands for tests, consults,

drugs, procedures, etc

Manipulative patient behaviors

• Recurrent failed adherence to care plan• Intentional production of sx, signs, or injury• Self-depreciation• Expressing surprise, hurt, disappointment with

physician• Threatening self-destructive behavior• Quoting what others or other physicians have

said or done

List here:

withhold information to avoid a diagnosis

list of what they need, including bizarre

ER pt allergic to all but demerol:

flattery

lie to obtain a medication

exaggerating sx to obtain treatment

request for disability paper work

requesting re-authorization of Rx not relevant to the visit

family member demanding unnecessary treatment

avoiding one treatment to get the next one

List more here

refusing discharge to escape home care

refusing to reveal sx of depression to avoid record

Differential Diagnosis (1)of manipulative behavior

• Normal behavior for a person who is independent, assertive, conscious of consumer rights and perhaps somewhat mistrustful. (esp. with authoritarian clinicians or beliefs in alt./comp. healing)

Differential Diagnosis (2)of manipulative behavior

• Axis I - Depression, e.g., suicide gesture preceding fatal repetition.

• Factitious disorders (intentional or feigned production of sx in order to assume sick role)

• Malingering (intentional production of sx for discrete external purpose.

• AODA - relationships with people take second place to obtaining the substance

Differential Diagnosis (3)of manipulative behavior

• Axis II - personality disorders– Antisocial– Narcissistic– Borderline– Histrionic

Case presentation

• 46 y/o professor• Highly accomplished, lots of grants• In bioscience field• Single parent 2 teens

• Severe respiratory symptoms 5 days• No signs / symptoms of complication• Urgent care Friday pm

• Demanding “antibiotic”• Insistent, persistent despite medical explanation• At 12 minutes of a 15 minute visit

• What management strategies are available?

Managementof manipulative behavior

• Manipulative behavior as a symptom– Be curious vs. judgmental– Careful understanding of behavior– Differential diagnosis– Hypothesis testing– Specific management

Managementof manipulative behavior (1)

• Careful understanding of the behavior– understand & acknowledge pt feelings– seek meanings for the patient– understand & acknowledge doctor

feelings– seek meanings for doctor

Managementof manipulative behavior (2)

• For activated independent patient – reduce authoritarian doctor

behavior– negotiate a management plan

Managementof manipulative behavior (3)

• For transient regressive states– what is the patient afraid of?

• Pain • being alone• unknown illness • death• lack of information • other?

– Listen actively for understanding

– PEARLS

Responding to Emotion Professional Rapport Building SkillsCohen-Cole SA & Bird J. • Partnership• Empathy• Apology• Respect• Legitimation• Support

Managementof manipulative behavior (4)

• In substance abuse disorders–set careful limits on

prescribing–refer to treatment program–develop a contract

Managementof manipulative behavior (5)

• For factitious disorders– confrontation

– refer for individual psychotherapy

Managementof manipulative behavior (6)

• For pure malingering–confrontation

–consultation with legal system

Managementof manipulative behavior (7)

• For Axis II, personality disorders– Antisocial: psychotherapy often

not successful.

– Others: long-term psychotherapy is more successful.

– Contracts and setting limits.

Managementof manipulative behavior (8)

• When manipulative behavior cannot be modified or contained– use Dr feelings as data, not for Rx plan– generally avoid acquiescence– set firm & explicit (not angry) limits– set up a relational contract – enlist a team of care givers– if intolerable, terminate relationship

If you want to read more:

1. Hamilton JD, et.al. The Manipulative Patient. Am J Psychotherapy. 1986;XL:189-200.

2. Murphy GE, Guze SB. Setting limits. Am J Psychotherapy 1960;14:30-47.

3. Adler G. Helplessness in the helpers. Br J Med Psychol 1972;45:315-326.

4. Adler G, Buie DH. The misuses of confrontation in borderline patients. Int J Psychoanal Psychother 1972;1:109-120.

5. Maltoberger JT, Buie DH. Counter-transference hate in the treatment of suicidal patients. Arch Gen Psychiatry 1974;30:625-633.

6. Groves JE. Management of the borderline patient ion a medical or surgical ward: the psychiatric consultant’s role. Int J Psychiatry Med 1975;6:337-348.

7. Zinn WM. Transference phenomena in medical practice: being whom the patient needs. Ann Intern Med 1990;113:293-298.

8. Groves JE. Taking care of the hateful patient. New Engl J Med 1978;298:883-887.

9. Hahn SR. et.al. The difficult patient: prevalence, psychopathology, and functional impairment. J Gen Intern Med 1996;11:1-8.

10. Hahn SR, et.al. The difficult doctor-patient relationship questionnaire. J Clin Epidemiol 1994;47:657.

The lecture ends here!Questions?Answers $0.25Answers requiring thought $1.00Correct answers $2.50

Comments?