Managing the disruptive patient

51st Annual Scientific Assembly Ontario College of Family Physicians November

2013

Jon Hunter MD FRCPC[Bob Maunder MD FRCPC]

Faculty/Presenter DisclosureFaculty/Presenter Disclosure

• Faculty: Jon Hunter• Program: 51st Annual Scientific Assembly

• Relationships with commercial interests:– NONE

Disclosure of Commercial Disclosure of Commercial SupportSupport

• This program has received NO financial support • This program has received NO in-kind support

• Potential for conflict(s) of interest:– NONE

Mitigating Potential BiasMitigating Potential Bias

• N/A

Objectives

1) participants will be able to recognize attachment styles

2) participants will learn how the attachment style of an individual influences their interaction with HCW’s

3) participants will derive techniques for managing disruptive attachment behaviors

Sarah Difficult

Call from FP unit:

• “Jon, you’ve got to help me with Sarah…she calls all day, overwhelming the secretary, and demands lots of attention, about all these flaky symptoms… when she’s here she’s so loud she’s putting other patients off…She seems to hate my suggestions, but when I try and end the appt. she’s hard to get out of the unit...I’m ready to strangle her…”

Literature Review

N = 500 outpatients -- 15% rated as difficult More likely to have:

• Mental disorder • > 5 somatic symptoms• > severe symptom• Poorer function • More unmet expectations• Less satisfaction with care• Higher use of services

Hahn, Kroenke,J. of Gen Int Med 1996 Jackson,Kroenke, Archives Int Med 1999

Literature Review

• 21 patients described by 9 FP’s as ‘difficult’

• 7/21 difficult patients vs.1/21 controls had (at least one) personality disorder

• 5/21 had dependent (‘wimpy’) personality

Schafer, Nowlis Archives Fam Med 1998

• Steinmetz, Tabenkin, Family Practice, 2001,

Literature Review

• Interview of 15 randomly sampled FP.’s in Israel

• >5 years in practice• Structured I/V + Questionnaire…

Steinmetz, Tabenkin, Family Practice, 2001

Literature ReviewDifficult Patient:

• ‘Everything hurts’• High anxiety• ‘Pain in the neck’• Demanding, exploiting • Angry at doctor• Uncooperative• Difficult psychiatric patient• Drug Addict

• Steinmetz, Tabenkin, Family Practice, 2001,

• James E Groves• Taking Care of the Hateful Patient• New England Journal of Medicine, 1978

• Hateful patients… “induce feelings which their caregivers find difficult to tolerate”

Literature Review

Attachment and disruptive behavior…

• How does understanding attachment style help you with Sarah Difficult?

• Let’s classify her:

Preoccupied/anxious attachment:

• I find that others are reluctant to get as close as I would like. I often worry that my partner doesn’t really love me or won’t want to stay with me. I want to merge completely with another person, and this desire sometimes scares people away.

Dismissing attachment:

• I am somewhat uncomfortable being close to others; I find it difficult to trust them, difficult to allow myself to depend on them. I am nervous when anyone gets too close, and often, [love] partners want me to be more intimate than I feel comfortable being.

Disorganized/fearful attachment:

• I am constantly frustrated by partners, I feel the need to be really close, but then they screw me over, and I get so angry I blow up. They can’t understand me, and when they back off, I get really scared of being alone, but even angrier that they’re leaving....

The attachment system…

Explore until it’s

dangerous

Stay close until it’s safe

Dimension of Attachment Anxiety

Dim

ensi

on o

f Atta

chm

ent A

void

ance

Sever

ity o

f Atta

chm

ent I

nsec

urity

Secure

Preoccupied

Fearfulor Disorganized

Dismissing

University of Toronto Consultation-Liaison Psychiatry Division

Adult attachment styles:

• Secure (55%)

• Anxious (Compulsively care-seeking) (20%)

• Dismissive (Compulsively self-reliant) (15%)

• Disorganized (Fearful) (10%)

Why you see insecure people as patients:

“we have a baby, . . . someone close to us departs or dies, a limb is lost or sight fails”

Bowlby J. Attachment and Loss, Vol. 1: Attachment. New York: Basic Books, 1969 , pg. 82

Why you see insecure people as patients:

Tertile of attachment insecurity →

low middle high

“trying to make myself feel better

by eating,smoking, drinking,

using drugs or medications”

8% 8% 33%

(Maunder, Lancee, Balderson et al., 2006)

What changes with different A/S’s?1) Healthcare Utilization

300

350

400

450

500

550

Mea

n A

nnua

l P

rimar

y C

are

Cos

ts

(US

$)

Secure Preoccupied Dismissing Fearful

Interpersonal Style

(Ciechanowski, 2000): Primary Care Costs in 701 People with Diabetes

What changes with different A/S’s?2) proportion of unexplained symptoms

Anxious attachment:

• Preoccupied with fear• Can’t cope by self, need to keep

other attached via constant distress signal

• Experienced as needy, or clingy

Anxious attachment

Management guidelines:• HCW as External Modulator of

patient• Attentive, supportive attitude• Preemptive contact to decrease

“distress signals”• Frequent, regular, time-limited

contact: - not contingent on distress

Anxious attachment

Management guidelines:• Present team as an integrated whole• Enhance internal regulation of

distress:– reminders of previous coping– relaxation techniques– benzodiazepines (ie night before and morning of chemo.)

A post-operative phone call & pain

0

2

4

6

8

10

12

14

16

18

Pain score # pain pills

phone callno callp < .001

p < .001

Proportion of diabetic patients with poorly controlled disease

0

20

40

60

80

1 2 3 4

Patient's Interpersonal Style

Perc

en

t o

f p

ati

en

ts

What changes with different A/S’s?3) adherence

Adherence domain Dismissing style(N=1463; 35.7%)

Odds Ratio†

General diet non-adherence 1.41

Exercise non-adherence 1.36

Foot care non-adherence 1.21

Current smoker 1.42

Oral hypoglycemic agents(<80% adherent)

1.23

† Reference group = Secure style (N=1806; 44.1%)

Dismissing attachment:

• Dislike dependence• Necessary lack of control may provoke

crisis– e.g. anaesthetic, sedation

• Noncompliance or poor sense of alliance

Dismissing attachment

Management guidelines:• Respect need for independence • Allow patient to set interpersonal distance -

Don’t crowd!• Re-frame investigations/treatments as

expediting return to self-reliance• Model identification and expression of affect• Model flexibility

Style of expressing worry and symptoms

High Health AnxietyStandardRepressive Coping

Se

lf-re

po

rte

d u

lce

rativ

e c

olit

is s

eve

rity

6

5

4

3

2

1

0

Colonic Mucosa

normal

friable Maunder & Greenberg,IBD, 2004

AdaptableDismissing Anxious

What changes with different A/S’s?4) symptom reportage

"Difficult" encounters in the emergency room (according to MD)

0

10

20

30

40

50

Secure Preoccupied Dismissing Fearful

Patient' s Interpersonal Style

Per

cen

tag

e

What changes with different A/S’s?5) Md-pt. interpersonal difficulty

Disorganized/fearful attachment

• Unstable approach and withdrawal• Help-seeking + help-rejecting• Complaining + dismissive• Demanding + angry

Disorganized/fearful attachment

• lowest frequency of scheduled preventive care

• highest frequency of missed visitsBUT….• highest frequency of same day (crisis)

appointmentsPaul Ciechanowski, Gen Hosp Psychiatry, 2006

Disorganized/fearful attachment

• Experienced as needy +++, frustrating.• No reliable strategy for relating

– oscillations, mixed messages• +++ difficult to reliably engage or comfort

Disorganized/fearful attachment

Management guidelines:

• Appreciate extent of patient’s fear• Assess suicidality• Attend to needs of staff • Deliver uniform messages, so as to prevent

abandonment, over-investigation and...• Use an independent guide to treatment:

“Usual high standard of care”

Summary

Adult attachment and CL:1. provides a useful shorthand for practical

individualization of management strategies2. is an evidence-based approach to optimizing

adaptation to med/surg. illness3. complements diagnosis-based approaches4. Generates patient-specific management plans

Resources

• Attachment insecurity as a disease risk factor– Maunder R.G., Hunter J.J., Attachment and psychosomatic

medicine: Developmental contributions to stress and disease. Psychosom Med, 63 (4), 2001, 556-567

– Maunder RG, Hunter JJ Attachment relationships as determinants of physical health. Journal of the American Academy of Psychoanalysis and Dynamic Psychiatry, 36: 11-32, 2008

– L McWilliams, S.J. Bailey, Associations between adult attachment ratings and health conditions: Evidence from the National Comorbidity Survey replication. Health Psychology, 29 (4), 446-453, 2010

• Measuring attachment insecurity– Ravitz P, Maunder RG, Hunter JJ, Sthankiya B, Lancee, WJ. Adult

Attachment Measures – a 25 year review. J Psychosom Res, , 69: 419-32, 2010.

Resources

• Identifying attachment prototypes– Maunder RG, Hunter JJ. Assessing patterns of

adult attachment in medical patients. Gen Hosp Psychiatry 31:123-130, 2009

• Attachment-influenced management– Hunter J., Maunder R.G. Using attachment

theory to understand illness behavior. Gen Hosp Psychiatry, 23 (4), 2001, 177-182

• Youtubes: - Search “Maunder and attachment”