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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
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....
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
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”