Common physician reactions to a patient with antisocial personality disorder are feelings of being used, exploited, or deceived. This can lead to physician anger and wishes to be free of the patient, uncover lies, and punish or imprison the patient. These patients fear that they will become vulnerable, lose respect or admiration from others, and become easy prey to manipulation when they become ill. They expect to be exploited, demeaned, or humiliated. Like the narcissistic patient, they often have low self-esteem, excessive self-love, compensatory feelings of superiority, grandiosity, recklessness, emotional shallowness, and show a lack of concern for others. They often react to medical care with entitled demands for special treatment. When caught in dishonesty, they may angrily attack or devalue the physician. They may resort to other psychopathic manipulations of deception, lying, cheating, or stealing. In fact, their friendly, facile, slick, superficial charm, and intelligent appearance is often beguiling for the physician. They can lose reality testing when stressed by the potential of getting caught in their deceptive practices. This is typically manifested by impulsive actions that reveal severely impaired or sometimes psychotic judgments. When receiving medical care for a legitimate illness, they typically function at the same level and often appear to have the same characteristic issues as the narcissistic personality disorder (Kernberg, 1992). They can often be managed similarly (see Narcissistic Personality Disorder).
To intervene with an antisocial patient, the family physician needs to be alert and anticipate that the patient may be requesting unnecessary medical care or even malingering or presenting a factitious disorder This patient may be seeking the secondary gain of illegal benefits or money, excuses for work absenteeism, or avoidance of legal problems, or just seeking caretaking. It is important not to collude with the patient's plans for secondary gain inadvertently. For example, if the physician thinks that a patient's request for disability is fraudulent or unwarranted, the patient should not be referred for additional evaluations. If deception is suspected, the physician can ask for verification of symptoms from other reliable sources. There is often dishonesty in a patient's communication in the form of withholding important information, partial truths, or outright lying, cheating, or stealing. If this occurs, avoid the common reaction of moralizing. Instead, grant the patient the reality that he has the ability to fool all the physicians if he wants. The patient can be told that the result of deception is that the physician may make poorly informed medical decisions. This will ultimately result in the patient receiving inadequate or poor medical care. The physician can explore with the patient why he needs to act self-destructively. Patients may need to be reminded that the physician's role is to help with medical problems and not to pass judgment or help the patient obtain unfair medical benefits.
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