Patients with severe unexplained somatic symptoms tend to use denial, externalization, and somatization, converting psychosocial distress and problematic interpersonal relationships into unexplained physical complaints. Patients with severe unexplained somatic symptoms tend to use high/low anxious coping or manipulative coping styles (see Table 46-1).
A family physician can attempt to relieve a core problem or a symptom interfering with medical care by fostering the patient's awareness of his or her problems. It is important to appreciate the unconscious psychological processes known as defense mechanisms. These psychological processes (e.g., denial, projection) are used to resolve internal conflicts, manage moods, mediate external dangers, and facilitate adaptations to reality. Coping styles, on the other hand, are typically behavioral patterns and methods of coping with the external environment.
By understanding the constellation of defenses and coping styles used by difficult patients, the physician may be able to modify the pathologic defense or coping style that is interfering with the patient-physician alliance and the delivery of medical care. A physician can use clarification, confrontation, and interpretation (see Table 46-1). For example, a borderline patient may feel hurt and abandoned by the physician's vacation and accuse the physician of not caring. This patient may use a defense mechanism called devaluation (physician is deprecated as uncaring) and a coping style of manipulation (threatens suicide). With this understanding, the physician can begin to help the patient by not taking the patient's efforts to devalue or manipulate personally. The physician can respond to the patient by empathizing with the patient's fears of abandonment. The physician may clarify that the patient has a distorted belief, and that the vacation is being incorrectly experienced as a personal abandonment of the patient. The physician may further clarify that the vacation does not communicate anything about the physician's future ability or wish to care for the patient. The patient can be reassured of the physician's return, future realistic medical availability, specific limits of availability, and medical coverage by another physician. In a preventive effort to allay a crisis and help a borderline patient manage separation fears, the physician (before the vacation) could suggest a new coping style of having the patient schedule a meeting with a medical colleague who will provide coverage while the physician is away. Often, it is helpful to anticipate issues that may arise for the patient and suggest specific problem solving and coping.
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