Difficult Patients Personality Disorders and Somatoform Complaints

Robert E. Feinstein and Frank Verloin deGruy III

Chapter contents

Personality Style vs. Personality Disorder

1038

Discussing Defense Mechanisms and Coping Styles

1051

Classification

1038

Prescribing Medication

1051

Personality Disorders

1038

Parallel Diagnostic Inquiry

1052

Management Algorithm for Somatization

1053

Unexplained Physical Symptoms vs. Somatoform Disorders

1038

Consultation Letter

1054

Management

1040

Pharmacotherapy and Psychotherapy for Somatoform Disorders

Patient Core Beliefs, Irrational Thoughts, and Fears

1040

1054

Defenses and Coping Styles

1048

Interventions for Specific Personality Disorders

1054

Patient Behaviors, Adherence, and Use of Medical Services

1048

Paranoid Personality Disorder

1054

Physician Reactions to Difficult Patients

1048

Schizoid and Schizotypal Personality

1055

General Management Principles for Difficult Patients

1049

Antisocial Personality Disorder, Malingering, and Factitious Disorders

1055

Attending to a Problematic Alliance

1049

Histrionic Personality Disorder; Conversion or Somatic Symptoms

1056

Choosing a Focus for the Interview

1049

Borderline Personality Disorder; Somatization Symptoms or Disorder

1056

Using Basic Psychotherapy Techniques

1049

Narcissistic Personality Disorder

1057

Attending to Patient's Emotional Needs

1050

Avoidant Personality Disorder and Somatization Disorder

1057

Modifying Patient's Surroundings

1050

Dependent Personality Disorder and Somatization Disorder

1057

Improving the Capacity to Test Reality

1050

Obsessive-Compulsive Personality Disorder, Hypochondriasis,

Empathizing with Patient's Worldview

1050

and Body Dysmorphic Disorders

1058

Accepting Patient's Limitations and Strengths

1050

Self-Defeating Personality Disorder

1058

Managing Unreasonable Expectations and Setting Reasonable Limits

1051

Conclusion

1059

Questioning Illogical Feelings, Thoughts, and Behaviors

1051

The chapters in Part Two of this book generally are devoted to topics in family medicine practice that can be understood and managed as discrete clinical problems. Although several problems might coexist in a patient, this is the usual way the family physician approaches health problems. In this chapter, however, we follow our conviction that the clinical encounter is the ground on which all problems in family medicine are addressed. An effective clinical encounter, at its best, develops as an extended, trusting partnership between patient and physician. However, disturbances or difficulties in the encounter can ruin even the best therapeutic plan. In this chapter we use the term difficult patients to refer to two patient groups: those with personality traits (styles) or personality disorders and those with unexplained physical symptoms or somatoform disorders.

Our treatment of "personality styles" follows a spectrum or dimensional approach. In the mildest form, personality traits are present in normal, healthy patients, and under certain circumstances are assets. Although sometimes unpleasant, these are not necessarily pathologic. At the other end of the spectrum are features of personality that are so extreme as to constitute full-blown disorders: Axis II of the DSM-IV-TR contains a set of personality disorders that are real, difficult, and disabling and that often present in primary care settings.

Our treatment of patients with "unexplained physical symptoms," as with personality styles, also follows this spectrum or dimensional approach. In it mildest form, unexplained physical complaints will present in generally normal, healthy patients. These benign physical complaints are often accompanied by psychological issues just as often as psychological symptoms are accompanied by physical complaints. Features of psychological problems just as psychological symptoms always accompany physical problems (Kroenke et al., 1994). Moreover, symptoms of both a physical and a psychological nature frequently appear in patients—indeed, in all people—without obvious explanation. Mild physical symptoms such as "butterflies" in the epigastrium just before a public speech may disappear as mysteriously as they appear and are of no consequence. At the other end of the spectrum are increasingly severe, persistent, or disabling, unexplained physical symptoms that eventually cross a threshold and become a disorder in their own right. The somatoform disorders are this family of full-blown diagnostic conditions, characterized by disabling physical symptoms with no physical explanation.

This chapter discusses difficult patients at all points on the personality and somatic continuum, from normal to disordered, to patients with comorbid conditions. Success in managing these difficult patients depends more often on the physician's reaction to the patient's personality traits or somatic complaints (and resulting interventions) than on assignment of a specific diagnosis. These problems do not exist in the patient, but rather in the transactions between patient and physician. Here the physician's task is not simply to discover and describe patient problems, but also to create a relationship with the patient that is therapeutic rather than problematic. Our approach here is to address difficult clinical encounters in terms of patients' personality style and somatic presentation and the responses elicited in physicians. Interventions based on the physician's responses and an understanding of the patient's issues offer a convenient and parsimonious framework for constructive management strategies.

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