Working with Manipulative Behavior Primary Care Conference June 1, 2005
description
Transcript of Working with Manipulative Behavior Primary Care Conference June 1, 2005
![Page 1: Working with Manipulative Behavior Primary Care Conference June 1, 2005](https://reader035.fdocuments.in/reader035/viewer/2022062314/5681474c550346895db48f7d/html5/thumbnails/1.jpg)
Working with
Manipulative BehaviorPrimary Care Conference
June 1, 2005
Norman Jensen MDProfessor of Medicine
University of Wisconsin - Madison
I have approved this message.
![Page 2: Working with Manipulative Behavior Primary Care Conference June 1, 2005](https://reader035.fdocuments.in/reader035/viewer/2022062314/5681474c550346895db48f7d/html5/thumbnails/2.jpg)
Intended learning outcomes
• Enhancement of– Concept of manipulative behavior
– Awareness of common contexts
– Awareness of management strategies
– Attitude toward the topic
– Motivation to learn more
![Page 3: Working with Manipulative Behavior Primary Care Conference June 1, 2005](https://reader035.fdocuments.in/reader035/viewer/2022062314/5681474c550346895db48f7d/html5/thumbnails/3.jpg)
Conflicts of interest
• I will mention no pharmaceuticals or medical equipment.
• I will receive no specific pay for this presentation …– in fact,– the more I work, the less I’m paid.
![Page 4: Working with Manipulative Behavior Primary Care Conference June 1, 2005](https://reader035.fdocuments.in/reader035/viewer/2022062314/5681474c550346895db48f7d/html5/thumbnails/4.jpg)
Manipulate Webster’s New Collegiate Dictionary 1980
• 2a. To manage or utilize skillfuly. B. To control or play upon by artful, unfair, or insidious means esp. to one’s own advantage. 3. To change by artful or unfair means so as to serve one’s purpose. Syn. doctor
![Page 5: Working with Manipulative Behavior Primary Care Conference June 1, 2005](https://reader035.fdocuments.in/reader035/viewer/2022062314/5681474c550346895db48f7d/html5/thumbnails/5.jpg)
Machiavellian Webster’s New Collegiate Dictionary 1980.
• NLM MESH heading for manipulation of the psychological type.
• The political theory of Machiavelli that politics is amoral and that any means however unscrupulous can justifiably be used in achieving political power. Characterized by cunning, duplicity, or bad faith.
![Page 6: Working with Manipulative Behavior Primary Care Conference June 1, 2005](https://reader035.fdocuments.in/reader035/viewer/2022062314/5681474c550346895db48f7d/html5/thumbnails/6.jpg)
Manipulation Hamilton JD, et. al. Am J Psychotherapy 1986;40;191.
• “… deliberately influencing or controlling the behavior of others to one’s own advantage by using charm, persuasion, seduction, deceit, guilt induction, or coercion … best restricted to conscious, intentional behavior … and [best] viewed [clinically] as a symptom, like chest pain or fever, with a multitude of causes, some transient, some chronic some more serious than others”.
![Page 7: Working with Manipulative Behavior Primary Care Conference June 1, 2005](https://reader035.fdocuments.in/reader035/viewer/2022062314/5681474c550346895db48f7d/html5/thumbnails/7.jpg)
Manipulative patient behaviors
• Seeking unwarranted “sick” certificates• Seeking Rx for non-Rx drugs• Recurrent lying• Recurrent refusals of care• Recurrent demands for special treatment• Recurrent denials of strong emotion• Recurrent demands for tests, consults,
drugs, procedures, etc
![Page 8: Working with Manipulative Behavior Primary Care Conference June 1, 2005](https://reader035.fdocuments.in/reader035/viewer/2022062314/5681474c550346895db48f7d/html5/thumbnails/8.jpg)
Manipulative patient behaviors
• Recurrent failed adherence to care plan• Intentional production of sx, signs, or injury• Self-depreciation• Expressing surprise, hurt, disappointment with
physician• Threatening self-destructive behavior• Quoting what others or other physicians have
said or done
![Page 9: Working with Manipulative Behavior Primary Care Conference June 1, 2005](https://reader035.fdocuments.in/reader035/viewer/2022062314/5681474c550346895db48f7d/html5/thumbnails/9.jpg)
List here:
withhold information to avoid a diagnosis
list of what they need, including bizarre
ER pt allergic to all but demerol:
flattery
lie to obtain a medication
exaggerating sx to obtain treatment
request for disability paper work
requesting re-authorization of Rx not relevant to the visit
family member demanding unnecessary treatment
avoiding one treatment to get the next one
![Page 10: Working with Manipulative Behavior Primary Care Conference June 1, 2005](https://reader035.fdocuments.in/reader035/viewer/2022062314/5681474c550346895db48f7d/html5/thumbnails/10.jpg)
List more here
refusing discharge to escape home care
refusing to reveal sx of depression to avoid record
![Page 11: Working with Manipulative Behavior Primary Care Conference June 1, 2005](https://reader035.fdocuments.in/reader035/viewer/2022062314/5681474c550346895db48f7d/html5/thumbnails/11.jpg)
Differential Diagnosis (1)of manipulative behavior
• Normal behavior for a person who is independent, assertive, conscious of consumer rights and perhaps somewhat mistrustful. (esp. with authoritarian clinicians or beliefs in alt./comp. healing)
![Page 12: Working with Manipulative Behavior Primary Care Conference June 1, 2005](https://reader035.fdocuments.in/reader035/viewer/2022062314/5681474c550346895db48f7d/html5/thumbnails/12.jpg)
Differential Diagnosis (2)of manipulative behavior
• Axis I - Depression, e.g., suicide gesture preceding fatal repetition.
• Factitious disorders (intentional or feigned production of sx in order to assume sick role)
• Malingering (intentional production of sx for discrete external purpose.
• AODA - relationships with people take second place to obtaining the substance
![Page 13: Working with Manipulative Behavior Primary Care Conference June 1, 2005](https://reader035.fdocuments.in/reader035/viewer/2022062314/5681474c550346895db48f7d/html5/thumbnails/13.jpg)
Differential Diagnosis (3)of manipulative behavior
• Axis II - personality disorders– Antisocial– Narcissistic– Borderline– Histrionic
![Page 14: Working with Manipulative Behavior Primary Care Conference June 1, 2005](https://reader035.fdocuments.in/reader035/viewer/2022062314/5681474c550346895db48f7d/html5/thumbnails/14.jpg)
Case presentation
• 46 y/o professor• Highly accomplished, lots of grants• In bioscience field• Single parent 2 teens
• Severe respiratory symptoms 5 days• No signs / symptoms of complication• Urgent care Friday pm
• Demanding “antibiotic”• Insistent, persistent despite medical explanation• At 12 minutes of a 15 minute visit
• What management strategies are available?
![Page 15: Working with Manipulative Behavior Primary Care Conference June 1, 2005](https://reader035.fdocuments.in/reader035/viewer/2022062314/5681474c550346895db48f7d/html5/thumbnails/15.jpg)
Managementof manipulative behavior
• Manipulative behavior as a symptom– Be curious vs. judgmental– Careful understanding of behavior– Differential diagnosis– Hypothesis testing– Specific management
![Page 16: Working with Manipulative Behavior Primary Care Conference June 1, 2005](https://reader035.fdocuments.in/reader035/viewer/2022062314/5681474c550346895db48f7d/html5/thumbnails/16.jpg)
Managementof manipulative behavior (1)
• Careful understanding of the behavior– understand & acknowledge pt feelings– seek meanings for the patient– understand & acknowledge doctor
feelings– seek meanings for doctor
![Page 17: Working with Manipulative Behavior Primary Care Conference June 1, 2005](https://reader035.fdocuments.in/reader035/viewer/2022062314/5681474c550346895db48f7d/html5/thumbnails/17.jpg)
Managementof manipulative behavior (2)
• For activated independent patient – reduce authoritarian doctor
behavior– negotiate a management plan
![Page 18: Working with Manipulative Behavior Primary Care Conference June 1, 2005](https://reader035.fdocuments.in/reader035/viewer/2022062314/5681474c550346895db48f7d/html5/thumbnails/18.jpg)
Managementof manipulative behavior (3)
• For transient regressive states– what is the patient afraid of?
• Pain • being alone• unknown illness • death• lack of information • other?
– Listen actively for understanding
– PEARLS
![Page 19: Working with Manipulative Behavior Primary Care Conference June 1, 2005](https://reader035.fdocuments.in/reader035/viewer/2022062314/5681474c550346895db48f7d/html5/thumbnails/19.jpg)
Responding to Emotion Professional Rapport Building SkillsCohen-Cole SA & Bird J. • Partnership• Empathy• Apology• Respect• Legitimation• Support
![Page 20: Working with Manipulative Behavior Primary Care Conference June 1, 2005](https://reader035.fdocuments.in/reader035/viewer/2022062314/5681474c550346895db48f7d/html5/thumbnails/20.jpg)
Managementof manipulative behavior (4)
• In substance abuse disorders–set careful limits on
prescribing–refer to treatment program–develop a contract
![Page 21: Working with Manipulative Behavior Primary Care Conference June 1, 2005](https://reader035.fdocuments.in/reader035/viewer/2022062314/5681474c550346895db48f7d/html5/thumbnails/21.jpg)
Managementof manipulative behavior (5)
• For factitious disorders– confrontation
– refer for individual psychotherapy
![Page 22: Working with Manipulative Behavior Primary Care Conference June 1, 2005](https://reader035.fdocuments.in/reader035/viewer/2022062314/5681474c550346895db48f7d/html5/thumbnails/22.jpg)
Managementof manipulative behavior (6)
• For pure malingering–confrontation
–consultation with legal system
![Page 23: Working with Manipulative Behavior Primary Care Conference June 1, 2005](https://reader035.fdocuments.in/reader035/viewer/2022062314/5681474c550346895db48f7d/html5/thumbnails/23.jpg)
Managementof manipulative behavior (7)
• For Axis II, personality disorders– Antisocial: psychotherapy often
not successful.
– Others: long-term psychotherapy is more successful.
– Contracts and setting limits.
![Page 24: Working with Manipulative Behavior Primary Care Conference June 1, 2005](https://reader035.fdocuments.in/reader035/viewer/2022062314/5681474c550346895db48f7d/html5/thumbnails/24.jpg)
Managementof manipulative behavior (8)
• When manipulative behavior cannot be modified or contained– use Dr feelings as data, not for Rx plan– generally avoid acquiescence– set firm & explicit (not angry) limits– set up a relational contract – enlist a team of care givers– if intolerable, terminate relationship
![Page 25: Working with Manipulative Behavior Primary Care Conference June 1, 2005](https://reader035.fdocuments.in/reader035/viewer/2022062314/5681474c550346895db48f7d/html5/thumbnails/25.jpg)
If you want to read more:
1. Hamilton JD, et.al. The Manipulative Patient. Am J Psychotherapy. 1986;XL:189-200.
2. Murphy GE, Guze SB. Setting limits. Am J Psychotherapy 1960;14:30-47.
3. Adler G. Helplessness in the helpers. Br J Med Psychol 1972;45:315-326.
4. Adler G, Buie DH. The misuses of confrontation in borderline patients. Int J Psychoanal Psychother 1972;1:109-120.
5. Maltoberger JT, Buie DH. Counter-transference hate in the treatment of suicidal patients. Arch Gen Psychiatry 1974;30:625-633.
![Page 26: Working with Manipulative Behavior Primary Care Conference June 1, 2005](https://reader035.fdocuments.in/reader035/viewer/2022062314/5681474c550346895db48f7d/html5/thumbnails/26.jpg)
6. Groves JE. Management of the borderline patient ion a medical or surgical ward: the psychiatric consultant’s role. Int J Psychiatry Med 1975;6:337-348.
7. Zinn WM. Transference phenomena in medical practice: being whom the patient needs. Ann Intern Med 1990;113:293-298.
8. Groves JE. Taking care of the hateful patient. New Engl J Med 1978;298:883-887.
9. Hahn SR. et.al. The difficult patient: prevalence, psychopathology, and functional impairment. J Gen Intern Med 1996;11:1-8.
10. Hahn SR, et.al. The difficult doctor-patient relationship questionnaire. J Clin Epidemiol 1994;47:657.
![Page 27: Working with Manipulative Behavior Primary Care Conference June 1, 2005](https://reader035.fdocuments.in/reader035/viewer/2022062314/5681474c550346895db48f7d/html5/thumbnails/27.jpg)
The lecture ends here!Questions?Answers $0.25Answers requiring thought $1.00Correct answers $2.50
Comments?