Miss Personality 2013

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So are there other special groups that hit the emergency department on holiday weekends like this?

One of the groups of patients that have a hard time in the regimented world of the ED are the ones with personality disorders. People with things called borderline personality disorder, histrionic personality disorder and avoidant personality disorder don’t mesh well with a place where someone else tells you what to wear, where to sit and stay and when to go to the bathroom.

According to the new DSM-5, a personality disorder is an enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individual’s culture, is pervasive and inflexible, has an onset in adolescence or early adulthood, is stable over time, and leads to distress or impairment. Let’s break down this DSM-speak for you, dear readers.

Personality disorders show us an enduring pattern of inner experience. It doesn’t matter what the circumstance, what the stress, or what the setting, folks with PDs are going to have a hard time.

Prime example: you know very well that if you go the ED for your health care that you are likely to wait. And wait. And wait. And wait some more.  A man with Narcisisstic PD will most likely respond to this “normal” stress by loudly proclaiming to the triage nurse that his illness is  much more important than anyone else’s, that his time is more valuable, and that his as-yet-undiagnosed condition will probably be worthy of publication in several juried medical journals. This is his inner world. He is more important than you. He is more interesting than you. He should be bumped ahead of you in line. Even though he might be indigent, he should be given the very best care there is. Just beacuse he’s, well, HIM.

The fact that these PDs start in teenage years or early adulthood is a problem, in that the patient with PD will learn very earily on how to get the system to respond. A woman with Borderline PD comes to the ED with moderate symptoms of depression and anxiety. All of her lab work and studies are normal, her physical exam is unchanged from the last one documented and she is bascially ready for discharge to outpatient followup. Her doctor, who she has already put on a very high pedestal, comes in to tell her that she is being released. In purely medical terms, she flips out. The doctor immediately falls off his pedestal, hard, and becomes the worst practitioner in the entire world, stupid and ignorant and incapable of seeing what kind of care she needs. She fusses. She fumes. She might show inappropriate, intense anger at being discharged (remember, she has just been told that she is basically okay, something most of us would be happy to hear in the ED as we are being sent home).

PDs are stable over time. From one ED visit to the next, the woman with Histrionic PD will show the same pattern of excessive emotionality, attention seeking, and dramatic acting out that will most likely lead many ED staff to shun her (not always consciously, mind you). This is the patient who opens her gown just a little too wide at the top, exposing her ample bosom to the male nurses or doctors when not necessary for examination. She is the one who will always have every hair in place, perfect makeup, and freshened bright red lipstick even though she has just reported abdominal pain that is “10 out of 10” and excruciating. She sexualizes the encounter, manipulates the staff, and if her perceived needs are not met she may have a dramatic fainting spell, pseudoseizure, or bizarre migraine out of the blue just as her discharge paperwork is being completed.

It is difficult enough to sort through the myriad symptoms, lab values, scans, x-rays, histories and old records to come up with a solid working diagnosis in the ED and get a patient triaged, diagnosed, treated and out the door. Add to that the pressure of working in the context of personality disorders, which are not uncommon in patients who present to the ED for treatment, and the ED staff may find themselves in a hell of a mess.

The trick here?

Stay cool.

Remember your training.

Use your head.

Don’t rise to the bait.

These folks are sick just like anyone else. It’s just that the way they respond to medical stress is the same way they respond to changes in their love life, a broken water pump in their car, or a clogged toilet in their bathroom.

See past that, to what the real issue of the moment is, and you’re halfway home.

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7 thoughts on “Miss Personality 2013

  1. “People with things called borderline personality disorder, histrionic personality disorder and avoidant personality disorder don’t mesh well with a place where someone else tells you what to wear, where to sit and stay and when to go to the bathroom.”

    Don’t mesh well. Yes, that’s one way of putting it. One thing that we understand but that I would have like to see made more explicit in your post is that people with personality disorders are responding to underlying pain, not only the immediate stress. That might be a good thing for ED staff to keep in the front of their minds as they try to behave professionally in some very trying situations.

    Thanks for another good post, Greg.

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  2. Excellent point. ED visits are just snapshots in life, and the underlying pain tends to be pervasive and constant for people with personality disorders. It is just magnified that much more by a medical emergency or physical stress. Thanks for reading and for that astute comment.

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  3. This is a very good reminder. It is so easy to get annoyed with or insulted by a patient with a PD. We need to be understanding, caring, and do our jobs.

    Your description of women who keep their gowns gapping suggestively reminds me of a funny story. I was straightening up the living room on the day of an appointment with my breast surgeon. I picked up a load of things to put back in my daughter’s room, not noticing that I was clutching one of her art projects to my chest.

    Fortunately, I later caught a glimpse of myself in the mirror before heading off to the Cancer Center. My cleavage was suggestively dusted with bronze glitter. Yikes! I was able to clean myself up. I really did not want my doctor to think that I was looking too forward to seeing him!

    Knowing him, he would have just done his job the same way and maybe chuckled to himself later. But it did get me thinking about about some of the occupational hazards of being a breast cancer surgeon. He is a handsome older man who is very kind and a good listener. Add the fact that he removes cancer and you’ve got the makings of a heroic figure. I’m sure he’s met his fair share of women who make attempts to extend their relationship beyond the clinic!

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  4. Oooooooh boy, is this a great post! Not only for the ED, but for many settings! I went into outpatient mental health settings for a while as “the nurse”, and as we ALLLLLLL know, that meant I was the person standing between the patient and “THE DOCTOR”……the hardest for me to deal with, tantrums and all, were the borderline personality disorder patients. Just as you described, and even moreso! One in particular stands out, even now, as showing up beautifully put together, from an upper middle class family, fairly young and attractive. Would not keep her appointments, but would show up on HER time, demanding to see the doc. My doc was a hilarious Turkish young man, easily embarrassed (which I regularly took advantage of! 🙂 ) and loads of fun to work with, but taught me LOADS about mental health. My background, to that point, had been mostly geriatrics where I have the patience of Job. But here? Well, let’s just say that more than one soda was thrown in the waiting room and more than one door was slammed by this particular lady, because she could not “just see the doctor”. Being an outpatient setting, serving close to 2000 patients, we had to maintain our boundaries, ya know? Well, she’d show up and show out, and I’d have to go tell her that we must make an appointment and keep that appointment because all these other people in the waiting room are here for their appointments today, and she missed hers yesterday without calling……etc. Lord have mercy, the deep breathing and smiling!!!!! WHEW! This went on and on and on and my doc would just smile knowlingly when I told him that she’d been in again and how she’d left “this” time…..finally, one day he was laughing out loud at me (and I deserved it, for everything I did to him….we had to have fun at work, ya know?!? lol) and looked at me and said, “Those patients who frustrate us the most do so because they most closely resemble our own behaviors.” WHOA DUDE!!!!! Say what?!? Oh my. Well, of course, I had never seen myself in that light, nor had I seen myself acting that way, expecting the world to fall at my feet. Honestly, quite the opposite. BUT! Did he ever make an impression on me and my tolerance level! Whew! Her next appearance led to some pretty heavy duty motivational interviewing and goal setting for and with her, and a LOT more of my own introspection! But never fear…….I got him back! 🙂

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