Category: Education

Difficult Interactions (III).

Post author By Maria Yang, MD
Post date July 18, 2013

(Note: If you found the previous posts in this series “woo woo”, you might find this one nearly intolerable.)

A final reason to stop talking in the midst of a difficult clinical interaction is so you can accept what the other person is doing.

When you accept someone else’s behavior, this does not mean that you necessarily agree with it. It doesn’t mean that you condone it, support it, or want it to happen more. It just means you accept what is happening.

We cannot control the behaviors of others. We can influence them, but we cannot control them. If we do not accept what is actually happening, we have no chance of influencing what happens next.

I worked in a residence where two men would occasionally pee in the elevator. They weren’t incontinent, there was no Foley catheter and bag that malfunctioned… they just periodically voided their bladders in that small space.

Willfully ignoring the yellow puddle in the elevator won’t resolve the problem. The odor would fill the elevator and other people would inadvertently step into the urine.

Wistfully wishing that they had voided their bladders elsewhere won’t resolve the problem, either. “Why didn’t they use the bathroom? If they really had to go, they could have at least peed into the plant next to the elevator. Should they wear adult diapers?” Trying to solve the problem before having a clear definition of the problem often only leads to frustration. You cannot define a problem until you accept that it is a problem.

It’s also common to realize that, when you’re silent and accepting what the other person is doing, the difficult interaction often softens. It is hard to argue with or resist someone when he is accepting what you are doing and saying in that moment.[1. It takes two to fight, two to tango, blah blah blah….] Furthermore, you are also practicing and modeling a useful skill. The other person might realize that he could use that skill at that moment, too.

To review: One reason why it is useful to stop talking during difficult interactions is so you can acknowledge the emotions you are experiencing. Another reason is to recognize and adjust the language you are using to describe the situation to yourself. A third reason is to accept what is actually happening so you can plan and take next steps. It seems like all of this would take a long time and result in awkward silences, but that doesn’t happen. For many people, staying silent isn’t a habit. It takes practice.

Consult-Liaison Education Informal-curriculum Medicine

Difficult Interactions (II).

Post author By Maria Yang, MD
Post date July 7, 2013

Another reason to stop talking in the midst of a difficult clinical interaction[1. I focus on clinical interactions here, but this arguably applies to any difficult interaction we have with our fellow human beings.] is to recognize what you are thinking and adjust the language accordingly. The words we use to describe events, even if only in our heads, will influence both our emotions and behaviors.

Here is an example. Who would you rather work with?

Person 1: This is a 28 year-old woman who is manipulative and immature. She will do anything to get attention; she’s so dramatic. She never takes responsibility for what she does and everyone else has to clean up the messes that she makes.

Person 2: This is a 28 year-old woman who struggles to deal with emotions she feels like she can’t control. She has difficulties with relationships, but she’s doing the best that she can with the skills she has to get her needs met. If she knew how to work with people more effectively, she would. She might also have fears that if she tried harder, she might fail. No one likes to feel shame.

These descriptions could be of the same person. However, your reactions to each description might be noticeably different.

Some may argue that this is an exercise in semantics or, worse, indulgence in delusion. “But, Dr. Yang, she really is manipulative….”[2. Like I noted here, we manipulate each other all the time. I’m arguably manipulating you right now with these words. We often use the word “manipulative” when the manipulation isn’t skillful. People would do something different if they could in that moment.]

It’s our job to be more flexible than our patients. That’s why we get paid to do what we do. Yes, you could argue that these are just word games. However, would you rather be helpful or would you rather be “right”?

If describing patient behaviors in neutral, if not generous, language will help you maintain your professionalism and deliver quality care, then give strong consideration to what words you choose.

Please note that you can still use neutral language even when you feel angry or frustrated:

She’s screaming and trying to bang her head against the wall right now because that’s the best that she knows how to cope with the situation. I’m getting really annoyed with this… and if she could do something different right now, she would.

What is happening and how you feel are both “true”.[3. Using neutral language in your head during difficult interactions can have the added benefits of making you slow down and reducing the intensity of your emotions.] Remember, you feel what you feel. Own it.

One more reason to follow before we all resume talking.

Consult-Liaison Education Informal-curriculum Lessons Medicine Observations

Personality Disorders to Difficult Interactions (I).

Post author By Maria Yang, MD
Post date July 2, 2013

I successfully delivered my talk on personality disorders recently. The second half of the talk strayed from personality disorders to a discussion about how to manage difficult interactions with people. The two topics are peripherally related, as you will recall that individuals with personality disorders often have difficulties with interpersonal relationships.

To be clear, though, just because you have a difficult interaction with someone doesn’t mean that that person has a personality disorder. There are plenty of people without personality disorders who behave in unbecoming ways.

Think about the last time you had a rough day. It is within the realm of possibility that, during that slice of time, you behaved in ways that suggest you have a personality disorder. It may not happen often, but it happens to all of us at some point.

Most of us rely on “gut feelings” to identify when we’re having difficult interactions with people. There are behavioral cues, though, that can serve as “red flags” to alert you that an interaction isn’t going well:

1. There are frequent interruptions. The other person keeps interrupting you… and you keep interrupting the other person.

2. There is a lot of repeating. You keep saying the same thing over and over again… and the other person keeps saying the same thing over and over again.

3. Many words are spoken, but nothing is really said. The literature describes this as “disengagement”. You’re just saying things to end the conversation. (e.g., “There’s nothing else I can do. Sorry. There’s nothing else I can do. Sorry.”)

Though emotional cues are valuable, sometimes it is easier to recognize these behavioral cues. We may not realize how we’re feeling until it reaches an uncomfortable intensity.

Once you recognize that you are in the midst of a difficult interaction, what can you do?

A useful first step is to stop talking.

The reason why it is important to stop talking is because when you stop talking, you can then self-reflect. I know that sounds “woo woo”. Hang in there with me.

Acknowledge the emotions you are experiencing. If you do not recognize and acknowledge what you are feeling, those emotions will likely manifest themselves in behaviors that you may not like.

If I refuse to acknowledge that I feel angry with someone, I might speak in a tone of voice that sounds sarcastic and condescending, give an icy glare, or say something biting and rude. Acknowledging what I am feeling gives me the opportunity to adjust my behavior accordingly. It gives me choices as to how I want to proceed.

To be clear, people aren’t stupid, so the other person probably knows that I feel angry. Acknowledging my anger, though, can cue me to take a deep breath, relax my face, or do something else to prevent the situation from getting worse. If I’m not paying attention to how I feel, I won’t do any of those things.

The other important aspect about acknowledging your emotions is that it grants you permission to feel what you feel. People sometimes have this idea that you must like all of your patients (or clients or customers or…). However, you won’t like all of your patients. That’s okay. That’s not the expectation. The expectation is that you show respect and provide the best care you can to them. That doesn’t mean that you have to like them.

You feel how you feel. There may be days when you feel anger towards people you like. And that’s okay. You will be much more effective if you acknowledge how you feel to yourself because you will be giving yourself choices. Those choices can give you significant influence over the rest of the interaction.

This is one important reason why you stop talking. More reasons to follow.

Consult-Liaison Education Medicine

Personality Disorders (IX): Definition and Etiology of the Dependent Type.

Post author By Maria Yang, MD
Post date June 13, 2013

There is very little data about dependent personality disorder. Psychoanalytic theorists have discussed their ideas about how this condition comes about, but there are few papers that discuss the reasons why it develops and what to do about it.

We’ll go through the DSM-4 criteria for it first:

A pervasive and excessive need to be taken care of that leads to submissive and clinging behavior and fears of separation, beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following:

Yikes. Would you have ever guessed that “clinging” would become a diagnostic criterion?

(1) has difficulty making everyday decisions without an excessive amount of advice and reassurance from others

The thought is that the person will make the “wrong” decision or that the decision will displease other people. The decisions, though, may not appear complicated to most people. (“Which cereal should I eat? You’re not going to be mad if I eat the Cookie Crisp, right? But maybe I should go with Lucky Charms. Which do you think will taste better?”)

(2) needs others to assume responsibility for most major areas of his or her life

Again, this suggests a lack of trust in oneself to make the “right” decisions. (“Which job should I apply for? Where should I live? What kind of food should I eat?”)

(3) has difficulty expressing disagreement with others because of fear of loss of support or approval. Note: Do not include realistic fears of retribution.

Perhaps this is also a fear of abandonment (see borderline personality disorder). Also note that this criterion includes a caveat about excluding “realistic fears”, whereas in borderline personality disorder, the excessive efforts apply to either “real or imagined” abandonment.

(I suppose it is noteworthy that this criterion refers to “expressing disagreement” and the borderline criterion refers to “excessive efforts”, though both are driven by “fear”.)

(4) has difficulty initiating projects or doing things on his or her own (because of a lack of self-confidence in judgment or abilities rather than a lack of motivation or energy)

Insecurity is all a matter of degree. Again, this difficulty with initiative must impair function, affect relationships, etc. Conversations like

“Where do you want to eat?”
“I don’t know, where do you want to eat?”

don’t count.

(5) goes to excessive lengths to obtain nurturance and support from others, to the point of volunteering to do things that are unpleasant

“Doormat” is not a clinical term, but this is what often comes to mind.

(6) feels uncomfortable or helpless when alone because of exaggerated fears of being unable to care for himself or herself

This is an interesting criterion because it comments directly on emotions rather than behaviors. Sometimes we think people feel uncomfortable or helpless, though they actually feel neither. Sometimes people do feel uncomfortable and helpless, though their behaviors don’t suggest this at all.

(7) urgently seeks another relationship as a source of care and support when a close relationship ends

This criterion, as with the last one, should be taken in conjunction with the other criteria for this diagnosis.

(8) is unrealistically preoccupied with fears of being left to take care of himself or herself

Fear underpins this diagnosis and drives the behaviors that seem like “clinging”.[1. One must be careful when assuming intentions from behaviors alone. You might see me eating a sack of cookies (behavior) and assume that I lack control (intention). I might actually be eating a sack of cookies (behavior) because I hadn’t eaten all day or I don’t want to share my cookies with other people. Maybe the sack is no longer full of cookies, but I am eating quickly because I am running late. The sack may not have cookies inside. You get my point.]

Here is a paper that reports some studies that describe possible etiologies of dependent personality disorder. Some authors found a relationship between “infantile feeding experiences and later dependency”, though the data is inconsistent and subject to the mothers’ reporting bias.

When people studied interactions between infants and parents and parenting styles, they found that parents who are overprotective and authoritarian may have children who ultimately develop dependent personality disorder.

The author correctly notes that parental behavior may actually reinforce dependent behaviors in children and vice versa. If the parent derives some benefit (psychological or otherwise) from a child who shows dependent behaviors, the parent may actually increase the authoritarian and overprotective behavior because the parent “likes” the reactions. This may drive the child to demonstrate even more of these behaviors. And on and on it goes.

These observations are in direct contrast to other hypothesizes about dependent personality disorder (for which there is no data, but only speculation): Some argue that children who lose their parents at an early age (due to death, adoption, etc.) are more likely to develop dependent personality disorder. Others argue that children who have chronic physical illness are also more likely to develop this condition.

One major component to consider is “fit”.[2. To learn more about “fit”, read about attachment theory.] We don’t choose our parents or our children. Sometimes, there just isn’t a “good fit” between parents and children. Some parents are anxious, which leads to overprotectiveness and authoritarian behavior. This may increase the likelihood that the child will develop dependent personality disorder or traits. If the child had different parents, he might have a different temperament as an adult. To be clear, many children do have anxious parents and never develop this condition.

And that’s all I got for dependent personality disorder. Next up is how to manage (not treat!) these conditions in settings like shelters and supportive housing. I shan’t let that task daunt me.

Consult-Liaison Education Medicine

Personality Disorders (VIII): The Definition of Borderline.

Post author By Maria Yang, MD
Post date June 10, 2013

If you haven’t read the proposed etiologies of borderline personality disorder first, please do so. An understanding of its causes makes the criteria seem less… judgmental and harsh.

Following is the definition of borderline personality disorder according to DSM-4.

A pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following:

The authors here focus on instability, not only when interacting with others, but also with oneself and one’s emotions.

(1) frantic efforts to avoid real or imagined abandonment. Note: Do not include suicidal or self-mutilating behavior covered in Criterion 5.

The vast majority of people don’t want to experience abandonment. “Frantic”, given the context, is open to interpretation. Upon reading this, you may think of multiple, desperate phone calls filled with promises that cannot be kept. These efforts, however, can also refer to someone who abruptly stays in bed and doesn’t acknowledge any communications from the outside world. “Frantic efforts” are not required to be loud.

(2) a pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation

“Alternating between extremes of idealization and devaluation” is often described as something like this:

January 15: “I love my doctor—she’s the best doctor I’ve ever had. She is smart and really understands what I’m talking about. Don’t see anyone else in that clinic; no one else there is as good as she is.”

February 1: “My doctor is terrible. She thinks she’s really good, but she’s not. I’m not sure why they let her graduate from medical school—she doesn’t know what she’s doing and her bedside manner is crap. I would not recommend her to my worst enemy.”

Recall the concept of “all good/all bad”.[1. This “all good/all bad” concept comes from object relations theory. Object relations is not my forte; I’m much too concrete.] That is reflected here.

(3) identity disturbance: markedly and persistently unstable self-image or sense of self

Recall the experiences of invalidation children may experience while growing up. If you are regularly told that your thoughts, emotions, and behaviors are “wrong”, you, too, might have doubts about who you are, what you feel, and what you do.

(4) impulsivity in at least two areas that are potentially self-damaging (e.g., spending, sex, substance abuse, reckless driving, binge eating). Note: Do not include suicidal or self-mutilating behavior covered in Criterion 5.

This might speak to heightened “emotional sensitivity” (more intense emotions that last a longer period of time), which is considered a biological cause of this condition.

People also often confuse these behaviors with the hypo/mania described in bipolar disorder.

(5) recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior

This criterion was already mentioned twice before we got here! This is why some people use the mental shortcut of, “Well, she’s always trying to kill herself, so she must be borderline”.[2. Try this exercise if you work in health care: Describe your patients as people instead of medical conditions. No, he’s not “the liver cancer in bed seven”, he’s “Mr. Smith, the man diagnosed with liver cancer”. Yes, emotional distance can be useful, but if you habitually think of your patients as diagnoses, that might lead you to treat your patients as if they weren’t people.] Like many shortcuts, this can lead you to the wrong conclusion.

Remember that Little Suzie learned that people seemed to only really understand her internal distress when she did things like injure herself. This is the best way she knows how to get her emotional needs met. This is a skills deficit. (To be clear, you could say that “she’s manipulative”, but we all manipulate each other all the time. I’m arguably manipulating you right now with these words. We often use the word “manipulative” when the manipulation isn’t skillful. People would do something different if they could in that moment.)

(6) affective instability due to a marked reactivity of mood (e.g., intense episodic dysphoria, irritability, or anxiety usually lasting a few hours and only rarely more than a few days)

This again refers to the “emotional sensitivity” discussed above in criterion 4. People also confuse this with mood fluctuations seen in bipolar disorder.

(7) chronic feelings of emptiness

This can be related to the “identity disturbance” described in criterion 3 above.

(8) inappropriate, intense anger or difficulty controlling anger (e.g., frequent displays of temper, constant anger, recurrent physical fights)

(I encourage all to use the word “inappropriate” with caution. What is “inappropriate” strongly depends on the context.)

This, too, refers to “emotion sensitivity” and the impulsivity that may result from it.

(9) transient, stress-related paranoid ideation or severe dissociative symptoms

This criterion explains the psychotic symptoms that can accompany borderline personality disorder. Some will recall the the name “borderline” came about because some theorists argued that these individuals are on the “borderline” between neurosis and psychosis.

Dissociation can be a skillful way of coping with stress. An extreme example is someone dissociating while getting raped. A more common example is someone dissociating a bit while at the dentist. Dissociation becomes a problem when it affects function (like dissociating while at a job interview).

Again, recall that 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”. People who work in health care settings often start using the word “borderline” to describe someone who they feel annoyed and frustrated with. That’s unfair. Words matter.

Next up is dependent personality disorder… for which there is sparse data.