Transcend dread: 8 ways to transform your care of ‘difficult’ patients

John Battaglia, MD

Medical director, Program of assertive community treatment, Clinical associate professor, Department of psychiatry, University of Wisconsin, Madison, WI

Although “the difficult patient” is not a diagnosis or specific clinical entity, clinicians universally struggle with such patients and have an immediate sense of shared experience when describing the phenomenon. In primary care, O’Dowd aptly described this type of patient as the “heartsink” patient, meaning the practitioner often feels exasperation, defeat, or dislike when he or she sees the patient’s name on the schedule.

This article discusses the literature on this topic and provides strategies for dealing with difficult patients in psychiatric practice.

Read full text (free access)

Listen to Dr. Battaglia explain the advantages of "plussing" your difficult patient

Comment on this article

Email the editor

Help your bipolar disorder patients remain employed

Charles L. Bowden, MD

Clinical professor of psychiatry and pharmacology, Nancy U. Karren Distinguished Chair of Psychiatry, The University of Texas Health Science Center at San Antonio

Bipolar disorder’s long-term course presents a therapeutic challenge when patients desire to remain employed, seek temporary or permanent disability status, or—most commonly—attempt to return to employment after a period of inability to work. As the experience of Mrs. S illustrates, previous capabilities that appear higher than the person’s present or recent work experience are a key issue to address in interpersonal therapy.

Evidence-based research is informative, but ultimately you must apply judgment and flexibility in setting and revising goals with the bipolar individual. Attention to the disorder’s core characteristics can help you equip patients for work that contributes to their pursuit of health.

Read full text (free access)

Comment on this article

Email the editor

Dissociative identity disorder: Time to remove it from DSM-V?

Numan Gharaibeh, MD

Staff psychiatrist, Department of psychiatry, Danbury Hospital, Danbury, CT

Dr. Gharaibeh is a an attending psychiatrist on the inpatient unit at Danbury Hospital in Danbury, CT. He teaches psychiatric residents from New York Medical College during their rotation in Danbury Hospital and physician assistant students from Quinnipiac University, Hamden, CT.

What is it about dissociative identity disorder (DID) that makes it a polarizing diagnosis? Why does it split professionals into believers and nonbelievers, stirring up heated debates, high emotions, and fervor similar to what we see in religion?

The DID controversy is likely to continue beyond the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-V), slated for publication in 2012. Proponents and opponents claim to have the upper hand in arguments about the validity of the DID diagnosis and benefits vs harm of treatment. This article examines the logic of previous and new arguments.

Read full text (free access)

Comment on this article

Email the editor

Paradigms shift rapidly in antipsychotic treatment

Henry A. Nasrallah, MD
Editor-in-Chief

Like the “paradigm shift” Thomas Kuhn coined in his seminal book, The Structure of Scientific Revolutions, paradigm shifts have been occurring at a breathless pace in psychiatry. Thanks to ongoing research, changes in the clinical standard of care for schizophrenia in the past 20 years are a case in point.

Let’s take 1988 as a starting point. That’s when clozapine was “resurrected” as the only drug with proven efficacy in refractory schizophrenia after several first-generation antipsychotics (FGAs) had been tried. However, because of its potentially fatal side effect (agranulocytosis), clozapine was designated as an absolute last-resort agent. It also was stigmatized for its many other side effects, including serious metabolic complications.

Read full text (free access)

Comment on this article

Email the editor