is a good question to ask every new
patient.) If so, move slowly and
explain everything. Explain not just
what you are doing but also why it is
necessary. Invite the patient to give
you suggestions about how to make
this easier for him. If the trauma
occurred in very early childhood, he
may be apologetic but also anxious
and unable to trust. This is different
from the narcissist who is unwilling to
trust.
THE PARANOID PATIENT
Paranoid disorders are disturbingly
common. The paranoid patient
is unable to trust, but is
angry, not anxious. She feels
victimized and exploited, and the
medicopharmaceutical conspiracy is
just one more group trying to deceive
and injure her. She will not be shy
about showing her hand and might
even volunteer that she “knows”
that doctors are shills for the drug
companies and she won’t be fooled.
Managing the Paranoid
My favorite exercise to assign medical
students is to have them try to
talk a paranoid patient out of their
delusion. Spoiler alert — it can’t be
done.
These patients are highly litigious,
so document well. Remember
that people have a right to selfdetermination,
even if they are
deluded, and document that you
assess the patient to be competent
to refuse medical care. Be straightforward
about your diagnosis and
treatment recommendations, and then
let the patient decide the next steps.
Don’t confront the delusions, but
don’t entertain them, either. Move the
conversation along quickly.
Figuring out what is beneath your
patients’ internet searches is key to
becoming their ally. If they Google it,
Grugle it! DMJ
November 2018 Dallas Medical Journal 19
Helping the Scientist
First, check your arrogance. The
Scientist is your ally, not your
competition. Validate her experience
and education, and ask that she
continue to bring relevant literature
to your attention for your review. Ask
if she is familiar with the literature
you favor and offer to send her some
references. Use scientific terms, but be
sure that she understands them the
first time. Recognize that she is the
one making important decisions about
her life and deserves honesty, respect
and humility. Join her team and she
will gladly follow.
THE WORRIER
He is moderately obsessive, probably
has a few compulsions. He’s been
in your office before with relatively
minor complaints. He has difficulty
moderating his anxiety and fear, and
is especially afraid that he may make
a fatal error. This fear is projected to
you.
Reassuring the Worrier
Bring the anxiety into the room. Tell
him, “I can see this is really scaring
you. I wonder if you’re afraid I might
miss something important.” Tell
him about the process of making
an accurate diagnosis, and that we
operate like pilots, using checklists
and guidelines to be sure we don’t
miss anything. Make an appointment
for a follow-up visit, but invite the
patient to cancel it if he is feeling
well. Give him an assignment to
bind his anxiety, like measuring and
recording the diameter of his abscess,
or checking his blood pressure at the
same time every day.
THE NARCISSIST
This can be among the most
distressing personalities to deal
with. You will not cure this patient
of his arrogance and getting into a
competition will get you nowhere.
Trust is difficult for narcissists — it
makes no sense to them.
Pacifying the Narcissist
Acknowledge this distrust directly: “I
can tell it’s hard for you to rely on my
expertise. Let’s just give it time and
see if you start to trust me.” When
the narcissist makes unreasonable
demands, acknowledge the frustration
of having to put up with the hassles of
medical care but set firm limits, “All of
our patients are given the same level
of individual attention and care.”
THE SOMATIC PATIENT
She feels her feelings in her body, but
has no insight into the mind-body
connection.
Reorienting the Somaticizer
Explain that in some African cultures,
people get broken stomachs, not
broken hearts. Somatic symptoms are
highly culturally determined, so invite
her to help you figure out what her
body might be trying to tell her.
In my residency, I experienced
cervical tension every time I was in
supervision with a certain attending.
She was a literal pain in the neck. My
pain was real, but not an indication
of any overt cervical pathology. Now
whenever I have that same pain in
the neck, I know that my childhood
anxiety is getting stirred up, and I
have an opportunity to deal with the
true cause of the pain.
More frequent office visits can
be beneficial because they can help
ameliorate her fears of abandonment.
THE TRAUMATIZED PATIENT
Medical procedures can be
traumatizing, especially to children.
Children imagine their skin as a
balloon, and puncturing it with a
needle, or worse yet — a scalpel —
can be terrifying. Their insides will
leak out, and that can’t be good! They
have no concept of the limitations
of our ability to feel pain. Pain to
them has the potential to escalate
exponentially to infinity and beyond,
and they don’t particularly want to
explore that dimension. Frightening
medical trauma can leave permanent
terror, even if the original trauma
occurred at too young an age for a
clear memory.
Validating the Trauma Survivor
Ask, “Has anything especially
frightening ever happened to you in
a hospital or doctor’s office?” (This
Thomas Grugle, MD, is a privatepractice
psychiatrist in Dallas. He is
medical director of Texas Health Dallas
Presbyterian Hospital psychiatry partial
hospital and a clinical professor at UT
Southwestern.