Lucy A. Epstein, MD

WEB AUDIO
Listen to Dr. Muskin discuss the patient-physician dynamic

Two strangers meet in the hospital cafeteria. Mrs. R, an elderly woman, asks Dr. W, a first-year medical resident, for help in getting a bottle of soda from the cooler. Afterward, Dr. W comments to a colleague with whom she is having lunch, “That woman reminds me of my grandmother.”

What does that comment reflect about Dr. W? It is a statement about the doctor’s transference. That is, she is aware of elements about Mrs. R that evoke internal responses appropriate to a prior important relationship.

What if Mrs. R was to subsequently faint, require admission to the hospital, and become Dr. W’s patient? If Dr. W’s comment indicates transference, would the same reaction to Mrs. R now be countertransference? Does that change if the doctor is unaware of emotions Mrs. R evokes? Is it still countertransference whether Dr. W is caring and compassionate, overly involved with Mrs. R, or—unaware of negative feelings associated with “grandmothers”—avoids the patient?

This article explores how complex internal experiences play out in the general medical setting and discusses how psychiatric consultants can help medical/surgical colleagues understand and manage difficult patient-physician relationships.

The therapeutic dyad

Countertransference and transference are concepts embedded in psychodynamic thinking. They are part of how many people think about interpersonal relations, whether or not they use these terms. Countertransference and transference may be conscious, but they always have an unconscious component. Factors that influence what will be transference and countertransference in adult life have both:

• a biological component because part of personality is genetic
  
• a psychological component based upon experiences throughout life ( Box 1 ).¹
  

Box 1

Transference is experiencing and/or relating to someone in the present as if that person was a significant individual from the past. The concept implies that all personal relationships contain elements of transference(s). That is, we all have the potential to displace or transfer to current situations infantile and internal conflicts that are out of place and thus not appropriate to the present person and/or situation.

Countertransference is a dimensional concept, not an all-or-nothing experience. Some reactions to patients are based entirely upon their transference to us and have nothing to do with us (therapists) as people. Others derive mostly from psychodynamics within the therapist ( Box 2 ). Countertransference has evolved to incorporate responses evoked by a combination of:

• the patient’s transference
  
• the therapist’s unique psychodynamics
  
• the real relationship in the therapeutic dyad.²
  

Box 2

 

Patients with medical illness

Psychiatrists think of countertransference as a psychological situation occurring in the office or on an inpatient psychiatric unit. We focus our attention on how we feel and what we think while working with patients. We talk about our reactions to patients in supervision, rounds, case conferences, and other situations where mental health professionals discuss patients.

Our medical/surgical colleagues’ reactions to patients often correlate with certain patient presentations and may have little to do with the actual person who is the patient.⁴ The medical setting provides an opportunity for countertransference to occur in the absence of apparent transference.

Somatic illness imposes on patients some degree of regression. This regression and attempts to cope with it are inherent to somatic illness and hospitalization. Several schemas⁵ describe basic coping mechanisms common to most patients ( Table ).^6,7 Recognizing a patient’s character style or personality type may help clinicians predict their countertransference when interacting with that patient. Uncooperative patients and those perceived as “difficult” are particularly likely to evoke negative countertransference.⁸

Table

Patients’ response to illness,
with common countertransference by medical staff

Patient’s coping mechanisms	Staff’s countertransference
Dependent personality
• Unconsciously wishes for unlimited care • Depends on others to feel secure • May make excessive requests of staff	• Gratification at being able to take care of patient’s needs • Resentment if patient’s needs seem insatiable
Obsessional personality
• Meticulous self-discipline • Illness represents loss of control • Will try to gain mastery over illness by focusing on details, information	• Relief at patient’s willingness to actively participate • Power struggle is possible
Histrionic personality
• Outgoing, colorful, lively • Attractiveness and sexuality important • Needs to feel the center of attention • Illness represents defect, loss of physical beauty	• Warm initial engagement • Fear of crossing boundaries • Wonder about veracity of complaints
Masochistic personality
• Satisfies unconscious needs by suffering • Needs to play victim role	• Frustration when reassurance does not help • May unconsciously play into patient’s need for punishment
Paranoid personality
• Pervasive doubt of others’ motivations • Often questions motives for interventions • Illness represents threat to safety	• Wary of lack of alliance • Anger that patient questions treatment motives • Frustrated at inability to form a trusting relationship with patient • Unsettled by lack of connection
Narcissistic personality
• Grandiose sense of self, which protects against shame, humiliation • May demand superior care, insult junior team members	• May feel flattered by ability to treat patient as VIP • May alternately feel devalued, wonder about competence
Source: References 6,7

CASE CONTINUED: No longer ‘grandmotherly’

Mrs. R and Dr. W are now in a patient-physician relationship. Dr. W is no longer handing Mrs. R a bottle of soda but is inquiring about her life, use of alcohol and other drugs, intimate activities, etc. Mrs. R reacts with anger at the “personal questions.” In addition, Dr. W orders tests that are uncomfortable for Mrs. R, who refuses to cooperate with some procedures.

Dr. W’s memories of her grandmother (who was encouraging, supportive, and loving) color her experience of Mrs. R. She ignores nursing staff’s complaints about Mrs. R being demanding and difficult as the patient becomes aggressive and increasingly confused.

Unable to see the patient as she really is, Dr. W becomes angry and defends Mrs. R’s behavior. The nurses feel Dr. W is unrealistic and ignore her at the nursing station. Late on a Friday night, Mrs. R becomes paranoid, hallucinating that “demons” are in her room. She tries to elope from the hospital. Dr. W is off for the weekend, and the staff requests an emergency psychiatric consultation.

Mrs. R evokes a reaction from the nurses because of how she interacts with them. Dr. W’s response—based on her experience of her grandmother—has nothing to do with the way Mrs. R relates interpersonally but reflects a reaction to the patient’s gender and age. Both reactions would be countertransference, using the modern definition.

If reactions to a patient such as Mrs. R are positive, no one seems to notice and the reactions might or might not influence her care. If the reactions are negative, they might influence her care and generate a request for a psychiatric consultation.

Countertransference might have a negative effect on patient care. For example, if a physician were to avoid Mrs. R because she is uncooperative, and if the nursing staff is intolerant of the patient’s confusion and agitation, she might be labeled as “demented” and be given medication without anyone exploring the etiology of her behavior.

 

Some patients cannot communicate because of neurologic disorders, intubation, language barriers, or because they are unconscious when admitted. Without information from the patient, medical staff may form ideas about the patient based on their unconscious fantasies. These fantasies may influence the patient’s care.⁹ Psychiatric consultants are not immune to countertransference, but we come into situations with the opportunity to experience all participants from the outside.

CASE CONTINUED: The psychiatric consultation

During the interview, the psychiatrist asks Mrs. R if she takes any medications. She retorts that she always takes “Centrum” at bed-time and demands to know why she is not getting her “vitamins.” She is given oxazepam and falls asleep.

The psychiatrist recommends benzodiazepine detoxification, suspecting Mrs. R is taking prazepam at home from an old prescription (when the medication was a brand called “Centrax”). This suspicion is confirmed when Mrs. R’s family brings in a large shopping bag of medications she has collected over decades, and Mrs. R identifies her nighttime “vitamin.”

A full evaluation for delirium is completed over the next 2 days. Mrs. R’s confusion and aggressive behavior respond to oxazepam.

Patients with particular character styles evoke predictable reactions from others, including psychotherapists. Discussing these reactions has been a part of psychiatric training for decades. A subset of patients has been described as “hateful,” as they routinely evoke extremely negative responses.¹⁰ Whether their primary disorder is psychiatric, medical, or some of both, these patients evoke strong countertransference reactions.

Psychiatrists may be comfortable discussing a “narcissistic patient, a dependent clinger with borderline features,” but our medical colleagues might not share our comfort with psychiatric jargon.¹¹ It may be more useful to say to medical staff that the patient “thinks of himself as very important, cannot accept his need to be taken care of, and tends to see things in black and white.”

Managing difficult patients

The characterizations that follow describe unconscious reactions to types of individuals who are routinely experienced as “difficult” patients. Some patients may exhibit a mixture of character styles ( Table ) and do not easily fall into 1 category. The concepts can be useful in clarifying the reactions that patients evoke in medical staff.

‘Dependent’ patients. Some patients demand continuous attention but are unaware of their insatiable neediness. Early in treatment, they may evoke positive countertransference because they are intensely grateful for attention. They can be enticing, unconsciously seductive, and gratifying to their doctors. Over time, they drain and exhaust their physicians, who resort to avoidance and wish to get rid of these patients.

Recommendation. Set limits to prevent the patient from feeling rejected or an actual rejection when he or she is transferred to another doctor’s care. Coach physicians to:

• ask patients to “Tell me what is most important for us to discuss today”
  
• be clear how long the visit will last.
  

Reassuring the patient that other issues will be addressed in the next visit prevents the physician from feeling overwhelmed by the patient consuming too much time.

‘Entitled’ patients. Another type of “difficult” patient projects an air of entitlement, which typically reflects an underlying insatiable neediness. They may use intimidation, guilt, and threats of punishment to get their doctors to provide the care they demand. These patients appear powerful (even though they may possess no special status), and they may be overtly devaluing of the physician while simultaneously demanding special attention.

The doctor resents the patient’s entitlement but develops an expectable countertransference fear that he or she will get in trouble if the demands are not met. Wishes to retaliate and “put the patient in his or her place” are common.

Recommendation. Saying, “It is understandable that you want the best care, and I plan to give you the best care,” makes it clear to the patient that the physician hears the patient’s concerns. Advise the physician to request the patient’s “understanding and compassion” for other patients who also need the physician’s time and attention.

‘Help-rejecting’ patients. “Help-rejecting” patients demand care but show little faith in treatment and do not follow treatment plans. The harder the physician tries to help, the less likely the plan will succeed. For these patients, treatment success evokes a fear of abandonment; thus, treatment must fail to maintain the relationship.

Common countertransference reactions are initial anxiety that the treatment plan was not adequate, followed by anger and depression as the physician feels stuck with a patient for whom nothing works.

 

Recommendation. Setting realistic goals for treatment helps the physician guide the patient, who expects to be told not to return the moment he or she gets better. Telling the patient that medical care does not stop when a particular malady is treated speaks to the patient’s fear of being abandoned.

When the patient adheres only partially to the plan and a psychiatric consultant is called for an “uncooperative” patient, help the doctor understand how the patient sees the world. It is the patient’s psychological needs—not the physician’s failure—that control the outcome of the care.

‘Self-destructive’ patients may appear unaware of their dangerous actions. They evoke malice from their doctors, who feel the patients are purposely engaging in life-threatening behaviors. The patients’ unconscious dependence remains unknown as their denial of the consequences of their behavior frightens and angers those involved in their care. Some of these patients cannot be stopped before their actions cause them permanent harm or death.

Recommendation. You might remind the physician that we all are entitled to live our lives as we choose. To decompress intense feelings, advise the physician to share, without blaming the patient, what medical staff can realistically do. Saying “We’ll do the best we can” (rather than “Treatment is useless for someone like you”) permits the patient to receive the degree of care he or she can accept without the physician feeling helpless. Understanding our limitations and obligations is part of using our countertransference to aid in patient care.

CASE CONTINUED: Feeling better

When Dr. W returns on Monday, she angrily calls the psychiatrist to complain that her patient has been placed on a benzodiazepine and at the “implication” that Mrs. R was abusing medication. When they talk in person, the psychiatrist explains the situation to Dr. W and suggests they meet with Mrs. R together.

Mrs. R is embarrassed when told about her behavior, identifies the pill, and admits taking prazepam for several weeks prior to hospitalization. She says she never understood how a vitamin could help her sleep so well. No longer delirious, Mrs. R is pleasant and asks many questions. She is surprised that “so young” a doctor was assigned to her case and asks if the chief of medicine could be brought in, as she is on the board of directors of another hospital. “No offense, dear,” she says to Dr. W; “I’m sure you did an excellent job, but usually only senior doctors take care of me.”

Later, Dr. W talks with the psychiatric consultant about her chance meeting with Mrs. R in the cafeteria and the discord with the nursing staff. She notes that she was doing an elective in another country when her grandmother died. She realizes that her feelings about her grandmother are superimposed on the patient, resulting in an inability to see the patient as she really is.

Dr. W accepts the psychiatrist’s suggestion to repair her relationship with the nurses with an apology. She now notes that Mrs. R is nothing like her grandmother and seems “pretty stuck up.” She is glad to be off the case and accepts the psychiatrist’s idea that Mrs. R’s need to feel important should not make Dr. W feel bad about herself.

Related resources

• Gabbard GO, ed. Countertransference issues in psychiatric treatment. In: Oldham JM, Riba MB, eds. Review of psychiatry series. Washington, DC: American Psychiatric Publishing, Inc.; 1999.
  
• Blumenfield M, Strain JJ, Grossman S. Psychodynamic approach. In: Blumenfield M, Strain JJ, eds. Psychosomatic medicine. Philadelphia, PA: Lippincott, Williams and Wilkins; 2006:817-828.
  

Drug brand names

• Oxazepam • Serax
  
• Prazepam • Centrax
  

Disclosure

The authors report no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.

WEB AUDIO
Listen to Dr. Muskin discuss the patient-physician dynamic

Two strangers meet in the hospital cafeteria. Mrs. R, an elderly woman, asks Dr. W, a first-year medical resident, for help in getting a bottle of soda from the cooler. Afterward, Dr. W comments to a colleague with whom she is having lunch, “That woman reminds me of my grandmother.”

What does that comment reflect about Dr. W? It is a statement about the doctor’s transference. That is, she is aware of elements about Mrs. R that evoke internal responses appropriate to a prior important relationship.

What if Mrs. R was to subsequently faint, require admission to the hospital, and become Dr. W’s patient? If Dr. W’s comment indicates transference, would the same reaction to Mrs. R now be countertransference? Does that change if the doctor is unaware of emotions Mrs. R evokes? Is it still countertransference whether Dr. W is caring and compassionate, overly involved with Mrs. R, or—unaware of negative feelings associated with “grandmothers”—avoids the patient?

This article explores how complex internal experiences play out in the general medical setting and discusses how psychiatric consultants can help medical/surgical colleagues understand and manage difficult patient-physician relationships.

The therapeutic dyad

Countertransference and transference are concepts embedded in psychodynamic thinking. They are part of how many people think about interpersonal relations, whether or not they use these terms. Countertransference and transference may be conscious, but they always have an unconscious component. Factors that influence what will be transference and countertransference in adult life have both:

• a biological component because part of personality is genetic
  
• a psychological component based upon experiences throughout life ( Box 1 ).¹
  

Box 1

Transference is experiencing and/or relating to someone in the present as if that person was a significant individual from the past. The concept implies that all personal relationships contain elements of transference(s). That is, we all have the potential to displace or transfer to current situations infantile and internal conflicts that are out of place and thus not appropriate to the present person and/or situation.

Countertransference is a dimensional concept, not an all-or-nothing experience. Some reactions to patients are based entirely upon their transference to us and have nothing to do with us (therapists) as people. Others derive mostly from psychodynamics within the therapist ( Box 2 ). Countertransference has evolved to incorporate responses evoked by a combination of:

• the patient’s transference
  
• the therapist’s unique psychodynamics
  
• the real relationship in the therapeutic dyad.²
  

Box 2

 

Patients with medical illness

Psychiatrists think of countertransference as a psychological situation occurring in the office or on an inpatient psychiatric unit. We focus our attention on how we feel and what we think while working with patients. We talk about our reactions to patients in supervision, rounds, case conferences, and other situations where mental health professionals discuss patients.

Our medical/surgical colleagues’ reactions to patients often correlate with certain patient presentations and may have little to do with the actual person who is the patient.⁴ The medical setting provides an opportunity for countertransference to occur in the absence of apparent transference.

Somatic illness imposes on patients some degree of regression. This regression and attempts to cope with it are inherent to somatic illness and hospitalization. Several schemas⁵ describe basic coping mechanisms common to most patients ( Table ).^6,7 Recognizing a patient’s character style or personality type may help clinicians predict their countertransference when interacting with that patient. Uncooperative patients and those perceived as “difficult” are particularly likely to evoke negative countertransference.⁸

Table

Patients’ response to illness,
with common countertransference by medical staff

Patient’s coping mechanisms	Staff’s countertransference
Dependent personality
• Unconsciously wishes for unlimited care • Depends on others to feel secure • May make excessive requests of staff	• Gratification at being able to take care of patient’s needs • Resentment if patient’s needs seem insatiable
Obsessional personality
• Meticulous self-discipline • Illness represents loss of control • Will try to gain mastery over illness by focusing on details, information	• Relief at patient’s willingness to actively participate • Power struggle is possible
Histrionic personality
• Outgoing, colorful, lively • Attractiveness and sexuality important • Needs to feel the center of attention • Illness represents defect, loss of physical beauty	• Warm initial engagement • Fear of crossing boundaries • Wonder about veracity of complaints
Masochistic personality
• Satisfies unconscious needs by suffering • Needs to play victim role	• Frustration when reassurance does not help • May unconsciously play into patient’s need for punishment
Paranoid personality
• Pervasive doubt of others’ motivations • Often questions motives for interventions • Illness represents threat to safety	• Wary of lack of alliance • Anger that patient questions treatment motives • Frustrated at inability to form a trusting relationship with patient • Unsettled by lack of connection
Narcissistic personality
• Grandiose sense of self, which protects against shame, humiliation • May demand superior care, insult junior team members	• May feel flattered by ability to treat patient as VIP • May alternately feel devalued, wonder about competence
Source: References 6,7

CASE CONTINUED: No longer ‘grandmotherly’

Mrs. R and Dr. W are now in a patient-physician relationship. Dr. W is no longer handing Mrs. R a bottle of soda but is inquiring about her life, use of alcohol and other drugs, intimate activities, etc. Mrs. R reacts with anger at the “personal questions.” In addition, Dr. W orders tests that are uncomfortable for Mrs. R, who refuses to cooperate with some procedures.

Dr. W’s memories of her grandmother (who was encouraging, supportive, and loving) color her experience of Mrs. R. She ignores nursing staff’s complaints about Mrs. R being demanding and difficult as the patient becomes aggressive and increasingly confused.

Unable to see the patient as she really is, Dr. W becomes angry and defends Mrs. R’s behavior. The nurses feel Dr. W is unrealistic and ignore her at the nursing station. Late on a Friday night, Mrs. R becomes paranoid, hallucinating that “demons” are in her room. She tries to elope from the hospital. Dr. W is off for the weekend, and the staff requests an emergency psychiatric consultation.

Mrs. R evokes a reaction from the nurses because of how she interacts with them. Dr. W’s response—based on her experience of her grandmother—has nothing to do with the way Mrs. R relates interpersonally but reflects a reaction to the patient’s gender and age. Both reactions would be countertransference, using the modern definition.

If reactions to a patient such as Mrs. R are positive, no one seems to notice and the reactions might or might not influence her care. If the reactions are negative, they might influence her care and generate a request for a psychiatric consultation.

Countertransference might have a negative effect on patient care. For example, if a physician were to avoid Mrs. R because she is uncooperative, and if the nursing staff is intolerant of the patient’s confusion and agitation, she might be labeled as “demented” and be given medication without anyone exploring the etiology of her behavior.

 

Some patients cannot communicate because of neurologic disorders, intubation, language barriers, or because they are unconscious when admitted. Without information from the patient, medical staff may form ideas about the patient based on their unconscious fantasies. These fantasies may influence the patient’s care.⁹ Psychiatric consultants are not immune to countertransference, but we come into situations with the opportunity to experience all participants from the outside.

CASE CONTINUED: The psychiatric consultation

During the interview, the psychiatrist asks Mrs. R if she takes any medications. She retorts that she always takes “Centrum” at bed-time and demands to know why she is not getting her “vitamins.” She is given oxazepam and falls asleep.

The psychiatrist recommends benzodiazepine detoxification, suspecting Mrs. R is taking prazepam at home from an old prescription (when the medication was a brand called “Centrax”). This suspicion is confirmed when Mrs. R’s family brings in a large shopping bag of medications she has collected over decades, and Mrs. R identifies her nighttime “vitamin.”

A full evaluation for delirium is completed over the next 2 days. Mrs. R’s confusion and aggressive behavior respond to oxazepam.

Patients with particular character styles evoke predictable reactions from others, including psychotherapists. Discussing these reactions has been a part of psychiatric training for decades. A subset of patients has been described as “hateful,” as they routinely evoke extremely negative responses.¹⁰ Whether their primary disorder is psychiatric, medical, or some of both, these patients evoke strong countertransference reactions.

Psychiatrists may be comfortable discussing a “narcissistic patient, a dependent clinger with borderline features,” but our medical colleagues might not share our comfort with psychiatric jargon.¹¹ It may be more useful to say to medical staff that the patient “thinks of himself as very important, cannot accept his need to be taken care of, and tends to see things in black and white.”

Managing difficult patients

The characterizations that follow describe unconscious reactions to types of individuals who are routinely experienced as “difficult” patients. Some patients may exhibit a mixture of character styles ( Table ) and do not easily fall into 1 category. The concepts can be useful in clarifying the reactions that patients evoke in medical staff.

‘Dependent’ patients. Some patients demand continuous attention but are unaware of their insatiable neediness. Early in treatment, they may evoke positive countertransference because they are intensely grateful for attention. They can be enticing, unconsciously seductive, and gratifying to their doctors. Over time, they drain and exhaust their physicians, who resort to avoidance and wish to get rid of these patients.

Recommendation. Set limits to prevent the patient from feeling rejected or an actual rejection when he or she is transferred to another doctor’s care. Coach physicians to:

• ask patients to “Tell me what is most important for us to discuss today”
  
• be clear how long the visit will last.
  

Reassuring the patient that other issues will be addressed in the next visit prevents the physician from feeling overwhelmed by the patient consuming too much time.

‘Entitled’ patients. Another type of “difficult” patient projects an air of entitlement, which typically reflects an underlying insatiable neediness. They may use intimidation, guilt, and threats of punishment to get their doctors to provide the care they demand. These patients appear powerful (even though they may possess no special status), and they may be overtly devaluing of the physician while simultaneously demanding special attention.

The doctor resents the patient’s entitlement but develops an expectable countertransference fear that he or she will get in trouble if the demands are not met. Wishes to retaliate and “put the patient in his or her place” are common.

Recommendation. Saying, “It is understandable that you want the best care, and I plan to give you the best care,” makes it clear to the patient that the physician hears the patient’s concerns. Advise the physician to request the patient’s “understanding and compassion” for other patients who also need the physician’s time and attention.

‘Help-rejecting’ patients. “Help-rejecting” patients demand care but show little faith in treatment and do not follow treatment plans. The harder the physician tries to help, the less likely the plan will succeed. For these patients, treatment success evokes a fear of abandonment; thus, treatment must fail to maintain the relationship.

Common countertransference reactions are initial anxiety that the treatment plan was not adequate, followed by anger and depression as the physician feels stuck with a patient for whom nothing works.

 

Recommendation. Setting realistic goals for treatment helps the physician guide the patient, who expects to be told not to return the moment he or she gets better. Telling the patient that medical care does not stop when a particular malady is treated speaks to the patient’s fear of being abandoned.

When the patient adheres only partially to the plan and a psychiatric consultant is called for an “uncooperative” patient, help the doctor understand how the patient sees the world. It is the patient’s psychological needs—not the physician’s failure—that control the outcome of the care.

‘Self-destructive’ patients may appear unaware of their dangerous actions. They evoke malice from their doctors, who feel the patients are purposely engaging in life-threatening behaviors. The patients’ unconscious dependence remains unknown as their denial of the consequences of their behavior frightens and angers those involved in their care. Some of these patients cannot be stopped before their actions cause them permanent harm or death.

Recommendation. You might remind the physician that we all are entitled to live our lives as we choose. To decompress intense feelings, advise the physician to share, without blaming the patient, what medical staff can realistically do. Saying “We’ll do the best we can” (rather than “Treatment is useless for someone like you”) permits the patient to receive the degree of care he or she can accept without the physician feeling helpless. Understanding our limitations and obligations is part of using our countertransference to aid in patient care.

CASE CONTINUED: Feeling better

When Dr. W returns on Monday, she angrily calls the psychiatrist to complain that her patient has been placed on a benzodiazepine and at the “implication” that Mrs. R was abusing medication. When they talk in person, the psychiatrist explains the situation to Dr. W and suggests they meet with Mrs. R together.

Mrs. R is embarrassed when told about her behavior, identifies the pill, and admits taking prazepam for several weeks prior to hospitalization. She says she never understood how a vitamin could help her sleep so well. No longer delirious, Mrs. R is pleasant and asks many questions. She is surprised that “so young” a doctor was assigned to her case and asks if the chief of medicine could be brought in, as she is on the board of directors of another hospital. “No offense, dear,” she says to Dr. W; “I’m sure you did an excellent job, but usually only senior doctors take care of me.”

Later, Dr. W talks with the psychiatric consultant about her chance meeting with Mrs. R in the cafeteria and the discord with the nursing staff. She notes that she was doing an elective in another country when her grandmother died. She realizes that her feelings about her grandmother are superimposed on the patient, resulting in an inability to see the patient as she really is.

Dr. W accepts the psychiatrist’s suggestion to repair her relationship with the nurses with an apology. She now notes that Mrs. R is nothing like her grandmother and seems “pretty stuck up.” She is glad to be off the case and accepts the psychiatrist’s idea that Mrs. R’s need to feel important should not make Dr. W feel bad about herself.

Related resources

• Gabbard GO, ed. Countertransference issues in psychiatric treatment. In: Oldham JM, Riba MB, eds. Review of psychiatry series. Washington, DC: American Psychiatric Publishing, Inc.; 1999.
  
• Blumenfield M, Strain JJ, Grossman S. Psychodynamic approach. In: Blumenfield M, Strain JJ, eds. Psychosomatic medicine. Philadelphia, PA: Lippincott, Williams and Wilkins; 2006:817-828.
  

Drug brand names

• Oxazepam • Serax
  
• Prazepam • Centrax
  

Disclosure

The authors report no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.

WEB AUDIO
Listen to Dr. Muskin discuss the patient-physician dynamic

Two strangers meet in the hospital cafeteria. Mrs. R, an elderly woman, asks Dr. W, a first-year medical resident, for help in getting a bottle of soda from the cooler. Afterward, Dr. W comments to a colleague with whom she is having lunch, “That woman reminds me of my grandmother.”

What does that comment reflect about Dr. W? It is a statement about the doctor’s transference. That is, she is aware of elements about Mrs. R that evoke internal responses appropriate to a prior important relationship.

What if Mrs. R was to subsequently faint, require admission to the hospital, and become Dr. W’s patient? If Dr. W’s comment indicates transference, would the same reaction to Mrs. R now be countertransference? Does that change if the doctor is unaware of emotions Mrs. R evokes? Is it still countertransference whether Dr. W is caring and compassionate, overly involved with Mrs. R, or—unaware of negative feelings associated with “grandmothers”—avoids the patient?

This article explores how complex internal experiences play out in the general medical setting and discusses how psychiatric consultants can help medical/surgical colleagues understand and manage difficult patient-physician relationships.

The therapeutic dyad

Countertransference and transference are concepts embedded in psychodynamic thinking. They are part of how many people think about interpersonal relations, whether or not they use these terms. Countertransference and transference may be conscious, but they always have an unconscious component. Factors that influence what will be transference and countertransference in adult life have both:

• a biological component because part of personality is genetic
  
• a psychological component based upon experiences throughout life ( Box 1 ).¹
  

Box 1

Transference is experiencing and/or relating to someone in the present as if that person was a significant individual from the past. The concept implies that all personal relationships contain elements of transference(s). That is, we all have the potential to displace or transfer to current situations infantile and internal conflicts that are out of place and thus not appropriate to the present person and/or situation.

Countertransference is a dimensional concept, not an all-or-nothing experience. Some reactions to patients are based entirely upon their transference to us and have nothing to do with us (therapists) as people. Others derive mostly from psychodynamics within the therapist ( Box 2 ). Countertransference has evolved to incorporate responses evoked by a combination of:

• the patient’s transference
  
• the therapist’s unique psychodynamics
  
• the real relationship in the therapeutic dyad.²
  

Box 2

 

Patients with medical illness

Psychiatrists think of countertransference as a psychological situation occurring in the office or on an inpatient psychiatric unit. We focus our attention on how we feel and what we think while working with patients. We talk about our reactions to patients in supervision, rounds, case conferences, and other situations where mental health professionals discuss patients.

Our medical/surgical colleagues’ reactions to patients often correlate with certain patient presentations and may have little to do with the actual person who is the patient.⁴ The medical setting provides an opportunity for countertransference to occur in the absence of apparent transference.

Somatic illness imposes on patients some degree of regression. This regression and attempts to cope with it are inherent to somatic illness and hospitalization. Several schemas⁵ describe basic coping mechanisms common to most patients ( Table ).^6,7 Recognizing a patient’s character style or personality type may help clinicians predict their countertransference when interacting with that patient. Uncooperative patients and those perceived as “difficult” are particularly likely to evoke negative countertransference.⁸

Table

Patients’ response to illness,
with common countertransference by medical staff

Patient’s coping mechanisms	Staff’s countertransference
Dependent personality
• Unconsciously wishes for unlimited care • Depends on others to feel secure • May make excessive requests of staff	• Gratification at being able to take care of patient’s needs • Resentment if patient’s needs seem insatiable
Obsessional personality
• Meticulous self-discipline • Illness represents loss of control • Will try to gain mastery over illness by focusing on details, information	• Relief at patient’s willingness to actively participate • Power struggle is possible
Histrionic personality
• Outgoing, colorful, lively • Attractiveness and sexuality important • Needs to feel the center of attention • Illness represents defect, loss of physical beauty	• Warm initial engagement • Fear of crossing boundaries • Wonder about veracity of complaints
Masochistic personality
• Satisfies unconscious needs by suffering • Needs to play victim role	• Frustration when reassurance does not help • May unconsciously play into patient’s need for punishment
Paranoid personality
• Pervasive doubt of others’ motivations • Often questions motives for interventions • Illness represents threat to safety	• Wary of lack of alliance • Anger that patient questions treatment motives • Frustrated at inability to form a trusting relationship with patient • Unsettled by lack of connection
Narcissistic personality
• Grandiose sense of self, which protects against shame, humiliation • May demand superior care, insult junior team members	• May feel flattered by ability to treat patient as VIP • May alternately feel devalued, wonder about competence
Source: References 6,7

CASE CONTINUED: No longer ‘grandmotherly’

Mrs. R and Dr. W are now in a patient-physician relationship. Dr. W is no longer handing Mrs. R a bottle of soda but is inquiring about her life, use of alcohol and other drugs, intimate activities, etc. Mrs. R reacts with anger at the “personal questions.” In addition, Dr. W orders tests that are uncomfortable for Mrs. R, who refuses to cooperate with some procedures.

Dr. W’s memories of her grandmother (who was encouraging, supportive, and loving) color her experience of Mrs. R. She ignores nursing staff’s complaints about Mrs. R being demanding and difficult as the patient becomes aggressive and increasingly confused.

Unable to see the patient as she really is, Dr. W becomes angry and defends Mrs. R’s behavior. The nurses feel Dr. W is unrealistic and ignore her at the nursing station. Late on a Friday night, Mrs. R becomes paranoid, hallucinating that “demons” are in her room. She tries to elope from the hospital. Dr. W is off for the weekend, and the staff requests an emergency psychiatric consultation.

Mrs. R evokes a reaction from the nurses because of how she interacts with them. Dr. W’s response—based on her experience of her grandmother—has nothing to do with the way Mrs. R relates interpersonally but reflects a reaction to the patient’s gender and age. Both reactions would be countertransference, using the modern definition.

If reactions to a patient such as Mrs. R are positive, no one seems to notice and the reactions might or might not influence her care. If the reactions are negative, they might influence her care and generate a request for a psychiatric consultation.

Countertransference might have a negative effect on patient care. For example, if a physician were to avoid Mrs. R because she is uncooperative, and if the nursing staff is intolerant of the patient’s confusion and agitation, she might be labeled as “demented” and be given medication without anyone exploring the etiology of her behavior.

 

Some patients cannot communicate because of neurologic disorders, intubation, language barriers, or because they are unconscious when admitted. Without information from the patient, medical staff may form ideas about the patient based on their unconscious fantasies. These fantasies may influence the patient’s care.⁹ Psychiatric consultants are not immune to countertransference, but we come into situations with the opportunity to experience all participants from the outside.

CASE CONTINUED: The psychiatric consultation

During the interview, the psychiatrist asks Mrs. R if she takes any medications. She retorts that she always takes “Centrum” at bed-time and demands to know why she is not getting her “vitamins.” She is given oxazepam and falls asleep.

The psychiatrist recommends benzodiazepine detoxification, suspecting Mrs. R is taking prazepam at home from an old prescription (when the medication was a brand called “Centrax”). This suspicion is confirmed when Mrs. R’s family brings in a large shopping bag of medications she has collected over decades, and Mrs. R identifies her nighttime “vitamin.”

A full evaluation for delirium is completed over the next 2 days. Mrs. R’s confusion and aggressive behavior respond to oxazepam.

Patients with particular character styles evoke predictable reactions from others, including psychotherapists. Discussing these reactions has been a part of psychiatric training for decades. A subset of patients has been described as “hateful,” as they routinely evoke extremely negative responses.¹⁰ Whether their primary disorder is psychiatric, medical, or some of both, these patients evoke strong countertransference reactions.

Psychiatrists may be comfortable discussing a “narcissistic patient, a dependent clinger with borderline features,” but our medical colleagues might not share our comfort with psychiatric jargon.¹¹ It may be more useful to say to medical staff that the patient “thinks of himself as very important, cannot accept his need to be taken care of, and tends to see things in black and white.”

Managing difficult patients

The characterizations that follow describe unconscious reactions to types of individuals who are routinely experienced as “difficult” patients. Some patients may exhibit a mixture of character styles ( Table ) and do not easily fall into 1 category. The concepts can be useful in clarifying the reactions that patients evoke in medical staff.

‘Dependent’ patients. Some patients demand continuous attention but are unaware of their insatiable neediness. Early in treatment, they may evoke positive countertransference because they are intensely grateful for attention. They can be enticing, unconsciously seductive, and gratifying to their doctors. Over time, they drain and exhaust their physicians, who resort to avoidance and wish to get rid of these patients.

Recommendation. Set limits to prevent the patient from feeling rejected or an actual rejection when he or she is transferred to another doctor’s care. Coach physicians to:

• ask patients to “Tell me what is most important for us to discuss today”
  
• be clear how long the visit will last.
  

Reassuring the patient that other issues will be addressed in the next visit prevents the physician from feeling overwhelmed by the patient consuming too much time.

‘Entitled’ patients. Another type of “difficult” patient projects an air of entitlement, which typically reflects an underlying insatiable neediness. They may use intimidation, guilt, and threats of punishment to get their doctors to provide the care they demand. These patients appear powerful (even though they may possess no special status), and they may be overtly devaluing of the physician while simultaneously demanding special attention.

The doctor resents the patient’s entitlement but develops an expectable countertransference fear that he or she will get in trouble if the demands are not met. Wishes to retaliate and “put the patient in his or her place” are common.

Recommendation. Saying, “It is understandable that you want the best care, and I plan to give you the best care,” makes it clear to the patient that the physician hears the patient’s concerns. Advise the physician to request the patient’s “understanding and compassion” for other patients who also need the physician’s time and attention.

‘Help-rejecting’ patients. “Help-rejecting” patients demand care but show little faith in treatment and do not follow treatment plans. The harder the physician tries to help, the less likely the plan will succeed. For these patients, treatment success evokes a fear of abandonment; thus, treatment must fail to maintain the relationship.

Common countertransference reactions are initial anxiety that the treatment plan was not adequate, followed by anger and depression as the physician feels stuck with a patient for whom nothing works.

 

Recommendation. Setting realistic goals for treatment helps the physician guide the patient, who expects to be told not to return the moment he or she gets better. Telling the patient that medical care does not stop when a particular malady is treated speaks to the patient’s fear of being abandoned.

When the patient adheres only partially to the plan and a psychiatric consultant is called for an “uncooperative” patient, help the doctor understand how the patient sees the world. It is the patient’s psychological needs—not the physician’s failure—that control the outcome of the care.

‘Self-destructive’ patients may appear unaware of their dangerous actions. They evoke malice from their doctors, who feel the patients are purposely engaging in life-threatening behaviors. The patients’ unconscious dependence remains unknown as their denial of the consequences of their behavior frightens and angers those involved in their care. Some of these patients cannot be stopped before their actions cause them permanent harm or death.

Recommendation. You might remind the physician that we all are entitled to live our lives as we choose. To decompress intense feelings, advise the physician to share, without blaming the patient, what medical staff can realistically do. Saying “We’ll do the best we can” (rather than “Treatment is useless for someone like you”) permits the patient to receive the degree of care he or she can accept without the physician feeling helpless. Understanding our limitations and obligations is part of using our countertransference to aid in patient care.

CASE CONTINUED: Feeling better

When Dr. W returns on Monday, she angrily calls the psychiatrist to complain that her patient has been placed on a benzodiazepine and at the “implication” that Mrs. R was abusing medication. When they talk in person, the psychiatrist explains the situation to Dr. W and suggests they meet with Mrs. R together.

Mrs. R is embarrassed when told about her behavior, identifies the pill, and admits taking prazepam for several weeks prior to hospitalization. She says she never understood how a vitamin could help her sleep so well. No longer delirious, Mrs. R is pleasant and asks many questions. She is surprised that “so young” a doctor was assigned to her case and asks if the chief of medicine could be brought in, as she is on the board of directors of another hospital. “No offense, dear,” she says to Dr. W; “I’m sure you did an excellent job, but usually only senior doctors take care of me.”

Later, Dr. W talks with the psychiatric consultant about her chance meeting with Mrs. R in the cafeteria and the discord with the nursing staff. She notes that she was doing an elective in another country when her grandmother died. She realizes that her feelings about her grandmother are superimposed on the patient, resulting in an inability to see the patient as she really is.

Dr. W accepts the psychiatrist’s suggestion to repair her relationship with the nurses with an apology. She now notes that Mrs. R is nothing like her grandmother and seems “pretty stuck up.” She is glad to be off the case and accepts the psychiatrist’s idea that Mrs. R’s need to feel important should not make Dr. W feel bad about herself.

Related resources

• Gabbard GO, ed. Countertransference issues in psychiatric treatment. In: Oldham JM, Riba MB, eds. Review of psychiatry series. Washington, DC: American Psychiatric Publishing, Inc.; 1999.
  
• Blumenfield M, Strain JJ, Grossman S. Psychodynamic approach. In: Blumenfield M, Strain JJ, eds. Psychosomatic medicine. Philadelphia, PA: Lippincott, Williams and Wilkins; 2006:817-828.
  

Drug brand names

• Oxazepam • Serax
  
• Prazepam • Centrax
  

Disclosure

The authors report no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.

Ms. J, age 33, arrives at the emergency department (ED) complaining of chest pain and shortness of breath—symptoms she says are similar to those she had during episodes of pulmonary embolism. Routine laboratory workup, including chest CT and ultrasound of the lower extremities, indicate a very low likelihood of PE, but she insists that she be admitted.

On the medical floor, nursing staff note that Ms. J appears short of breath only when directly observed. Medical records reveal multiple visits to other hospitals with repeated requests for admission. When gently confronted, she maintains she will die
if she is not treated.

Has your hospital’s medical staff ever been puzzled by a patient’s inconsistent presentation or unsettled by a concern that he or she was not being straightforward with them? Have they suspected that a patient such as Ms. J may be voluntarily producing his or her symptoms?

This article suggests a 3-step approach by which the consultation-liaison psychiatrist can help medical staff identify and manage patients with factitious illness.

Cardinal features

In factitious illness, the patient’s symptoms are:

• under voluntary control and consciously produced
  
• not a direct result of a medical or psychiatric condition
  
• produced to assume the sick role (not to accrue secondary gain—a core feature of malingering).
  

Patients with factitious illness tend to present with realistic scenarios that suggest a physical or psychological disorder.

CASE: Self-inflicted injury

Ms. H, age 50, surprises even the most seasoned clinicians when she presents to the ED with brain parenchyma herniating from an open wound in her skull. She denies having picked at her scalp and does not endorse a history of obsessive-compulsive disorder or trichotillomania.

On the medical floor, however, she is seen picking at the wound, which leaves blood on her protective mittens. Surgical repair is repeatedly attempted, and her case is complicated by chronic infections and a nonhealing wound.

Clinical presentation

Factitious disorder presents 3 diagnostic and treatment challenges for a hospital’s medical staff:

• To recognize and treat (even self-inflicted) serious medical conditions that can be life-threatening.
  
• To orchestrate appropriate diagnostic evaluation. (Remember that factitious illness is a diagnosis of exclusion.)
  
• To handle countertransference reactions to patients that can be intense; physicians may experience anger, frustration, resignation, and hatred.
  

You can help medical staff manage these patients’ behaviors and minimize barriers to care by explaining the disorder as a manifestation of psychiatric suffering.

CASE: ‘Suicidal’ but not depressed

Mr. B, age 48, presents to the ED with thoughts of suicide and profoundly depressed mood. On examination, however, he does not appear depressed. He repeatedly requests food, cigarettes, and assistance in finding shelter, which lead to concern that his main goal is secondary gain. However, because Mr. B has a history of serious suicide attempts—including some while an inpatient—the ED physician is reluctant to dismiss his complaints and unsure about how to proceed.

3-step diagnostic approach

Treating factitious illness is predicated upon making the correct diagnosis, which requires the medical team to investigate and gather data from collateral sources, such as outside hospital medical records and other providers. The diagnostic process can be summarized in 3 steps:

Step 1. Determine whether the patient has an identifiable medical or psychiatric problem that could explain the symptoms.

Step 2. Determine whether the symptoms are consciously or unconsciously produced. Somatoform disorders—such as conversion disorder and somatization disorder, for example—are thought to result from processes outside the patient’s control.

Step 3. Distinguish if the motivation is to obtain the sick role (consider factitious illness) or if material benefits are the goal (consider malingering). Both motivations may be operative in a given patient.

Medical evaluation. Certain aspects of the patient’s medical presentation can steer the physician to making a diagnosis of factitious illness (Table 1).¹ For patients with physical symptoms, staff should order standard evaluations based on clinical judgment (such as ECG and cardiac markers to evaluate chest discomfort). Sometimes somatized symptoms are superimposed on an identifiable physical problem, and effective management includes treating both the medical illness and its created counterpart.²

Table 1

Medical clues to a patient with factitious illness

Vague symptom history that frays upon examination
Irritability and evasiveness with continued questioning
Familiarity with hospital procedures and protocols (some patients have received medical training)
Multiple scars as evidence of past procedures and hospitalizations
Acceptance of painful medical procedures without complaint
Itinerant lives devoid of close personal relationships
Failure to accurately identify themselves
Lack of a verifiable history
Source: Reference 1

 

Psychiatric evaluation. Physicians should think of factitious psychiatric illness when:

• a patient’s behavior is notably different when he believes he is being directly observed and when he believes he is alone³
  
• psychiatric symptoms do not readily fit into diagnostic categories (such as a vague mix of memory loss, suicidal thoughts, and psychosis)
  
• the patient is suggestible or provides a diffusely positive review of systems (for example, he may report additional symptoms after having observed other patients).
  

When evaluating a patient with suspected factitious psychiatric symptoms, perform a comprehensive psychiatric evaluation to identify an Axis I or II disorder. Rule out possibilities such as dementia associated with complaints of memory loss, psychosis associated with reports of hallucinations, or affective symptoms or Axis II pathology associated with thoughts of suicide. Patients with factitious disorder often have an underlying psychiatric illness such as a personality disorder, but the Axis II disorder does not fully explain the presenting complaint.

The psychiatric presentations of Munchausen syndrome can be especially complicated, as they are usually associated with less objective evidence than are medical presentations (Box).^4-10 Clarity of the history and diagnosis may be in the eye of the beholder.

Admission characteristics

Somatic complaints. Chaos often surrounds the hospitalized patient with factitious illness. The ED commonly is their gateway, and they tend to arrive in the evening or on weekends when less experienced staff are on call.¹¹

Box

Because the patients’ somatic complaints predominate, the ED physician must complete a full evaluation, even if aspects of the history are inconsistent. Patients tend to appeal to physicians’ nurturing qualities in an attempt to have them provide care and attention.¹²

Escalating demands. During the hospital stay, patients with factitious illness may make repeated requests for care, which may escalate into demands if their needs are not met.¹³ At this point, staff often start to experience negative countertransference reactions. As medical tests reveal little to no evidence of an organic basis for their symptoms and no cohesive psychiatric diagnosis is reached, patients may complain of misdiagnosis and mistreatment.¹³

Patients usually leave before psychiatric consultation can be obtained, and the underlying suffering that led to their factitious complaints remains unaddressed. Typically, patients are lost to follow-up until the next presentation at another hospital, where the process begins again.

What motivates patients?

The motivation behind factitious presentations can be bewildering. Asher’s paper on Munchausen syndrome described several possible reasons for patients’ behavior, such as desire to be the center of attention, holding a grudge against the medical profession, drug seeking, looking for shelter, and running from police.⁵ This list, however, includes correlates of secondary gain, which with today’s psychiatric nomenclature would lead to a diagnosis of malingering.

Psychological factors. Some clinicians have tried to address underlying psychiatric factors, but data on evaluation and management are limited because these patients usually eschew psychiatric examination. Although the patient is voluntarily producing the symptoms, unconscious psychological factors are at play and are an essential part of the picture.¹⁴

When assessed, patients appear to have lived rootless lives with few attachments, which may have been the result of sadistic and unsatisfying relationships with authority figures of their youth.^15,16 Their grandiosity and distortion of the truth suggest a narcissistic need to overcome feelings of incompetence or impotence.¹⁷ Their ambivalent relationship to hospitals and physicians may reflect a need for caretaking, arising from early relationships and past caretakers.

Lastly, there is a component of masochism; this makes some individuals (erroneously) believe that if you don’t inflict pain you don’t care about them.¹³

 

Treatment challenges

Because patients with factitious disorder are not easily studied, no particular treatment is well-supported in the literature. Approaches that have been reported include preventing patients from being re-admitted to medical facilities, admitting patients for psychiatric treatment, and providing outpatient therapies such as individual psychodynamic psychotherapy, behavioral modification, and group psychotherapy.¹⁸

Other management strategies suggested in the literature include:

• reframing cognitive distortions
  
• drawing up a set of realistic hospitalization goals (with a written contract)
  
• maximizing the therapeutic alliance
  
• avoiding team splitting
  
• minimizing iatrogenic harm.¹⁹
  

Whatever the treatment, educate the medical staff about this complex disorder (Table 2), including the hazards of premature and unsubstantiated interventions or painful procedures. Also help them manage countertransference reactions. Provide an outlet for the staff’s intense emotions, and help them place such emotions into a therapeutic context.

Table 2

Recommended care for a patient with factitious illness

Fully investigate all medical and psychiatric complaints, especially if physical safety is threatened
Maintain a healthy skepticism about unusual or illogical presentations while attempting to preserve an empathic connection with the patient
Be aware of countertransference reactions, as they may provide valuable insight about the underlying cause of the patient’s symptoms
Realize that psychiatric symptoms and medical presentations fall on a continuum from conscious to unconscious; at times there may be a mix of motivations
Report all findings nonjudgmentally, both to the patient and in medical documentation

Confront patients? The efficacy and style of confronting patients with factitious illness have been hotly debated. Although no consensus has emerged, an empathic, nonthreatening confrontation may help the patient accept much-needed psychiatric care.¹³

Nevertheless, prepare the physician for the patient to respond to confrontation with denial and resistance because he or she feels exposed and humiliated. If the physician makes it clear that ongoing medical care will still be available—even if the symptoms are fabricated—the patient may be more willing to accept psychiatric treatment.¹³

Related resources

• Barsky AJ, Stern TA, Greenberg DB, Cassem NH. Functional somatic symptoms and somatoform disorders. In: Stern TA, Fricchione GL, Cassem NH, et al, eds. The Massachusetts General Hospital handbook of general hospital psychiatry 5th ed. Philadelphia: Mosby/Elsevier; 2004:269-91.
  
• Elwyn TS, Ahmed I. Factitious disorder. EMedicine from WebMD. Last updated April 13, 2006. www.emedicine.com/med/topic3125.htm.
  

Ms. J, age 33, arrives at the emergency department (ED) complaining of chest pain and shortness of breath—symptoms she says are similar to those she had during episodes of pulmonary embolism. Routine laboratory workup, including chest CT and ultrasound of the lower extremities, indicate a very low likelihood of PE, but she insists that she be admitted.

On the medical floor, nursing staff note that Ms. J appears short of breath only when directly observed. Medical records reveal multiple visits to other hospitals with repeated requests for admission. When gently confronted, she maintains she will die
if she is not treated.

Has your hospital’s medical staff ever been puzzled by a patient’s inconsistent presentation or unsettled by a concern that he or she was not being straightforward with them? Have they suspected that a patient such as Ms. J may be voluntarily producing his or her symptoms?

This article suggests a 3-step approach by which the consultation-liaison psychiatrist can help medical staff identify and manage patients with factitious illness.

Cardinal features

In factitious illness, the patient’s symptoms are:

• under voluntary control and consciously produced
  
• not a direct result of a medical or psychiatric condition
  
• produced to assume the sick role (not to accrue secondary gain—a core feature of malingering).
  

Patients with factitious illness tend to present with realistic scenarios that suggest a physical or psychological disorder.

CASE: Self-inflicted injury

Ms. H, age 50, surprises even the most seasoned clinicians when she presents to the ED with brain parenchyma herniating from an open wound in her skull. She denies having picked at her scalp and does not endorse a history of obsessive-compulsive disorder or trichotillomania.

On the medical floor, however, she is seen picking at the wound, which leaves blood on her protective mittens. Surgical repair is repeatedly attempted, and her case is complicated by chronic infections and a nonhealing wound.

Clinical presentation

Factitious disorder presents 3 diagnostic and treatment challenges for a hospital’s medical staff:

• To recognize and treat (even self-inflicted) serious medical conditions that can be life-threatening.
  
• To orchestrate appropriate diagnostic evaluation. (Remember that factitious illness is a diagnosis of exclusion.)
  
• To handle countertransference reactions to patients that can be intense; physicians may experience anger, frustration, resignation, and hatred.
  

You can help medical staff manage these patients’ behaviors and minimize barriers to care by explaining the disorder as a manifestation of psychiatric suffering.

CASE: ‘Suicidal’ but not depressed

Mr. B, age 48, presents to the ED with thoughts of suicide and profoundly depressed mood. On examination, however, he does not appear depressed. He repeatedly requests food, cigarettes, and assistance in finding shelter, which lead to concern that his main goal is secondary gain. However, because Mr. B has a history of serious suicide attempts—including some while an inpatient—the ED physician is reluctant to dismiss his complaints and unsure about how to proceed.

3-step diagnostic approach

Treating factitious illness is predicated upon making the correct diagnosis, which requires the medical team to investigate and gather data from collateral sources, such as outside hospital medical records and other providers. The diagnostic process can be summarized in 3 steps:

Step 1. Determine whether the patient has an identifiable medical or psychiatric problem that could explain the symptoms.

Step 2. Determine whether the symptoms are consciously or unconsciously produced. Somatoform disorders—such as conversion disorder and somatization disorder, for example—are thought to result from processes outside the patient’s control.

Step 3. Distinguish if the motivation is to obtain the sick role (consider factitious illness) or if material benefits are the goal (consider malingering). Both motivations may be operative in a given patient.

Medical evaluation. Certain aspects of the patient’s medical presentation can steer the physician to making a diagnosis of factitious illness (Table 1).¹ For patients with physical symptoms, staff should order standard evaluations based on clinical judgment (such as ECG and cardiac markers to evaluate chest discomfort). Sometimes somatized symptoms are superimposed on an identifiable physical problem, and effective management includes treating both the medical illness and its created counterpart.²

Table 1

Medical clues to a patient with factitious illness

Vague symptom history that frays upon examination
Irritability and evasiveness with continued questioning
Familiarity with hospital procedures and protocols (some patients have received medical training)
Multiple scars as evidence of past procedures and hospitalizations
Acceptance of painful medical procedures without complaint
Itinerant lives devoid of close personal relationships
Failure to accurately identify themselves
Lack of a verifiable history
Source: Reference 1

 

Psychiatric evaluation. Physicians should think of factitious psychiatric illness when:

• a patient’s behavior is notably different when he believes he is being directly observed and when he believes he is alone³
  
• psychiatric symptoms do not readily fit into diagnostic categories (such as a vague mix of memory loss, suicidal thoughts, and psychosis)
  
• the patient is suggestible or provides a diffusely positive review of systems (for example, he may report additional symptoms after having observed other patients).
  

When evaluating a patient with suspected factitious psychiatric symptoms, perform a comprehensive psychiatric evaluation to identify an Axis I or II disorder. Rule out possibilities such as dementia associated with complaints of memory loss, psychosis associated with reports of hallucinations, or affective symptoms or Axis II pathology associated with thoughts of suicide. Patients with factitious disorder often have an underlying psychiatric illness such as a personality disorder, but the Axis II disorder does not fully explain the presenting complaint.

The psychiatric presentations of Munchausen syndrome can be especially complicated, as they are usually associated with less objective evidence than are medical presentations (Box).^4-10 Clarity of the history and diagnosis may be in the eye of the beholder.

Admission characteristics

Somatic complaints. Chaos often surrounds the hospitalized patient with factitious illness. The ED commonly is their gateway, and they tend to arrive in the evening or on weekends when less experienced staff are on call.¹¹

Box

Because the patients’ somatic complaints predominate, the ED physician must complete a full evaluation, even if aspects of the history are inconsistent. Patients tend to appeal to physicians’ nurturing qualities in an attempt to have them provide care and attention.¹²

Escalating demands. During the hospital stay, patients with factitious illness may make repeated requests for care, which may escalate into demands if their needs are not met.¹³ At this point, staff often start to experience negative countertransference reactions. As medical tests reveal little to no evidence of an organic basis for their symptoms and no cohesive psychiatric diagnosis is reached, patients may complain of misdiagnosis and mistreatment.¹³

Patients usually leave before psychiatric consultation can be obtained, and the underlying suffering that led to their factitious complaints remains unaddressed. Typically, patients are lost to follow-up until the next presentation at another hospital, where the process begins again.

What motivates patients?

The motivation behind factitious presentations can be bewildering. Asher’s paper on Munchausen syndrome described several possible reasons for patients’ behavior, such as desire to be the center of attention, holding a grudge against the medical profession, drug seeking, looking for shelter, and running from police.⁵ This list, however, includes correlates of secondary gain, which with today’s psychiatric nomenclature would lead to a diagnosis of malingering.

Psychological factors. Some clinicians have tried to address underlying psychiatric factors, but data on evaluation and management are limited because these patients usually eschew psychiatric examination. Although the patient is voluntarily producing the symptoms, unconscious psychological factors are at play and are an essential part of the picture.¹⁴

When assessed, patients appear to have lived rootless lives with few attachments, which may have been the result of sadistic and unsatisfying relationships with authority figures of their youth.^15,16 Their grandiosity and distortion of the truth suggest a narcissistic need to overcome feelings of incompetence or impotence.¹⁷ Their ambivalent relationship to hospitals and physicians may reflect a need for caretaking, arising from early relationships and past caretakers.

Lastly, there is a component of masochism; this makes some individuals (erroneously) believe that if you don’t inflict pain you don’t care about them.¹³

 

Treatment challenges

Because patients with factitious disorder are not easily studied, no particular treatment is well-supported in the literature. Approaches that have been reported include preventing patients from being re-admitted to medical facilities, admitting patients for psychiatric treatment, and providing outpatient therapies such as individual psychodynamic psychotherapy, behavioral modification, and group psychotherapy.¹⁸

Other management strategies suggested in the literature include:

• reframing cognitive distortions
  
• drawing up a set of realistic hospitalization goals (with a written contract)
  
• maximizing the therapeutic alliance
  
• avoiding team splitting
  
• minimizing iatrogenic harm.¹⁹
  

Whatever the treatment, educate the medical staff about this complex disorder (Table 2), including the hazards of premature and unsubstantiated interventions or painful procedures. Also help them manage countertransference reactions. Provide an outlet for the staff’s intense emotions, and help them place such emotions into a therapeutic context.

Table 2

Recommended care for a patient with factitious illness

Fully investigate all medical and psychiatric complaints, especially if physical safety is threatened
Maintain a healthy skepticism about unusual or illogical presentations while attempting to preserve an empathic connection with the patient
Be aware of countertransference reactions, as they may provide valuable insight about the underlying cause of the patient’s symptoms
Realize that psychiatric symptoms and medical presentations fall on a continuum from conscious to unconscious; at times there may be a mix of motivations
Report all findings nonjudgmentally, both to the patient and in medical documentation

Confront patients? The efficacy and style of confronting patients with factitious illness have been hotly debated. Although no consensus has emerged, an empathic, nonthreatening confrontation may help the patient accept much-needed psychiatric care.¹³

Nevertheless, prepare the physician for the patient to respond to confrontation with denial and resistance because he or she feels exposed and humiliated. If the physician makes it clear that ongoing medical care will still be available—even if the symptoms are fabricated—the patient may be more willing to accept psychiatric treatment.¹³

Related resources

• Barsky AJ, Stern TA, Greenberg DB, Cassem NH. Functional somatic symptoms and somatoform disorders. In: Stern TA, Fricchione GL, Cassem NH, et al, eds. The Massachusetts General Hospital handbook of general hospital psychiatry 5th ed. Philadelphia: Mosby/Elsevier; 2004:269-91.
  
• Elwyn TS, Ahmed I. Factitious disorder. EMedicine from WebMD. Last updated April 13, 2006. www.emedicine.com/med/topic3125.htm.
  

Ms. J, age 33, arrives at the emergency department (ED) complaining of chest pain and shortness of breath—symptoms she says are similar to those she had during episodes of pulmonary embolism. Routine laboratory workup, including chest CT and ultrasound of the lower extremities, indicate a very low likelihood of PE, but she insists that she be admitted.

On the medical floor, nursing staff note that Ms. J appears short of breath only when directly observed. Medical records reveal multiple visits to other hospitals with repeated requests for admission. When gently confronted, she maintains she will die
if she is not treated.

Has your hospital’s medical staff ever been puzzled by a patient’s inconsistent presentation or unsettled by a concern that he or she was not being straightforward with them? Have they suspected that a patient such as Ms. J may be voluntarily producing his or her symptoms?

This article suggests a 3-step approach by which the consultation-liaison psychiatrist can help medical staff identify and manage patients with factitious illness.

Cardinal features

In factitious illness, the patient’s symptoms are:

• under voluntary control and consciously produced
  
• not a direct result of a medical or psychiatric condition
  
• produced to assume the sick role (not to accrue secondary gain—a core feature of malingering).
  

Patients with factitious illness tend to present with realistic scenarios that suggest a physical or psychological disorder.

CASE: Self-inflicted injury

Ms. H, age 50, surprises even the most seasoned clinicians when she presents to the ED with brain parenchyma herniating from an open wound in her skull. She denies having picked at her scalp and does not endorse a history of obsessive-compulsive disorder or trichotillomania.

On the medical floor, however, she is seen picking at the wound, which leaves blood on her protective mittens. Surgical repair is repeatedly attempted, and her case is complicated by chronic infections and a nonhealing wound.

Clinical presentation

Factitious disorder presents 3 diagnostic and treatment challenges for a hospital’s medical staff:

• To recognize and treat (even self-inflicted) serious medical conditions that can be life-threatening.
  
• To orchestrate appropriate diagnostic evaluation. (Remember that factitious illness is a diagnosis of exclusion.)
  
• To handle countertransference reactions to patients that can be intense; physicians may experience anger, frustration, resignation, and hatred.
  

You can help medical staff manage these patients’ behaviors and minimize barriers to care by explaining the disorder as a manifestation of psychiatric suffering.

CASE: ‘Suicidal’ but not depressed

Mr. B, age 48, presents to the ED with thoughts of suicide and profoundly depressed mood. On examination, however, he does not appear depressed. He repeatedly requests food, cigarettes, and assistance in finding shelter, which lead to concern that his main goal is secondary gain. However, because Mr. B has a history of serious suicide attempts—including some while an inpatient—the ED physician is reluctant to dismiss his complaints and unsure about how to proceed.

3-step diagnostic approach

Treating factitious illness is predicated upon making the correct diagnosis, which requires the medical team to investigate and gather data from collateral sources, such as outside hospital medical records and other providers. The diagnostic process can be summarized in 3 steps:

Step 1. Determine whether the patient has an identifiable medical or psychiatric problem that could explain the symptoms.

Step 2. Determine whether the symptoms are consciously or unconsciously produced. Somatoform disorders—such as conversion disorder and somatization disorder, for example—are thought to result from processes outside the patient’s control.

Step 3. Distinguish if the motivation is to obtain the sick role (consider factitious illness) or if material benefits are the goal (consider malingering). Both motivations may be operative in a given patient.

Medical evaluation. Certain aspects of the patient’s medical presentation can steer the physician to making a diagnosis of factitious illness (Table 1).¹ For patients with physical symptoms, staff should order standard evaluations based on clinical judgment (such as ECG and cardiac markers to evaluate chest discomfort). Sometimes somatized symptoms are superimposed on an identifiable physical problem, and effective management includes treating both the medical illness and its created counterpart.²

Table 1

Medical clues to a patient with factitious illness

Vague symptom history that frays upon examination
Irritability and evasiveness with continued questioning
Familiarity with hospital procedures and protocols (some patients have received medical training)
Multiple scars as evidence of past procedures and hospitalizations
Acceptance of painful medical procedures without complaint
Itinerant lives devoid of close personal relationships
Failure to accurately identify themselves
Lack of a verifiable history
Source: Reference 1

 

Psychiatric evaluation. Physicians should think of factitious psychiatric illness when:

• a patient’s behavior is notably different when he believes he is being directly observed and when he believes he is alone³
  
• psychiatric symptoms do not readily fit into diagnostic categories (such as a vague mix of memory loss, suicidal thoughts, and psychosis)
  
• the patient is suggestible or provides a diffusely positive review of systems (for example, he may report additional symptoms after having observed other patients).
  

When evaluating a patient with suspected factitious psychiatric symptoms, perform a comprehensive psychiatric evaluation to identify an Axis I or II disorder. Rule out possibilities such as dementia associated with complaints of memory loss, psychosis associated with reports of hallucinations, or affective symptoms or Axis II pathology associated with thoughts of suicide. Patients with factitious disorder often have an underlying psychiatric illness such as a personality disorder, but the Axis II disorder does not fully explain the presenting complaint.

The psychiatric presentations of Munchausen syndrome can be especially complicated, as they are usually associated with less objective evidence than are medical presentations (Box).^4-10 Clarity of the history and diagnosis may be in the eye of the beholder.

Admission characteristics

Somatic complaints. Chaos often surrounds the hospitalized patient with factitious illness. The ED commonly is their gateway, and they tend to arrive in the evening or on weekends when less experienced staff are on call.¹¹

Box

Because the patients’ somatic complaints predominate, the ED physician must complete a full evaluation, even if aspects of the history are inconsistent. Patients tend to appeal to physicians’ nurturing qualities in an attempt to have them provide care and attention.¹²

Escalating demands. During the hospital stay, patients with factitious illness may make repeated requests for care, which may escalate into demands if their needs are not met.¹³ At this point, staff often start to experience negative countertransference reactions. As medical tests reveal little to no evidence of an organic basis for their symptoms and no cohesive psychiatric diagnosis is reached, patients may complain of misdiagnosis and mistreatment.¹³

Patients usually leave before psychiatric consultation can be obtained, and the underlying suffering that led to their factitious complaints remains unaddressed. Typically, patients are lost to follow-up until the next presentation at another hospital, where the process begins again.

What motivates patients?

The motivation behind factitious presentations can be bewildering. Asher’s paper on Munchausen syndrome described several possible reasons for patients’ behavior, such as desire to be the center of attention, holding a grudge against the medical profession, drug seeking, looking for shelter, and running from police.⁵ This list, however, includes correlates of secondary gain, which with today’s psychiatric nomenclature would lead to a diagnosis of malingering.

Psychological factors. Some clinicians have tried to address underlying psychiatric factors, but data on evaluation and management are limited because these patients usually eschew psychiatric examination. Although the patient is voluntarily producing the symptoms, unconscious psychological factors are at play and are an essential part of the picture.¹⁴

When assessed, patients appear to have lived rootless lives with few attachments, which may have been the result of sadistic and unsatisfying relationships with authority figures of their youth.^15,16 Their grandiosity and distortion of the truth suggest a narcissistic need to overcome feelings of incompetence or impotence.¹⁷ Their ambivalent relationship to hospitals and physicians may reflect a need for caretaking, arising from early relationships and past caretakers.

Lastly, there is a component of masochism; this makes some individuals (erroneously) believe that if you don’t inflict pain you don’t care about them.¹³

 

Treatment challenges

Because patients with factitious disorder are not easily studied, no particular treatment is well-supported in the literature. Approaches that have been reported include preventing patients from being re-admitted to medical facilities, admitting patients for psychiatric treatment, and providing outpatient therapies such as individual psychodynamic psychotherapy, behavioral modification, and group psychotherapy.¹⁸

Other management strategies suggested in the literature include:

• reframing cognitive distortions
  
• drawing up a set of realistic hospitalization goals (with a written contract)
  
• maximizing the therapeutic alliance
  
• avoiding team splitting
  
• minimizing iatrogenic harm.¹⁹
  

Whatever the treatment, educate the medical staff about this complex disorder (Table 2), including the hazards of premature and unsubstantiated interventions or painful procedures. Also help them manage countertransference reactions. Provide an outlet for the staff’s intense emotions, and help them place such emotions into a therapeutic context.

Table 2

Recommended care for a patient with factitious illness

Fully investigate all medical and psychiatric complaints, especially if physical safety is threatened
Maintain a healthy skepticism about unusual or illogical presentations while attempting to preserve an empathic connection with the patient
Be aware of countertransference reactions, as they may provide valuable insight about the underlying cause of the patient’s symptoms
Realize that psychiatric symptoms and medical presentations fall on a continuum from conscious to unconscious; at times there may be a mix of motivations
Report all findings nonjudgmentally, both to the patient and in medical documentation

Confront patients? The efficacy and style of confronting patients with factitious illness have been hotly debated. Although no consensus has emerged, an empathic, nonthreatening confrontation may help the patient accept much-needed psychiatric care.¹³

Nevertheless, prepare the physician for the patient to respond to confrontation with denial and resistance because he or she feels exposed and humiliated. If the physician makes it clear that ongoing medical care will still be available—even if the symptoms are fabricated—the patient may be more willing to accept psychiatric treatment.¹³

Related resources

• Barsky AJ, Stern TA, Greenberg DB, Cassem NH. Functional somatic symptoms and somatoform disorders. In: Stern TA, Fricchione GL, Cassem NH, et al, eds. The Massachusetts General Hospital handbook of general hospital psychiatry 5th ed. Philadelphia: Mosby/Elsevier; 2004:269-91.
  
• Elwyn TS, Ahmed I. Factitious disorder. EMedicine from WebMD. Last updated April 13, 2006. www.emedicine.com/med/topic3125.htm.