A Final Suggestion

Most people with personality disorders have less refined interpersonal social skills. They succeed in getting what they want through more obvious manipulation, such as overpraising or creating feelings of guilt or anger. Every physician has to recognize that such feelings are not normal during a patient encounter and should be recognized for what they are: manipulation by the patient. Rather than reacting to those emotions, the physician should recognize them as a sign of a personality disorder and respond accordingly with no emotional responses and the establishment of limits for that encounter. A typical response could be: “I understand that you say you are in a lot of pain. I am going to do everything I can to help you get that pain under control now and after discharge. What I am not able to do, however, is provide opioids for this particular situation. I am certain that we will still be able to take steps to get your pain better controlled.”

Dr. Ducharme is editor in chief of the Canadian Journal of Emergency Medicine, clinical professor of medicine at McMaster University, and chief medical officer of McKesson Canada.