Manipulative patients 1

The term “manipulative” is highly charged and in some cases quite pejorative. Of course, there are patients who truly fit the description of manipulative: i.e., they intentionally exploit the position, needs, unconscious fears or weaknesses of others in a calculated attempt to gratify their own needs or wishes, usually without concern for the social consequences or the feelings of others.

The problem is that this description may apply to anyone from a successful CEO to a patient with borderline personality disorder to a “street person” in a third-world country, trying to survive starvation. What we call manipulative, in other words, may have more to do with our own feelings of being “used” than to any specific diagnostic designation. For example, one study (Lewis & Appleby, British Journal of Psychiatry, July 1988; see comment in Feb. 1989 issue) found that when psychiatrists were asked to read a case vignette and indicate their attitudes toward the patient, the patients given a previous diagnosis of personality disorder were seen as less deserving of care than patients with similar vignettes who had not been so labelled. This often happens as soon as the term “borderline” is used to describe a patient.

On the other hand, there is no question that some patients with antisocial, narcissistic or borderline personality disorder are manipulative in extremely destructive ways. For example, BPD patients may use the threat of suicide to control, paralyze, or punish others, often related to transference reactions toward staff. For guidelines on how to deal with this, see the article by M.H. Stone, American Journal of Psychotherapy, Spring 1993. You may also want to see the paper on counter-transference hate by Maltsberger & Buie (Archives of General Psychiatry, May 1974) and on a more practical note, the book Treating Difficult Personality Disorders by M. Rosenbluth and I. Yalom.

In short, you won’t need to learn how to detect the manipulative patient – he or she will detect you! The real issue is how to deal with your own reaction once you realise you are being manipulated.

Some manipulative behavioural strategies

  1. [TheMost Famous]
    “There’s only one pain medicine that works for me; begins with a “D”, Duh . .Dem . . .Demerol!
  2. [“You’re So Great!”]
    “—I remember you! You took care of me before . . . You’re the BEST nurse . . .—Not like that other one that was so MEAN and made me wait hours for some pain medicine!”
  3.  [Any Drug Allergies?]
    “I’m allergic to ALL pain medicines EXCEPT Dilaudid.”
  4. [“I really have disease”]
    “I’m here from out of town (thousands of miles away). And, I’ve just gotten an attack of {chest pain, kidney stones, my rare disease], I’m having terrible pain. I just happen to have a copy of my {chart, X-rays, doctor’s letter} with me . . . No, I don’t have a copy of the cath report . . . —I forget where that was done!”
  5. [Allergies to Alternative Agents]
    “My allergies are Codeine, Toradol™, Darvon™, Aspirin and NSAIDs, ALL psych meds; —Percodan™’s OK!  {Five days after the release to market of Toradol™ occured the first probably spurious claim to me of “allergy” to the new drug.}
  6. [Uniquely Tolerant]
    “I have a ‘high tolerance to pain medicines’ —That’s NOT enough; I’m going to need at least 150 mgms of Demerol™ and 75mgms of Vistaril™! {Last reported episode of pain six months ago
  7. [“Your Golden Opportunity”]
    “Why, yes, I am the Executive Producer for The Rolling Stones, a really big Hollywood Movie Director, International Financier, Grand Vizier for Ali Pasha, etc., and I know all those other famous people,  and can get you a fabulous travelling job as personal Nurse to so-and-so.  Here’s my card.  I want you to come see me after the end of the month when I get back to Monaco and I’ll take you all around in my personal 150′ yacht . . . Oh, yes, you can bring a couple of friends, too.  I’m just so grateful to you for helping me out.”
  8. [“The Stone Soup Method:”]
    “Oh, good, that’s beginning to feel a little better, Thank You! . . . Say, do you think you could get me a couple of extra pillows, —and, —and, some warm blankets?  This bed is so hard.  I know that it’s not your fault.  That’s great.  Thank You.   Gee, I really haven’t eaten . . . Do you think that you could find a little something to eat.  That would be great.  Maybe, some turkey and some nice soup . . . Yes, thank you so much.  And, could you just turn off the light as you go?   Do you have a TV here or anything?  Say, by the way, . . .
  9. [Contentious]
    “Say, WHO does that doctor think he is? —Saying that he can’t give me any pain medicine unless he can diagnose a treatable disease!  He’s a Quack!  He’s no REAL doctor . . . —I’ve been to all the best doctors there are!   You can’t get away with this!  I want a phone to call my lawyer RIGHT NOW!   I’m gonna sue Your Ass!  You’re never gonna work again!  I want your NAMES!   —And I  want your Supervisor, RIGHT NOW!
  10. [“The ‘Rush’ Act”:]
    “You don’t have to give it that slow!  —Just push it right in!”
  11. [“Sarah Bernhard:”]
    When surreptitiously observed, patient appears comfortable or resting, yet when patient knows himself to be watched there is a histrionic display of writhing and moaning and grimmacing; effort is put forth only when secondary benefits may be gained.
  12. [“The Dying Swan”:]
    The patient who has somehow gotten in the car that has brought him {usually with “excruciating” back pain} now professes to be entirely incapable of self-movement to extricate himself to the awaiting gurney.   Often compounded with a “flop act” when trying to undress the patient for monitoring and examination which appears without evidence for recognizable neuromuscular disease.   Seemingly without gumption to resist or overcome the influence of any actual disease.
  13. [“Pseudo-Collapse”:]
    For a dramatic entrance, or to forestall unwanted discharge, the malingerer goes to a public area (with witnesses) and ostentatiously crumples to the floor and begs for help.  No injury has occurred in the “Hollywood Fall”.
  14. [The False Swoon  & “The Drop Test’:]
    The malingered loss of consciousness has inconsistent or self-beneficial findings to the exam, such as the “victim’s” hand and arm, seemingly flaccid, when elevated and dropped over the face defies gravity and cannot fall upon the victim in injurious fashion, but falls gracefully aside.  Resistance to eye-opening, lack of Lash reflexes, and breath-holding during administration of Aromatic Spirits of Ammonia, are not normal responses.

[Another Tip-Off Phrase:]  “None of the Doctors has ever been able to give me a diagnosis or to fix it.  I’ve been to Doctor after Doctor; it’s always the same.  I want you to tell me what’s wrong.”


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