In the last issue, we discussed several points that bear repeating:

Some new points:

• Disruptive behavior is typically not related to chemical dependence (though it can be!)
• It's crucial to have appropriate expectations. The causes of disruptive behavior do not develop overnight, and it's unrealistic to expect the physician to change his or her behavior overnight with no slip-ups. That's one reason it's important to make the referral to NCPHP before the environment reaches the point of "zero tolerance" for minor infractions.
• The physician with disruptive behavior is often a technically excellent clinician. However, their self-assessment often exceeds reality.

Common causes of disruptive behavior:

Medical problem(s): While medical problems are not usually the cause of disruptive behavior, NCPHP has encountered poorly controlled diabetes, Cushings disease, and undiagnosed CNS tumors causing personality and behavior changes. If medical problems are a factor, there will often be an acute change in behavior or personality.

Sleep deprivation/fatigue: This is usually due either to the consequences of the behavior (e.g. threatened loss of privileges, etc.), or related to overwork and other self-care issues. In other words, sleep problems are more of a symptom than a cause.

Adjustment disorder: Marital, financial, family, legal and other stresses are often found in conjunction with disruptive behavior. Personal stress tends to exaggerate pre-existing personality traits, and it's typically not the healthy traits that blossom! Physicians referred to NCPHP for disruptive behavior will often minimize underlying stress, or say they have "already dealt with it". Unfortunately, life has a way of presenting us with new and recurrent stresses, and the development of healthy coping skills is necessary.

Personality disorder (or traits): The American Psychiatric Association’s Diagnostic and Statistical Manual – Fourth Edition  (DSM-IV) defines a personality disorder as "an enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individual's culture" manifested in the person's cognition, emotional response, interpersonal relations and/or impulse control. Personality traits are those noticeable characteristics that do not rise to the level of a personality disorder. Obviously, we all have some pathological personality traits, and the line between "healthy" and "unhealthy" is often fuzzy.

The DSM lists ten distinct personality disorders. The ones most commonly associated with disruptive behavior are:

• Obsessive-Compulsive
• Narcissistic
• Borderline
• Schizoid
• Paranoid         
• Antisocial

The two most frequently encountered are:

Obsessive-Compulsive (O-C): It can be very difficult to agree on what's acceptable vs. unacceptable behavior. At one end of the spectrum is the individual who is extremely rigid, domineering, stubborn, and so focused on getting the details perfect that they miss the major goal of the activity. The perfectionism interferes with task completion, and the O-C doctor will typically run way behind schedule or be hopelessly behind on documentation. They need to be in control and have trouble delegating tasks.

At the other end of the spectrum is the physician who is appropriately compulsive about patient care. Who doesn't want their surgeon to be detail-oriented in the operating room, or their internist to be compulsive in doing a work-up for disease? Indeed, medicine is increasingly rule-driven, and the consequences of not being appropriately compulsive are steadily rising

The key is in the word "appropriate". The disruptive O-C physician typically has trouble accepting input from anyone else as to what is appropriate, and almost always has problems in working out differences of opinion. They tend to avoid their anxious feelings through control and action rather than using introspection or diplomacy. Therefore, development of awareness, tolerance and alternate coping skills for anxiety is crucial.

Narcissistic: Many would say that the phrase "narcissistic physician" is redundant.  Indeed, we are trained and expected to be confident in our abilities, and to forego self-doubt in times of crisis. The trick is to avoid what has been called the "M-Deity syndrome", or pathologic narcissism. DSM-IV criteria for Narcissistic Personality Disorder includes:

• Arrogance or “condescending superiority"
• Exaggerated sense of achievements and talents
• Lack of empathy
• Craving for admiration
• Strong sense of entitlement

In addition, the pathologically narcissistic physician is often intolerant of imperfection (or perceived imperfection) in others. As with all personality disorders, the narcissist has his or her origins early in life. Parents may set unrealistically high standards for the child, who begins to think of himself as "special". The parents are typically unable to emotionally nourish the child, and provide harsh criticism for failure. The child internalizes these attitudes and is later unable to empathize with others, etc. Otto Kernberg characterized the unconscious dynamic as: "I am grandiose because I feel unlovable; I cannot be loved unless I am perfect." While these underpinnings of the disorder do not excuse the problems, insight into the narcissist's deep-seated feelings of inadequacy can help the person begin to change behavior over the long term.

How to document and refer: Proper documentation is crucial in helping NCPHP reach a successful outcome, as well as for legal reasons. NCPHP will require the following information from the referral source:

• Problem behaviors with as many examples of specific incidents as possible.
• What is disciplinary protocol and where is physician in that process (e.g. verbal warning, written warning, etc.)
• Time frame for corrective action
• Consequences of noncompliance with contract, either reoccurrence of behavior or lack of follow-through with treatment recommendations
• Perceived need for physician to sign formal monitoring contract with NCPHP

The referral source is also encouraged to do the following:

• Require the physician or PA to sign a release of information form to allow NCPHP to communicate basic findings and recommendations back to the referral source
• Set a time limit for the evaluation to occur