Detection and management of the unstable patient

Facial Plast Surg Clin N Am 13 (2005) 169 – 180

Detection and management of the unstable patient David Powell, MD, Todd Hobgood, MD Department of Otolaryngology, The Ohio State University Medical Center, 4100 U.H.C., 456 W. 10th Avenue, Columbus, OH 43210, USA

Practitioners of facial plastic and reconstructive surgery receive advanced training in the diagnosis and management of congenital, traumatic, and senescent deformity and dysfunction. Yet little—if any— formal education is devoted to what should be of primary importance to the facial plastic surgeon: which patients are psychologically appropriate surgical candidates and which are not. Surgery is stressful under even the best circumstances, and some patients will decompensate under this stress. As every doctor knows, the overly distressed patient demands a disproportionate amount of time, energy, and emotional resources from his or her caregivers. Some dissatisfied patients are inconsolable, and feelings of distress can transform into resentment against the surgeon. In such cases the distressed patient becomes the disgruntled patient, and the doctor – patient relationship erodes. In extreme cases this phenomenon might result in injury to the surgeon’s reputation or damaging and costly legal action. Other patients are potentially disruptive to a medical practice, or even dangerous to a physician and his or her staff. While danger to life and limb is rarely encountered in medical practice, it does occur. In fact, if a doctor dies at work, a leading cause of death is homicide [1]. Those medical professionals most at risk include practitioners of emergency medicine, psychiatry, obstetrics/gynecology, urology—and plastic surgery. Cosmetic surgeons and psychiatrists are murdered more often than are any other doctors. The specialties listed above are felt to be at increased risk of unstable patient behavior, including violence, because their practice has powerful psychological elements. Emergency physicians regularly

This article was originally published in Facial Plastic Surgery Clinics of North America 11:3, August 2003.

deal with intoxicated patients and have increased interactions with acutely distressed patients and family members. Psychiatry, obstetrics/gynecology, and urology doctors regularly deal with psychological stress factors—in the first specialty, therapeutic interaction deals entirely with psychological issues; the others deal with the psychologically explosive issues of reproductive and sexual health. Aesthetic surgery has significant psychological elements as well, particularly facial surgery. The face is central to identity. One authority, Mary Ruth Wright, believes that behind every request for plastic surgery lies the patient desire for an improved self-perception [2]. The literature is full of reports documenting enhancement of self-perception or self-esteem following cosmetic surgery [3 – 6]. Thus cosmetic surgery has the potential to heal, albeit in a psychological rather than physical sense [2]. Some patients have psychological problems more complex than unhappiness with their appearance or self-image, however. Some exist in a state of psychological tension and will react unpredictably to surgery. Others do not have the capacity for an improved self-perception. These patients and their physicians are likely to have an unsatisfying experience no matter what the objective results of surgery. Patient selection based on psychological criteria might therefore be described as critically important to positive outcomes in the field of cosmetic surgery. For the purposes of this discussion, the unstable patient is defined as any patient who threatens the stability of the caregiver’s practice with an inappropriate or disproportionate reaction to medical evaluation or treatment. This includes the spectrum of patients from those who simply disrupt clinical care routines, demand additional time and attention, or otherwise interfere with the care of other patients to those who engage in threatening or violent behavior.

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The violent patient, rarely encountered in everyday practice, nonetheless deserves special comment because of their potentially devastating impact. Neither type of patient should be confused with the dissatisfied patient, a normal (although hopefully infrequently encountered) patient in any cosmetic surgery practice. Dissatisfied patients might have a legitimate complaint. This type of patient is in pain (see failure, below), and their complaints are a request for help and care, however much they might sting the surgeon. Authorities advise that dissatisfied patients should be seen at frequent intervals, listened to, and advised of reasonable options for future management (ie, close observation or revision surgery) [7]. Although frequent visits might cause emotional strife in the surgeon, they reassure the dissatisfied patient and help build rapport. Most dissatisfaction is temporary, and any chance to interact with the dissatisfied patient is a chance to build a stronger doctor – patient relationship. Managed correctly, the majority of dissatisfied patients maintain a high opinion of their cosmetic surgeon and will frequently refer other patients [7]. Cosmetic surgical success or failure will be discussed in the most meaningful context—that of patient satisfaction. Investigators have determined that the patient’s perception is more important than actual objective results in long-term patient happiness following cosmetic surgery [5]. A successful cosmetic surgical outcome results in a happy, contented patient. A cosmetic surgery failure creates psychological pain in the patient stemming from his or her perception of a persisting or new deformity or impairment. Psychological pain in the surgeon, perhaps stemming from a substandard result or other complication, is also noteworthy. In such cases it is wise to minimize one’s disappointment, allow the patient to enjoy his or her result, and maintain a strong professional relationship with the patient.

Identifying the unstable patient Unstable patients are frequently encountered in the field of facial plastic surgery. In a recent poll of 600 members of the AAFPRS and diplomates of the ABFPRS with an average of 18 years of experience in the area of cosmetic surgery, 80 of the 168 responders reported that either they or a staff member were harassed, threatened, or assaulted by a patient or a patient’s family member [8]. Even if failure to respond to the survey were interpreted as a negative response, this would still mean that the incidence of

unstable patient encounters in facial plastic surgery is over more than 13% in the polled group. Demographic features of unstable, potentially violent patients have been elucidated by this and other studies. Men are more frequently disruptive than women. In the facial plastic surgery survey, the majority (75%) of unstable patients were men. This statistic correlates with reports that male patients are more likely to engage in unstable or violent behavior—two to five times more frequently—than are female patients [9,10]. Young patients aged 16 to 29 years are several times more likely than patients in other age groups to behave aggressively or commit violence against healthcare workers. Older patients, age 45 to 65, are much more likely to be satisfied with cosmetic surgery outcomes. Drug intoxication, particularly alcohol or cocaine, is highly associated with unstable and violent patient behavior [1]. Withdrawal from alcohol or narcotics has an even greater association with disruptive or abusive patient behavior [1]. Certain personality disorders (especially paranoid and antisocial types; see below), psychosis, mania, and schizophrenia are forms of psychopathology that are positively correlated with unstable or violent behavior [11,12]. The patient’s area of concern is also of significance. In earlier reports, the rhinoplasty patient, particularly the male seeking a change in nasal appearance, had been felt to represent an increased risk of unstable, threatening, or aggressive behavior [13]. One psychodynamic explanation of this observation is that the nose, a prominent midline structure with heritable characteristics, might have psychosexual significance, particularly to men. Changes in nasal appearance might destabilize hidden psychological conflict. Despite the ever-increasing frequency of male cosmetic surgery and social acceptance of all forms of cosmetic surgery, the male rhinoplasty patient continues to exhibit an increased risk of unstable behavior. In the author’s recent survey, more than half of the 80 reported unstable patients presented for evaluation of a nasal deformity [8]. Interestingly, another 17% presented for evaluation of chronic pain or a scar revision. The balance (approximately 23%) had presented for relatively routine concerns related to aging facial appearance.

History Several risk factors for unstable patients can be obtained during the history portion of the initial patient evaluation. During the initial interview, it is acceptable to ask if the patient has had any previous

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cosmetic surgery, and if so, whether the experience was positive or negative. Patients who have had a positive outcome from previous cosmetic surgery have demonstrated the capacity to handle the stress of surgery and to experience satisfaction with the result. Beware the patient who denigrates a previous plastic surgeon without just cause (see personality disorders, below). It is also reasonable during the initial interview to ask if the patient has seen any other physicians about the planned surgery. Consultations with two or three physicians to collect information and choose a surgeon are reasonable, but endless information seeking, or ‘‘doctor shopping,’’ indicates indecisiveness and might be predictive of a demanding patient who is difficult to satisfy. Additionally, one should approach with caution the patient who has had multiple operations on the same feature or body part, particularly without an obvious deformity or complication from initial surgery. Such patients might suffer from body dysmorphic disorder, a condition in which there is a preoccupation with an imagined or slight defect in appearance. Their preoccupation might disrupt normal or occupational function and can lead to a request for multiple revision surgeries. Such patients are best treated with psychotherapy, not additional surgery [14]. Chief complaint specificity can often be revealing. Patients who are likely to be satisfied will often list a specific complaint (ie, ‘‘My nose is too long,’’ or ‘‘I’d like to get rid of the wrinkles around my eyes.’’) As the patient becomes less specific, the facial plastic surgeon should realize that the likelihood of a successful outcome drops. A patient who states, for instance, that he or she is simply dissatisfied with his or her appearance, or is simply unhappy, is much more likely to be dissatisfied with a surgical outcome no matter what the objective result. Such patients might have a hidden agenda, hoping that facial rejuvenation or other cosmetic surgery will lead to changes in other aspects of their lives, and they might feel cheated when the desired life changes fail to materialize postoperatively [15]. If repeated efforts to communicate with the vague patient produce only confusion, exasperation, or uncertainty, the patient should be deferred. Patient motivation for surgery is an important indicator of successful cosmetic surgery. Patients who desire surgery for personal reasons (internal motivation) that they can easily articulate are much more likely to be satisfied with their results than patients who have difficulty explaining why they want surgery. The facial plastic surgeon should be aware, in particular, of the patient who relies on a spouse or significant other to provide the reason for

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surgery, a phenomenon known as external motivation. Patients who do not know why they are requesting cosmetic surgery are unlikely to have the internal resources to deal with the psychological stresses of surgery and its recovery. Duration of desire for cosmetic improvement is another easily assessable predictor of cosmetic surgical success. Patients who have desired a change in their appearance for a significant period of time, who have saved or budgeted for their surgery, and who have made plans and allowances in their schedules to accommodate surgery and a recovery period have a relatively greater likelihood for surgical success. In contrast are patients who express a sudden desire for surgery. At its most benign, this behavior represents a superficial appreciation for the profound impact of a change in one’s appearance, the stresses of surgery, and the time, energy, and effort of the surgeon and his or her staff. In other instances a sudden desire for surgery might represent mania, psychosis, or thought disorder [12]. For example, one patient recently examined in the Division of Facial Plastic Surgery at Ohio State University during a consultation for scar revision expressed a sudden and forceful desire for a rhinoplasty. Subsequent investigation revealed that the patient had a history of schizophrenia. Such patients have a low likelihood of satisfaction after facial aesthetic surgery and are certainly capable of disruptive behavior. With regard to social history, it is acceptable to inquire whether or not the patient has a history of substance abuse. Such patients are at increased risk of noncompliance, which can jeopardize a surgical outcome, and they represent an increased risk for violent or disruptive behavior in the office. Substance abuse, particularly alcoholism, is highly associated with disruptive and violent behavior [16]. It is also reasonable to inquire about the patient’s personal life—relationships, employment, children, and so forth. It is not uncommon to uncover significant social stresses such as recent job termination or separation from a spouse; indeed, such an occurrence might be one of the inciting events for a consultation with a cosmetic surgeon. Although such factors are not necessarily contraindications for cosmetic surgery, the desire for cosmetic surgery might be a transient reaction in this psychologically dynamic patient. Significant life stresses such as these might result in an adjustment disorder if work or social function is impaired [17]. Such patients would benefit from psychological evaluation or counseling before undertaking cosmetic surgery, a stressful event in the best of circumstances. Finally, a psychological reaction to surgery is common. In one series, Goin et al identified

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a 50% incidence of transient depression in 50 female patients after facelift surgery [4]. To minimize psychological discomfort from treatment, the patient should be free of impairment from other stresses before undertaking surgery. A history of psychiatric disease or psychological therapy is important and reasonable to investigate in the cosmetic surgery patient. For patients actively undergoing therapy, some authorities advise communication between the cosmetic surgeon and mental health professional to verify that the patient is stable enough to undergo the psychologically challenging experience of surgery and convalescence [18]. In all instances, the cosmetic surgeon should be aware of a patient’s psychological diagnosis. Some, such as the paranoid schizophrenic with a history of delusional persecution, should be avoided at all costs (see psychological assessment, below). In the recent poll of facial plastic surgeons, more than 36% of 80 unstable patients had a significant psychiatric history (the most common being mood disorders) [8]. Through exhaustive investigation of recidivism in violent crime, Monahan has elucidated that the single greatest predictive factor for violent behavior is a past history of violent behavior [16]. Approximately 20% of the unstable patients reported in the survey of 600 facial cosmetic surgeons had a history of previous violent behavior. In particular, a history of childhood violence, either experienced or perpetrated, is the most common historic factor among adults who go on to commit violent acts. It is possible to glean this history by psychological testing or evaluation, but this information might otherwise be difficult to obtain in a routine patient history and physical examination.

Psychological assessment During the history and physical examination, the surgeon should perform at least an informal psychological evaluation of the patient. Patients might not be forthcoming about mental health problems or conditions, feeling (in some cases, correctly) that the cosmetic surgeon will withhold treatment. For patients who arouse the suspicion that they will be difficult to care for and satisfy, the cosmetic surgeon should consider conducting a more formal psychological assessment or referring the patient to a qualified mental health professional. In such cases it is advised that there be a pre-existing relationship with an unbiased psychiatrist or psychologist willing to evaluate potential cosmetic surgery patients without viewing the referral as ‘‘patient dumping’’ [18].

It is acceptable for the surgeon to request of the mental health caregiver an evaluation of the patient’s overall psychological condition and his or her potential for successfully handling surgery and recuperation [19].

Personality disorders One area of particular scrutiny in the area of cosmetic surgery patient selection is the occurrence of personality disorders in this population. People with personality disorders engage in patterns of behavior that are self-serving and neglectful or emotionally injurious to others. In general, these people do not have the capacity to care deeply or meaningfully for others and they lack empathy. Personality disorders are classified as Axis II disorders in the DSM IV-R. These patients are difficult to manage in part because their behavior is perceived as normal or appropriate by the patient (ego-syntonic) and they do not cause the patient psychological distress (unlike, for instance, the ego-dystonic psychological pain experienced by the anxious, depressed, or phobic Axis I patient). Personality disorder patients are therefore notoriously difficult to interact with and care for because they feel content with themselves and regard others, including caregivers, as the ones who are wrong in any disagreement or conflict. Although personality disorder types vary in the expression of their dysfunction, they share certain characteristics. Chiefly, they have a scant, superficial emotional life (principally characterized by failure in multiple personal and professional relationships); a blaming, disregarding, or hostile attitude toward authority; a grossly inflated sense of importance; and aversion of personal responsibility [17]. Because they are abrasive and difficult, these patients are frequently identified early by office staff or clinic personnel before the surgeon even meeting them. They might behave abusively toward staff or show disregard for their efforts (for instance, by breaking multiple appointments). In an impressive examination conducted for more than 1 year in a plastic surgery practice, Napoleon identified a formal personality disorder in approximately 70% of 133 sequential cosmetic surgery patients [20]. A full description of these disorders is beyond the scope of this article. Because patients with personality disorders are likely to be encountered in a cosmetic surgery practice, and because they demand greater care and effort on the part of the surgeon, a brief description of the types listed above will be offered based on the DSM IV-R.

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Antisocial personality disorder People with antisocial personality disorder have a history replete with instances of truancy, cruelty, vandalism, fighting, drug abuse, unemployment, child or spouse neglect or abandonment, frequent job termination, and lying. Although often superficially charming or ingratiating, one chief characteristic is a lack of remorse for injuries they inflict on others. Their maladaptive behavior frequently breaks the law, and they often have readily obtainable criminal records or bad credit ratings. They are capable of threats and violence to obtain what they want. They are most often identified by their flagrant and often contradictory lies because they lie about even inconsequential or trivial events. Questions that might help identify these individuals include: Have you ever been arrested or pulled over by the police? (yes); Do you handle yourself well in physical fights that occur from time to time? (yes); If you felt the situation warranted it, would you be able to lie convincingly? (yes). All questions for identification of personality disorder patients were supplied by Dr. Nockowitz and are based on questions developed by Jeremy Roberts.

Borderline personality disorder A highly unstable mood, affect, behavior, and self-image can identify borderline personality disorder patients. These patients engage in a defense mechanism known as splitting, in which people in their environment are categorized as either ‘‘all good’’ or ‘‘all bad.’’ In the clinical setting, this might manifest as a sometimes-seductive idealization of the surgeon or anticipated outcome of surgery, which might later reverse and become a complete devaluation of the caregiver and his or her efforts. In the survey of 600 facial plastic surgeons, one third of the reported unstable patients engaged in idealization of their caregiver before a later reversal. These patients might demonstrate inappropriate intense anger, suicide threats, self-mutilating behavior, extreme impulsiveness (eg, spending, promiscuity), or identity disturbance (eg, changes in sexual orientation, career choice, religious values). Because they have fears of abandonment and engage in cycles of idealization and devaluation, the doctor – patient relationship— like other relationships in the patient’s life— is often chaotic and ends badly. These patients can be identified by asking if they have frequently been let down by others (yes); if other people frequently make them angry (yes), if they have ever felt like hurting themselves when other people have hurt them (yes).

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Narcissistic personality disorder Narcissistic patients are encountered frequently in a cosmetic surgery practice. These patients have a heightened sense of self-importance. They feel that they are unique and deserving of special treatment. They lack empathy, exploit others, and are hypersensitive to criticism. Although they engage in fantasies of beauty, power, brilliance, and success, they are frequently envious and might be prone to depression when others do not indulge their fragile selfesteem. They can be identified by asking whether other people measure up to their standards (no), whether they get angry when criticized (yes), or whether they feel they are a very special person compared with others (yes). Paranoid personality disorder Paranoid personality disorder patients are characterized by pervasive expectations of exploitation, harm, disloyalty, or threats from others. These people bear grudges and are unforgiving. They are easily slighted, are suspicious, are jealous, and are reluctant to confide in others out of the fear that any information they impart might be used against them later. Consequently, they are rarely encountered in medical practice. They are worthy of note when encountered, however, because paranoid patients (including paranoid schizophrenics or delusional paranoid disorder patients) are capable of violence and are the most likely types to murder their physicians. Some authorities believe that paranoid ideation is the only absolute psychological contraindication for cosmetic surgery [18]. Paranoid patients can be identified by asking if they feel that other people are generally disloyal or dishonest (yes), whether or not they keep certain information private to protect themselves from the wrong people (yes), if they get jealous fairly easily (yes), or if it seems that others often try to take advantage of them (yes). Dependent and histrionic personality disorders Dependent and histrionic personality disorder patients might be encountered. Dependent types are identified by a pervasive pattern of submissive behavior, including assigning responsibility for important decisions to others (such as the physician). They are afraid of abandonment, are easily hurt by disapproval, and are uncomfortable when alone. They can be identified by asking if they plan their day around a significant other’s activities (yes), if they prefer that others make the important decisions in their home (yes), and if they worry about being disliked if they argue with family members or spouse (yes). Histrionic types demand attention, approval, and praise.

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They are uncomfortable when they are not the center of attention. They might act seductive and seek physicians of the opposite sex, and they tend to be disliked by staff members of the same sex. Although they might act out a broad spectrum of emotions, this behavior is more a superficial performance than truly heartfelt. Histrionics can be identified by asking if people of the opposite sex find them attractive (emphatic yes), if they find they are often the center of attention (yes), if they think they would be a good actor or actress (yes). Obsessive – compulsive personality disorder Obsessive – compulsive personality disorder is typified by a pervasive pattern of inflexible, perfectionist behavior. Such patients are scrupulous and vigilant; for instance they might record conversations or take notes during an interview with a physician. A preoccupation with detail and exacting standards might interfere with task initiation or completion. Although their countless questions and meticulous record keeping might be viewed as threatening by the physician, they are not likely to pursue legal action. Furthermore, their personality might be helpful in that they are extremely compliant with all instructions. They might be identified by asking if they are perfectionists (yes), if they keep lists or keep checking things such as that the stove is off or the door is locked (yes), if they have difficulty feeling a task is complete because they need to do just a little more (yes). Other Other, less frequently encountered personality disorders are schizoid (unemotional loners with few if any friends), schizotypal (odd beliefs, behavior, speech, or appearance; magical thinking, inappropriate social interactions), passive – aggressive (hostile toward authority, poor work performance, sulky when instructed or advised, procrastination, ‘‘forgetting’’ appointments or instructions). Authorities have reported that personality disorders are not absolute contraindications for cosmetic surgery [10,20]. It simply must be understood by the health care team that such patients routinely demand special treatment or extra attention and might therefore interfere with the care of other patients. The most commonly encountered disorders in the series reported by Napoleon were histrionic, narcissistic, dependent, and borderline types. In this report, personality disorder patients who were particularly difficult to satisfy were borderline, obsessive – compulsive, antisocial, narcissistic, and paranoid. Napoleon reported that histrionic and dependent types are best managed with a warm, nurturing ap-

proach by the physician, whereas narcissistic, borderline, obsessive – compulsive, and schizoid patients are optimally managed with a more assured, detached approach. Wright advises a less emotional, calm, detached approach for all cosmetic surgery patients with personality disorders. Based on a preponderance of anecdotal reports and a more formal investigation by Wright, cosmetic surgeons are advised to avoid performing surgery or otherwise developing a close professional association with paranoid patients. Both investigators recommend allotment of extra time for all personality disorder patients, and Wright reminds us that surgery cannot mend what is broken—the capacity to feel deeply or genuinely. Affect The psychological assessment should also include observation of patient mood and affect. Mood disorders, chiefly depression and mania, are readily apparent when severe. Depression is extremely common and can accompany additional psychopathology such as psychoses or personality disorders. The depressed patient and the adjustment disorder patient with depressed mood might report adhedonia (inability to experience pleasure), inability to think or concentrate, feelings of worthlessness or guilt, fatigue, and have recurring thoughts of death. Manic patients report decreased need for sleep, inflated self-esteem or grandiose ideation, impulsive behavior (eg, a sudden desire for cosmetic surgery or compulsive spending), flight of ideas, and pressured speech. Depressed and manic types of patients are capable of explosive or violent behavior [17]. Affect is the term used in the field of mental health to describe the emotional content of the patient’s nonverbal communication expressed during interactions with others. A flat or blunted affect, typified by absence of facial expression and monotonous voice, might indicate profound mental illness such as schizophrenia. Other forms of significant psychopathology such as psychotic disorders or delusional disorders usually become apparent upon repeated interactions with the patient.

Caregiver psychological factors A psychological dynamic exists between caregiver and patient that can offer additional clues in the identification of the unstable patient [21]. One simple but reliable indicator of a potentially unstable patient is the phenomenon of the disliked patient. Persistently disliked patients are likely to suffer from

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significant psychopathology, particularly organic brain syndromes [22]. Even in the absence of psychological disease, the lack of rapport between surgeon and patient might make optimal outcomes difficult to obtain. Patients who exhibit persistent maladaptive behavior such as behaviors associated with personality disorders provoke feelings of anger, tension, irritability, and frustration in their caregivers, but healthcare workers might be reluctant to acknowledge these feelings as unacceptable. Instead, the caregiver might begin to dread encounters with the patient. It is significant if the physician or a staff member feels afraid of the patient. Clues that such feelings exist include avoiding the patient, cutting visits short, or failure to return phone calls from the patient. During an interview or examination of such patients, physicians might become aware that they are leaning away, crossing arms or legs, thinking of excuses to terminate the examination, or even that they have elevated vital signs. The caregiver might simply have a gut feeling that the patient is unstable or dangerous. All such behavior or feelings are significant and should be taken seriously by the cosmetic surgeon. The majority of communication is nonverbal, and even if the conversation is superficially normal or acceptable, gut feelings of fear or dread are definite harbingers of patient disruptive behavior. In the facial plastic surgery survey, nearly 40% of the facial plastic surgeons who encountered unstable patients reported a gut feeling of patient instability before the actual incident [8]. These gut feelings are probably the result of limbic activity in which multiple subtle cues—a collection of observations of the subject’s voice, posture, expression, affect, speech, verbal expression, and so forth—are processed subconsciously to produce a single subjective impression (R. Nockawitz, personal communication). Instances in which the caregiver experiences strong aversion for the patient should result in a nonconfrontational disengagement from the patient.

Physical examination The patient’s physical examination might offer clues that one is dealing with an unstable or potentially violent patient. Considerable overlap exists between the patient’s psychological state and physical presentation. Some physical examination findings might therefore contribute to the psychological assessment detailed above. Intoxication, particularly with alcohol or cocaine, might be apparent on examination. Although these two drugs have opposite intoxicating effects, both are

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disinhibiting and are highly associated with disruptive or violent behavior. Alcohol intoxication causes slurred speech, belligerence, unsteadiness, nystagmus, and flushing associated with disinhibition. Cocaine intoxication is suggested by euphoria, psychomotor agitation, grandiosity, pupillary dilation, tachycardia, and elevated blood pressure [16,17]. Withdrawal, particularly from narcotics, sedatives, and alcohol, is also associated with unstable behavior (see delerium, below). The cosmetic surgeon is most likely to encounter withdrawal in postoperative patients who are unable to replenish their own supplies of the abused drug. Withdrawal from these central nervous system depressants causes psychomotor agitation, nausea, vomiting, autonomic hyperactivity, anxiety, irritability, and hallucinations or illusions. When detected, withdrawal from virtually any abused substance warrants hospitalization and medical or psychiatric evaluation. Organic brain syndromes, especially delirium and dementia, might become apparent during evaluations of the patient. Delirium is more often detected postoperatively and indicates an underlying disorder of metabolism. Dementia is often a concern in dealing with elderly patients—the population often treated by practitioners of facial rejuvenation surgery [23]. Both disorders are associated with cognitive impairment, but delirium is more acute and can be associated with psychomotor agitation. Attention and awareness are more often impaired in delirium, whereas thought and memory are more consistently impaired in dementia. Both disorders are associated with violent or disruptive behavior. Other organic brain syndromes (eg, traumatic brain injuries) might present in a similar manner to dementia, with disordered thought and behavior, nonsequiturs, inappropriate comments or jokes, socially unacceptable behavior, unusual or bizarre associations, sudden outbursts, and neglect of personal appearance or hygiene. All organic brain disorders warrant evaluation by a psychiatrist and are, almost by definition, associated with unstable behavior [17]. A complete history of all patient scars is within the province of any physician who performs cosmetic surgery. A physical examination should include careful inspection of the entire head and neck region and other exposed skin for any scar. Some scars are related to previous surgery and a complete history of the surgical treatment should be requested. The patient’s attitude about the previous surgery and the resulting scars might be revealing. If a patient lies (ie, denies that obvious postoperative scars are from surgery) or otherwise seeks to avoid discussing the previous surgery, he or she might have ambivalent or negative feelings about the previous surgical experience and

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any future surgery should be approached with caution. Worse, patients who are not open and completely honest about previous cosmetic surgery might have a hidden agenda, including malingering, or have primitive coping mechanisms for dealing with psychological stress. In one instance, the author examined a patient who presented for a scar revision, and the patient attributed scars obviously from a previous facelift to a knife attack perpetrated by her ex-husband. The mutual trust normally present in a doctor – patient relationship was undermined by the patient’s adherence to an obvious falsehood or delusion. Most scars are from unplanned trauma rather than surgery. The history of these scars and the patient’s attitude toward them should be politely but thoroughly explored. In most instances, facial and hand scars are from innocuous injuries and the patient will have a matter-of-fact explanation. Overly elaborate explanations suggest obfuscation or emotional conflict. Some scars are classic for fighting and such patients should be approached with caution (see Figs. 1, 2). In particular, hand, forearm, and facial scars that are irregular and poorly repaired (wide or hypertrophied, suggesting healing by secondary intention) suggest trauma, either occupational or from brawling. As previously stated, the best single predictor for violence is a past history of violent behavior [16]. Patients with scars from fighting should be approached with caution. Tattoos, which were once uncommon, are frequently encountered and should be investigated when detected on physical examination. Like scars, most tattoos are benign and the patient will usually openly (if somewhat sheepishly) discuss their significance. Benign tattoos are usually professional and have some meaning, such as a person’s name, a school or frater-

Fig. 1. Hand scars such as these might signify a history of brawling.

Fig. 2. Scars from penetrating trauma such as gunshots or, as in this case, stabbing, are frequently irregular, pitted, or dimpled.

nity affiliation, a military connotation, or some other easily understood emblem. Tattoos that do not require an explanation are the most benign. Some might appear to have obscure or even arcane significance, but if the patient has a plausible, ready explanation, they deserve little concern. Some tattoos, although professional or aesthetic, convey meaning that is socially unacceptable (eg, a swastika or a violent or sexually explicit act), and however lucid the explanation, the surgeon might be justified in considering the patient capable of disruptive behavior. Finally, tattoos that are monochromatic and amateurish might signify gang activity or incarceration, and such patients frequently have a history of violence (Figs. 3, 4). For patients who arouse the suspicion that they might be capable of disruptive or violent behavior, the physician should consider the possibility that the patient might be carrying a weapon. The incidence of weapon carrying in urban emergency department patients has been reported to be as high as 17%, and up to 8% among hospital inpatients [1]. These frightening statistics demand respect and consideration, even in the rarefied air of a facial plastic surgery practice. No one has ever reported the incidence of weapon possession among cosmetic surgery patients, but it is safe to assume that it is not 0%. Bulky clothing with deep or bulging pockets might suggest a hidden weapon. Many patients will openly carry knives on their belts; others might even carry a

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action. The credentials of patients who claim a professional obligation to carry a weapon can be quietly investigated if warranted.

Management of the unstable patient In instances in which a doctor – patient relationship has been established and the cosmetic surgeon finds him- or her-self the primary caregiver for an unstable patient, management strategies should be implemented to minimize the damage or disruption such patients can cause. The following strategies have been reported by numerous investigators as effective in the management of potentially disruptive patients [24 – 30]. Fig. 3. Tattoos on hands, knuckles, or the webbing between fingers are correlated with gang activity or incarceration. The owner of this tattoo stated that he received it after surviving gang activity in prison for 2 years.

firearm. The only possible excuse for such behavior is a professional obligation to carry a weapon—as in law enforcement—otherwise, patients should be firmly prohibited from bringing weapons on future visits, and managed cautiously in any further inter-

(1) Personal information of staff should be protected, including home addresses and phone numbers, and possibly last names. (2) Charts of unstable patients should be flagged. This facilitates discussion between office personnel to prepare for the patient’s visit. (3) The office should be fully staffed when the patient arrives, but other patients should not be present. The waiting environment should be clean and pleasant. In the survey of 600

Fig. 4. Tattoos are common and most are benign, such as tattoo A. Benign tattoos are often professional and convey meaning to their owner or to others. Beware homemade tattoos such as B. Monochromatic, irregular, misspelled, or grammatically incorrect tattoos are often an indicator of incarceration or gang activity, as this one from a convict stating ‘‘Born to die.’’

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facial plastic surgeons, nearly 40% of the reported disruptive behavior occurred in the waiting room [8]. In optimal circumstances, security devices such as locking doors between public and private spaces and closed surveillance equipment should be present and active. The patient’s wait should be brief. (4) The physician and staff should remove any potential weapons from their bodies and the examination room (ie, neckties, scarves, stethescopes, scalpels, or scissors). (5) The patient should be treated respectfully and kindly by any office staff member with whom he or she interacts. One school of thought is that the number of staff members the patient is exposed to should be minimized; others have suggested that a subtle ‘‘show of force’’ with multiple personnel might diffuse a potentially violent patient. (6) The patient should be asked to change into a gown or other patient attire, if feasible. The patient should disrobe as completely as possible before the examination. This might separate him or her from a concealed weapon. (7) During the time spent with the patient, the physician and staff should maintain an awareness of the patient’s hands. Threatening gestures might signify an impending outburst. Hands that are hidden from view might be touching a weapon. It is acceptable to ask permission to examine the patient’s hands (ie, for his or her radial pulse and capillary refill) or to recruit the patient’s help by holding equipment to keep his or her hands in view. (8) Permission should be obtained before touching the patient—touch might be regarded as an assault or a threat by a paranoid or antisocial patient. The caregiver should never argue, turn his or her back, condescend, threaten, or isolate him- or herself with an unstable patient. Such patients should not be engaged in a power struggle. Power struggles have a winner and a loser, and the doctor will always be the loser in such a conflict. (9) The examination should be unobtrusively chaperoned, preferably by a staff member the same sex as the patient. Some investigators have recommended that a member of the opposite sex might have a calming effect on the patient. Communication should be simple and polite. (10) The patient and caregiver should have access to the exit. Some authorities have suggested that the caregiver place him- or herself

between the patient and the exit, but this might result in the patient feeling trapped. An examination room with two exits represents an ideal solution, but this might be impractical. (11) If the patient feels slighted or persecuted, listen to him or her attentively, apologize, and offer to help him or her. A respectful distance should be maintained from the patient if he or she is agitated. The caregivers should remain calm. Empty promises that cannot be kept should not be made, but the patient can be offered mutually acceptable alternatives. (12) The patient should be observed for signs of an impending outburst such as sweating, pressured speech, profanity, psychomotor agitation, hypervigilance, threats, clenched jaw or fists, staring, trembling, pacing, and exaggerated movements or gestures. In some cases the patient might withdraw from interaction before an attack. The physician might simply get the ‘‘gut feeling’’ that an attack is imminent. If any signs of an impending attack occur, the physician should get help, separate him- or her-self from the patient, and maintain a respectful interaction with the patient. (13) If a patient has harassed the physician or a staff member, arrival and departure routines should be varied.

Managing the violent patient Office protocols should exist for management of the violent patient. Although violence is rarely encountered, the office staff and medical personnel should be aware of their role or responsibility in such an emergency. The safety of other patients and office workers is the top priority in the event of office violence. It has been established that pre-established evacuation and management plans minimize disruption and save lives. The cosmetic surgeon, the ultimate authority in office health care decisions, has a leadership role in the event of a crisis. Other responsibilities, such as for evacuation or notification of authorities, should be divided ahead of time. Violence in health care has multiple etiologies, including disgruntled former or current employees, a domestic abuse situation that spills over into the workplace, the commission of another crime (such as a robbery), and families or friends of patients. Management of office violence should be the same in any instance involving the execution of previously established office procedures. There is no instance

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in which violence—defined as aggressive behavior aimed at inflicting harm or discomfort on its victims and including threats, harassment, and physical assault—should be tolerated in the workplace. When violence occurs, security or law enforcement should be notified immediately. All other patients and unnecessary personnel should be evacuated through the nearest exit. A distance should be maintained from the violent individual. Clear, simple interaction with the violent individual should be maintained by the predetermined team leader. The patient should be informed that the authorities have been notified, and he or she should be asked to leave through the nearest exit. No effort should be made to overpower the patient unless absolutely necessary to minimize injury to another patient or office worker. As long as the option to keep away from the violent individual exists it should be exercised. It is the responsibility of security forces to restrain or subdue violent individuals, and the physician might be held liable for injuries inflicted on a violent patient if he or she is physically restrained by office personnel. Any incident of patient violence—be it threat, harassment, or physical assault—should be documented and reported to law enforcement authorities. It is the office physician’s responsibility to arrange medical care and psychological counseling for any victim of workplace violence.

Summary The vast majority of doctor – patient interactions in the field of facial plastic surgery are mutually rewarding. Unstable patients will be encountered, however, because of the psychological components of cosmetic surgery. The harm or chaos such patients cause can be minimized by an awareness of unstable patient characteristics, an effort to screen for unstable behavior potential, and development of plans and protocols to manage such patients when they are encountered.

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