How to Work with Neurotic Patients

Your new patient walks in and you’ve got 10 minutes to prepare.

You’re a good physiotherapist so you best check their medical history.

This is what you see:

-Anxiety
-Depression
-Fibromyalgia
-Chronic pain

… and the list goes on.

I used to always think – man, how can one person have this many problems?

After meeting enough of these patients, I started to notice speech patterns.

I can’t do this because…

I won’t do this because…

I have to be careful because…

I have this because…

What are the side effects?

What are the problems that might arise?

I can’t afford to get more sick…

Sound familiar?

Although it’s not for me to say whether the patient’s experience is true – I will say this.

If you put them on the OCEAN personality model, almost all of these patients will test high in neuroticism.

That’s why it’s important you learn more about this characteristic, and how you can guide them toward the best rehab plan for them.

If you’d like to watch the video version, it is in the video below. Otherwise, read on!

First off, what’s neuroticism?

Neuroticism is one of the personality factors measured in the OCEAN model, which stands for openness to experience, conscientiousness, extraversion, agreeableness and neuroticism.

It describes a personality trait that is volatile and frequently affected by negative emotion.

Let me make something very clear. ‘Negative’ emotion just means emotions that don’t feel very good, like anxiety, sadness and fear. It DOESN’T mean that negative emotion is somehow ‘bad’ or ‘evil’ from a moralistic standpoint. It simply is what it is.

Next, the question is ‘why would neuroticism exist if it doesn’t feel very good?’ The paradigm that answers this question best comes from evolutionary biology. That is, there must be an evolutionary basis for the development of this personality trait. And this is why:

Because neuroticism keeps us alive more than any other trait.

When you are about to cross the road, you should be a little anxious – because that will drive you to check.

If you are afraid of going out at night (especially for women), this is probably not a bad thought to have for safety purposes.

So neuroticism is important for survival purposes – but how is it relevant for us in the clinic?

Heightened Anxiety and Stress prolongs Recovery Time

The first issue is neurotic people tend to hyper-fixate on pain. As we know, pain is normal during the rehabilitation process. This hyper-fixation makes them generally hyper-protective and nervous about any pain symptoms.

Is it getting worse?

Why isn’t the pain gone yet?

It’s been 3 days, why am I still in pain?

Why are you telling me to rehab through pain?

These chronic feelings of stress and anxiety compound onto each other and can be completely debilitating.

From a physiological perspective, the physiological markers of stress and anxiety are not productive for health and recovery. They impact sleep and mood, further compounding the problem.

The Internet Facilitates Spiralling

What do you do when you first start experiencing pain?

You head to Dr Google.

And what does Dr Google say you have?

Cancer.

Let the spiralling begin.

So what the hell do we do?

Great question. As clinicians, I daresay that many of our patients are actually neurotic by nature. After all, if they’ve taken the time to come see you to get treatment… then they care on some level.

People who aren’t very neurotic (like myself), very rarely feel the need to ‘go get it checked out’, because I don’t think it’s going to get worse. And most of the time – that’s exactly what happens.

In fact, I’d argue that it’s almost better to assume all patients are neurotic by default, because even those who aren’t will benefit from what I’m about to suggest. I utilise three tactics when I am speaking to a neurotic person.

Tactic #1 – Focus on Action-Process Based Language

Which phrase would sound better for you?

1. Your back is weak.
2. Let’s strengthen your back.

I’m essentially saying the same thing, right? But how it’s received will be very different. Most neurotic patients will hear A) and think ‘oh my god… why?!?!’

But when they hear B) they’ll think ‘okay so what do we do?’

One drives action and behaviour in the direction of rehab.

The other facilitates a spiral.

Here’s another example.

1. Don’t do anything that hurts.
2. Keep up all activities that feel comfortable.

Again, basically saying the same thing, but will be received very differently.

Another reason why you want to use action-based language is because it gives neurotic patients a sense of control. If you said to someone: ‘there’s nothing we can do right now,’ they’re likely to spiral out. But if you said to someone ‘let’s focus on basic movement,’ they’re still doing nothing.

Tactic #2 – Say only what is Necessary

I know sometimes we think that giving the patient all we know is good for them. In reality, it is good for you because it makes you feel validated in your expertise.

Maturity is being strategic with the amount of information you give – and this means you have to gauge whether the information you give is actually going to help or harm.

You don’t want to be another Dr. Google.

So what pieces of information should you leave out?

Information that is out of their control, or unlikely but catastrophic in nature.

For example, poorly managed lower back pain can lead to chronic back pain, and some patients struggle for decades with it. Although this is true, it’s probably not helpful to say this to a neurotic patient.

Instead, you might want to say ‘lower back issues will improve from 8-12 weeks with structured exercise and knowing what to do.’ That’s it.

Similarly, if you suspect there is a tissue tear of some sort and want to refer for further scans. You probably don’t want to say ‘Hey I suspect you have a tear so let’s scan it.’

You do want to say ‘Hey, your recovery has stalled a little bit so let’s have a deeper look to see where else we can improve your rehab.’

Same outcome but very differently received.

Tactic #3: Improve your Vocabulary

The final tactic is to improve your vocabulary, paying particular attention to words that carry negative connotations versus ones that don’t.

Let me give you an example.

Your muscle is torn.

Your muscle is strained.

Technically a strain is a tear, right? So why not use torn?

Well for one, torn sounds much worse than a strain, right? And that’s the point.

Here’s another example.

1. You have inflammation in your ankle.
2. You have some swelling.

Same same, but different. Inflammation sounds like something is on fire. Swelling sounds a bit more ‘watery.’

In health, part of our expertise comes from how we relay information, not just on what treatment plans work best. If you want to be the best physiotherapist you can, then start being mindful of words and watch your treatment outcomes change.

Until Next Time,
Phil