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Difficult Dental Patient Psychological Schemas

Challenging patient behaviors: Psychological schemas and how they impact the dental appointment

Nov. 1, 2023
Have you ever encountered a difficult patient and thought, “I do NOT get paid enough for this!”? The author looks at the causes of these challenging behaviors and how they can affect the dental visit.

Editor’s note: This is part one of a four-part series. Read part two: Patient red flags and personality disorders. Read part three: Effective reasoning with unreasonable dental patients. Read part four: Strategies for listening to difficult patients.

There is a camaraderie among us as dental professionals. We all share this bond of being wrists deep in anerobic bacteria and managing patient behaviors on a daily basis. We’ve all experienced stressful incidents and problem patients where we think, “I do not get paid enough for this stuff!” We’ve all had patients who refuse to sit still or who yell at us, but more of us are starting to experience patients who are aggressive, verbally abusive, or, unfortunately, even violent.

Do you think patients, in general, are becoming more demanding, unreasonable, or aggressive? This is beyond just the annoying or particular patient; these difficult patients are problematic. When we don’t meet their unreasonable expectations or impossible demands, their behavior morphs into unacceptable and aggressive actions, leaving us thinking, “I really don’t get paid enough for this stuff!”

You may also be interested in … How to spot a difficult dental patient

The Association of American Medical Colleges1 reported that health-care providers are five times more likely to experience workplace violence than all other industries. Aggressive and violent acts against health-care workers grew 63% in the decade prior to the pandemic, and further increased significantly from 2020 to 2023.

More than half of all health-care workers have experienced verbal or physical abuse from patients.1 Specific to oral health care, 60% have experienced abuse in the workplace, with approximately 55% of those experiences being verbal abuse from patients, including shouting, expletive language and name-calling, threats, or sexual harassment.2

In this four-part series, we examine some of the causes of patients’ bad behaviors and consider best practices for how to deal with these difficult patients.

Also by the author … Elder abuse and mistreatment: How should dental professionals respond?

What are schemas?

Schemas are psychological core beliefs that are developed over time, starting in childhood and adolescence, and then expanding and intensifying throughout adulthood. Schemas are formed from repetitions of experiences, emotions, and sensations a patient experiences.3,4 How patients experience a situation and their cognitive interpretation of that situation will influence subsequent actions and development of schemas. Differences in schemas explain differences in behaviors and actions of difficult patients, especially in stressful situations.4,5

Early maladaptive schemas

Behavioral health professionals focus on understanding early maladaptive schemas (EMS) to understand patients’ behaviors and reframe their problematic behavioral actions and reactions with schema therapy.6 In childhood and adolescence, there are five universal emotional needs that must be met in order for a patient to develop secure and healthy attachments to others later in their life: 1. autonomy; 2. sense of identity/competence; 3. freedom to express valid emotions and needs; 4. spontaneity/play; and 5. self-control/realistic limits.3,7 If these emotional needs are consistently unmet or undermet, the patient will develop EMS.5,8

Prior negative dental experiences can increase anxiety and impact patients’ behaviors, but their past life experiences and EMS can trigger strong emotions, problematic behaviors, and violent actions when seeking dental care. EMS cause excessive irrational thinking and bad patient behaviors, which present challenges for dental professionals.4,6,8

15 early maladaptive schemas

Examples of what patients with EMS may think, feel, or say:3,9,10

Abandonment: expecting that others will leave them without warning

  • “Everyone who cares about me will eventually leave me.”
  • “All of my relationships are doomed to failure.”

Defectiveness: believing they failed and will always fail

  • “I am a damaged person.”
  • “When others get to know me, they learn my flaws and abandon/reject me.”

Dependence: believing they are incompetent and cannot care for themselves

  • “I need to rely on others to care for me.”
  • “I’m not able to handle the day-to-day by myself.”

Embarrassment/shame: believing others view them as unacceptable or “not good enough”

  • “There is something fundamentally wrong with me, and I need to hide it from others.”
  • “I possess certain characteristics that are undesirable and that others can easily detect. This is why others see me as less than themselves.”

Emotional deprivation: expecting no one to be emotionally supportive

  • “No one will ever really love me.”
  • “I will always be alone in this world.”

Emotional inhibition: emotional restraint due to fear of losing control

  • “If I’m not careful, I will lose control of myself.”
  • “Showing any emotions would make me weak.”

Entitlement: believing they deserve special treatment

  • “I should be able to do whatever I want.”
  • “I shouldn’t have to play by the rules because I am superior.”

Failure: believing they are unlovable or invalid

  • “No matter what I do, nothing will be good enough.”
  • “I am not capable of performing well at anything. What’s the point of trying?”

Mistrust: assuming that everyone is looking to harm them

  • “If others get close to me, they will betray me.”
  • “Everyone is trying to take advantage of me.”

Negativism: extreme focus on negative things; the inability to see anything positive

  • “Bad things always happen to me. I’m cursed.”

Self-sacrifice: attention to others’ needs at the expense of their own

  • “I will feel guilty if I don’t focus on the needs of others.”
  • “Putting others first makes me feel validated.”

Social isolation: feeling different and isolated from others

  • “No one accepts me because I’m so different.”
  • “I am superior to others, and they will never meet my expectations.”

Subjugation: believing their needs/emotions are controlled by others

  • “I need to ask others in order to avoid negative outcomes.”
  • “I need to ignore my own instincts and follow what others tell me.”

Unrelenting standards: believing it is necessary to achieve unreasonable standards to avoid criticism

  • “I need to be perfect for others to accept me.”
  • “If I make a mistake, I will never recover from it.”

Vulnerability to harm: always expecting a real or perceived injury or illness

  • “I will always be vulnerable to some major catastrophe.”
  • “I always need to use caution to protect myself.”

EMS associated with personality and mental disorders

EMS are highly correlated with later development of personality disorders and mental diseases/disorders,3,4,7 including major depressive disorder, panic disorders, eating disorders, bipolar disorder,9 obsessive-compulsive disorder, personality disorders,4,7 substance abuse/alcoholism,5 schizophrenia, and post-traumatic stress disorder.8

You may also be interested in … Are you anxious about your anxious patients?

Why should dental professionals be concerned with schemas?

Schemas are relevant to dental providers when managing patients’ behaviors and preventing patients from becoming aggressive or violent. For example, if a patient believes they are entitled to special treatment, they may behave in a self-centered and demanding manner. This can annoy the dental team and alienate others in the office. The patient may make unreasonable demands that the dental team cannot meet. The patient will view this as a personal attack for failure to meet their unreasonable expectations and become aggressive (yelling, cursing, berating staff, threatening staff) and blame the dental provider for their inappropriate actions.4,8,10 Schemas can be so extreme that a patient is delusional and believes a distorted perception of reality.4,6,10

Distorted thinking in patients with EMS

Examples of real situations contrasted with distorted thinking:10

Reality: Hygienist to patient: “You look great today.”

Distortion: If I look great today, I must have looked like a slob every other time I’ve been here.

Reality: The patient is uncomfortable during probing.

Distortion: This is the worst pain I’ve ever felt. It’s worse than childbirth.

Reality: The patient presents with pain that started two days ago.

Distortion: I’ve been in pain forever … for as long as I can remember.

Reality: The patient experiences cold sensitivity due to recession.

Distortion: It always hurts, all the time ... 100% of the time … every time you touch me.

Reality: The patient presents with severe gingivitis, CAL up to 9 mm, and purulence upon probing.

Distortion: You’re making my gums bleed!

How dental professionals can help

Patients with EMS experience irrational thinking, which leads to frustration, bad behavior, and often aggressive or violent actions. Regardless of the schema, all patients want to feel understood, be treated with respect and as an equal, and have freedom to make decisions about their dental care. Dental professionals can navigate EMS by listening to patients, addressing their feelings, and incorporating their emotional needs into treatment planning.6,10

Author’s note: Part two of this series will expand on how early maladaptive schemas influence personality disorders and red flags for patient behaviors.

Editor’s note: This article first appeared in Through the Loupes newsletter, a publication of the Endeavor Business Media Dental Group. Read more articles and subscribe to Through the Loupes.


  1. Boyle P. Threats against health care workers are rising. Here’s how hospitals are protecting their staffs. AAMC (Association of American Medical Colleges) News. August 8, 2022. https://www.aamc.org/news/threats-against-health-care-workers-are-rising-heres-how-hospitals-are-protecting-their-staffs
  2. Binmadi NO, Alblowi JA. Prevalence and policy of occupational violence against oral healthcare workers: systematic review and meta-analysis. BMC Oral Health. 2019;19(1):279. doi:10.1186/s12903-019-0974-3
  3. Aafjes-van Doorn K, Kamsteeg C, Silberschatz G. Cognitive mediators of the relationship between adverse childhood experiences and adult psychopathology: a systematic review. Dev Psychopathol. 2020;32(3):1017-1029. doi:10.1017/S0954579419001317
  4. Janovsky T, Rock AJ, Thornsteinsson EB, Clark GI, Murray CV. The relationship between early maladaptive schemas and interpersonal problems: a meta-analytic review. Clin Psychol Psychother. 2020;27(3):408-447. doi:10.1002/cpp.2439
  5. Sakulsriprasert C, Thawornwutichat R, Phukao D, Guadamoz TE. Early maladaptive schemas and addictive behaviors: a systematic review and meta-analysis. Clin Psychol Psychother. 2023. doi:10.1002/cpp.2882
  6. Hunzaker MBF, Valentino L. Mapping cultural schemas: from therapy to method. Am Sociol Rev. 2019;84(1):950-981. doi:10.1177/0003122419875638
  7. Steylaerts B, Dierckx E, Schotte C. Relationships between DSM-5 personality disorders and early maladaptive schemas from the perspective of dimensional and categorical comorbidity. Cognit Ther Res. 2023;47(3):454-468. doi:10.1007/s10608-023-10349-w
  8. Van Wijk-Herbrink MF, Lobbestael J, Bernstein DP, Broers NJ, Roelofs J, Arntz A. The influence of early maladaptive schemas on the causal links between perceived injustice, negative affect, and aggression. Int J Forensic Ment Health. 2021;20(2):133-149. doi:10.1080/14999013.2020.1842562
  9. Bӓr A, Bӓr HE, Rijkeboer MM, Lobbestael J. Early maladaptive schemas and schema modes in clinical disorders: a systematic review. Psychol Psychother. 2023;96(3):716-747. doi:10.1111/papt.12465
  10. Shannon JW. Reasoning with unreasonable people: focus on disorders of emotional regulation. Professional conference presentation. Institute for Brain Potential; June 18, 2022.