Evidence-Based Reviews

Transcend dread: 8 ways to transform your care of ‘difficult’ patients

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An empathic, relaxed approach can ease frustration and improve the therapeutic alliance


 

References

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In a psychiatric clinic, Dr. B treats Ms. D, a single 28-year-old, for depression. She has multiple pain and gastrointestinal complaints that have responded poorly to treatment, morbid obesity, chronic tiredness, irritability, and Cluster B personality traits. Ms. D is lonely, unemployed, and seems to be in perpetual crisis. She states “unless someone does something to make this better, I just might kill myself.” She blames Dr. B for failing to adequately treat her depression; he has tried many medications to no avail. In psychotherapy sessions, Ms. D complains instead of examining methods for improvement, and she does not complete psychotherapy homework. She is extremely passive in her approach to getting better.

Ms. D asks Dr. B fill out the necessary paperwork so she can qualify for disability. Dr. B informs her that he will not do so because he believes she is capable of employment and that receiving disability would make her less likely to improve. Ms. D and her parents file letters of complaint about Dr. B to the supervisor of the psychiatric clinic for lack of treatment efficacy and for not supporting her disability claim. Dr. B dreads seeing Ms. D on his appointment list, and realizes she repulses him.

Although “the difficult patient” is not a diagnosis or specific clinical entity, clinicians universally struggle with such patients and have an immediate sense of shared experience when describing the phenomenon. In primary care, O’Dowd1 aptly described this type of patient as the “heartsink” patient, meaning the practitioner often feels exasperation, defeat, or dislike when he or she sees the patient’s name on the schedule.

This article discusses the literature on this topic and provides strategies for dealing with difficult patients in psychiatric practice.

Patient characteristics

Most published reports of difficult patients involve descriptive case series or physician accounts, most often describing patients presenting in nonpsychiatric specialties, including family practice, emergency medicine, rheumatology, gastroenterology, plastic surgery, and dentistry, among others.2-7

In a survey of physicians in 4 primary care clinics, subjects rated 96 (15%) of 627 adult patients as “difficult.”8 Difficult patients were significantly more likely than others to have a mental disorder ( Table 1 ).8 They also had more functional impairment, higher health care utilization, and lower satisfaction with care.

A separate primary care clinic study found uncannily similar results—physicians rated 74 (15%) of 500 new walk-in patients as “difficult.”9 Compared with other patients, the difficult patients had:

  • higher rates of psychiatric illness, somatization (>5 somatic complaints), and more severe symptoms
  • poorer functional status, more unmet expectations, less satisfaction with care, and higher use of health services.
In addition, physicians with a “poor attitude” toward psychosocial problems were much more likely to rate an encounter as difficult.

Fewer articles on difficult patients have been published in psychiatric literature, although some commonalities have emerged ( Box ).10-12 Often suffering from chronic conditions without well-defined treatment endpoints, difficult patients do worse clinically, have higher use of health services, and are less happy with their care than other patients.

Difficult patients challenge our competence as physicians and evoke personal distress. Physicians with less job satisfaction, less clinical experience, less training in counseling, and a poor attitude toward psychosocial problems are more likely to perceive a patient as difficult.13,14

Table 1

Common psychiatric disorders in difficult patients

Multisomatoform disorder
Panic disorder
Dysthymia
Generalized anxiety disorder
Major depressive disorder
Alcohol abuse or dependence*
*Researchers categorized patients as having “probable” alcohol abuse or dependence but did not determine if they met DSM-IV-TR criteria for these disorders
Source: Reference 8
Box
Why certain patient types evoke negative reactions

An Ovid Medline search of psychiatric literature for “difficult patients” found only 9 articles published from 1996 to 2008, and most were editorials or essays.10

Groves11 grouped difficult patients into 4 categories:

  • dependent clingers
  • entitled demanders
  • manipulative help-rejecters
  • self-destructive deniers.

For a description of the behaviors and personality traits associated with each of these 4 categories and strategies to address them, see “The nurse who worked the system,” Current Psychiatry, July 2009. Groves emphasized that a physician’s negative reactions evoked by such patients—once understood through introspection—may facilitate better understanding and psychological management in their care.

Hinshelwood12 wrote about the cognitive dissonance psychiatrists encounter when trying to balance the different responses evoked by patients with schizophrenia and severe personality disorders.

When confronted with a psychotic patient’s severely damaged reality testing, psychiatrists often depersonalize the patient in an effort to be “scientific.” Conversely, patients with severe personality disorders threaten the psychiatrist with their emotional instability. The psychiatrist loses the role of objective observer and instead becomes a “moral evaluator,” seeing the patient as “good” or “bad” instead of as a person in need of help.

Hinshelwood cautioned that patients such as this are difficult not because their treatment is complicated but because they challenge our identity as scientists and put us in personal difficulty.

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