One of the more interesting posters at last month’s American Psychiatric Association Annual Meeting was presented by Ricardo Salazar of UT San Antonio and the South Texas Psychiatric Practice-Based Research Network (PBRN). The topic was “the Difficult Patient in Psychiatric Practice” and it surveyed psychiatrists about which patients they considered “difficult” and why.
It might sound somewhat disrespectful (and maybe a little naïve) to label a patient as “difficult.” However, doctors are people too, and it would be even more naïve to think that doctors don’t have their own reactions to (and opinions of) the patients they treat—something referred to in psychoanalytic theory as “countertransference.” Let’s face it: doctors simply don’t like dealing with some patients. (That’s why some choose private practice, to cherry-pick those whom they do like.)
Nevertheless, I think this topic needs more attention, particularly in today’s environment. Much of what we do in mental health (both psychopharmacologically and in therapy) has a questionable evidence base, and yet the experience of clinicians and of patients is that our interventions frequently work. I maintain that clinical benefit often results more from the interpersonal relationship between a patient and a doctor who listens and seems to understand, than from the pill that a doctor prescribes or the specific protocol that a therapist follows. (This is yet another reason why quick-throughput psychiatry, dictated by brain scans, blood tests, and checklists, is bound to fail for most patients.)
Anyway, Dr Salazar’s study used a scale called the “Difficult Doctor-Patient Relationship Questionnaire (DDPRQ-10),” developed by Steven Hahn and colleagues in 1994. I had not heard of this scale before. Here are some sample questions:
1. How much are you looking forward to this patient’s next visit after today?
3. How manipulative is this patient?
4. To what extent are you frustrated by this patient’s vague complaints?
6. Do you find yourself secretly hoping this patient will not return?
8. How time-consuming is caring for this patient?
As a patient, I might find some of these questions mildly offensive (“does my doctor secretly hope I won’t return??”), but as a doctor I must admit that some days I look at my schedule and see a name that makes me dread that hour. (If you’re a doctor and you’re reading this and you do not agree, you’re either fooling yourself, you’re perfect, or you’re IBM’s Watson.) Recognizing those feelings, however, often helps me to prepare for the session—and examine my own biases and faults—and such appointments often turn out to be the most satisfying (at least for the patient).
Salazar’s study showed that, on average, psychiatrists considered approximately 15% of their patients to be “difficult.” The most common diagnoses among the “difficult” patients were schizophrenia (32%), bipolar disorder (19%), cognitive disorder (24%), and personality disorder (32%). Patients with depression (11%) or anxiety (9%)—and, interestingly, patients who were in psychotherapy (11%)—were considered less difficult. Not surprisingly, patients with alcohol and substance use disorders were also labeled difficult (23%), but patients with somatization (defined in this study as “unexplained physical complaints”) were less so (10%).
A fascinating review of 94 studies published between 1979 and 2004 described four reasons why patients may be considered “difficult”: (1) chronicity– i.e., patients fail to improve over time; (2) severe, unmet dependency needs which patients then project onto the caregiver; (3) severe character pathology (especially borderline, narcissistic, and paranoid types); and (4) an inability to “reflect” (which the authors attribute to a history of insecure attachment early in life). The authors also described three types of difficult patients: the “unwilling care avoider” who doesn’t see himself as sick; the “ambivalent care seeker” who is often demanding and dependent, but is frequently self-destructive and self-sabotaging; and the “demanding care claimer” who is aggressive, attention-seeking and manipulative, but who sees himself as a patient only when necessary to achieve his own goals (legal, financial, or otherwise).
Of course, every patient interaction is a two-way street. Regarding psychiatrists, the Salazar study found that young (<40 yrs old) psychiatrists, and those working in a group practice, claimed to have more difficult patients. Another large study published in 2006 examined 1391 physicians to identify which features of doctors underlie their perceptions of patients as “frustrating.” They found that high frustration was associated with doctors who were younger (<40 yrs old), worked >55 hrs/week, had symptoms of depression, stress, or anxiety (yes, that’s in the doctor, not the patient), and had “a greater number of patients with psychosocial problems or substance abuse.” Two-way street, indeed.
It’s commonly said that “there’s no such thing as a stupid question.” By the same token, I would posit that there’s no such thing as a difficult patient. To be sure, some patients present with difficult problems, challenging histories, poor interpersonal skills, and needs that simply can’t be met with the interventions available to the physician. But every patient suffers in his or her own way. Doctors bring their own baggage to the interaction, too, in the form of strong opinions, personal biases, lack of knowledge, or—conversely—the perception that we know what’s going on, when in reality we do not.
When you add in the extrinsic factors that make the interaction even more strained—shorter appointments, care that is dictated by some third party rather than the doctor or the patient, poorly designed electronic medical record systems, or financial conflicts of interest that violate the doctor-patient trust—the “difficulties” just keep piling up.
It’s important that we look at every aspect of the doctor-patient interaction in order to improve the quality and efficacy of the care we provide. Patients should not need to worry about whether they’re perceived as “difficult” or “frustrating.” And when these perceptions do exist, we must critically examine the impact it has on their care, and what it says about the professionals we call upon to treat them.
Thought Broadcast 
Actually I think these questions are pretty stupid, unless maybe there’s a better word:
1. How much are you looking forward to this patient’s next visit after today?
I didn’t think patients were supposed to please us so that we should look forward to seeing them. For my part it depends on how much I believe I’m helping them.
3. How manipulative is this patient?
Manipulation is not about the patient but about the relationship: What does the patient do to try to get you to do something you don’t want to do. And how well do you handle it. Do you feel guilty when you say no.
4. To what extent are you frustrated by this patient’s vague complaints?
This should be two questions: Do you regard some/any of the patient’s complaints as vague? Do you get frustrated by vague complaints? Again, question two is about the doc, not the patient. From a systemic perspective frustration follows from inability to lower expectations.
6. Do you find yourself secretly hoping this patient will not return?
Secretly? So if you verbalize it to someone it doesn’t count?
8. How time-consuming is caring for this patient?
This one probably misses the point. Some patients, some of the time, require more of your time. Often the resentment (not countertransference. That’s only for psychoanalytic treatments) comes when a third party demands your time to complete a form for some non-clinical purpose. You will resent that less if you charge the patient a fee for such activity.
All of this applies at least as much to non-psychiatrists. Med schools should do a better job of providing skills to them to deal with such situations.
Moviedoc,
You heated things up on ‘Shrink Rap’, and then you walked away.
I told Dr. Balt I would do my best to watch the tone on this site.
I hope you’ll do the same.
Duane
Judi Chamberlain, Confessions of a non-compliant patient –
http://www.narpa.org/Judi/confessions.htm
For many people, “non-compliance” is the key to recovery.
If you are a psychiatrist, and don’t understand this basic principle, perhaps you chose the wrong profession
Duane Sherry, M.S.
discoverandrecover.wordpress.com
It seems to me that “frustrating” and “difficult” is somewhat synonomous with the behaviors and issues many patients bring to the psychiatric interview and session; esp those who are schizophrenic, character disordered, bipolar, etc. As a non medical person I wonder if these people are less able to introspect than the normal neurotic one might see for psychotherapy in a private setting, Those who are need of the most help, by virtue of their problems, may well be also the most resistent.
Carol
http://apainedlife.blogspot.com/
(I think those questions are also appropriate relative to chronic pain patient’s and their docs. May I have your permission to copy and paste them at my http://www.womeninpainawareness.ning.com site? )
I can see both sides of this:
The patients with schizophrenia and bipolar disorder have the greatest disease burden and so they will be more difficult to treat.
The doctor wants to be the healer and will become increasingly frustrated when such patients cycle once again, despite best treatment efforts.
For me, if any doctor saw me as “difficult” and cringed when they saw my name on the appointment calendar, I would want them to speak up about it. I’d rather find another doctor than spend any more time with one who had no respect for me as a patient.
Having worked in a community clinic for the last 3+ years, I’ve had my share of “demanding care claimers,” who have no discernible psychopathology but who insist that I write a prescription for Valium or Xanax, fill out a form, or send a letter to their public defender. These are relatively easy to triage. (Or they would be, until my supervisors tell me to acquiesce to their demands– see my previous posts.)
However (and the reason I wrote this post), the other “cringe-inducing” patients have been those who’ve been discharged from several prior psychiatrists, and who come with multiple complaints– mostly somatic in nature– and a laundry list of drugs. What I’ve learned (by exploring my own reaction to them and not trying to fight it) is that, for the most part, they simply need someone to listen, to empathize, and to remind them that things will be okay. And that the valiant medication strategies that prior doctors have attempted are essentially useless, and they can get by– and in most cases thrive– on less. In the end, these have been my greatest treatment successes.
Dr. Balt,
There are times when I find you to be very complex, and hard to figure out… Oftentimes, I feel frustrated that (in my opinion) you’ve almost got it, but not quite… you tend to stroll back into the biopsychiatry that you were taught in medical school…
And then you write stuff like this –
“.. they simply need someone to listen, to empathize, and to remind them that things will be okay. And that the valiant medication strategies that prior doctors have attempted are essentially useless, and they can get by– and in most cases thrive– on less. In the end, these have been my greatest treatment successes.”
And then, I can only think to myself…
“Thank God… He gets it!”
“Thank you.”
Duane Sherry
Nothing to add, but thanks for an informative blog article which I find (as a pt) particularly useful this Monday morning for reasons too boring to go into here.
(As for the comments/follow-ups, I’ll sit on my hands.)
Some of the comments miss the point, likely due to them not being psychiatrists. It is not the most severely disabled that are the most “frustrating” or “difficult”, but the less severely disabled. In fact, there seems to be an inverse correlation between the number of medications a person is on and the severity of the illness. True-Blue Schizophrenics often do well on a single antipsychotic, while the “borderline” will have a med from every class piled on them.
Schizophrenics and Bipolar patients can be difficult to treat, but it is not the kind of difficult this post refers to.
This is a really interesting article and it has certainly given me something to think about.
Just a quick question, when people say bipolar can be difficult to treat (in the sense Gary above refers to, not as in they are being difficult), do you generally only refer to the more severe forms of bipolar, or do the milder forms, such as bipolar II, fall into this category too? I would be interested to hear thoughts on this.
I agree with Gary that there are two kinds of “difficult.”
There are difficult cases, which most psychiatrists find interesting and rewarding (although sometimes time-consuming and frustrating), because we entered this field to be challenged, not simply to write routine scripts for straightforward symptoms.
Then there are difficult patients, which my post (and the study) refers to. Sometimes the difficulty arises from a personality conflict (we all experience that from time to time, we’re human), sometimes from excessive demands or expectations, and sometimes from a disagreement over what treatment approach to take.
What I’ve had to recognize, however, is that in the doctor-patient relationship, the patient is suffering and comes to me for help. It’s never the other way around. Those demands, expectations, and disagreements are usually part of the patient’s suffering, and I need to address them (checking my ego at the door) in order for the patient to improve. In the cases when the patient is irrational or self-defeating, however, it’s my responsibility to speak up about it (as Jackie wrote above) instead of letting it simmer within me and affect the treatment.
Bec, in my opinion, any condition can be “difficult” or “easy”; there’s no reason to think that bipolar I would be more difficult than bipolar II.
That said, I think the reason why patients with cognitive disorders, personality disorders, schizophrenia, and substance disorders were highly rated as “difficult” in the study is because these disorders don’t have simple cookbook-style therapies (or effective medications), and many mental health professionals take it personally when their (our) interventions don’t work. Labeling the patient as difficult is a way to project the provider’s disappointment onto something/someone else. Just my theory.
Addendum: “Borderline personality” is, unfortunately, one of the labels that psychiatrists sometimes use for patients who are difficult. The truth is, borderline PD is a distinct entity, patients do suffer, and it is a challenge to treat. Learning some basic strategies for working with these patients can go a long way. David Allen has written a fantastic series of such strategies in his blog.
I wanted to say to Bec that it may not be accurate to call Bipolar II a “milder” form of Bipolar I. By several measures, most notably time spent ill, BP II has been found to be more debilitating, with higher rates of suicide.
Dear Steve,
I have really enjoyed your insightful comments about this particularly unexplored area in psychiatry. There is nothing more powerful than human transference to move the world in either direction. Ultimately, pure scientists are fooled, and good doctors are Nobel winners. Not to take it personal, is a spectrum of the unique human mind.
Dr. Salazar
Dr Salazar,
Thanks for commenting. I should point out to readers that another aspect of your poster (which I did not mention in my article) was that it incorporated data from a large number of “real-world” clinical practices, rather than a small number of concentrated, specialized academic clinics. As our field moves toward “comparative effectiveness” studies and how our interventions are applied in naturalistic practice settings, networks like the South Texas Psychiatric Practice-Based Research Network will become more more important in psychiatric research, and this study shows how such an arrangement can provide useful data quickly and efficiently.
David Allen doesn’t even think BPD is a mental disorder. He clearly doesn’t care much for borderlines, to put it mildly. My God, if it weren’t for people like Marsha Linehan, John Gunderson and Otto Kernberg, I might believe that you all thought we were irredeemable monsters.
No wonder it’s so difficult for borderlines to get better. Even our doctors hate us.
With havin so much written content do you ever run into any problems of plagorism or copyright violation? My
site has a lot of exclusive content I’ve either created myself or outsourced but it looks like a lot of it is popping it up all over the web without my authorization. Do you know any ways to help prevent content
from being stolen? I’d genuinely appreciate it.
It seems many providers forget how this artificial, structured and detached relationship can affect clients. It’s like interacting with a riddle Sphinx. The role-playing can be highly infantilizing. That, combined with the expectations therapy dangles, can bring out the weakest and most helpless in people.
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How Not To Be A Difficult Patient | Thought Broadcast