CHAPTER 22: Management of Difficult Patients in the Chronic Pain Setting

WHO ARE DIFFICULT PATIENTS?

There are patients in every practice who give the doctor and staff a feeling of “heartsink” every time their names are seen on the day's appointment list and evoke feelings of exasperation, defeat, guilt, negativity, and sometimes active dislike.¹ Important factors in the assessment of difficult patients include identifying past or current history of abuse, depression, psychosocial stress, occupational stress, and not having sufficient coping skills. Patients whom physicians find to be difficult are also high users of health care services, and they may be dissatisfied with the care they receive.

Difficult patients often fail to respond to nerve blocks, medications, or physical therapy, and they may be noncompliant with treatment, harbor objections to their physicians’ approaches to their care, or be resistant to forming an effective alliance with their medical providers. Individuals with chronic pain may be difficult because of the psychosocial stressors that arise from having chronic pain, and these psychological symptoms, in turn, may lead to a preoccupation with physical symptoms, feelings of worthlessness, loneliness, fear of abandonment, and becoming socially isolated.

Particularly in Western societies, being sick implies certain expectations, including rights and duties.² The perceived “rights” of being sick include being temporarily exempt from “normal” social roles, with the more severe the sickness, the greater the exemption, and that the sick person is not held responsible for his or her condition (beyond the patient's control or absence of blame). The duties of a patient, which are quite applicable to those in pain, include the obligation to try to “get well,” to seek help from a professional, and to cooperate in the process of “trying to recover.” Patients with chronic pain who do not fulfill or comply with the social expectations of the sick role run the risk of being perceived as malingering or difficult by their clinicians and becoming isolated from friends and families.³

Because physicians are under increasing time pressures, patients with pain who exhibit vague symptoms and who are unresponsive to many different interventions for pain can be particularly frustrating, especially when the burden of providing treatment is shouldered by a lone individual rather than by an interdisciplinary team. Not all patients with difficult behavior exhibit significant psychopathology, such as major depression, anxiety, or a personality disorder. Patients who are otherwise “normal” can also be perceived as difficult when they arrive at a pain center for treatment with unrealistic expectations. They may have had problems in previous health care settings in which they were accused of exaggerating their pain and may suffer from a lack of sleep, poor eating habits, and long commutes on public transportation to their appointments, which can also contribute to outbursts, hostility, and unstable behavior. They may feel that their physicians are dismissive or skeptical of their pain rather than understanding and sympathetic. Even comparatively well-adjusted patients can have the idea that their pain physicians ...