Journal of General Internal Medicine

, Volume 11, Issue 1, pp 1–8 | Cite as

The difficult patient

Prevalence, psychopathology, and functional impairment
  • Steven R. Hahn
  • Kurt Kroenke
  • Robert L. Spitzer
  • David Brody
  • Janet B. W. Williams
  • Mark Linzer
  • Frank Verloin deGruyIII
Original Articles


OBJECTIVE: To determine the proportion of primary care patients who are experienced by their physicians as “difficult,” and to assess the association of difficulty with physical and mental disorders, functional impairment, health care utilization, and satisfaction with medical care.

DESIGN: Survey.

SETTING: Four primary care clinics.

PATIENTS: Six-hundred twenty-seven adult patients.

MEASUREMENTS: Physician perception of difficulty (Difficult Doctor-Patient Relationship Questionnaire), mental disorders and symptoms (Primary Care Evaluation of Mental Disorders, [PRIME-MD]), functional status (Medical Outcomes Study Short-Form Health Survey [SF-20]), utilization of and satisfaction with medical care by patient self-report.

RESULTS: Physicians rated 96 (15%) of their 627 patients as difficult (site range 11–20%). Difficult patients were much more likely than not-difficult patients to have a mental disorder (67% vs 25%, p<.0001). Six psychiatric disorders had particularly strong associations with difficulty: multisomatoform disorder (odds ratio [OR]=12.3, 95% confidence interval [CI]=5.9–25.8), panic disorder (OR=6.9, 95% CI=2.6–18.1), dysthymia (OR=4.2, 95% CI=2.0–8.7), generalized anxiety (OR=3.4, 95% CI=1.7–7.1), major depressive disorder (OR=3.0, 95% CI=1.8–5.3), and probable alcohol abuse or dependence (OR=2.6, 95% CI=1.01–6.7). Compared with not-difficult patients, difficult patients had more functional impairment, higher health care utilization, and lower satisfaction with care, whereas demographic characteristics and physical illnesses were not associated with difficulty. The presence of mental disorders accounted for a substantial proportion of the excess functional impairment and dissatisfaction in difficult patients.

CONCLUSIONS: Difficult patients are prevalent in primary care settings and have more psychiatric disorders, functional impairment, health care utilization, and dissatisfaction with care. Future studies are needed to determine whether improved diagnosis and management of mental disorders in difficult patients could diminish their excess disability, health care costs, and dissatisfaction with medical care, as well as the physicians’ experience of difficulty.

Key words

Doctor-patient relationship difficult patients Difficult Doctor-Patient Relationship Questionnaire (DDPRQ) PRIME-MD psychopathology 


Unable to display preview. Download preview PDF.

Unable to display preview. Download preview PDF.


  1. 1.
    Groves JE. Taking care of the hateful patient. N Engl J Med. 1978;298:883–7.PubMedCrossRefGoogle Scholar
  2. 2.
    Anstett R. The difficult patient and the physician-patient relationship. J Faro Pract. 1980;11:281–6.Google Scholar
  3. 3.
    Lipsitt DR. Medical and psychological characteristics of “crocks.” Int J Psychiatry Med. 1970;1:15–25.Google Scholar
  4. 4.
    Drossman DA. The problem patient: evaluation and care of medical patients with psychosocial disturbances. Ann Intern Med. 1978;88:366–72.PubMedGoogle Scholar
  5. 5.
    Smith RC, Zimny GH. Physician’s emotional reactions to patients. Psychosomatics. 1988;29:392–7.PubMedGoogle Scholar
  6. 6.
    Merrill JM. Laux L. Thornby JI. Troublesome aspects of the patient-physician relationship: a study of human factors. South Med J. 1987;80:1211–5.PubMedCrossRefGoogle Scholar
  7. 7.
    Lin EHB, Katon W, Von Korff M. et al. Frustrating patients: physician and patient perspectives among distressed high users of medical services. J Gen Intern Med. 1991;6:241–6.PubMedCrossRefGoogle Scholar
  8. 8.
    Schwenk TL, Marquez JT, Lefever D, Cohen M. Physician and patient determinants of difficult physician-patient relationships. J Fam Pract. 1989;28:59–63.PubMedCrossRefGoogle Scholar
  9. 9.
    McGaghie WC, Whitenack DC. A scale for measurement of the problem patient labeling process. J Nerv Ment Dis. 1982;170:598–604.PubMedCrossRefGoogle Scholar
  10. 10.
    Novack DH, Landau C. Psychiatric diagnoses in problem patients. Psychosomatics. 1985;26:853–8.PubMedGoogle Scholar
  11. 11.
    Crutcher JE, Bass JM. The difficult patient and the troubled physician. J Fam Pract. 1980;11:933–8.PubMedGoogle Scholar
  12. 12.
    Hahn SR, Thompson KS, Stern V, Budner NS, Wills TA. The difficult doctor-patient relationship: somatization, personality and psychopathology. J Clin Epidemiol. 1994;47:647–58.PubMedCrossRefGoogle Scholar
  13. 13.
    Spitzer RL, Williams JBW. Kroenke K, et al. Utility of a new procedure for diagnosing mental disorders in primary care: the PRIME- MD 1000 study. JAMA. 1994;272:1749–56.PubMedCrossRefGoogle Scholar
  14. 14.
    Stewart AL, Hays RD, Ware JE. The MOS Short-Form General Health Survey: reliability and validity in a patient population. Med Care. 1988;26:724–32.PubMedCrossRefGoogle Scholar
  15. 15.
    Stewart AL, Greenfield S, Hays RD, et al. Functional status and well-being of patients with chronic conditions: results from the Medical Outcomes Study. JAMA. 1989;262:907–13.PubMedCrossRefGoogle Scholar
  16. 16.
    Wells KB, Stewart A, Hays RD, et al. The functioning and well-being of depressed patients: results from the Medical Outcomes Study. JAMA. 1989;262:914–9.PubMedCrossRefGoogle Scholar
  17. 17.
    Woodwell DA. Office visits to internists, 1989. Advance Data. National Center for Health Statistics, No. 209, April 28, 1992.Google Scholar
  18. 18.
    Rosenblatt RA, Cherkin DC, Schneeweis R, Hart LG. The content of ambulatory medical care in the United States: an interspecialty comparison. N Engl J Med. 1983;309:892–7.PubMedCrossRefGoogle Scholar
  19. 19.
    Schulberg HC, Bums BJ. Mental disorders in primary care: epidemiologic, diagnostic and treatment research directions. Gen Hosp Psychiatry. 1988;10:79–87.PubMedCrossRefGoogle Scholar
  20. 20.
    Kessler LG, Cleary PD, Burke JD Jr. Psychiatric disorders in primary care: results of a follow-up study. Arch Gen Psychiatry. 1985;42:583–7.PubMedGoogle Scholar
  21. 21.
    Von Korff M, Shapiro S, Burke JD, et al. Anxiety and depression in a primary care clinic: comparison of Diagnostic Interview Schedule, General Health Questionnaire, and practitioner assessments. Arch Gen Psychiatry. 1984;44:152–6.Google Scholar
  22. 22.
    Katon W, Schulberg H. Epidemiology of depression in primary care. Gen Hosp Psychiatry. 1992;14:237–47.PubMedCrossRefGoogle Scholar
  23. 23.
    Oldham JM. Personality disorders: current perspectives. JAMA. 1994;272:1770–6.PubMedCrossRefGoogle Scholar
  24. 24.
    Kaplan G, Lipkin M Jr. Gordon GH. Somatization in primary care: patients with unexplained and vexing medical complaints. J Gen Intern Med. 1988;3:177–90.PubMedCrossRefGoogle Scholar
  25. 25.
    Smith GR Jr. Somatization Disorder in the Medical Setting. DHHS Publication No. (ADM) 90-1631. Washington, DC: U.S. Government Printing Office, 1990.Google Scholar
  26. 26.
    Rost KM. Akins RN. Brown FW, Smith GR. The comorbidity of DSM-1II-R personality disorders in somatization disorders. Gen Hosp Psychiatry. 1992;14:322–6.PubMedCrossRefGoogle Scholar
  27. 27.
    Katon W. Kleinman A. Rosne G. Depression and somatization: a review. Am J Med. 1982;72:127–35, 241-7.PubMedCrossRefGoogle Scholar
  28. 28.
    Kroenke K, Spitzer RL, Williams JBW. et al. Physical symptoms in primary care: predictors of psychiatric disorders and functional impairment. Arch Fam Med. 1994;3:774–9.PubMedCrossRefGoogle Scholar
  29. 29.
    Kellner R. Schneider-Braus K. Distress and attitudes in patients perceived as hypochondriacal by medical staff. Gen Hosp Psychiatry. 1988;10:157–62.PubMedCrossRefGoogle Scholar
  30. 30.
    Smith RC. Unrecognized responses and feelings of residents and fellows during interviews with patients. J Med Educ. 1986;61:982–4.PubMedGoogle Scholar
  31. 31.
    Gorlin R. Zucker HD. Physicians reactions to patients: a key to teaching humanistic medicine. N Engl J Med. 1983;308:1059–63.PubMedCrossRefGoogle Scholar
  32. 32.
    Wills TA. Hahn SR. Altruism in medical settings. In Montada L, Bierhoff HW. eds.Altruism in Social Systems. Lewiston, NY: CJ Hogrefe. 1991;204–23.Google Scholar
  33. 33.
    Zinn WM. Transference phenomena in medical practice: being whom the patient needs. Ann Intern Med. 1990;113:293–8.PubMedGoogle Scholar

Copyright information

© Society of General Internal Medicine 1996

Authors and Affiliations

  • Steven R. Hahn
    • 1
  • Kurt Kroenke
    • 2
  • Robert L. Spitzer
    • 3
    • 4
  • David Brody
    • 5
  • Janet B. W. Williams
    • 3
    • 4
  • Mark Linzer
    • 6
  • Frank Verloin deGruyIII
    • 7
  1. 1.the Albert Einstein College of MedicineBronx
  2. 2.Uniformed Services University of the Health SciencesBethesda
  3. 3.The Biometrics Research DepartmentNew York State Psychiatric InstituteNew York
  4. 4.the Department of PsychiatryColumbia UniversityNew York
  5. 5.Mercy Catholic Medical CenterDarby
  6. 6.New England Medical CenterBoston
  7. 7.South Alabama College of MedicineMobile

Personalised recommendations