The Difficult Pain Patient

Type

Identifying features

Treatment strategies

Dependent clinger

Escalating need for reassurance and over time becomes more helpless

Set limits with realistic expectations

Entitled demanders

Initially present as needy but soon exhibit aggressive and intimidating behavior

Do not react to their anger, but instead acknowledge the situation and discuss realistic expectations

Manipulative help-rejecters

Generally ungrateful for any help and are often pessimistic about treatment outcome

Paradoxically advocate adopting skeptical attitude toward treatment and schedule regular appointments

Self-destructive deniers

Tend to engage in behaviors that thwart attempts to improve their condition

Avoid vengeful feelings and punishment; instead focus on and treat underlying depression

As noted, there are many potential causes for patients seeming to be difficult, including the challenge of hard-to-treat pain syndromes (such as complex regional pain syndrome), leading the patient down a path of multiple treatment failures and frustration. In addition, many patients have ongoing psychosocial stressors, and others may have unrealistic expectations. However, it is not often the patient’s fault as there are some physician characteristics and healthcare system-related issues that can lead to a difficult pain patient. For instance, in a physician’s zeal to offer hope and optimism, they may convey to a patient that they will be 75% or even 100% better from the prescribed treatment (such as an epidural steroid injection). For a chronic painful condition, this approach leads inevitably to disappointment and frustration in the patient as they are the ones left dealing with the aftermath of unfilled promises from the provider. It is more appropriate to have a discussion at the initial evaluation regarding realistic expectations for treatment success, such as a 30 or 50% improvement in their condition over the next 3–6 months. Similarly, pain specialists commonly face the patient expectation that we will prescribe opioids, and often the referring physician has given the patient this message, creating unrealistic expectations. In addition, higher insurance co-pays and deductibles and restricted access to specialty care also contribute to increased patient frustration, anger, and pain, which the patient carries in with them to the initial consultation.

10.2.2 Borderline Personality Disorder

Borderline personality disorder (BPD) can be one of the most challenging patient experiences for healthcare providers. They are often difficult to diagnose and will catch the healthcare provider by surprise. They exhibit pervasive patterns of instability of interpersonal relationships, self-image, and affect with marked impulsivity. BPD patients see things as “black and white” and easily go from different extremes of emotions. BPD may amplify the pain or be the sole cause. The symptoms of BPD can occur in a variety of combinations, and individuals with the disorder have many, if not all, of the following traits: fears of abandonment, extreme mood swings, difficulty in relationships, unstable self-image, difficulty managing emotions, impulsive behavior, self-injuring acts, suicidal ideation, and transient psychotic episodes. It is important to understand that BPD patients are quite impaired and often have very little insight into their limitations. These patients often have a history of significant physical or sexual abuse as a child, predisposing them to develop BPD as a maladaptive coping mechanism to deal psychologically with the trauma. Thus, while these patients often create angry feelings within the provider, it is crucial to remember that BPD patients suffer profound mental anguish and to have empathy for their plight.

Dealing with the BPD patient can be challenging, and early recognition is important to prevent the path of costly invasive procedures that are likely to fail. The pain should be managed conservatively as response to treatment can be difficult to assess. Try to be understanding of emotional extremes, and do not react negatively, despite the anger you may be feeling. The BPD pain patient should be co-managed with a psychiatrist or psychologist. Randomized controlled trials have shown that dialectical behavioral therapy is effective in teaching BPD patients to control and not react to their emotions.

10.2.3 Affective Disorder

Affective disorder is highly prevalent among pain patients with 30–50% of pain clinic patients having an untreated major depression or anxiety disorder [2]. Affective disorder (AD) may emerge in the course of treatment, especially if the patient is not responding. AD results in poor coping and poor motivation, and the patient tends to blame the physician for lack of response to therapy. If not recognized and treated, response to pain treatment is very poor. For instance, it has been shown that high levels of depression or anxiety symptoms predict poor analgesic responses to epidurals, facet blocks, and opioids [6–8]. Preexisting psychosocial disturbances will have significant effects on the chronic pain patient’s prognosis and stress the importance of exploring the psychosocial history of the patient prior to developing the pain problem.

A combination of psychotropic medications and psychotherapy is the most effective treatment. However, it is often challenging to get the patient to buy into mental healthcare as they feel the provider does not believe they have a physical problem. Try to educate the patient on the importance of embracing a biopsychosocial approach to their problem. Use language they understand, and educate on all aspects of the pain experience including physical, emotional, and social. Addressing these aspects as one is more likely to gain the patient’s trust rather than addressing them in isolation.

10.2.4 Somatization

Somatization (SZ) is best thought of as a process of amplification. It is characterized by self-perpetuating somatic symptoms in the absence of organic pathology. They present with a multitude of unexplained symptoms in the presence of normal results from physical examination and diagnostic tests [9]. However, this should not be confused with the chronic pain patient who will often present with pain as their only symptom with normal laboratories and radiological studies. SZ patients tend to catastrophize, embrace the “sick role,” and present with many difficult-to-diagnose symptoms. They have high disability and healthcare utilization. However, be careful in labeling patients as SZ before making reasonable attempts to make the diagnosis of their symptoms. For example, fibromyalgia (now referred to as widespread pain) may present as SZ. However, it is a recognized condition with a biological basis.

In dealing with the SZ, the time will come to have an honest discussion with the patient. Point out that you believe that the patient is experiencing the symptoms but they are not life-threatening and do not require treatment. Discussing amplification processes within the brain is helpful as well. Psychiatric consultation is important but puts the consultation in the context of a biopsychosocial approach to the patient’s problem. Cognitive behavioral therapy and antidepressant medications may help. It is important to keep treatment conservative as these patients enjoy the sick role and are likely to experience idiosyncratic reactions to treatment and invasive therapies.

10.2.5 Hostile Patient

Hostile patients are common in pain clinic settings and can present a very stressful situation for staff members. These patients can become verbally and may be physically abusive. All pain clinic staff should be educated on how to deal with these patients so as not to escalate a stressful situation into an out-of-control situation. Data suggest that pain medicine physicians are at a greater risk of violence from patients than other medical specialists [10, 11].

A risk management article published by Princeton Insurance (www.riskreviewonline.com, 2002) outlines six steps for dealing with angry patients : (1) remain calm and collected, (2) handle the problem in private, (3) listen to the patient’s complaints uninterrupted, (4) convey kindness and reassurance, (5) try and reach a solution, and (6) document the encounter. Wasan et al. recommend five “As” for dealing with the hostile patient: (1) acknowledge the problem, (2) allow the patient to vent uninterrupted in a private place, (3) agree on what the problem is, (4) affirm what can be done, and (5) assure follow-through [3].

However, there are times when a resolution is not possible, and extremes will be required for the safety of the staff and the patient. All clinics should have policy and procedures for summoning the police or security.

10.2.6 The Suicidal Patient

Suicidal ideation and attempts are common among chronic pain patients [2]. Many pain patients exhibit passive death wishes in which they wish they were dead but do not actively want to end their life or have a plan. Patients with suicidal intent (actively want to end their life) should be taken seriously. For those with a plan to end their life should be transferred to the emergency room for an evaluation. In these cases, it may require sending a police officer to the patient’s home if suicidal intent with plan is expressed over the phone. Assessment and treatment of suicidal patients are summarized in Table 10.2 [3].

Table 10.2

Suicide assessment and treatment

• Evaluate intent and lethality

• Evaluate existence and feasibility of plan

• Identify evidence of self-destructive behavior and past attempts

• Attempt to establish an alliance with the patient

• Consider a safety contract

• Refer to mental health specialist

• If suicide intent with plan is present, escort to the emergency room

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