title: The difficult patient: prevalence, psychopathology, and functional impairment.
abstract: 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.
  
  
  METHODS
  Survey.
  
  
  METHODS
  Four primary care clinics.
  
  
  METHODS
  Six-hundred twenty-seven adult patients.
  
  
  METHODS
  Physician perception of difficulty (Difficult Doctor-Patient Relationship Questionnaire), mental disorders and symptoms (Primary Care Evaluation of Mental Disorders, [PRIME-MDI]), 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 35% [corrected], p < .0001). Six psychiatric disorders had particularly strong associations with difficulty: multisomatoform disorder (odds ratio [OR] = 12.3. 95% confidence interval [CI] = 5.9-26.8), 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.
authors.affiliation: Albert Einstein College of Medicine, Bronx, NY, USA.
authors.forename: S R
authors.initials: SR
authors.lastname: Hahn
authors.forename: K
authors.initials: K
authors.lastname: Kroenke
authors.forename: R L
authors.initials: RL
authors.lastname: Spitzer
authors.forename: D
authors.initials: D
authors.lastname: Brody
authors.forename: J B
authors.initials: JB
authors.lastname: Williams
authors.forename: M
authors.initials: M
authors.lastname: Linzer
authors.forename: F V
authors.initials: FV
authors.lastname: deGruy
mesh_terms: D000328:Adult; D005260:Female; D006801:Humans; D016015:Logistic Models; D008297:Male; D016017:Odds Ratio; D010349:Patient Compliance / Q000523:psychology*; D010554:Personality Disorders / Q000523:psychology; D010817:Physician-Patient Relations; D015995:Prevalence; D011320:Primary Health Care / Q000706:statistics & numerical data; D012803:Sick Role; D011795:Surveys and Questionnaires; D016312:Treatment Refusal; D014481:United States