Jeffery Streimer

Department of Consultation Liaison Psychiatry, Royal North Shore Hospital, Sydney,Australia

This paper will briefly outline how to differentiate the various types of difficult and sometimes 'hateful' patients as well as introducing a practical approach to managing the interactions with them.

While an adverse treatment situation can evoke negative aspects of almost anyone's character, certain patients present particular challenges to the pain specialist. In the more common circumstance, the nature of the illness / injury itself or simple exposure to the stress of illness, fear of the treatment environment or the direct effects of neuroactive agents and medications can induce atypical emotional and behavioural decompensation.

In less common instances, mental illness or personality disorder can lead to abnormal illness behaviour. Primary paranoid mental states, substance intoxication/ withdrawal and delirium all can lead to hateful reactions to treatment. The most challenging group includes those patients whose personality style is openly hateful or passively demanding and frustrating.

By defining core treatment goals, setting realistic limits and by communicating them effectively, crises that threaten the treatment relationship can be resolved.This requires that doctors become aware of and monitor both the patients' as well as their own emotional and behavioural reactions.

The presentation will examine how to detect the 'steam roller', the 'underminer', the 'wet blanket' and the 'clinger' interactional styles and the predictable clinician responses they typically evoke.

By applying this approach the physician's communications with hateful painful patients can be kept focused on enhancing an effective therapeutic alliance while minimising negative interactions and reactions that commonly derail the doctor-patient relationship.