Patients with Challenging Behaviors: Boundary Issues

By Isabel N. Schuermeyer, MD, Tatiana Falcone, MD, and Kathleen Franco, MD

From time to time, all physicians encounter patients whose behavior evokes negative emotions. In 1978, Groves detailed four types of patients — “dependent clingers, entitled demanders, manipulative help-rejecters and self-destructive deniers” — that even the most seasoned physicians dread, and provided suggestions for managing interactions with them. The topic was revisited and updated in 2006 by Strous et al.

This article further updates the topic of managing challenging patients to reflect the current practice climate. We provide a more modern view of challenging patients and provide guidance on handling them.

Constantly seeking reassurance

A 25-year-old professional presents to a new primary care provider concerned about a mole on her back. She discusses her sun exposure and family history of skin cancer and produces photographs documenting changes in the mole over time. Impressed with this level of detail, the physician takes time to explain his concerns before referring her to a dermatologist. Later that day, she calls to let the doctor know that her procedure has been scheduled and to thank him for his care. A few weeks after the mole is removed, she returns to discuss treatment options for the small remaining scar.

After this appointment, she calls the office repeatedly with a wide array of concerns, including an isolated symptom of fatigue that could indicate cancer and the relative merits of different sunscreens. She also sends the physician frequent e-mail messages through the personal health record system with pictures of inconsequential marks on her skin.

Needing reassurance is normal — to a point

Many patients seek reassurance from their physicians, and this can be done in a healthy and respectful manner. But requests for reassurance may escalate to becoming repeated, insistent and even aggressive. This can elicit reactions from physicians ranging from feeling annoyed and burdened to feeling angry and overwhelmed. This can lead to significant stress, which, if not managed well, can lead to excessive control of physician behavior and substandard care.

Reassurance-seeking behavior can manifest anywhere along the spectrum of health and disease. It may be a symptom of health anxiety or hypochondria.

Why so needy?

Attachment theory may help explain neediness. Parental bonding during childhood is associated with mental and physical health and health-related behaviors in adults. People with insecure-preoccupied attachment styles tend to be overly emotionally dependent on the acceptance of others and may exhibit dependent and care-seeking behaviors with a physician.

Needy patients are often genuinely grateful for the care and attention from a physician. In the beginning, the doctor may appreciate the patient’s validation of care provided, but this positive feeling wanes as calls and requests become incessant. As the physician’s exhaustion increases with each request, the care and well-being of the patient may no longer be the primary focus.

Set boundaries

Be alert to signs that a patient is crossing the line to an unhealthy need for reassurance. Address medical concerns appropriately, then institute clear guidelines for follow-up, which should be reinforced by the entire care team if necessary.

The following strategies can be useful for defining boundaries:

• Instruct the patient to come to the office only for scheduled follow-up visits and to call only during office hours or in an emergency.
• Be upfront about the time allowed for each appointment and ask the patient to help focus the discussion according to his or her main concerns.
• Consider telling the patient, “You seem really worried about a lot of physical symptoms. I want to reassure you that I find no evidence of a medical illness that would require intervention. I am concerned about your phone calls and e-mails, and I wonder what would be helpful at this point to address your concerns?”
• Consider treating the patient for anxiety.

It is important to remain responsive to all types of patient concerns. Setting boundaries will guide patients to express health concerns in an appropriate manner so that they can be heard and managed.

Dr. Schuermeyer is Director of Psycho-Oncology, Department of Psychiatry and Psychology. Dr. Falcone is staff in the Epilepsy Center, Department of Psychiatry and Psychology. Dr. Franco is staff in the Department of Psychiatry and Psychology.

This abridged article originally appeared in Cleveland Clinic Journal of Medicine and can be read in full here.