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Doctors experience 10-20 percent of patient interactions as being personally difficult, but the sources of difficulty are incompletely understood. In particular, physician-perceived difficulty has not been studied from the perspective of an established model of interpersonal relationships. Our objective was to determine whether a relationship exists between patients' attachment style and the degree of difficulty experienced by their attending physician in an Emergency Department in Pretoria, South Africa. Patients of an Emergency Department (n = 165) completed the Experiences in Close Relationships-Revised Questionnaire to measure attachment anxiety and attachment avoidance. Their physicians (n = 26), blind to the attachment measure, rated perceived difficulty using the Difficult Doctor-Patient Relationship Questionnaire. Four categories of attachment style were identified by cluster analysis of attachment scores. Patients were divided into difficult and non-difficult groups using a cut-off score. Two percent of patients with a secure attachment style were experienced as difficult, whereas the prevalence of difficulty in the insecure styles was 'preoccupied' 17 percent, 'dismissing' 19 percent and 'fearful' 39 percent (chi(2) = 16.383, df = 3, p = 0.0009), supporting the hypothesis that the physician's perception of patient difficulty is related to the patient's attachment style. The degree to which physicians serve attachment functions for patients in crisis merits further investigation. [ABSTRACT FROM AUTHOR]