INTRODUCTION
Patients with a personality disorder are common in medical practice; yet, establishing and maintaining a therapeutic alliance with such patients can be challenging for clinicians. Complications associated with patients with comorbid personality disorders are myriad, including suboptimal utilization of medical care (over-and under-use), difficulty adhering to treatment plans, providing a history embedded with distortions, and problematic relationships with clinicians. In addition, these patients are more likely to be hospitalized. An understanding of personality disorders allows physicians to anticipate the challenging interpersonal and behavioral problems that can arise in working with these patients and can help physicians work through the negative emotions that these patients may arouse. This facilitates the development and implementation of appropriate treatment plans, improved alliance between patient and clinician, and better outcomes.
The American Psychiatric Association (APA) defines a personality disorder as: an enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individual’s culture, is pervasive and inflexible, has an onset in adolescence or early adulthood, is stable over time, and leads to distress or impairment. People suffering from personality disorders have dysfunctional beliefs about self and others. These dysfunctional beliefs and patterns of relating impair their capacity to establish and maintain intimate relationships, function at work, and experience pleasure in life. These patients have difficulty negotiating complex situations and coping with stress and anxiety. The sick role and the demands of medical care can be particularly problematic for them. The stress of illness is often extreme and sets into motion defensive and inflexible emotional processes, cognitions, and behaviors—with negative consequences for their medical treatment. In addition, these patients’ difficulties in relating to others typically manifest in the doctor–patient relationship. They may be quite demanding or disrespectful of the needs of others, or the need to trust or confide in others may trigger so much anxiety that they avoid building relationships.
Personality theorists have long debated how best to understand and classify personality disorders. The debate has centered on two models. The categorical model, adopted by the APA, views personality disorders as entities that are distinct from one another—that is, classified in separate categories—and also distinct from normalcy. This model blends more easily with traditional medical diagnosis than does the dimensional model, which views personality disorders as entities that overlap each other and that are not distinct from normalcy, so that the maladaptive traits of patients with personality disorders represent normal traits that are exaggerated. The APA’s Diagnostic and Statistical Manual 5 (DSM-5), uses a categorical model but discusses the use of a dimensional framework in a new provisional section.
DIAGNOSTIC CLASSIFICATION OF PERSONALITY DISORDERS
DSM-5 groups personality disorders into three clusters based on descriptive similarities. Cluster A includes paranoid, schizoid, and schizotypal personality disorders—individuals who often appear odd or eccentric; cluster B includes antisocial, borderline, histrionic, and narcissistic personality disorders—individuals who often appear dramatic, emotional, or erratic; and cluster C includes avoidant, dependent, and obsessive–compulsive personality disorders—individuals who often appear anxious or fearful. Given the unique nature of any individual personality, a patient can exhibit traits of two or more personality disorders, or meet the full diagnostic criteria for more than one disorder. Hence, co-occurrence is very common. National survey data suggest that approximately 15% of the general population have at least one personality disorder. Table 29-1 indicates the prevalence of each personality disorder within the general US population. It is important to remember that the prevalence is higher in medical patients.
| Cluster | Personality Disorder | Discriminating Feature | Prevalence in General Population (%) |
| A: Odd or eccentric | Paranoid Schizoid Schizotypal | Suspicious Socially indifferent Eccentric | 4 3.1 3 |
| B: Dramatic, emotional, or erratic | Antisocial Borderline Histrionic Narcissistic | Disagreeable Unstable Attention seeking Self-centered | 3.6 2 1.8 0.5 |
| C: Anxious or fearful | Avoidant Dependent Obsessive-compulsive | Inhibited Submissive Perfectionistic | 2.4 0.49 7.9 |
Diagnosing a personality disorder can be difficult. To make an accurate diagnosis, it is usually necessary for the physician to get to know the patient over time, to learn how the patient reacts and relates to people in other situations, and to obtain collateral information from family and friends. Clinicians should attend to three key issues.
First, it is important to differentiate a true personality disorder from personality traits that become exaggerated under stress. The stress of illness often causes a patient to behave in maladaptive ways; because of this, many patients, at one time or another, seem to have a personality disorder. Patients who do not suffer from a true personality disorder, however, are usually capable of more adaptive functioning. The maladaptive behavior itself is less “enduring” and “engrained” and more situational and modifiable. In these cases, the physician can successfully intervene by supporting and strengthening these patients’ own natural coping skills.
Second, it is also important to differentiate personality disorders from disorders such as major depression or generalized anxiety disorder. For example, patients with panic disorder may—out of sheer terror—become extremely dependent on their physician. If their panic disorder is diagnosed and treated, they may reveal an underlying independent and self-sufficient personality. Similarly, a patient’s grandiosity and arrogance may stem largely from a bipolar mania rather than a narcissistic personality disorder. When patients who do have a personality disorder are evaluated, looking for episodic and/or comorbid psychiatric disorders is particularly important as the latter are more frequent and difficult to treat if patients actually have a personality disorder. Treating an episode of major depression in a patient with borderline personality disorder, however, can alleviate suffering and lead to better coping with illness.
Third, it is important to distinguish personality disorders from personality changes caused by general medical conditions, such as traumatic brain injury, stroke, epilepsy, or endocrine disorders. Patients with one of these problems may exhibit many of the characteristics of a personality disorder. These behaviors can be distinguished from a true personality disorder, however, in that they typically represent a change from baseline personality characteristics. Medical conditions such as these may also exacerbate preexisting personality traits (e.g., obsessive mannerisms). Treatment of the underlying medical problem may bring about reversal of the personality changes.
Finally, personality disorder diagnoses, like other mental disorder diagnoses, are often misunderstood and may serve to stigmatize the patient. These diagnoses should therefore be made carefully, deferred in cases of uncertainty, and noted in medical records and correspondence only when their notation is likely to be helpful in enhancing patient care.
The primary care provider may find many challenges in working with patients with personality disorders. Personality disorders often significantly impair the quality of interpersonal relationships. Because the doctor–patient relationship requires effective communication about important health issues of a personal nature, tensions and at times overt conflict may develop between patients with personality disorders and their providers. These tensions may also affect other members of the health care team and may be especially pronounced in the context of acute illness or crisis situations. In fact, the first diagnostic clues suggesting personality dysfunction or disorder may appear as difficulties in the doctor–patient relationship.
For patients with personality disorders, physical illness can cause exaggerated degrees of emotional distress, not always expressed to the provider. Although some patients do tell their providers about their emotional distress, others may instead manifest distress as noncompliance with the agreed-upon plan of evaluation or treatment or as changed, unexpected, or undesirable behavior (as judged by the physician) toward the physician.
In response to patients’ actions or statements, physicians may have a significant emotional reaction to the patients and may change their behavior toward them. Even when they experience no subjective distress from a medical condition or the doctor–patient relationship, patients with personality dysfunction may have such aberrant expectations of others that their statements or behaviors are troubling or burdensome to the physician. Physicians must be aware of their own emotional responses to such patients so as to avoid reacting inappropriately. Physicians who deny their negative feelings toward patients may fail to recognize a personality disorder or other psychiatric diagnosis, or fail to address the diagnostic and treatment needs of the patient with the necessary compassion, rigor, and thoroughness. When clinicians recognize and deal with their negative feelings, they are better able to make thoughtful and appropriate responses to these patients’ symptoms and behavior, minimizing the emotional strain for both patient and doctor and optimizing the quality of the medical outcome.
Appreciating the unique vulnerabilities associated with each personality disorder can aid in identifying problematic behaviors and can help to maintain the necessary degree of cooperation and collaboration, even when the patient has significant personality dysfunction. Table 29-2 outlines typical responses to illness by patients with each of the most common personality disorders, details troublesome reactions by physicians, and suggests strategies to avoid further problems with these challenging patients.
| Personality Disorder | Paranoid | Schizoid | Schizotypal | Antisocial | Borderline |
|---|---|---|---|---|---|
| Prominent features of disorder | Distrust and suspiciousness of others, such that their motives are interpreted as malevolent | Pattern of detachment from social relationships and a restricted range of emotional expression | Odd beliefs, inappropriate affect, perceptual distortions, and desire for social isolation | Disregard for and violation of the rights of others, beginning in adolescence | Pattern of instability in interpersonal relationships, self-image and affects, and marked impulsivity |
| Patient’s experience of illness | Heightened sense of fear and vulnerability | Threat to personal integrity; increased anxiety because illness forces interaction with others | May have odd interpretations of illness, increased anxiety because of interactions with others, may become overtly psychotic | Sense of fear may be masked by increased hostility or entitled stance | Terrifying fantasies about illness; feels either completely well or deathly ill |
| Problematic behavior in the medical care setting | Fear that physician or others may harm them Misinterpretation of innocuous or even helpful behaviors Increased likelihood of argument or conflict with staff | May delay seeking care until symptoms become severe, out of fear of interacting with others May appear detached and unappreciative of help | May delay care because of odd and magical beliefs about symptoms, may not recognize symptoms as a sign of illness May appear odd and eccentric and paranoid toward others | Irresponsible, impulsive, or dangerous health behavior, without regard for consequences to self or others Angry, deceitful, or manipulative behavior | Mistrust of physicians and delay in seeking treatment Intense fear of rejection and abandonment Abrupt shifts from idealizing to devaluing caregivers; splitting Self-destructive threats and acts |
| Common problematic reactions to patient by caregiver | Defensive, argumentative, or angry response that “confirms” patient’s suspicions Ignoring the patient’s suspicious or angry stance | Overzealous attempts to connect with patient Frustration at feeling unappreciated | Frustration about patient’s misinterpretation of illness Not wanting to connect with an odd and eccentric patient | Succumbing to patient’s manipulation Angry, punitive reaction when manipulation is discovered | Succumbing to patient’s idealization and splitting Getting too close to patient causing overstimulation Despair at patient’s self-destructive behaviors Temptation to punish patient angrily |
| Helpful management strategies by caregiver | Attend to and be empathic toward patient fears, even when irrational in appearance Carefully detail care plan for patient with advance information about risks of procedures/treatments Maintain patient’s independence when possible and optimize the patient’s control Not overly friendly, but professional, objective stance | Appreciate need for privacy and maintain a low-key approach Focus on technical elements of treatment; these are better tolerated Encourage patient to maintain daily routines Do not become overly personally involved or too zealous in trying to provide social supports | Try not to be turned off by patient’s odd appearance Try to educate patient about the illness and its treatment Do not become overly involved in trying to provide social support | Carefully, respectfully investigate patient’s concerns and motives Communicate directly; avoid punitive reactions to patient Set clear limits in context of medically indicated interventions | Don’t get too close to patient Schedule frequent periodic check-ups Provide clear, nontechnical answers to questions to counter scary fantasies Tolerate periodic angry outbursts, but set limits Be aware of patient’s potential for self-destructive behavior Discuss feelings with coworkers and schedule multidisciplinary team meetings |
| Personality Disorder | Histrionic | Narcissistic | Avoidant | Dependent | Obsessive-Compulsive |
| Prominent features of disorder | Pattern of excessive attention seeking and emotionality | Pervasive pattern of grandiosity, need for admiration, and lack of empathy for others | Pattern of social inhibition because of fears of being rejected or humiliated by others | Pervasive and excessive need to be taken care of that leads to submissive and clinging behavior, and fears of separation | Pattern of preoccupation with orderliness, perfectionism, control |
| Patient’s experience of illness | Threatened sense of attractiveness and self-esteem | Illness may increase anxiety related to doubts about personal adequacy and disrupts image of self as resilient and superior | Illness may heighten sense of inadequacy and worsen low self-esteem | Fear that illness will lead to abandonment and helplessness | Fear of losing control over bodily functions and over emotions generated by illness; feelings of shame and vulnerability |
| Problematic behavior in the medical care setting | Overly dramatic, attention-seeking behavior, with tendency to draw caregiver into excessively familiar relationship Inadequate focus on symptoms and their management, with over emphasis on feeling states May provide answers they believe physician wants to hear Tendency to somatize | Demanding, entitled attitude Excessive praise toward caregiver may turn to devaluation, in effort to maintain sense of superiority Denial of illness or minimization of symptoms | May not be forthcoming about symptom severity, may easily agree with physician out of fear of not being liked | Dramatic and urgent demands for medical attention Angry outbursts at physician if not responded to Patient may contribute to prolong illness or encourage medical procedures in order to get attention May abuse substances and medications | Anger about disruption of routines Repetitive questions and excessive attention to detail Fear of relinquishing control to health care team |
| Common problematic reactions to patient by caregiver | Performing excessive workup (when patient is dramatic) or inadequate workup (when patient is vague) Allowing too much emotional closeness, thereby losing objectivity Frustration with patient’s dramatic or vague presentation | Outright rejection of patient’s demands, resulting in patient distancing self from caregiver Excessive submission to patient’s grandiose stance | Feeling overly concerned for the patient, taking on a paternalistic role that may increase patient’s sense of inadequacy May feel angry and betrayed by patient if the patient’s symptoms turn out to be more extensive than initially reported | Inability to set limits to availability, thus leading to burnout Hostile rejection of patient | Impatience and cutting answers short Attempts to control treatment planning |
| Helpful management strategies by caregiver | Show respectful and professional concern for feelings, with emphasis on objective issues Avoid excessive familiarity | Generous validation of patient’s concerns, with attentive but factual response to questions Allow patients to maintain sense of competence by rechanneling their “skills” to deal with illness, obviating need for devaluation of caregivers Present treatment recommendations in the context of their right to the best care | Provide reassurance, validate patient’s concerns Encourage reporting of symptoms and concerns | Provide reassurance and schedule frequent periodic check-ups Be consistently available but provide firm realistic limits to availability Enlist other members of the health care team in providing support for patient Help patient obtain outside support systems Avoid hostile rejection of patient | Thorough history taking and careful diagnostic workups are reassuring Give clear and thorough explanation of diagnosis and treatment options Do not overemphasize uncertainties about treatments Avoid vague and impressionistic explanations Treat patient as an equal partner; encourage self-monitoring and allow patient participation in treatment |
In most cases, a stable therapeutic alliance with patients who have personality disorders can be maintained by implementing the behavioral strategies suggested in the following sections. Sometimes other factors must also be addressed. As mentioned earlier, comorbid diagnoses must be treated (e.g., depression or anxiety disorders). Pharmacotherapy and psychotherapy are often more complex for patients with comorbid disorders. This is particularly evident when patients with personality disorders have concurrent substance-abuse problems or psychotic symptoms (e.g., hallucinations, delusions, and paranoid ideation). In such cases, mental health consultation can be particularly helpful.
When a provider feels unable to continue productive work with a patient with a personality disorder, it may be appropriate to transfer the patient to another clinician. Although such transfers of care may be both necessary and helpful, they require consideration of the impact of the transfer on the well-being of the patient. Patients with certain personality disorders may experience such transfers as rejection or abandonment, perceptions that may exacerbate their emotional distress and potentially disrupt their medical treatment. Prior consultation with a mental health provider can be useful in determining whether such a transfer might be helpful and can aid in carrying it out smoothly.
The remainder of this chapter discusses the 10 personality disorders as they manifest in the medical setting, and, for each, presents management recommendations.
PARANOID PERSONALITY DISORDER
Patients with paranoid personality disorder have a long-standing pattern of distrust and suspiciousness. They perceive the behavior and motives of others as malevolent in nature and expect others, in many situations, to disappoint or take advantage of them. They are reluctant to confide in others and can be preoccupied with unwarranted doubts about the loyalty or trustworthiness of friends and associates. They may perceive seemingly benign or innocuous statements or behavior by others as threatening, insulting, or hurtful. To defend against their perceived vulnerability, they usually adopt a rigid, distanced, or guarded position. In general, persons with this personality structure find intimate relationships undesirable and difficult, which often leave them without any significant social supports.
Long-standing psychotic symptoms, such as delusions and hallucinations, suggest a diagnosis of paranoid delusional disorder or paranoid schizophrenia. Although persons with paranoid personality disorder usually do not have frank paranoid delusions, at times of extreme stress they may develop such symptoms for brief periods. Paranoid ideation may also be associated with medical causes or with alcohol or substance abuse or withdrawal.
Illness is difficult for individuals with paranoid personality disorder because illness makes them more dependent, and, hence, more vulnerable. Communicating personal information to the physician may challenge the self-protective, rigid way they approach social interactions. Patients may experience a heightened sense of vulnerability and fear of harm by the physician. In their fearful state, they may perceive innocuous or even overtly helpful behavior as threatening. They may then question or challenge the physician about the content of an intervention or the motives behind it. This can lead to conflict and argument between patient and doctor or to the patient disengaging from care.
Physicians confronted with such a paranoid stance may react in ways that exacerbate the situation. If they feel that their intentions are inappropriately suspect they might argue with the patient or become defensive, perhaps using an angry tone. This kind of reaction may frighten the patient and may be perceived as confirmation of the patient’s suspicion. Although such a response should be avoided, ignoring the patient’s distrustful or angry behavior can also be problematic; the patient’s concerns, however irrational, may increase if not addressed.
It is essential to address the patient’s concerns and fears empathically, however irrational they seem. Although the physician may see the patient’s concern as unrealistic, to the patient the fear is real. Dismissing these patients’ concerns or calling them paranoid will not address their emotional needs and may instead create distance in the doctor–patient relationship. A professional, “matter-of-fact” or objective stance is most reassuring to these patients. Excessive friendliness or reassurance may be misinterpreted and may intensify their paranoia. It is important to give these patients detailed information about their proposed treatment plan, allowing them to feel they are in control of the treatment and can make independent decisions. Provide factual information about risks associated with the treatment, whenever possible, before any major procedures or changes in treatment.
CASE ILLUSTRATION 1
Simon, a 42-year-old, single, male parking lot attendant, presents to the urgent care clinic complaining of 3 months of tension headaches and fatigue in the context of what he calls “job stress.” The only notable finding in the physical examination is a mild elevation of blood pressure. The physician also observes that Simon seems angry and anxious. When asked about his job stress, Simon reveals anxieties about not being able to trust two new coworkers, along with fears that his supervisors are conspiring to dismiss him from his job. He also mentions, hesitantly, that he had not sought evaluation of his headaches sooner because he worried that the physician would dismiss his fears as unfounded or “crazy.” Additional social history reveals difficulty with close relationships and recurrent problems adjusting to changes in the workplace.
The physician listens in a nonjudgmental and empathic manner. He responds with scientific curiosity asking specific and thorough questions in order to define the nature of the complaint. An over-the-counter analgesic for the headaches and buspirone for anxiety and agitation are prescribed after a discussion of the likely diagnosis and the pros and cons of each treatment option. The physician plans follow-up measurements of the blood pressure and suggests that Simon see a psychiatrist for further evaluation of his very stressful job situation.
Simon feels that his concerns have been taken seriously. He finds the referral to a psychiatrist acceptable because it has been proposed in a way that offers support and does not dismiss his fears as pathological. The physician’s matter-of-fact responses to Simon’s somatic complaints help increase the patient’s trust in the physician.
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