Clinical Significance
Personality disorders develop early in life, result in ongoing emotional angst, and tend to be challenging to manage and virtually impossible to “cure.”
Table 10.1 describes the
Diagnostic and Statistical Manual of Mental Disorders, 4th edition, text revision (
DSM-IV-TR) criteria for personality disorders (
1). The specific types of personality disorders will be discussed individually and as “clusters.”
Collectively, personality disorders are estimated to occur in the general population at rates from 10% to 15% (
2). They are more frequently encountered in primary care settings with an average prevalence of 20% to 30% (
3,
4). Patients with personality disorders are more likely to have had increased outpatient, emergency, and inpatient visits (
5). Other studies have found higher levels of dissatisfaction with care, lower scores on functioning scales, and increased antidepressant prescriptions in patients
who have a personality disorder (
5,
6).
Primary care providers rarely receive sufficient training in psychiatry, and most clinical rotations do not cover Axis II pathology but instead focus almost exclusively on Axis I disorders. The medical literature has historically labeled personality disordered patients as “difficult” or even “hateful” rather than identifying the specific disorders or traits that lead to the difficult patient-provider interactions (
7). Nonetheless, it remains important for primary care clinicians to identify those patients with personality disorders or personality disorder traits, because these patients are at increased risk for a multitude of other conditions, including alcohol and SUD disorders, depression, bipolar disorder, and somatization disorder (
8,
9 and
10).
Patients with Cluster A personality disorders (i.e., paranoid, schizoid, and schizotypal personality disorders) are more prone to substance use and social isolation. Individuals with Cluster B disorders (i.e., antisocial, borderline, histrionic, or narcissistic personality disorders) may engage in deliberate self-injury and high-risk physical and sexual behaviors, with consequent increased risk of injury, disease, and infection. The lifetime prevalence of suicidal ideation in patients with borderline personality disorder (
BPD) is approximately 75%, and up to 10% of
BPD patients complete suicide (
11). These patients are also more sensitive to perceived “abandonment,” and may act in inappropriate ways to retain contact with their providers. Patients with Cluster C pathology (i.e., avoidant, dependant, or obsessive compulsive personality disorders) may be more avoidant, less compliant with treatment, and more anxious on an everyday basis.
Diagnosis
Personality disorders are categorized in Axis II of the five-axis
DSM-IV-TR diagnostic classification. While there is no specific nomenclature for such, mental health professionals often note “traits” of personality disorders on Axis II if they are unable to make a diagnosis of the full personality disorder. Features that distinguish “normal” personality traits from pathologic ones include inflexibility and maladaptive behavior. Common characteristics of personality disorders and the clusters to which they belong are listed in
Table 10.2. Although personality disorder diagnoses are intended to be made based on enduring patterns of behavior, patients may not meet criteria for the full disorder at a later (or earlier) time period based on mitigating circumstances or severity of comorbid Axis I conditions. For example, the National Institute of Mental Health (NIMH) Collaborative Longitudinal Personality Disorders Study found that only 44% of patients diagnosed with
BPD retained the
diagnosis 2 years later (
12). Therefore, the patient
who exemplified
BPD one year may seem vastly different and no longer meet the diagnostic criteria a few years later. Moreover, it may take several encounters with a patient to accurately recognize long-standing and pervasive character pathology (e.g., an individual may appear “borderline” while on an isolated “bad day” but is usually capable of coping with stressors in a healthy and adaptive manner). As such, health care providers are encouraged to obtain collateral history and see patients several times before definitively giving a personality disorder diagnosis.
Our visceral response or feelings about a patient encounter can often be helpful when considering an Axis II diagnosis. It is helpful to consider underrecognized feelings and emotions that may subtly influence the patient-provider relationship.
Transference is loosely defined as the unconscious reenactment of feelings or behaviors toward the provider based on previous experiences of the patient with significant others or caretakers. In challenging therapeutic encounters, it is often useful to discuss the provider’s thoughts and feelings about patients (
countertransference) as they may relate to identification of personality pathology and treatment of the patient.
Table 10.3 identifies feelings that may arise in health care providers and the disorders that are typically associated with such feelings. Particularly problematic may be feelings of anger, leading to retaliation against or punishment of the patient that is not appropriate to the circumstance. This contrasts with clearly defined
consequences that
should follow inappropriate behavior by the patient, including termination of care following repeated breaches of clinic rules despite explanations of limits and responses to violations of those limits. Equally dangerous are feelings of attraction to patients that lead to indiscretions of a sexual or romantic nature. Balint groups provide a forum for health care professionals to discuss the emotional content of the patient-provider relationship and can be helpful in processing the strong feelings evoked by patients with a personality disorder. These groups are led by health care professionals with psychological training and provide guidance to the members about countertransferential feelings to ensure the preservation of healthy clinical relationships.
A routine physical examination should be completed on all patients thought to have a personality disorder. Providers should check for self-inflicted injuries in patients with borderline pathology, including cuts, burns, or other forms of self-mutilation. Patients
who self-inflict injuries
often hide their wounds by wearing long sleeves or pants. Patients with borderline or dependent personality disorders are at increased risk for domestic violence and should be carefully assessed for signs of physical abuse. All patients with a suspected personality disorder should be asked about alcohol and illicit substance use. Obtaining collateral information from other care providers as well as family members and friends can help establish a diagnosis or confirm the presence of traits.
