General Considerations
Personality disorders (PDs) are a heterogeneous group of deeply ingrained and enduring behavioral patterns characterized by inflexible and extreme responses to a broad range of situations, manifesting in cognition (ways of perceiving and interpreting self, others, and events), affectivity (range, intensity, lability, and appropriateness of response), interpersonal functioning, and impulse control. PDs impinge on medical practice in multiple ways, including self-destructive behaviors, interpersonal disturbances, and nonadherence. Appropriate physician responses and effective treatments exist for many PDs. Correct diagnosis and proper intervention will help to improve patient outcomes. Borderline personality disorder (BPD) is an extremely debilitating disorder which can significantly interfere with the doctor-patient relationship. BPD will receive extra focus in several sections of this chapter.
Ten PDs are currently distinguished clinically. They are often grouped into three clusters: odd or eccentric (cluster A); dramatic, emotional, or erratic (cluster B); and anxious or fearful (cluster C). These groupings are helpful in broadly categorizing PD difficulties but are limited in their usefulness because they do not signify similarities in etiologies and treatment response. Table 54-1 summarizes the 10 PDs.
| Cluster | Personality Disorder | Clinical Features |
|---|---|---|
| Cluster A: odd, eccentric | Paranoid | Suspicious; overly sensitive; misinterpretations |
| Schizotypal | Detached; perceptual and cognitive distortions; eccentric behavior | |
| Schizoid | Detached; introverted, constricted affect | |
| Cluster B: dramatic, emotional, erratic | Antisocial | Manipulative; selfish, lacks empathy; explosive anger; legal problems since adolescence |
| Borderline | Dependent and demanding; unstable interpersonal relationships, self-image, and affects; impulsivity; micropsychotic symptoms | |
| Histrionic | Dramatic; attention seeking and emotionality; superficial, ie, vague and focused on appearances | |
| Narcissistic | Self-important; arrogance and grandiosity; need for admiration; lacks empathy; rages | |
| Cluster C: anxious, fearful | Avoidant | Anxiously detached; feels inadequate; hypersensitive to negative evaluation |
| Dependent | Clinging, submissive, and self-sacrificing; needs to be taken care of; hypersensitive to negative evaluation | |
| Obsessive-compulsive | Preoccupied with Orderliness, Perfectionism, and Control |
PDs are relatively common, with a prevalence of 7.6% in the general US population. Patients with PDs may seek help from family physicians for physical complaints, rather than psychiatric help. Higher rates for all types of PDs are found in medical settings. Prevalence of BPD in the general community is 1.4%.
PDs have a pervasive impact because they are central to who the person is. They are major sources of long-term disability and are associated with greatly increased mortality. Patients with PDs have fewer coping skills and during stressful situations may have greater difficulties, which are worsened by poor social competency, impulse control, and social support. Patients with BPD are frequently maltreated in the forms of sexual, physical, and emotional abuse; physical neglect; and witnessing violence. PDs are identified in 70%-85% of persons identified as criminal, 60%-70% of persons with alcohol dependence, and 70%-90% of persons who are drug dependent.
Borderline, schizoid, schizotypal, and dependent PDs are associated with high degrees of functional impairments and greater risk for depression and alcohol abuse. Obsessive-compulsive and narcissistic PDs may not result in appreciable degrees of impairment. Dependent PD is associated with a marked increase in health care utilization.
Pathogenesis
PDs are syndromes rather than diseases. Avoidant, dependent, and schizoid PDs appear to be heritable. Similarly, schizotypal disorder is considered to be heritable, as one end of a schizotypal-schizophrenia spectrum. Twin and adoption studies suggest a genetic predisposition for antisocial PD, as well as environmental influences, via poor parenting and role modeling. Histrionic PD may be related to indulged tendencies toward emotional expressiveness.
BPD may result from both constitutional and environmental factors. Genetically, BPD is five times more common among first-degree relatives of those with the disorder, but to say to what degree BPD is heritable is difficult given the reciprocity between family and child that occurs during development. BPD symptoms have been attributed to highly pathologic and conflicted interactions between parent and child. The conflict brings great ambivalence about relationships and interferes with the child’s ability to regulate affect. (Additional discussion of this process appears later, under Termination of Care, later.) Child sexual abuse has been thought causal in BPD, but a recent meta-analysis did not support this hypothesis. It is certainly the case that traumatic childhood experiences are common in patients with BPD. As a group, patients with antisocial and borderline PDs report higher frequencies of perinatal brain injury, head trauma, and encephalitis.
Substance abuse disorders frequently co-occur in community and clinical populations, particularly with antisocial, borderline, avoidant, and paranoid PDs. Anorexia nervosa, bulimia nervosa, and binge eating may be seen in patients who are obsessional, borderline, and avoidant, respectively. Self-injurious skin picking can be conceptualized as an impulse control disorder and has been found with significant frequency in patients with obsessive-compulsive PD and BPD. Up to 50% of patients with BPD have major depressive disorders or bipolar disorders.
Prevention
Except for efforts to address the roots of criminal behaviors that are common in antisocial PD, there is no literature on prevention of PDs. Primary prevention could consist of better treatment of parental mental illnesses that have a negative impact on parent-child interactions and public health interventions to reduce prenatal brain insults. Both primary and secondary prevention could occur with increased interventions in family functioning and parenting skills.
Clinical Findings
PDs were once referred to as character disorders. Various descriptive labels have appeared in the literature, such as the oral fixated character, the impulsive personality, and the introverted personality type. Each of these represents a theory of personality (psychoanalytic, developmental, and analytical, respectively).
Currently, there are few points of correspondence between personality theory and diagnosis of PDs. A relatively atheoretical, categorical perspective dominates clinical practice in the United States. The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR) exemplifies the categorical perspective. PDs appear as “Axis II disorders,” which should not imply that PDs are conditions that are less severe than clinical disorders such as depression, which appear on Axis I. Instead, the additional axis provides a place where pervasive, persisting disorders may be differentially recorded. Mental retardation, similarly pervasive and persistent, is also an Axis II disorder.
Clinical lore about appearance and presentations of PDs exists. Anything extreme in appearance that is not ethnically appropriate or currently fashionable may suggest a PD. Examples include flamboyant jewelry, particularly in men, tattoos and piercing in older men and women, steel-toed boots in men, and excessive cosmetics and large hair ribbons in women.
The patient’s style of interacting with the physician can be revealing about personality difficulties. For example, the dependent patient will seek much advice and be unable to make an independent decision. The patient with antisocial PD may be “smooth talking” or threatening. Interactions with patients with BPD can be very difficult. The patient may switch from extreme idealization to devaluation of the physician. The patient may cause “splitting” among staff, with some people siding with the patient and others extremely angry with the patient. Table 54-2 describes problem behaviors associated with various PDs, as well as helpful responses and management strategies.
| Personality Disorder | |||||
|---|---|---|---|---|---|
| Paranoid | Schizotypal | Schizoid | Antisocial | Borderline | |
| Patient’s perspective | People are malevo-lent. Situation is dangerous. | Understanding of care may be odd or near delusional. | Illness will bring too much attention and invade privacy. | Threatened if unable to feel “on top.” Illness presents opportunity for crime. | Fears abandonment. Overreacts to symptoms and situation. |
| Problem behaviors | Fearful. Misconstrues events and explanations. Irrational. Argumentative. | Odd health beliefs and behaviors. Poor hygiene. Avoids care. | Unresponsive to kindness. Difficult to motivate. Avoids care. | Acts out to gain control. Malingering. Uses staff and physicians. Superficially charming. Drug seeking. | Idealizes, then devalues care. Self-destructive acts. Splits staff. |
| Helpful physician responses and management strategies | Be empathic toward patient’s fears, even when they seem irrational. Carefully ex-plain care plan. Provide advance information about risks. Protect patient’s independence. | Communicate directly. Avoid misinterpreting patient as intentionally noncompliant. Do not reject patient for oddness. Honor patient’s beliefs. | Manage personal frustration at feeling unappreciated. Maintain a low-key approach. Appreciate patient’s need for privacy. | Do not succumb to patient’s anger and manipulation. Avoid punitive reactions to pa-tients. Motivate by addressing patient’s self-interest. Set clear limits that interventions must be medically indicated. | Manage feelings of hopelessness about patient. Avoid getting too close emotionally. Schedule frequent periodic checkups. Tolerate periodic angry out-bursts, but set lim-its. Monitor for self-destructive behavior. Discuss feelings with coworkers. |
Physician countertransference may be a sign of a PD. Reactions such as anger, guilt, desire to punish, desire to reject, desire to please, sexual fantasies, and a sense that the physician is the “one person” capable of helping the patient are all examples of physician countertransference responses to patient PDs. Self-reflection about the encounter is recommended for managing the strong feelings and interpersonal conflict encountered in medical care.
Physicians may over- or underattribute patient difficulties to BPD; therefore, it is important to be sensitive to BPD phenomena and to ascertain whether patient difficulties and symptoms represent BPD. BPD diagnostic criteria call for a pervasive pattern of instability in interpersonal relationships, self-image, and affect, and marked impulsivity beginning by early adulthood and present in a variety of contexts as indicated by at least five of the following:
Frantic efforts to avoid real or imagined abandonment (not including suicidal behaviors).
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