Personality is a complex concept—and an important one: it reflects human beings’ basic psychological infrastructure.1,2 This means that it plays a critical role in determining how people live their lives and negotiate the myriad challenges that life presents. In medicine, personality has direct effects on the propensity to seek health care, the ease and accuracy of providing a medical history, adherence to treatment, and the adequacy of health-related social support networks. It further predicts self-care and lifestyle issues, for example choice of employment (or profession), eating and drinking habits, exercise, and risk-taking behaviors, including substance use and sexual habits.3
In Chapter 5 on anxiety disorders we discussed the difference between obsessive compulsive disorder (OCD) and obsessive compulsive personality disorder, the major difference being patients with OCD are anxious and distressed by their thoughts and behaviors while those with the personality disorder are not.
Before discussing these and other personality disorders, however, let’s first expand on another point from Chapter 5: that many obsessive and compulsive personality traits reflect neither OCD nor obsessive compulsive personality disorder. Like all personality traits, most are quite normal—defined as functioning to help people adapt most effectively to life, which is especially important in choosing a life pathway or career.4 We described the adaptive features of obsessive and compulsive traits with the example of their being necessary for becoming a successful surgeon, while other personality traits also are valuable in becoming a successful physician—or any other person—such as the importance of dependency traits for a successful marriage or of histrionic traits for making one attractive.
Adaptive dependency personality traits, for example, are one of these essential traits for all people and associated to “attachments” so vital to making and maintaining human relationships. Medical students and residents are dependent on faculty to provide them with the education and training required to become successful physicians and to function with increasing independence in their patient care. In contemporary medical practice we are all dependent on multilayered systems involved in the care of our patients. These systems involve other health care professionals we are dependent on from the various levels of nursing personnel, to laboratory technicians, to pharmacists. We are also dependent on each other for consultation and coverage. Primary care practitioners are dependent on a wide range of fellow professionals and paraprofessionals from the pathologist who provides biopsy reports to their “front-office” personnel and secretaries who schedule appointments and maintain efficient patient flow.
Adaptive personality traits of suspiciousness are also very important because clinicians are detectives who investigate all forms of injury and illness. Suspiciousness informs our judgments from the workups for each individual patient to being more attentive and wary of the knowledge and skill levels of a senior medical student compared to those of a senior or chief resident. It is also a good practice to be more wary of the histories provided to us by those we suspect of substance abuse than other forms of illness. We even use terms reflecting this quality, such as “high level of suspicion” and “a suspicious lesion.” In respect to our attention to responsibilities to patients and each other, it would indeed be foolish to ignore a suspicious odor of alcohol on the breath of a trainee or colleague on duty.
The operative word in each of the examples is “adaptive.” Each example above requires the mature appreciation that there are circumstances when obsessiveness, compulsiveness, dependency, and/or suspiciousness are useful, even necessary, for our best functioning as physicians and in life.
When the traits become exaggerated, they can become harmful and interfere with effective learning and psychosocial functioning. That is, they have become maladaptive, which defines the personality disorders we’ll address in this chapter. Rather than help the person live an effective, happy life, as in the earlier examples, they interfere with having one. For example, from the above situations, dependency and suspiciousness (paranoia) can become sufficiently exaggerated that they dominate all aspects of a patient’s life. This almost always interferes with healthy functioning, often severely.4,5 In fact, pathological exaggeration of any personality trait defines the various personality disorders we’ll discuss.
Healthy adaptive functioning requires an expanded repertoire of psychological strategies and behaviors that are appropriate in a wide range of interpersonal, social, and occupational settings. It is helpful to think of patients with a personality disorder as being limited or constrained in their manner or style of dealing with others in social and work situations and in managing their lives. Instead, they respond in the same, exaggerated way to most situations. Regardless of the interpersonal, social, or occupational circumstance, this rigidity in how one acts in the complex situations life presents permeates every facet of their life so extensively that they cannot respond with appropriate adaptive congruence and flexibility. They appear to respond in much the same way to almost every situation. This is especially true for their health-related behaviors.
THE PERSONALITY DISORDERS
Personality disorders are common in the general population, affecting up to 15% of the U.S. population.6 Personality disorder behaviors may diminish with advancing age, but it is important to remember these disorders are lifelong.7,8 Patients with personality disorders are high utilizers of both mental health and primary care services primarily due to their difficulty in fully cooperating with their care. This inability to fully cooperate with a negotiated care plan increases overall morbidity.9 Further complicating their care, personality disorders are highly comorbid with other mental disorders, especially anxiety and depression, and worsen their prognoses.10-12 As described in earlier chapters, due to the shortage of psychiatrists, primary care clinicians often become “front-line” managers of these patients.
In this chapter, we provide descriptions of each personality disorder according to The Diagnostic and Statistical Manual of Mental Disorders, 5th ed. (DSM-5) criteria6 and provide brief examples of the manner in which these patients present problems in health care settings. We also provide guidance on early recognition, general management, and referral to mental health professionals.4
DSM-5 defines personality disorders 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 in functioning.6 Whereas patients with adaptive personality traits establish a good patient-clinician relationship, patients with personality disorders are a source of frustration to the clinician and the expanded clinic staff. These patients are typically described as “difficult” and their responses to treatment are often disappointing.12,13
DSM-5 first presents personality disorders in a “categorical” manner with features common to each of the disorders. Many clinician-researchers argue, however, that personality features are sufficiently complex and fluid that they find the categorical approach too limiting. DSM-5 therefore also offers an alternative “dimensional” model based on the level of impairment: some, moderate, severe, and extreme impairment. The categorical and dimensional models are complementary. Both provide clinicians expanded methodologies to assess and clarify areas of dysfunction in those patients they suspect of having a personality disorder or of possessing dysfunctional traits that may impair patients’ abilities to cooperate with their care.
The next step in reaching a diagnosis is to identify general descriptive features of personality dysfunction. DSM-5 further divides the personality disorders into 3 “clusters” emphasizing descriptively how these patients may present. Cluster A patients exhibit odd and/or eccentric behavior; Cluster B patients exhibit erratic, emotional, or dramatic behavior; and Cluster C patients exhibit anxious and fearful behavior. These clustered features are likely to be accentuated when patients are under the stress of physical illness and they assist the clinician in narrowing down a more specific diagnosis. Table 10-1 lists the categorical personality disorders according to the cluster where they occur. Thus, first identify the cluster representing the patient’s symptoms to narrow down the differential diagnosis. Then, use the criteria we provide below to identify which of the 3 or 4 specific personality disorders is present.
Cluster A: Odd and/or eccentric behavior
Cluster B: Erratic, emotional, or dramatic behavior
Cluster C: Anxious and fearful behavior
Patients who have personality disorders are common in all medical practices and specific diagnosis can be difficult because many times diagnostic features overlap. Further, clinicians rarely see patients at their best because illnesses are stressful and reactions to stress alter ordinary emotions and behavior; that is, they make the basic personality structure, be it an adaptive trait or a disabling disorder, more apparent and manifest. What clinicians observe during medical visits may be completely normal behavioral stress responses even if it suggests a personality disorder. Differentiating normal stress responses from disordered responses requires careful observation, reflection, time, and patience. Primary care clinicians see patients repeatedly and are in an ideal position to determine ingrained and maladaptive behavioral styles in their patients. If the patient has a personality disorder, it will be at least partially observable when they are not under some medical stress, such as seeing them when an illness has resolved or outside your practice.
Patients who develop reputations as being “difficult” require more careful evaluation and are more likely to have personality disorders.14 Hence, your office staff and others contacting the patient can be helpful. Screening instruments are also helpful when a personality disorder is suspected. The simplest of these is the Standardized Assessment of Personality-Abbreviated Scale (SAP-AS) found in Table 10-2, an 8-item yes/no questionnaire.15 The alpha coefficient for the total score is 0.68 and Lin’s concordance coefficient for the total score is 0.89. A score of 3 or more on this screen identified 94% of psychiatric patients with DSM-IV personality disorder; sensitivity 0.94 and specificity 0.85.
We now address the specific (categorical) personality disorders with examples of typical patient behaviors, the feelings and reactions of clinicians and staff, and general strategies to promote optimal outcomes.
Patients suffering from paranoid personality disorder generally surprise, confuse, and unnerve both clinicians and staff because they look for, expect, and perceive threat and malevolence from everyone and anywhere. Patients with this disorder seem to be perpetually “on guard” and may become hostile and argumentative in their interactions. The questions they ask and the manner in which they ask them imply skepticism and hyper-suspiciousness. Many times these patients conform to the concept of “the self-fulfilling prophecy” in that their interactional style evokes guarded or hostile responses from other people, serving only then to confirm their overdetermined expectations.
Clinical example: In training and in practice we developed a systematic survey of local pharmacies for their prices for various medications. We shared the information with patients, especially those experiencing financial hardship or without health care coverage. Most patients are pleasantly surprised that we offer this advice and are very appreciative of the courtesy. A patient who had, during his visit, exhibited features of paranoid personality disorder, responded very differently. “You think I don’t know what’s going on here. You and the pharmacist at that drug store have a “kick-back” arrangement don’t you?”
Clinician emotional reactions: The comment was both surprising and off-putting, evoking a feeling of irritation that required instant containment. Other common responses to patients with paranoid personality disorder include fear (often of being sued) as well as anger and frustration. To respond in a manner that is, in any way, argumentative is likely to perpetuate the problem, rather than lead to a solution.
Clinician therapeutic response: In a friendly tone: “I never really considered that possibility but I suppose in some rare cases that might be true. We would consider it a favor if you might do your own survey and, at your recheck appointment, let us know if you were able to find this prescription at a better price.”
These patients have a history of leading constrained and, at times, nearly solitary lives. They often indicate being satisfied with this lifestyle and do not miss or even desire interactions with others. During schooling, they are often identified by teachers and fellow students as “loners” as they have few, if any, friendships and do not participate in extracurricular activities. They typically seek employment where they work alone or in jobs requiring minimal interaction with fellow employees. They find interactions with others unpleasant and generally drift toward a life of increasing isolation and, many times, never date or marry. Because of the more intimate features of sharing their medical history and the physical examination, they tend to delay seeking care so that they may present at their initial visit with advanced illness.
Clinical example: A 53-year-old, overweight, single man was brought to the clinic by his elder brother who was tired of hearing about the patient’s headaches and “spells of feeling dazed, dizzy, and weak.” He waited in his brother’s car prior to his examination because the waiting area “was too full.” He was reluctant to provide history, declined a patient gown, and insisted on being examined through his clothing. He was found to have hypertension and evidence of end-organ involvement. He admitted not liking to see physicians and wanted to end the visit as quickly as possible. “Just give me a prescription and I’ll get out of your hair.”
Clinician emotional reactions: In contrast to the paranoid patient, this man’s overall behavior elicits a more empathic response. Due to the self-imposed constraint and isolation in these patients’ lives, it is common for clinicians to “feel sorry” for them. Clinicians then generally feel an increased responsibility to provide care but find the patients’ resistance and nonresponse to expressions of empathy frustrating.
Clinician therapeutic response: “Your brother was right to bring you in today because your blood pressure is high now and most likely has been for some time. This can be treated and will require follow-up visits. We will make these visits as short and efficient as possible.” Provide as thorough an examination as the patient will allow and give brief verbal feedback and instructions in a neutral tone of voice. Provide ample written information the patient may review later. Follow-up appointments need to be reinforced, but gently. Efforts should be made to reschedule the patient at the beginning of the day or other times when the waiting area is quiet. Follow-up visits should be shorter than with other patients and with interactions being clear, straightforward, and efficient. Positive feedback should be clear and measured when these patients cooperate with their care and adhere to their treatment plans.