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 that can significantly interfere with the physician-patient relationship. BPD will receive extra focus in several sections of this chapter.
Significant deliberation on PDs preceded the publication of the fifth edition of the Diagnostic and Statistical Manual (DSM-5) in May 2013. DSM-5 continues to distinguish 10 PDs clinically, while also formulating an alternative model that emphasizes core impairments in personality functioning and pathologic traits. For Currents, we have chosen to retain description of all 10 PDs as it seems certain that clinicians will continue to use their labels (eg, histrionic personality) for years to come. Table 58-1 summarizes the 10 PDs.
Table 58-1.Clinical features and clusters of 10 DSM-5 personality disorders. |Favorite Table|Download (.pdf) Table 58-1.Clinical features and clusters of 10 DSM-5 personality disorders.
|Cluster ||Personality Disorder ||Clinical Features |
|Cluster A: odd, eccentric || |
Suspicious; overly sensitive; misinterpretations
Detached; perceptual and cognitive distortions; eccentric behavior
Detached; introverted, constricted affect
|Cluster B: dramatic, emotional, erratic || |
Manipulative; selfish, lacks empathy; explosive anger; legal problems since adolescence
Dependent and demanding; unstable interpersonal relationships, self-image, and affects; impulsivity; micropsychotic symptoms
Dramatic; attention seeking and emotionality; superficial, ie, vague and focused on appearances
Self-important; arrogance and grandiosity; need for admiration; lacks empathy; rages
|Cluster C: anxious, fearful || |
Anxiously detached; feels inadequate; hypersensitive to negative evaluation
Clinging, submissive, and self-sacrificing; needs to be taken care of; hypersensitive to negative evaluation
Preoccupied with orderliness, perfectionism, and control
Personality disorders 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%.
Personality disorders have a pervasive impact because they are central to the person’s identity. 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% ...