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INTRODUCTION

Patients with personality disorders are common in medical practice and have worse medical outcomes than patients without personality disorders. A personality disorder interferes with the therapeutic alliance between patient and clinician and as a result, clinicians face challenges in multiple critical dimensions of patient care: eliciting an accurate symptom history, explaining the assessment, reaching agreement over a treatment plan, and motivating behavior change. As a consequence of this impairment in the patient–clinician relationship, patients with personality disorders often experience suboptimal utilization of medical care (both over- and under-use) leading to worse medical outcomes and higher hospitalization rates. Furthermore, such patients are often experienced as “difficult” by clinicians, who in turn, may feel increasingly unsatisfied and frustrated themselves, leading to risk of burnout (see Chapter 4).

This chapter provides a framework to help recognize, understand, and manage the common personality disorders and styles encountered in medical practice. Applying this framework can help clinicians anticipate the challenging interpersonal, behavioral, and medical problems that may arise in working with these patients and enable clinicians to work through their own negative emotions that these patients may engender. These skills will lead to more appropriate treatment plans, improved alliance between patient and clinician, and better outcomes.

The Diagnostic and Statistical Manual of Mental Disorders (DSM-5) 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 the resulting maladaptive interpersonal behaviors 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 emotions, cognitions, and behaviors—with negative consequences for their medical treatment. In addition, these patients’ difficulties in relating to others typically manifest in the clinician–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.

DIAGNOSTIC CLASSIFICATION OF PERSONALITY DISORDERS

Personality theorists have long debated how best to understand and classify personality disorders, with debate centering on two models. The categorical model, used in the DSM-5, views personality disorders as entities that are distinct from one another—that is, classified in separate categories—and also distinct from normalcy. This model is contrasted with the dimensional model, which views personality disorders as entities that overlap each other and that are on a spectrum with normalcy so that the maladaptive traits of patients with personality ...

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