Establishing successful relationships with patients who are suffering from personality disorders can be quite challenging for health care providers, yet these patients are common in medical practice. Complications associated with patients with comorbid personality disorders are myriad, including suboptimal utilization of medical care (over- and under-use), difficulty adhering to treatment plans, and more problematic relationships with clinicians. In addition, these patients are more likely to be hospitalized. An understanding of personality disorders allows physicians to anticipate the challenging interpersonal and behavioral problems that can arise in working with these patients and can help physicians work through the negative emotions that working with such patients may arouse. This facilitates the development and implementation of appropriate treatment plans, improved alliance between patient and clinician, and better outcomes.
The current edition of the American Psychiatric Association Diagnostic and Statistical Manual of Mental Disorders, 4th edition, Text Revision (DSM-IV-TR) defines 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, and impaired capacity to establish and maintain relationships with others, 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 emotional processes, cognitions, and behaviors—with negative consequences for their medical treatment. In addition, these patients' difficulties in relating to others manifest themselves in the doctor–patient relationship. They may be quite demanding or disrespectful of the needs of others, or they may experience such anxiety when they need to trust or confide in others that they avoid building relationships.
Personality theorists have long debated how best to understand and classify personality disorders. The debate has centered on two models. The categorical model, adopted by DSM-IV, views personality disorders as entities that are distinct from one another—that is, classified in separate categories—and also distinct from normalcy. This model blends more easily with traditional medical diagnosis than does the dimensional model, which views personality disorders as entities that overlap each other and that are not distinct from normalcy, so that the maladaptive traits of patients with personality disorders represent normal traits that are exaggerated.
In fact, both models hold some truth. Some personality disorders, such as schizotypal and paranoid, may belong to a spectrum of illness that includes psychotic Axis I disorders and are thus better explained by a categorical model. Other personality disorders, such as histrionic and obsessive-compulsive personality, may depict exaggerated normal traits, reinforcing the concept of a dimensional model.
DSM-IV classifies personality disorders on a separate axis, Axis II, and groups them into three clusters based on descriptive similarities. Cluster A includes paranoid, schizoid, and schizotypal personality disorders—individuals who often appear odd or eccentric; cluster B includes antisocial, borderline, histrionic, and narcissistic personality disorders—individuals who often appear dramatic, emotional, or erratic; and cluster C includes avoidant, dependent, and obsessive-compulsive personality disorders—individuals who often appear anxious or fearful. Given the unique nature of any individual personality, a patient can exhibit traits of two or more personality disorders, or meet the full diagnostic criteria for more than one disorder. Hence, co-occurrence is very common. National survey data suggest that approximately 15% of the general population have at least one personality disorder. Table 26–1 indicates the prevalence of each personality disorder within the general U.S. population. It is important to remember that the prevalence is higher in medical patients.
Table 26–1. DSM-IV personality disorders and their prevalence.
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Table 26–1. DSM-IV personality disorders and their prevalence.
|Cluster||Personality Disorder||Discriminating Feature||Prevalence in General Population|
|A: odd or eccentric||Paranoid||Suspicious||4%|
|B: dramatic, emotional, or erratic||Borderline||Unstable||2%|
|C: anxious or fearful||Avoidant||Inhibited||2.4%|
Diagnosing a personality disorder can be difficult. To make an accurate diagnosis, it is usually necessary for the physician to get to know the patient over time, to learn how the patient reacts and relates to people in other situations, and to obtain collateral information from family and friends. Clinicians should attend to three key issues.
First, it is important to differentiate a true personality disorder from personality traits that become exaggerated under stress. The stress of illness often causes a patient to behave in maladaptive ways; because of this, many patients, at one time or another, seem to have a personality disorder. Patients who do not suffer from a true personality disorder, however, are usually capable of more adaptive functioning. The maladaptive behavior itself is less "enduring" and "engrained" and more situational and modifiable. In these cases, the physician can successfully intervene by supporting and strengthening these patients' own natural coping skills.
Second, it is also important to differentiate personality disorders from such Axis I disorders as major depression or generalized anxiety disorder. For example, patients with panic disorder may—out of sheer terror—become extremely dependent on their physician. If their panic disorder is diagnosed and treated, they may reveal an underlying independent and self-sufficient personality. Similarly, a patient's grandiosity and arrogance may stem largely from a bipolar mania rather than a narcissistic personality disorder. When patients who do have a personality disorder are evaluated, looking for Axis I disorders is particularly important as the latter are more frequent and difficult to treat if patients actually have a personality disorder. Treating an episode of ...