Patients with a personality disorder are common in medical practice; yet, establishing and maintaining a therapeutic alliance with such patients can be challenging for clinicians. 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, providing a history embedded with distortions, and 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 these patients may arouse. This facilitates the development and implementation of appropriate treatment plans, improved alliance between patient and clinician, and better outcomes.
The American Psychiatric Association (APA) 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 patterns of relating 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 emotional processes, cognitions, and behaviors—with negative consequences for their medical treatment. In addition, these patients’ difficulties in relating to others typically manifest in the doctor–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.
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 the APA, 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. The APA’s Diagnostic and Statistical Manual 5 (DSM-5), uses a categorical model but discusses the use of a dimensional framework in a new provisional section.
DIAGNOSTIC CLASSIFICATION OF PERSONALITY DISORDERS
DSM-5 groups personality disorders 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, ...