29: Personality Disorders

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.

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, 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 29-1 indicates the prevalence of each personality disorder within the general US population. It is important to remember that the prevalence is higher in medical patients.

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 disorders such 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 episodic and/or comorbid psychiatric 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 major depression in a patient with borderline personality disorder, however, can alleviate suffering and lead to better coping with illness.

Third, it is important to distinguish personality disorders from personality changes caused by general medical conditions, such as traumatic brain injury, stroke, epilepsy, or endocrine disorders. Patients with one of these problems may exhibit many of the characteristics of a personality disorder. These behaviors can be distinguished from a true personality disorder, however, in that they typically represent a change from baseline personality characteristics. Medical conditions such as these may also exacerbate preexisting personality traits (e.g., obsessive mannerisms). Treatment of the underlying medical problem may bring about reversal of the personality changes.

Finally, personality disorder diagnoses, like other mental disorder diagnoses, are often misunderstood and may serve to stigmatize the patient. These diagnoses should therefore be made carefully, deferred in cases of uncertainty, and noted in medical records and correspondence only when their notation is likely to be helpful in enhancing patient care.

Doctor–Patient Relationship Issues

The primary care provider may find many challenges in working with patients with personality disorders. Personality disorders often significantly impair the quality of interpersonal relationships. Because the doctor–patient relationship requires effective communication about important health issues of a personal nature, tensions and at times overt conflict may develop between patients with personality disorders and their providers. These tensions may also affect other members of the health care team and may be especially pronounced in the context of acute illness or crisis situations. In fact, the first diagnostic clues suggesting personality dysfunction or disorder may appear as difficulties in the doctor–patient relationship.

For patients with personality disorders, physical illness can cause exaggerated degrees of emotional distress, not always expressed to the provider. Although some patients do tell their providers about their emotional distress, others may instead manifest distress as noncompliance with the agreed-upon plan of evaluation or treatment or as changed, unexpected, or undesirable behavior (as judged by the physician) toward the physician.

In response to patients’ actions or statements, physicians may have a significant emotional reaction to the patients and may change their behavior toward them. Even when they experience no subjective distress from a medical condition or the doctor–patient relationship, patients with personality dysfunction may have such aberrant expectations of others that their statements or behaviors are troubling or burdensome to the physician. Physicians must be aware of their own emotional responses to such patients so as to avoid reacting inappropriately. Physicians who deny their negative feelings toward patients may fail to recognize a personality disorder or other psychiatric diagnosis, or fail to address the diagnostic and treatment needs of the patient with the necessary compassion, rigor, and thoroughness. When clinicians recognize and deal with their negative feelings, they are better able to make thoughtful and appropriate responses to these patients’ symptoms and behavior, minimizing the emotional strain for both patient and doctor and optimizing the quality of the medical outcome.

Appreciating the unique vulnerabilities associated with each personality disorder can aid in identifying problematic behaviors and can help to maintain the necessary degree of cooperation and collaboration, even when the patient has significant personality dysfunction. Table 29-2 outlines typical responses to illness by patients with each of the most common personality disorders, details troublesome reactions by physicians, and suggests strategies to avoid further problems with these challenging patients.

Management of Patients with Personality Disorders

In most cases, a stable therapeutic alliance with patients who have personality disorders can be maintained by implementing the behavioral strategies suggested in the following sections. Sometimes other factors must also be addressed. As mentioned earlier, comorbid diagnoses must be treated (e.g., depression or anxiety disorders). Pharmacotherapy and psychotherapy are often more complex for patients with comorbid disorders. This is particularly evident when patients with personality disorders have concurrent substance-abuse problems or psychotic symptoms (e.g., hallucinations, delusions, and paranoid ideation). In such cases, mental health consultation can be particularly helpful.

When a provider feels unable to continue productive work with a patient with a personality disorder, it may be appropriate to transfer the patient to another clinician. Although such transfers of care may be both necessary and helpful, they require consideration of the impact of the transfer on the well-being of the patient. Patients with certain personality disorders may experience such transfers as rejection or abandonment, perceptions that may exacerbate their emotional distress and potentially disrupt their medical treatment. Prior consultation with a mental health provider can be useful in determining whether such a transfer might be helpful and can aid in carrying it out smoothly.

The remainder of this chapter discusses the 10 personality disorders as they manifest in the medical setting, and, for each, presents management recommendations.

Symptoms & Signs

Patients with paranoid personality disorder have a long-standing pattern of distrust and suspiciousness. They perceive the behavior and motives of others as malevolent in nature and expect others, in many situations, to disappoint or take advantage of them. They are reluctant to confide in others and can be preoccupied with unwarranted doubts about the loyalty or trustworthiness of friends and associates. They may perceive seemingly benign or innocuous statements or behavior by others as threatening, insulting, or hurtful. To defend against their perceived vulnerability, they usually adopt a rigid, distanced, or guarded position. In general, persons with this personality structure find intimate relationships undesirable and difficult, which often leave them without any significant social supports.

Differential Diagnosis

Long-standing psychotic symptoms, such as delusions and hallucinations, suggest a diagnosis of paranoid delusional disorder or paranoid schizophrenia. Although persons with paranoid personality disorder usually do not have frank paranoid delusions, at times of extreme stress they may develop such symptoms for brief periods. Paranoid ideation may also be associated with medical causes or with alcohol or substance abuse or withdrawal.

Illness Experience & Illness Behavior

Illness is difficult for individuals with paranoid personality disorder because illness makes them more dependent, and, hence, more vulnerable. Communicating personal information to the physician may challenge the self-protective, rigid way they approach social interactions. Patients may experience a heightened sense of vulnerability and fear of harm by the physician. In their fearful state, they may perceive innocuous or even overtly helpful behavior as threatening. They may then question or challenge the physician about the content of an intervention or the motives behind it. This can lead to conflict and argument between patient and doctor or to the patient disengaging from care.

The Doctor–Patient Relationship

Physicians confronted with such a paranoid stance may react in ways that exacerbate the situation. If they feel that their intentions are inappropriately suspect they might argue with the patient or become defensive, perhaps using an angry tone. This kind of reaction may frighten the patient and may be perceived as confirmation of the patient’s suspicion. Although such a response should be avoided, ignoring the patient’s distrustful or angry behavior can also be problematic; the patient’s concerns, however irrational, may increase if not addressed.

Specific Management Strategies

It is essential to address the patient’s concerns and fears empathically, however irrational they seem. Although the physician may see the patient’s concern as unrealistic, to the patient the fear is real. Dismissing these patients’ concerns or calling them paranoid will not address their emotional needs and may instead create distance in the doctor–patient relationship. A professional, “matter-of-fact” or objective stance is most reassuring to these patients. Excessive friendliness or reassurance may be misinterpreted and may intensify their paranoia. It is important to give these patients detailed information about their proposed treatment plan, allowing them to feel they are in control of the treatment and can make independent decisions. Provide factual information about risks associated with the treatment, whenever possible, before any major procedures or changes in treatment.

Simon feels that his concerns have been taken seriously. He finds the referral to a psychiatrist acceptable because it has been proposed in a way that offers support and does not dismiss his fears as pathological. The physician’s matter-of-fact responses to Simon’s somatic complaints help increase the patient’s trust in the physician.

Symptoms & Signs

Individuals with schizoid personality disorder remain detached from social relationships and exhibit a restricted range of emotional expression in their interactions with others, often appearing cold or indifferent. Because patients with this disorder find emotions, intimacy, and conflict threatening, they tend to isolate themselves and avoid close or sexual relationships. They prefer dealing with technical or abstract concepts rather than people, and so they may devote their time to pursuits such as mathematical games. Work can be problematic if it involves interactions with others, but many individuals can perform quite well if they work with some degree of independence.

Differential Diagnosis

Patients with schizoid personality disorder do not exhibit prolonged psychotic symptoms. They may, however, suffer a brief psychotic decompensation during times of extreme stress. In addition, schizoid personality disorder may in some cases precede the development of psychotic conditions, such as schizophrenia or delusional disorder. It can also coexist with schizotypal, paranoid, or avoidant personality disorders.

Illness Experience & Illness Behavior

Illness can be especially stressful for these patients because it gives rise to strong emotions with which they are not prepared to cope. The necessity of interacting with caregivers when ill, often around quite intimate issues, forces them to do the very thing they systematically avoid. They may therefore delay seeking care until their symptoms become more serious. When they finally present for medical attention, they may appear indifferent or detached as a way of protecting themselves from overwhelming emotion. They may show little facial expression and may not respond in kind to caregivers’ empathic nods or comments—which may make establishing a therapeutic relationship difficult.

The Doctor–Patient Relationship

Because these patients often appear cold or indifferent, physicians may consider them as unappreciative of help. They may also be puzzled or frustrated by their patients’ delay in seeking medical care and their apparent passivity in the face of illness. As a result, caregivers may make overzealous attempts to connect with patients by trying to be especially empathic, a tactic that may instead frighten them away. On the other hand, providers may themselves draw back and lose their enthusiasm for helping patients who seem so unappreciative or uninvolved in their own treatment.

Specific Management Strategies

Understanding that individuals with schizoid personality disorder have difficulty tolerating emotions and intimate interactions is important. Physicians should appreciate their patients’ need for privacy and should maintain a low-key approach, avoiding attempts to reach out by becoming too close or by insisting on providing social support. It is helpful to focus on the more technical aspects of treatment, as these are better tolerated, and encourage patients to maintain daily routines. Caregivers should remain available and provide steady but unobtrusive help.

Symptoms & Signs

Patients with schizotypal personality disorder behave in an odd and eccentric manner, are socially inept and isolated, and experience cognitive or perceptual distortions. Their distortions include magical thinking, odd beliefs, ideas of reference, bodily illusions, or telepathic and clairvoyant experiences. These beliefs and distortions are inconsistent with subcultural norms, occur frequently, and are an important and pervasive core component of the patient’s experience. The patient’s enduring psychotic-like symptoms may worsen under stress. Patients often dress in an odd and peculiar fashion and their affect is often inappropriate; for example, they may laugh inappropriately during the visit while talking about their problems.

These patients are socially isolated and usually have few or no close friends. Their social isolation stems from their odd behavior as well as from their persistent social anxiety due to suspiciousness or paranoia toward others.

Differential Diagnosis

Schizotypal personality disorder shares the symptom of suspiciousness and paranoia with paranoid personality disorder and that of social isolation with schizoid personality disorder. However, the latter two disorders do not present with odd and peculiar mannerisms and behaviors and also lack cognitive or perceptual distortions.

The differential diagnosis includes schizophrenia. Although patients with schizotypal personality disorder lack signs and symptoms of overt psychosis, the disorder is considered a schizophrenia-spectrum disorder. This means that it may be related to schizophrenia. Family studies show an increased risk of schizophrenia in relatives of patients with schizotypal personality disorder and an increased risk of schizotypal personality disorder in families of patients with schizophrenia.

Illness Experience & Illness Behavior

Patients with schizotypal personality disorder may present late in the course of their illness because they may have odd interpretations of their illness and may, therefore, not recognize the serious nature of their symptoms. Also, like patients with schizoid personality disorder, they do not like to interact with and seek the company of others. Illness forces them to interact with health care providers and their support staff, something they may not be prepared to do. This may lead to increased paranoid ideation or overt psychotic symptoms.

The Doctor–Patient Relationship

These patients’ eccentric appearance may cause the clinician to be hesitant in approaching them. Odd and weird interpretations of illness may lead to misunderstandings between patient and clinician. It may be challenging for the physician to improve these patients’ understanding of their problems.

Specific Management Strategies

Clinicians should try to overcome their apprehension about treating these patients, often caused by their eccentric appearance. It is helpful to find out what these patients think about their symptoms and to help them obtain a better understanding of their illness. At the same time, the physician should not get overly involved in trying to increase their patients’ social support or exposure to others. Knowing that patients with schizotypal personality disorder desire social isolation is important. Occasionally, assessing decision-making capacity can be complicated by odd or magical beliefs associated with the illness. Consultation can be helpful.

Symptoms & Signs

Persons with antisocial personality disorder demonstrate a disregard for others and behavior that violates others’ rights. The diagnosis can be made only in persons over the age of 18 years, and it requires a history of conduct disorder prior to that age. Characteristics include lack of conformity to social norms and laws, using lies or other deceitfulness for personal gain, and impulsiveness and irresponsibility in many settings. These individuals may be threatening, manipulative, or harmful to others, and they are generally not remorseful. Their tendencies toward aggressive behavior may not be immediately evident, but contact with collateral sources frequently reveals a criminal record. These character traits affect relations with both strangers and family alike, as persons with antisocial personality disorder may engage in inconsiderate, angry, or harmful behaviors. These individuals may present themselves in a superficially grandiose manner, and they can also initially appear somewhat charismatic, until others recognize their charm as manipulative.

Differential Diagnosis

Antisocial personality disorder can overlap significantly with other personality disorder traits, most commonly narcissistic, histrionic, or borderline personality disorder. Because substance abuse is a frequent comorbid diagnosis, it is important to distinguish between the problems when making the diagnosis.

Illness Experience & Illness Behavior

To mask the fear that illness may cause, patients with antisocial personality disorder may unconsciously adopt an excessively self-assured, entitled, or hostile stance. Irresponsible, impulsive, or dangerous health behavior may help these patients deny their vulnerability to illness. This behavior can occur without regard for medical consequences, and many patients show blatant disregard for the health care personnel and resources from which they have benefited. Patients may assume a privileged, self-deserving stance and can become antagonistic if they fail to obtain the desired response. They may attempt to manipulate their physician, malingering to obtain things such as drugs or inappropriate disability benefits. This behavior can be an embellishment of a real illness, or it can occur when they are not ill.

The Doctor–Patient Relationship

Because these patients often behave in ways that are noncompliant, ungracious, or dishonest, they are frequently irritating to health care providers. Physicians may become angry with these individuals or reject them if they see that the treatments in which they have invested their knowledge and time have not been followed, or if they discover these patients have manipulated them.

Specific Management Strategies

Managing manipulative patients can be particularly challenging. If the patient successfully manipulates the physician, the outcome is usually detrimental to the patient’s overall health (broadly defined). On the other hand, although recognizing the manipulative behavior may avert a detrimental health outcome, the physician’s confrontation can alienate the patient. The more authoritarian the physician’s stance, the more likely it is that the patient will become oppositional, reducing the possibility for development of an effective therapeutic alliance.

The key here is to maintain an objective, thorough, nonauthoritarian, and respectful approach to investigating the patient’s presenting complaints. If the patient’s presentation or motives are suspicious, the provider should gather corroborating data from collateral sources (other providers or family members) when needed. Such behavior by the physician can cause the patient to become hostile, with additional deterioration in the doctor–patient relationship. If confrontation or disagreement is necessary, it is essential to avoid humiliating the patient while identifying the attempted manipulation. Communication should be direct and factual with these patients, based on what is medically indicated, and clear limits should be set on the diagnostic or treatment plan.

In dealing with Randy, the physician uses her past experience with him as a guide. Randy’s self-destructive behavior, hostility, and disregard for others are met with clear limit setting by the physician, who responds in a calm and nonpunitive manner, emphasizing her concern for the patient’s long-term well-being.

Symptoms & Signs

Patients with borderline personality disorder exhibit instability in their self-image, their affect, and their relationships with others. They can be quite impulsive and may engage in self-destructive behaviors, such as substance abuse, self-mutilation, and suicide attempts. These behaviors reflect a deep sense of emptiness and an intense fear of abandonment by others. On the other hand, patients with borderline personality disorder are also often fearful of closeness. They experience many contradictory emotions and feelings that are not integrated into a stable sense of who they are and that may be associated with rapid shifts in mood. This instability can cause frequent changes in goals and values. These patients usually have difficulty differentiating reality from fantasy and tend toward all-or-nothing thinking in their view of themselves and others, alternating between overidealization and devaluation.

Differential Diagnosis

Some patients with borderline personality disorder may suffer brief psychotic episodes when under stress. They may, for example, become very anxious or experience auditory hallucinations. The brief duration and specific association with stressors distinguishes these episodes from psychotic disorders. In addition, patients with borderline personality disorder also often suffer from a concurrent mood disorder, such as major depression or bipolar disorder, which should, of course, be treated. Other personality disorders (e.g., histrionic or narcissistic) may co-occur or be confused with borderline personality disorder.

Illness Experience & Illness Behavior

Patients with borderline personality disorder have difficulty distinguishing reality from fantasy, and they may have terrifying fantasies about illness. The complex and contradictory feelings engendered in response to illness can feel intolerable to these patients, so they may try to cope by pretending that they are completely well and denying the presence of illness. Alternatively, they may become convinced that they are deathly ill, even when suffering from a mild illness. Having felt wounded in earlier relationships, individuals with borderline personality disorder mistrust and fear caregivers. In an attempt to cope with their simultaneous intense wish for, and fear of, closeness, they tend to conceptualize caregivers as all good or all bad—a mechanism called “splitting.” To complicate things further, these conceptualizations are not stable. Even an overidealized caregiver can abruptly be devalued if a borderline patient becomes angry and disappointed or feels abandoned. In addition, patients with borderline personality disorder may respond to feeling overwhelmed by engaging in impulsive and self-destructive acts, such as self-mutilation, substance abuse, and suicide attempts. They may also be noncompliant with treatment in order to test the limits of the clinician’s availability, devalue the clinician, or even to remain ill and thus maintain an ongoing relationship with the caregiver.

The Doctor–Patient Relationship

A common mistake clinicians make in treating patients with borderline personality disorder is getting too emotionally close or over-involved in meeting their needs. This occurs when clinicians feel intensely drawn to help patients through their suffering and spend a great deal of time with them. This usually causes overstimulation of the patient’s emotions, leading to initial idealization of the clinician and then increased instability and acting out. It should be noted that the patient’s emotional behavior can cloud the clinician’s judgment, causing the clinician to succumb to the patient’s idealization and splitting. The idealization lasts only so long; the clinician will inevitably disappoint the patient. The borderline patient’s self-destructive or often provocative behaviors can then cause despair and helplessness in caregivers. Caregivers may also feel tempted to punish the patient, for example, by becoming uncharacteristically inflexible or even verbally hostile or by withholding needed (e.g., pain) medication or care (e.g., more frequent visits).

Specific Management Strategies

While providing basic support and reassurance, clinicians should be careful not to become emotionally over-involved with the borderline patient. It is appropriate to counter the patient’s frightening fantasies about illness and “overwhelming neediness” by scheduling frequent periodic check-ups and providing clear, nontechnical answers to questions. Caregivers may have to tolerate periodic angry outbursts, but it is appropriate to set firm limits on both the patient’s disruptive behavior and on the caregiver’s response. When a multidisciplinary team of clinicians is involved, meetings of all providers should be arranged, to allow them to vent their feelings about the patient and to reach consensus on a treatment plan. It is helpful to select a small number of caregivers to interact with the patient directly and to present the same clear and consistent plan. This approach often prevents splitting. Finally, it is essential to remain aware of these patients’ potential for self-destructive and/or overly demanding behavior and not to retaliate by displaying anger at them when setting limits or even punishing them (e.g., not responding).

In this case, regular meetings of all the involved clinicians and staff (e.g., trainees, the attending physician, consultants, receptionist, and the nurse practitioner) allow them to present the same coherent plan to the patient, minimize the splitting, and reduce the patient’s anxiety and unpredictable behavior. This approach successfully combines increased support and limit setting.

Symptoms & Signs

Histrionic personality disorder is marked by excessive attention seeking and emotionalism. These patients may present with dramatic, theatrical shows of feeling, or they may dress or behave in a sexually provocative fashion in an unconscious effort to engage others and draw attention to themselves. The emotions they express may be shallow and inconsistent, but the patients may still believe that the sharing of those feelings creates a special closeness (which they often exaggerate) with the physician. These patients have a tendency to prefer subjective and intuitive impressions to objective, linear, logical thinking. They often have somatic complaints, with impressive—but inconsistent—presentations.

Differential Diagnosis

Histrionic personality disorder may be difficult to distinguish from narcissistic or borderline personality disorder, and patients in each of these categories may exhibit traits common to patients in the others. Patients with histrionic personality disorder are deeply affected by perceived frailties in relationship bonds, as are patients with borderline personality disorder. The latter, however, display less emotional stability and are more impulsive and self-destructive. Patients with histrionic personality disorder may crave attention—as patients with narcissistic personality disorder crave admiration—but the former tend to be less grandiose, arrogant, and self-absorbed.

Illness Experience & Illness Behavior

Medical illness represents a particular threat to the emotional well-being of patients with histrionic personality disorder, who derive much of their sense of self-worth and personal desirability from their sense of physical attractiveness. To reduce the fear of being deemed less desirable by others, these patients may attempt to bolster their physical appearance or embellish their abilities.

As a result, patients of either gender may engage in flirtatious or seductive behavior. When they feel weak and vulnerable, they may express their emotions with more intensity, in an attempt to strengthen their bond with the physician. In addition, because these patients focus on feelings, rather than on carefully observed physical symptoms, they may present with a collection of loosely connected somatic complaints. Their descriptions of the symptoms may reflect their desire to capture the physician’s interest.

The Doctor–Patient Relationship

In working with the histrionic patient, the physician may be drawn in by the patient’s dramatic and somewhat dependent style, become overly involved, and perhaps embark on an excessive workup. As the physician becomes increasingly engaged by the patient’s style, the patient may then become anxious, distant, or noncompliant, puzzling and frustrating the physician. Alternatively, the physician may instead pursue too cursory an evaluation, because of a lack of objective information, or out of frustration with the patient’s emotional and vague style.

Specific Management Strategies

Because the patient with histrionic personality disorder has a vague and global emotional (rather than a precise, logical) style and may display contrasting behaviors—that range from excessive anxiety about potentially minor symptoms to inappropriate indifference about significant medical problems—it is essential that the physician maintain an objective stance. The physician must offer a supportive and logical approach to the patient’s problems. This requires being both sensitive to the patient’s emotional concerns and sufficiently distanced to avoid any degree of closeness that the patient might misperceive as intimate or sexual.

This approach is successful because the physician shows positive regard for the patient and her problems—while clearly setting the limits of the doctor–patient relationship.

Symptoms & Signs

Narcissistic personality disorder is characterized by a long-standing pattern of grandiosity, with a need for praise and admiration that stands out in contrast to a lack of sensitivity to the feelings of others. These persons may have an exaggerated sense of self-importance and social status and require excessive admiration. They may be driven toward attaining an idealized position in terms of social, personal, romantic, or career accomplishment. In this regard, they may be envious and potentially devaluing of others whose accomplishments they perceive as exceeding their own. Beneath the grandiosity and devaluation exists an underlying view of self as inferior or inadequate. To avoid these beliefs and their associated painful effects, patients seek to convince self and others of their “specialness” or “unusual talent.”

Differential Diagnosis

Narcissistic personality disorder may be difficult to distinguish from borderline, antisocial, histrionic, or obsessive-compulsive personality disorders, and in many cases it may overlap with these disorders. When the differentiation is unclear, identifying a high degree of grandiosity and a need for admiration can help clarify the diagnosis. In contrast to persons with borderline personality disorder, persons with narcissistic personality disorder have a more stable self-image and display less impulsiveness and sensitivity to relationship losses. In addition, persons with narcissistic personality disorder are generally less aggressive and deceitful than are persons with antisocial personality disorder, who also display evidence of childhood conduct disorder. Persons with histrionic personality disorder, in contrast, may be relatively more dramatic and emotional than those with narcissistic personality disorder. Although persons with narcissistic personality disorder, like those with obsessive-compulsive personality disorder, may be perfectionists, the former often have a higher self-assessment of their accomplishments.

Clinicians must be careful not to misdiagnose a person with transient hypomanic or manic grandiosity as having narcissistic personality disorder. Similarly, it is important to distinguish between narcissistic personality disorder and transient substance-related personality changes (e.g., from central nervous system stimulants) or personality changes caused by a general medical condition.

Illness Experience & Illness Behavior

Health problems are a particular blow to patients with narcissistic personality disorder. Illness threatens these patients’ unconscious attempts to maintain an intrapsychic and external image of untarnished well-being, resiliency, and superiority. Medical problems and physical limitations may disrupt this image, threaten their public personas, and leave them fearing disruption of their (unrealistically unchallengeable) sense of self. In an attempt to defend against this threat, patients may minimize the significance of symptoms or deny the presence of the illness. More commonly, as patients try to recapture their admired, idealized status, they may demand special treatment, second opinions, or transfer of care to more “senior” or “well-known” clinicians. These patients may devalue, criticize, or question the behavior or credentials of the treating physician, or they may fail to comply with treatment recommendations.

The Doctor–Patient Relationship

Narcissistic patients’ arrogant and grandiose behavior, combined with demands for special treatment, can be extremely irritating to physicians. Reactions to these patients can take many forms. Sometimes, in an attempt to avoid conflict, physicians submit to the demands. With particularly critical patients, providers may feel frustration, resentment, and even anger. Alternatively, they may feel devalued and question their own competence. Frustration may be especially great if the physician expends special energy on behalf of a charismatic or demanding patient, only to later become the butt of unfair criticism. Physicians may reject or avoid the patient, withhold treatment, or respond in an angry manner—responses that can harm both the patient and the doctor–patient relationship.

Specific Management Strategies

The most effective strategy for dealing with narcissistic patients is to be respectful and nonconfrontational about their sense of specialness and entitlement and to help them use their self-perceived talents in the service of their treatment. If narcissistic patients feel vulnerable and threatened by the illness, they are more likely to criticize and devalue the physician. Thus, physicians should not take this devaluation personally, and instead understand it as the patients’ attempt to cope with their own intense insecurity. Providers can appeal to the patients’ narcissism by explaining that they chose a particular course of action because they believe it represents the best possible care—a course of action they feel the patients deserve. Physicians can further support the patients by validating their concerns about the illness and pointing to their patients’ ability to respond competently to its challenges. This approach helps the patients feel more secure and able, allowing them to ally confidently with—rather than defensively attack—their physicians.

This response is reassuring to the patient, because it validates her concerns and satisfies her narcissistic feelings of entitlement.

Symptoms & Signs

Patients with avoidant personality disorder have a long-standing pattern of excessive anxiety in social situations and in intimate relationships, and extreme hypersensitivity to what other people think about them. These patients desire relationships but avoid them because of fears of being rejected, humiliated, or embarrassed. If they do engage in social situations or relationships, they are constantly preoccupied with being rejected, criticized, and not being liked by others. As a result, these patients have low self-esteem, feel socially inept, have feelings of inferiority, and are shy and inhibited.

Differential Diagnosis

Patients with schizoid personality disorder also avoid social situations and relationships but they do desire social isolation. In contrast, patients with avoidant personality disorder strongly desire relationships but avoid them because of anxiety and fears of rejection and humiliation.

Avoidant personality disorder should be distinguished from social phobia. Whereas patients with avoidant personality disorder try to avoid social interactions in general, patients with social phobia usually have more specific concerns related to social performance, such as saying something inappropriate to unfamiliar people at a social gathering.

Illness Experience & Illness Behavior

Illness provokes anxiety and increases feelings of ineptness in patients with avoidant personality disorder. Patients may delay care or not be forthcoming about their problems out of fear of not being liked or being rejected by the caregiver. They may blame their physical discomfort on themselves and may actually not ask for appropriate pain relief. Because these patients feel that they may not deserve attention by their physician, they may be reluctant to undergo necessary medical procedures.

The Doctor–Patient Relationship

Physicians treating patients with avoidant personality disorder may initially not realize the full extent of their patients’ symptoms. Because these patients are shy and easily agreeable to what their physicians propose, physicians may be prone to take a more paternalistic stance with them. If they discover later that the patient’s symptoms are more severe than initially reported, clinicians may react with concern or feel betrayed by the patient for withholding information and for their passive attitude.

Specific Management Strategies

Patients with avoidant personality disorder need reassurance and permission to express their distress and concerns in a nonjudgmental environment. It is helpful for health care providers to explain that they are interested in knowing about the patient’s problems.

This reassuring and supportive approach encourages the patient to communicate with his physician and not hold back out of fear of being rejected.

Symptoms & Signs

Patients with dependent personality disorder have a pervasive and excessive need to be taken care of. They experience intense fear of separation and abandonment and feel great discomfort when they are alone. This leads to submissive and clinging behavior in their interpersonal relationships. These patients have difficulty making independent decisions without a great deal of advice and reassurance, and they are afraid of disagreeing with others.

Differential Diagnosis

It is important to distinguish dependent personality disorder from the dependency that arises from panic disorder, mood disorders, or agoraphobia. Patients suffering from medical illnesses may also become very dependent on others, without having this disorder. Dependent personality disorder can sometimes be confused with other personality disorders, and dependent personality traits may be the result of chronic substance abuse.

Illness Experience & Illness Behavior

Patients with dependent personality disorder fear that illness will lead to both helplessness and abandonment by others. In their interactions with caregivers, they may become very needy and make dramatic demands for urgent medical attention. If the response is not what they wish, they may display angry outbursts at the physician. They may also blame their physical discomfort on others, including their physician. In addition, they may use addictive substances or overuse medications in a desperate attempt to obtain immediate relief from their suffering. Because receiving medical care may fulfill their wishes for attention from others, some dependent patients may unconsciously contribute to prolonging their illness, or—in some extreme cases—they may encourage unnecessary medical procedures.

The Doctor–Patient Relationship

Clinicians treating patients with dependent personality disorder may initially react with aversion to their patients’ clingy and demanding behavior. Alternatively, clinicians may find it difficult to set limits on their availability and may try to provide reassurance by attempting to meet every demand, which ultimately leads to burnout or feelings of inadequacy. Eventually, caregivers may react in a hostile fashion and openly reject these patients.

Specific Management Strategies

Effective ways to provide reassurance to dependent patients and allay their fear of being abandoned include scheduling frequent periodic check-ups and being consistently available. It is nonetheless important to provide firm, realistic limits to this availability early in treatment or as soon as the patient’s dependent traits become apparent. To prevent burnout, enlist other members of the health care team in providing support for the patient. In addition, physicians should help these patients find outside support systems to lessen fears of abandonment. They must also be alert to the patients’ potential contribution to prolonging their illness or to their possible abuse of substances or medications.

This approach usually helps diminish the patient’s anxiety and decreases the frequency of phone calls. If the patient’s distress does not improve with such interventions, a referral for psychotherapy and evaluation for a possible underlying anxiety disorder are indicated.

Symptoms & Signs

Individuals with obsessive-compulsive personality disorder are preoccupied with orderliness, perfectionism, and control. They are excessively concerned with details and rules, tend to be overly moralistic, and are usually focused on work to the exclusion of leisure. They find it difficult to adapt themselves to others and instead insist that others follow their plans. Their general inflexibility and restricted emotional expression betray an underlying fear of losing control. Because they can be indecisive, they feel distressed when faced with the need to make decisions.

Differential Diagnosis

Obsessive-compulsive disorder (see Chapter 26) is distinguished from obsessive-compulsive personality disorder by the presence of actual obsessions (repetitive intrusive thoughts) and compulsions. Sometimes, however, both disorders coexist in one patient, and obsessive-compulsive personality disorder can also be confused with other personality disorders.

Illness Experience & Illness Behavior

Illness is threatening to persons with obsessive-compulsive personality disorder because it generates an intense fear of losing control over bodily functions and emotions. Patients may experience extremely unsettling feelings of shame and vulnerability. They may also feel anger at the disruption of their usual daily routines by medical appointments and treatments. They may fear having to relinquish control to health care providers. In the physician’s office, their intense anxiety tends to drive them to ask repetitive questions and to pay excessive attention to detail.

The Doctor–Patient Relationship

Caregivers may react to patients with obsessive-compulsive personality disorder by becoming impatient at their repetitive questions, cutting their answers short. They may feel their competence challenged by their patients’ insistence on knowing every single detail and reason for choosing a particular treatment. Clinicians may also inadvertently attempt to control treatment planning rather than making it a joint effort, without realizing how important it is for these patients to remain in control.

Specific Management Strategies

Helpful strategies in working with patients with obsessive-compulsive personality disorder include taking a comprehensive history, performing a careful diagnostic workup, giving patients a clear and thorough explanation of their diagnosis and treatment options, and providing and explaining laboratory test results. It is important not to overemphasize uncertainties about treatments or the patient’s possible response to treatment. Patients find it reassuring when clinicians cite literature reports and avoid vague and inexact impressionistic explanations. It is helpful to treat these patients as equal partners, encourage self-monitoring, allow their participation in treatment, and give them recognition for their clear reasoning and high standards.

Reassurance is essential here. The doctor explains that the surgeon is both trustworthy and well known to him. He praises Sam for his thoroughness and initiative in finding out about treatment alternatives before making a decision. He answers basic questions in a precise manner and defers some questions to the surgeon, explaining that these will be better answered by a specialist. He reassures Sam that he will not wait for a written report but will personally contact the surgeon after the consultation to discuss treatment options. The physician also suggests a follow-up appointment to help Sam with his decision.

Although Sam continues to express concern that the surgery will disrupt his work, his anxiety decreases somewhat after the physician takes his concerns seriously. His questions are answered precisely, and the physician further suggests an article in the literature that he can read to learn more about the treatment of inguinal hernias.

Effective psychopharmacological treatment does not exist for a given personality disorder. Nevertheless, pharmacotherapy plays an important role. Medication can be beneficial in targeting symptom clusters within the disorder and in treating other comorbid disorders, such as major depression, bipolar affective disorder, substance abuse, posttraumatic stress disorder, panic disorder, social anxiety, and obsessive–compulsive disorder.

Symptoms such as paranoid ideation and suspiciousness in patients with cluster A disorders (paranoid, schizoid, and schizotypal personality disorder) may improve with low-dose antipsychotic treatment (e.g., haloperidol, risperidone, olanzapine, ziprasidone, quetiapine, and aripiprazole). In case of overt psychotic symptoms, a psychiatric consultation and treatment with an antipsychotic medication should be considered.

Patients with cluster B disorders (antisocial, borderline, histrionic, and narcissistic personality disorder), who often appear dramatic and emotional, should be evaluated for prominent mood symptoms and the coexistence of an Axis I disorder, especially mood, anxiety, and substance-abuse disorders.

Patients with prominent depressive symptoms should be treated with selective serotonin reuptake inhibitors (SSRIs) or other antidepressants, such as fluoxetine, sertraline, paroxetine, citalopram, and escitalopram. Patients with prominent mood swings, irritability, or impulsive behaviors may be candidates for treatment with a mood stabilizer (e.g., valproate or lithium) or a second-generation antipsychotic. However, a psychiatric consultation is recommended for this type of treatment. Medications have been most extensively used in patients with borderline personality disorder. Borderline patients with more affective dysregulation can be considered for treatment with an antidepressant, mood stabilizer, and/or low-dose antipsychotic medication. Antipsychotics can also be considered in borderline patients with dissociative or psychotic symptoms.

Anxiety and fear are the most dominant symptoms of patients with cluster C disorders (avoidant, dependent, and obsessive-compulsive personality disorder). Symptoms in these patients may improve by treatment with an SSRI. Time-limited symptomatic treatment with a benzodiazepine might be considered.

In addition to psychopharmacological treatments, patients may be referred for various psychosocial and psychotherapeutic treatments, including dialectical behavioral therapy for borderline personality disorder, cognitive behavioral therapy, and psychodynamic therapies.