Prominent features of disorder | Distrust and suspiciousness of others, such that their motives are interpreted as malevolent | Pattern of detachment from social relationships and a restricted range of emotional expression | Odd beliefs, inappropriate affect, perceptual distortions, and desire for social isolation | Disregard for and violation of the rights of others, beginning in adolescence | Pattern of instability in interpersonal relationships, self-image and affects, and marked impulsivity |
Patient’s experience of illness | Heightened sense of fear and vulnerability | Threat to personal integrity; increased anxiety because illness forces interaction with others | May have odd interpretations of illness, increased anxiety because of interactions with others, may become overtly psychotic | Sense of fear may be masked by increased hostility or entitled stance | Terrifying fantasies about illness; feels either completely well or deathly ill |
Problematic behavior in the medical care setting | Fear that physician or others may harm them Misinterpretation of innocuous or even helpful behaviors Increased likelihood of argument or conflict with staff | May delay seeking care until symptoms become severe, out of fear of interacting with others May appear detached and unappreciative of help | May delay care because of odd and magical beliefs about symptoms, may not recognize symptoms as a sign of illness May appear odd and eccentric and paranoid toward others | Irresponsible, impulsive, or dangerous health behavior, without regard for consequences to self or others Angry, deceitful, or manipulative behavior | Mistrust of physicians and delay in seeking treatment Intense fear of rejection and abandonment Abrupt shifts from idealizing to devaluing caregivers; splitting Self-destructive threats and acts |
Common problematic reactions to patient by caregiver | Defensive, argumentative, or angry response that “confirms” patient’s suspicions Ignoring the patient’s suspicious or angry stance | Overzealous attempts to connect with patient Frustration at feeling unappreciated | Frustration about patient’s misinterpretation of illness Not wanting to connect with an odd and eccentric patient | Succumbing to patient’s manipulation Angry, punitive reaction when manipulation is discovered | Succumbing to patient’s idealization and splitting Getting too close to patient causing overstimulation Despair at patient’s self-destructive behaviors Temptation to punish patient angrily |
Helpful management strategies by caregiver | Attend to and be empathic toward patient fears, even when irrational in appearance Carefully detail care plan for patient with advance information about risks of procedures/treatments Maintain patient’s independence when possible and optimize the patient’s control Not overly friendly, but professional, objective stance | Appreciate need for privacy and maintain a low-key approach Focus on technical elements of treatment; these are better tolerated Encourage patient to maintain daily routines Do not become overly personally involved or too zealous in trying to provide social supports | Try not to be turned off by patient’s odd appearance Try to educate patient about the illness and its treatment Do not become overly involved in trying to provide social support | Carefully, respectfully investigate patient’s concerns and motives Communicate directly; avoid punitive reactions to patient Set clear limits in context of medically indicated interventions | Don’t get too close to patient Schedule frequent periodic check-ups Provide clear, nontechnical answers to questions to counter scary fantasies Tolerate periodic angry outbursts, but set limits Be aware of patient’s potential for self-destructive behavior Discuss feelings with coworkers and schedule multidisciplinary team meetings |
Personality Disorder | Histrionic | Narcissistic | Avoidant | Dependent | Obsessive-Compulsive |
Prominent features of disorder | Pattern of excessive attention seeking and emotionality | Pervasive pattern of grandiosity, need for admiration, and lack of empathy for others | Pattern of social inhibition because of fears of being rejected or humiliated by others | Pervasive and excessive need to be taken care of that leads to submissive and clinging behavior, and fears of separation | Pattern of preoccupation with orderliness, perfectionism, control |
Patient’s experience of illness | Threatened sense of attractiveness and self-esteem | Illness may increase anxiety related to doubts about personal adequacy and disrupts image of self as resilient and superior | Illness may heighten sense of inadequacy and worsen low self-esteem | Fear that illness will lead to abandonment and helplessness | Fear of losing control over bodily functions and over emotions generated by illness; feelings of shame and vulnerability |
Problematic behavior in the medical care setting | Overly dramatic, attention-seeking behavior, with tendency to draw caregiver into excessively familiar relationship Inadequate focus on symptoms and their management, with over emphasis on feeling states May provide answers they believe physician wants to hear Tendency to somatize | Demanding, entitled attitude Excessive praise toward caregiver may turn to devaluation, in effort to maintain sense of superiority Denial of illness or minimization of symptoms | May not be forthcoming about symptom severity, may easily agree with physician out of fear of not being liked | Dramatic and urgent demands for medical attention Angry outbursts at physician if not responded to Patient may contribute to prolong illness or encourage medical procedures in order to get attention May abuse substances and medications | Anger about disruption of routines Repetitive questions and excessive attention to detail Fear of relinquishing control to health care team |
Common problematic reactions to patient by caregiver | Performing excessive workup (when patient is dramatic) or inadequate workup (when patient is vague) Allowing too much emotional closeness, thereby losing objectivity Frustration with patient’s dramatic or vague presentation | Outright rejection of patient’s demands, resulting in patient distancing self from caregiver Excessive submission to patient’s grandiose stance | Feeling overly concerned for the patient, taking on a paternalistic role that may increase patient’s sense of inadequacy May feel angry and betrayed by patient if the patient’s symptoms turn out to be more extensive than initially reported | Inability to set limits to availability, thus leading to burnout Hostile rejection of patient | Impatience and cutting answers short Attempts to control treatment planning |
Helpful management strategies by caregiver | Show respectful and professional concern for feelings, with emphasis on objective issues Avoid excessive familiarity | Generous validation of patient’s concerns, with attentive but factual response to questions Allow patients to maintain sense of competence by rechanneling their “skills” to deal with illness, obviating need for devaluation of caregivers Present treatment recommendations in the context of their right to the best care | Provide reassurance, validate patient’s concerns Encourage reporting of symptoms and concerns | Provide reassurance and schedule frequent periodic check-ups Be consistently available but provide firm realistic limits to availability Enlist other members of the health care team in providing support for patient Help patient obtain outside support systems Avoid hostile rejection of patient | Thorough history taking and careful diagnostic workups are reassuring Give clear and thorough explanation of diagnosis and treatment options Do not overemphasize uncertainties about treatments Avoid vague and impressionistic explanations Treat patient as an equal partner; encourage self-monitoring and allow patient participation in treatment |