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GENERAL CONSIDERATIONS

Personality disorders (PDs) are a heterogeneous group of deeply ingrained and enduring behavioral patterns characterized by inflexible and extreme responses to a broad range of situations, manifesting in cognition (ways of perceiving and interpreting self, others, and events), affectivity (range, intensity, lability, and appropriateness of response), interpersonal functioning, and impulse control. PDs impinge on medical practice in multiple ways, including self-destructive behaviors, interpersonal disturbances, and nonadherence. Appropriate physician responses and effective treatments exist for many PDs. Correct diagnosis and proper intervention will help to improve patient outcomes. Borderline personality disorder (BPD) is an extremely debilitating disorder that can significantly interfere with the physician-patient relationship. BPD will receive extra focus in several sections of this chapter.

Significant deliberation on PDs preceded the publication of the fifth edition of the Diagnostic and Statistical Manual (DSM-5) in May 2013. DSM-5 continues to distinguish 10 PDs clinically, while also formulating an alternative model that emphasizes core impairments in personality functioning and pathologic traits. For Currents, we have chosen to retain description of all 10 PDs as it seems certain that clinicians will continue to use their labels (eg, histrionic personality) for years to come. Table 58-1 summarizes the 10 PDs.

Table 58-1.Clinical features and clusters of 10 DSM-5 personality disorders.

Personality disorders are relatively common, with a prevalence of 7.6% in the general US population. Patients with PDs may seek help from family physicians for physical complaints, rather than psychiatric help. Higher rates for all types of PDs are found in medical settings. Prevalence of BPD in the general community is 1.4%.

Personality disorders have a pervasive impact because they are central to the person’s identity. They are major sources of long-term disability and are associated with greatly increased mortality. Patients with PDs have fewer coping skills and during stressful situations may have greater difficulties, which are worsened by poor social competency, impulse control, and social support. Patients with BPD are frequently maltreated in the forms of sexual, physical, and emotional abuse; physical neglect; and witnessing violence. PDs are identified in 70–85% ...

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