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 which can significantly interfere with the doctor-patient relationship. BPD will receive extra focus in several sections of this chapter.
Ten PDs are currently distinguished clinically. They are often grouped into three clusters: odd or eccentric (cluster A); dramatic, emotional, or erratic (cluster B); and anxious or fearful (cluster C). These groupings are helpful in broadly categorizing PD difficulties but are limited in their usefulness because they do not signify similarities in etiologies and treatment response. Table 54-1 summarizes the 10 PDs.
Table 54-1. Clinical Features and Clusters of 10 DSM-IV-TR Personality Disorders. |Favorite Table|Download (.pdf)
Table 54-1. Clinical Features and Clusters of 10 DSM-IV-TR Personality Disorders.
|Cluster||Personality Disorder||Clinical Features|
|Cluster A: odd, eccentric||Paranoid||Suspicious; overly sensitive; misinterpretations|
|Schizotypal||Detached; perceptual and cognitive distortions; eccentric behavior|
|Schizoid||Detached; introverted, constricted affect|
|Cluster B: dramatic, emotional, erratic||Antisocial||Manipulative; selfish, lacks empathy; explosive anger; legal problems since adolescence|
|Borderline||Dependent and demanding; unstable interpersonal relationships, self-image, and affects; impulsivity; micropsychotic symptoms|
|Histrionic||Dramatic; attention seeking and emotionality; superficial, ie, vague and focused on appearances|
|Narcissistic||Self-important; arrogance and grandiosity; need for admiration; lacks empathy; rages|
|Cluster C: anxious, fearful||Avoidant||Anxiously detached; feels inadequate; hypersensitive to negative evaluation|
|Dependent||Clinging, submissive, and self-sacrificing; needs to be taken care of; hypersensitive to negative evaluation|
|Obsessive-compulsive||Preoccupied with Orderliness, Perfectionism, and Control|
PDs 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%.
PDs have a pervasive impact because they are central to who the person is. 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% of persons identified as criminal, 60%-70% of persons with alcohol dependence, and 70%-90% of persons who are drug dependent.
Borderline, schizoid, schizotypal, and dependent PDs are ...