Personality Disorders

Inflexible and maladaptive personality disorders cause distress or social or occupational impairment. A patient with a personality disorder typically has problems in at least two of these areas: cognition, affectivity, interpersonal functioning, and impulse control. Pervasive manifestations occur across a range of situations. A personality disorder is stable and of long duration, typically begins in adolescence or early adulthood, and is diagnosed in adulthood.

The two primary classification approaches to personality disorders are categorical and dimensional. The categorical approach, currently represented in DSM-IV-TR, describes people as having clusters of associated traits, symptoms, or behaviors that form discrete “prototypes,” or categories of personality. The dimensional approach, likely the wave of the future, assesses multiple traits or dimensions of a personality that are present, absent, or have varying degrees of intensity; measurable dimensions of personality might include novelty seeking, harm avoidance, reward dependence, cooperativeness, and self-directedness. Categorical approaches have the advantage of colorfully describing and differentiating distinct groups of different personality types. This classification convention remains popular with family physicians because it follows the concept of disease categories within general medicine. The Diagnostic and Statistical Manual of Mental Disorders, fourth edition, text revision (DSM-IV-TR), uses a categorical personality disorder classification as part of a multiaxial system that encourages physicians to consider personality variables in every patient (American Psychiatric Association [APA], 2000).

The preliminary diagnosis of a personality disorder begins by identifying the appropriate cluster or dimension, because it is easiest to recognize the broad traits of a cluster diagnosis first. The three clusters of personality disorders are cluster A, odd and eccentric; cluster B, dramatic, emotional, or erratic; and cluster C, anxious or fearful. These clusters or dimensions are subdivided into specific personality subtypes with general characteristics (Box 46-1). Because personalities are complicated, it is not unusual for a patient to meet the criteria for two cluster diagnoses and more than one specific personality disorder diagnosis.

Unexplained Physical Symptoms vs. Somatoform Disorders

Physical symptoms appear and disappear on a regular basis in normal people. Less than 3% of these symptoms result in a visit to a physician (Banks et al., 1975), but more than half the visits to primary care physicians are for symptoms. Even symptoms severe enough to trigger a visit are usually self-limited; about three-quarters improve or disappear in 2 weeks, and over half of those remaining have improved or disappeared at 3 months (Kroenke and Jackson, 1998). Most patients do not remember having a symptom that they reported 1 year earlier (Simon and Guerje, 1999). From this cohort of symptomatic patients, a substantial number have symptoms sufficiently persistent, severe, or numerous to justify a diagnostic workup, which usually reveals a medical problem that the family physician manages in the usual way, as described throughout this text. In about one third of patients, however, the symptoms are causing impairment and no physical explanation can be found; alternatively the symptom is out of proportion to the supposed explanatory finding; these patients are somatic. At the more severe end of the continuum, somatic symptoms cluster into discrete diagnostic categories: the somatoform disorders, including somatization disorder, conversion disorder, somatoform pain disorder, hypochondriasis, factitious disorder, malingering, and body dysmorphic disorder. Primary care physicians tend not to pursue diagnoses to the level of these categories, because it is a time-consuming process not yet shown to improve patient outcomes. However, these categories have promising implications for managing the difficult clinical relationship, particularly in the context of personality types and disorders.

About 15% of primary care encounters are experienced by physicians as “difficult,” as determined by the self-administered DDPRQ (Hahn et al., 1996). Patients classified as difficult are not distinguished by the usual demographic categories (age, gender, race, social status) but rather by the presence of somatoform complaints; other DSM Axis I conditions, particularly depression and anxiety disorders; and unique personality styles, up to and including DSM Axis II personality disorders. There is extensive overlap among these symptom clusters, particularly at the less severe end of the spectrum.

Unexplained physical symptoms are often benign and transitory, and only 3% of patients with these symptoms see a physician. Somatic complaints are described by patients within all domains of the traditional review of symptoms. Somatoform disorders are a group of severe psychiatric conditions that present with physical symptoms that suggest a medical condition but that cannot be adequately explained by a medical condition. Patients can have both a medical condition and unexplained physical symptoms that meet criteria for a somatoform condition. Box 46-2 describes somatoform disorders (DSM-IV-TR classification). Social or occupational impairment in these patients exceeds what would be expected based on physical complaints.

Patient Core Beliefs, Irrational Thoughts, and Fears

Understanding core beliefs has therapeutic implications. The family physician can use simple principles of cognitive-behavioral therapy (CBT) to facilitate the management of these patients. The theory of CBT is that patients have core beliefs, a worldview, and personality/somatic-specific fears that can be identified and modified by bringing them to conscious awareness (Beck and Freeman, 1990; Greenberger and Padesky, 1995).

Core beliefs and fears are deeply held, intense, and idiosyncratic in quality. When stress occurs against the background of a core belief, a reinforcing feedback sequence ensues. The core belief is acted on by the stressor, which leads to irrational fears, negative moods or emotions that lead to maladaptive physical symptoms or behaviors, which in turn confirm or amplify the core belief or fear. Core beliefs and fears are readily activated during a visit to the physician, when a patient has symptoms, feels sick, or is vulnerable. For example, a patient with hypochondriasis may fear she has a serious illness. She may have a core belief and fear that she is dying. She may believe that the physician knows she is severely ill but will not tell her. The physician, however, by understanding the patient’s core beliefs and associated fears, can prevent unnecessary worry. The physician can empathize with the patient; discuss the patient’s core beliefs and fears of an illness; help the patient recognized the distorted, irrational, or illogical thoughts; and ultimately, interpret the patient’s defenses and suggest alternative ways for coping.

The CBT sequence of stress, acting on core beliefs and irrational fears, and subsequent development of symptoms or maladaptive behaviors is described for difficult patients in Table 46-1. Adherence to medical recommendations and use of medical services are somewhat predictable based on the particular personality or somatoform disorder.

Defenses and Coping Styles

Patients with severe unexplained somatic symptoms tend to use denial, externalization, and somatization, converting psychosocial distress and problematic interpersonal relationships into unexplained physical complaints. Patients with severe unexplained somatic symptoms tend to use high/low anxious coping or manipulative coping styles (see Table 46-1).

A family physician can attempt to relieve a core problem or a symptom interfering with medical care by fostering the patient’s awareness of his or her problems. It is important to appreciate the unconscious psychological processes known as defense mechanisms. These psychological processes (e.g., denial, projection) are used to resolve internal conflicts, manage moods, mediate external dangers, and facilitate adaptations to reality. Coping styles, on the other hand, are typically behavioral patterns and methods of coping with the external environment.

By understanding the constellation of defenses and coping styles used by difficult patients, the physician may be able to modify the pathologic defense or coping style that is interfering with the patient-physician alliance and the delivery of medical care. A physician can use clarification, confrontation, and interpretation (see Table 46-1). For example, a borderline patient may feel hurt and abandoned by the physician’s vacation and accuse the physician of not caring. This patient may use a defense mechanism called devaluation (physician is deprecated as uncaring) and a coping style of manipulation (threatens suicide). With this understanding, the physician can begin to help the patient by not taking the patient’s efforts to devalue or manipulate personally. The physician can respond to the patient by empathizing with the patient’s fears of abandonment. The physician may clarify that the patient has a distorted belief, and that the vacation is being incorrectly experienced as a personal abandonment of the patient. The physician may further clarify that the vacation does not communicate anything about the physician’s future ability or wish to care for the patient. The patient can be reassured of the physician’s return, future realistic medical availability, specific limits of availability, and medical coverage by another physician. In a preventive effort to allay a crisis and help a borderline patient manage separation fears, the physician (before the vacation) could suggest a new coping style of having the patient schedule a meeting with a medical colleague who will provide coverage while the physician is away. Often, it is helpful to anticipate issues that may arise for the patient and suggest specific problem solving and coping.

Patient Behaviors, Adherence, and Use of Medical Services

Difficult patients often display characteristic behaviors that affect their adherence to medical recommendations and use of medical services. Understanding these behaviors can also help physicians manage their expectations of these difficult patients and improve the chances for effective interventions that might improve medical adherence and health outcomes. In general, patients with cluster A personality disorders (paranoid, schizoid, and schizotypal) tend not to adhere to medical recommendations and underuse medical services. They may require outreach to involve them in their own medical care. Cluster B patients (antisocial, histrionic, borderline, narcissistic, and self-defeating) tend to have variable adherence to medical recommendations and may misuse, overuse, or underuse medical care. Cluster C patients (dependent, obsessive-compulsive, avoidant) tend to adhere to medical recommendations because of fear of the consequences of nonadherence. They are ambivalent users of the medical system and tend to use medical services appropriately when others are involved in their care.

Patients with somatic symptoms tend to overuse medical services and are reluctant to adhere to medical recommendations, even while seeking care from several providers. Somatic patients usually seek relief of physical symptoms through medical, not psychological, interventions. Patients with hypochondriasis or body dysmorphic disorder often initially avoid physicians out of fear or shame that they will be viewed as “crazy.” Once they become patients, however, somatic patients also tend to pressure physicians to order many diagnostic tests and perform multiple procedures. They also tend not to adhere to medical recommendations.

Physician Reactions to Difficult Patients

Although DSM-IV-TR is a useful aid for making a diagnosis, family physicians often recognize a patient with a personality trait or unexplained physical complaint by their own reaction to the patient. Physicians working with difficult patients seem to have specific and characteristic reactions to these patients that need to be recognized, understood, and used for the patient’s benefit. Patient-generated feelings provoked in the physician are created through the interpersonal interaction between patient and physician. These reactions to a patient should alert the physician to a possible diagnosis of a difficult patient. Typical physician reactions to patients that are provoked by the patient are also called patient-generated countertransferences. These include intense feelings, uncharacteristic fantasies, or atypical behaviors by the physician.

Attending to a Problematic Alliance

To establish a good working alliance based on trust, acceptance, and confidence, the family physician should begin each patient encounter by listening, asking open-ended questions, and continually striving for empathy. The alliance is also fostered by the physician’s own self-awareness, ability to acknowledge mistakes, and efforts to adapt to the patient’s wishes or needs that will foster improved health. Problems often occur in developing an alliance with a patient who has a personality or somatoform disorder. If tension develops in the alliance, the physician should first ask what the patient thinks of the current problem. If the patient expresses the problem clearly, the physician should join with the patient in solving the problem to deliver effective medical care. If the problem is the physician-patient relationship, nondefensive reflective listening, clarifications, admitting mistakes, and expressing new efforts to improve the situation are often helpful. If the physician believes that there is a different problem affecting the alliance, the physician may say, “I believe that there is a different problem [identify the problem, e.g., psychosocial distress, problem drinking] that is affecting my ability to help you get well and offer you the best medical care available. We need to think about this problem and come up with some solutions.”