Personality Disorders

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[edit] Personality Disorders

Philip R. Muskin

Elizabeth Haase

The term personality refers to an individual's habitual and pervasive patterns of thinking, feeling, and acting. Personality has two main components: temperament and character. Temperament is "hard-wired," is not influenced by sociocultural learning, and includes the automatic elements of individual emotional response. In genetic and adopted twin studies, temperament has been shown to be 50% heritable, with the remainder encoded and fixed by random repetitive environmental experience. In contrast, character refers to elements of personality that mature over the life span and are 85% to 90% determined by nongenetic factors. These include advanced intellectual functions (e.g., abstract thinking), self-concept, typical fantasies, characteristic defenses and coping styles, repeating but individualized patterns of interpersonal interaction, values, and ideals.

The term personality disorder is used when the person's style of behavior "deviates markedly from the expectations of the individual's culture, is pervasive and inflexible…and leads to distress and impairment."^[1] The lifetime prevalence of personality disorders in a community sample is approximately 10% to 13%.^[2] However, 42% of patients referred from a primary care setting for a behavioral health assessment are found to have a personality disorder.^[3] The rates of personality disorders vary depending on the clinical population studied^[4] (Table 54-1). What patients with personality disorders think about themselves and how they deal with others cause difficulties at work and in relationships. They are poorly equipped to handle the complex situations and increased stress created by the sick role and the demands of medical care.

Table 54-1 Personality Disorder Rates in Various Clinical Populations

✢Axis II is for the personality disorders and mental retardation, and for noting maladaptive features of personality. All other psychiatric diagnoses are coded on Axis I.

[edit] CLASSIFICATION

The classification of personality disorders is controversial, with two major models: categorical and dimensional. The Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) uses a categorical model, in which personality disorders are diagnosed by the presence of a minimum number of prototypical features. This model establishes a "threshold" above which recognizable pathologic types are defined, in the same way hypertension is defined with consistent measurements above a certain number.

The dimensional model defines personality disorders as extremes of normal personality traits. Traits are identified on a continuum, using various conceptual schemas. For example, paranoia is seen as a pathologic form of a normally adaptive trait (i.e., vigilance toward the possibility of an external threat). The dimensional approach to personality is useful to the primary care physician for two reasons. First, under the stress of medical illness, a normal personality trait may appear suddenly dysfunctional, just as a normotensive patient may show "white-coat hypertension" on office visits. Recognizing that a normal trait is being expressed in an extreme form, then responding appropriately to these changes in the patient's behavior, helps the physician to work effectively with a distressed patient during a crisis. Second, since all patients have a personality but few have personality disorders, patients need their physicians to understand and respond to their personality style. A physician who notes "emotionally intense," "anxious," or "impulsive tendencies" can anticipate how these traits might require management under stress, for example, allowing the emotionally labile patient time for tears or stating to the impulsive patient, "You may want to terminate the chemotherapy when you get discouraged. How can we anticipate this?" Such approaches derive from knowledge about the dimensions of normal personality (Table 54-2).

Table 54-2 Personality Style–Personality Disorder Continuum

[edit] Psychologic Defenses

A third way of understanding patients with personality disorders, which is critical in working with medically ill patients, is by their typical level of psychologic defenses. A defense is an automatic psychologic mechanism used to handle "psychic danger," that is, anxiety arising when a person experiences a conflict between inner wishes or drives and the demands of reality. Defenses are most adaptive when they allow maximal expression of wishes and needs with a minimum of negative consequences. Four levels of defenses are grouped by how effectively they allow a patient to express needs and wishes without causing negative external consequences.^[5] Many people employ a mixture of these levels at various times. An otherwise stable individual may use lower level defenses when confronted with a serious medical illness; this is called regression. The levels of defense are mature, neurotic, borderline, and psychotic (Box 54-1).

Mature defenses allow the person to deal most effectively with the demands of real life and inner psychologic conflicts. This level of defense allows for flexibility and adaptability in people. Neurotic defenses are less adaptable because the person's psychologic conflicts limit the emotional options. When stressed, patients who use neurotic defenses primarily can become problem patients. Their anxiety, need for information, depression, or need for attention can block the physician's delivery of care. Borderline defenses are based on a psychologic process known as splitting. Patients who rely on splitting see themselves and others in totally black or white terms, and they may rapidly change their perceptions from one to the other. Because this prevents them from having an integrated and modulated view of events, they are prone to transient episodes of misperception, derealization, depersonalization, and moments of temporary psychosis that severely limit their ability to respond to medically challenging situations. These patients are often classified as "difficult" by their physicians.

For patients using psychotic defenses, reality is too painful to be experienced. Patients may deny that they are ill at all, although not every patient who does so or who refuses treatment is psychotic.^[6][7] Psychotic patients may accept that they are ill but have delusions about the etiology (e.g., voodoo curse). Some psychotic patients function well during a medical illness, but many require extra attention, need pharmacologic treatment of their psychiatric symptoms, and benefit greatly from a psychiatric consultation.

A strong correlation exists between the level of defenses used by the person and global measures of mental health. In primary medical practice this assessment is crucial because it guides the physician in predicting how a patient will cope with medical illness, what measures will support the patient psychologically, and what issues may arise that turn the person into a "difficult patient."

[edit] ETIOLOGY

Psychoanalytic theory contends that personality structure arises from a child's drives and wishes interacting with the environmental feedback received from parents, siblings, and others. Freud believed that the child was born with certain temperamental dispositions that developed in discrete stages: oral, anal, and genital. Stressful life experiences at these early stages were seen to have a permanent impact on personality formation.

This view is remarkably consistent with current scientific consensus about the etiology of personality disorders. Certain personality traits are clearly genetically determined. The environment can have a protective or a destabilizing effect on patients with these biologic vulnerabilities. Environment and genetics can interact; an individual's psychologic perception of external events is modulated from birth by temperament, so a "shared environment" does not have the same impact on every member of a family. An anxious child may experience parents as more aggressive than a relaxed child. Also, because genes appear to turn on and off during different stages of development, these genetic predispositions may increase or decrease as the child grows up.

People with personality disorders report more experiences of physical and sexual abuse than those without disorders. Their histories are notable for sustained deficits in care; an isolated incident of severe abuse is much less predictive of personality disorder than chronic moderate neglect. The incidence of abuse is highest for patients with borderline and antisocial personality disorders, approaching 60% in borderline patients.^[8]

[edit] PATIENT EVALUATION

Patients with personality disorders are often viewed as difficult patients.^[9][10] Their distorted views, maladaptive defenses, and interpersonal abrasiveness thwart effective care. Such patients frustrate physicians by noncompliance and self-destructive health behavior. They communicate their needs poorly through repeated and vague complaints, which consume time and waste resources. They are simultaneously clinging and hostile, or "hateful patients."^[11] Physicians dread their visits, hope they will not return, and are reluctant to schedule return visits. The physician often feels inadequate, helpless, rageful, and guilty or feels "tricked" after patient encounters. Finding a patient "difficult" is usually the physician's first clue to the presence of a personality disorder. Many problems in the physician-patient relationship, however, are not caused by personality disorders. Patients' reactions to the fear of illness, the differing expectations of the social role of the patient and physician, and sociocultural pressures influencing the humane practice of medicine all can have a negative impact on the patient-physician relationship.

[edit] Initial Assessment

The medical encounter evokes within patients many aspects of the parent-child relationship. Physicians touch, care for, sometimes hurt, and often tell their patients what to do. As with children, patients occasionally depend on the physician for functions they normally perform independently. The stimulation of childhood fears in the patient and the parental functions of the physician in the medical encounter leads to regression. In regression, patients stop using more mature behavior and defenses and fall back on earlier coping skills. A common example of regression is a child's return to bed-wetting or thumb-sucking after the birth of a sibling. A patient's ability to relinquish control temporarily when ill may facilitate medical care; however, the person's overall function may be more childlike, less reality oriented, less stable, and less able to respond efficiently to others' needs. This behavior may surprise the physician. When regressed, a patient uses primitive defenses. In every setting, people unconsciously expect and recreate patterns of behavior with former caregivers. This phenomenon is known as transference because early relationships are transferred into a new, often inappropriate, situation.

The limitations on confidentiality, reimbursement, and flexibility in medical care have resulted in new difficulties in the physician-patient relationship that do not reflect personality disorders. Patients are more vigilant and suspicious; physicians are more frustrated, and their time, authority, and ability to evaluate and treat patients seem compromised. Such issues are best addressed with open acknowledgment of the realities affecting each party.

[edit] Assessment for Medical Causes

The next step in the assessment of difficult or unusual behavior is an evaluation for medical and psychiatric illness that may exacerbate underlying personality traits or mimic traits of a personality disorder. A medical illness that is responsible for a change in the patient's behavior may respond to pharmacologic treatment, whereas personality disorders require management in the primary care setting.

An axis I DSM-IV psychiatric disorder is likely in more than 60% of patients labeled as difficult, especially somatoform disorders, major depression, dysthymia, alcohol abuse, generalized anxiety disorder, and panic disorder. Axis I psychiatric illness influences personality in two ways. First, apparent personality traits may be symptoms of a psychiatric illness (Table 54-3). Seductive dress may be an expression of mania; pill noncompliance may be an expression of a specific phobia of choking. Such patients may seek medical care at times of greater mental, not physical, disturbance. Treating the psychiatric disorder may curtail the acute dramatic expressions of personality disturbance. For example, an untreated major depressive disorder in a patient with borderline personality disorder and bulimia could present as increased self-induced vomiting, with the resultant medical complications.

Table 54-3 DSM-IV Axis I Disorders That May Simulate Personality Problems

It cannot be overemphasized how often medical illnesses and medications used in medical practice disturb personality (Box 54-2). Prominent among these are the dementias, vascular diseases of the brain, bulbar diseases, seizure disorders, and other chronic neurologic illnesses. Generally, such disorders cause existing personality traits to become more rigid and extreme, although many patients develop de novo changes in personality or new features. For example, temporal lobe epilepsy may lead to the development of schizotypal features (e.g., stereotyped interests) or parapsychotic experiences (e.g., derealization).

[edit] Physician Responses

Recognition of an underlying personality disorder often starts with a physician's awareness of uncharacteristic responses to a patient. These patients are often difficult, draining, or unrewarding. Patients with personality disorders evoke three patterns of unusual subjective response. First, emotional responses to such patients tend to be stronger than usual and intrude into professional reasoning. Feelings of love or sexual arousal, or feelings of wanting to rescue a patient or give special care, may alternate rapidly with feelings of hate or betrayal. Physicians may have unusual fantasies about a patient in free hours, dream of a patient, or worry about the patient excessively. The feelings elicited by patients with personality disorders often compel physicians to atypical behaviors. Physicians may order extra tests to placate a patient and may offer free services or unreasonable availability. Such thoughts and behaviors reflect the physician's response to the intensity of the patient's emotional needs. Because they arise in reaction to, or counter to, the patient's transferred expectations of interpersonal relationships, these expressions are known as countertransference. These experiences are the cue to a physician that the patient's personality dynamics are impacting on the professional relationship.

[edit] MANAGEMENT

Primary care physicians frequently see and must adeptly manage the common personality types in medical practice, but they rarely need to make formal DSM-IV personality diagnoses. Awareness of a problem is typically more useful than a DSM-IV personality diagnosis. A general management approach for patients with more severe personality disorders can prevent many disruptive explosions in the physician's office. General techniques that diffuse conflict include the following:

• Consistency. Strategies that help difficult patients manage medical care include minimizing changes in plans, medications, schedules, and personnel; making sure all staff respond to a patient with the same information; clarifying the length and time of visits in advance; and anticipating and planning for vacations and future events explicitly. Consistency is particularly important for dependent and borderline patients.
  
• Clarifying the treatment contract. Exploring the patient's hopes regarding treatment and explaining the rationale, method, limits, and objectives of treatment can prevent disappointments and misunderstandings, to which such patients may react dramatically. Paranoid, obsessive-compulsive, and narcissistic patients may especially benefit from this approach.
  
• Limit setting. Explaining which behaviors and requests will or will not be allowed forms the foundation of management techniques. The physician must not be manipulated or intimidated by the patient or be punitive or rejecting of the patient. Both are overreactions to patients' behavior, often their aggression. A confident, balanced, and supportive approach works best, allowing unimportant behaviors to go unchallenged while standing firm on disruptive or dangerous outbursts. Examples include providing physical therapy, but not narcotics, for patients with a history of addiction, and hearing out a patient's anger, but clarifying that throwing things will not be accepted.
  

Beyond general strategies, particular character styles can generate extreme reactions in physicians. Groves^[11] identifies four common "hateful" personality types: dependent clingers, entitled demanders, manipulative helprejecters, and self-destructive deniers. These patients always seem to be entitled and dependent while simultaneously hopelessly filled with rejecting self-hatred. They are destructive of care, which can provoke punishment, attack, or withdrawal from their physicians. Kahana and Bibring^[12] list seven categories of difficult medical patients (with approximately corresponding DSM-IV diagnoses): (1) dependent/needy (borderline, dependent), (2) orderly/controlled (obsessive-compulsive), (3) dramatizing/captivating (histrionic), (4) long suffering/self-sacrificing (self-defeating), (5) guarded/querulous (paranoid), (6) superior (narcissistic), and (7) uninvolved/aloof (schizoid, avoidant). Table 54-4 outlines interventions for these particular styles.

Table 54-4 Personality Types and Management Recommendations

The following sections focus on the five most common and most troublesome behaviors—anger, anxiety, sadness, seductiveness, and suspiciousness—and ways for the physician to address these behaviors productively. The key is to (1) understand why the patient is responding in a particular manner, (2) attempt to demonstrate that understanding to the patient, and (3) legitimize or validate the emotion as understandable given what the patient is experiencing. This is an operationalized definition of empathy, which will solve these problems. Inappropriate responses can then be gently confronted as not in keeping with the reality of the situation as experienced by the physician.

[edit] Anger

Although any of the personality types may respond with anger when confronted with frightening medical news, antisocial, borderline, and paranoid personalities are most likely to respond this way. People who rely on facts to control their world (i.e., obsessional people) may also respond with anger if they feel they are not being given adequate information. The anger may be overtly or subtly expressed. Anger frightens other people, including physicians; the initial response is to engage the "flight-or-fight" mechanisms. One approach is not to react to the patient but to think for a moment and then respond. During that moment the physician understands that anger is an emotion that substitutes for fear. Telling patients that what they experience as the "real" emotion is not real will be heard as invalidating and will be rejected. Saying instead, "I see that you are angry, but I am not sure I understand what is causing you to feel this way," may be more successful than presenting psychologic interpretation. Once the patient has explained the feelings, the physician can follow up with, "It is understandable that you would feel angry given what you have said. I think we can work this out together." The physician then outlines a plan to deal with the issues; not retaliating with more anger reassures the patient of good intentions. At times the only approach may be to suggest that some time elapse before talking again, then schedule the next conversation. The physician can disagree with the anger but still respect the person's need to feel angry.

[edit] Anxiety

Anxious responses may take several forms, some of which may not appear as anxiety to the physician. The overtly anxious person is most helped by the physician identifying that the anxiety is understandable. Understandable does not mean the physician shares the patient's anxiety and cannot face a realistic appraisal of the situation. "You are much too anxious given what I have told you," is less effective than, "I appreciate that what we are discussing is making you anxious, but I want you to know I see this as something we can deal with together effectively." By adding the word "together," the physician establishes partnership with the patient, which is calming.

Patients who have an obsessional personality style may demonstrate their anxiety by asking many questions, often repeatedly. Their demand on time will be frustrating to the physician. In this situation the empathic response is first to identify the behavior (i.e., the repetitive questions or the need to know more and more). The physician might say, "I realize that we have been over this before. Perhaps I have not done an adequate job of explaining this to you, so let me review it now. Sometimes, when people are anxious about hearing bad news, they miss the facts and then don't feel that they know enough. I want you to understand thoroughly what is going on." Obsessional people do best when they have information with which they can control their anxiety. Giving pamphlets to patients, suggesting appropriate research literature, or suggesting websites help the patient to contain the emotions. Acknowledging that the patient is "distressed" or that the illness has caused anxiety helps the patient consider the repeated questioning as anxiety rather than as necessary information seeking. This also helps when patients blame physicians for not providing enough information.

[edit] Sadness

An important moment in a patient-physician relationship occurs when the physician comments, "You look sad." Tears may come but are typically brief. If the physician fails to recognize and validate these feelings, the patient may regard the physician as insensitive and cold. Ignoring the sadness is most likely to result in noncompliance, missed follow-up visits, or a search for a new physician. Identifying and empathizing with the patient's sadness form the core of physician support. Any patient can feel sad, but this should alert the physician that this patient could be at risk for a mood disorder. Once identified as sadness appropriate to the condition, the physician can inquire at future visits about the patient's mood, sleep, appetite, and interest in activities. This brief assessment can be rapidly diagnostic for a major depressive disorder. When patients experience their physicians as compassionate and empathic, they are more likely to reveal important information. This allows the physician to understand the patient better, which leads to greater compliance and better overall health care. If left unidentified, the patient who becomes depressed may present with a variety of physical complaints that do not respond well to "medical" treatment. By acknowledging the patient's emotions, the physician can connect the emotions to physical symptoms, diagnose the depression, and offer effective treatment.

[edit] Seductiveness

Patients with antisocial, borderline, histrionic, and narcissistic personality styles may use seductive behavior with the physician. Seduction can vary from minimal to overtly sexual, but much of what constitutes seduction is not sexual in nature. The seductive behavior is the patient's attempt to feel in control of the situation; to ensure that the patient is admired, respected, or acceptable; and to control anxiety. Sexually seductive behavior makes most physicians uncomfortable because it threatens their professional identity with inappropriate impulses. A natural response is chastising the patient or becoming angry or rejecting. Patients who need to act seductively will then increase their seductive efforts to receive attention, or they will feel angry because they are not actually seeking sex. The behavior should not be ignored, however, since this is likely to yield the same result as chastisement. Having a nurse in the room during a physical examination may be a practical solution, but this is not appropriate in other situations. The patient may need to be told that the physician is uncomfortable, even though the patient may feel rejected. These patients need the reassurance that their illness does not make them less attractive, appealing, interesting, important, or powerful. Comments on these issues address the patient's psychologic needs and reduce the motivation to use seductive behavior to assuage underlying fears.

Seduction may occur in nonsexual ways, such as offering the physician favors, tickets, or gifts. All patients do this to some extent; the physician's psychologic reaction determines the seductive potential. If the physician feels uncomfortable with the type of gift, the expense, or the feeling of being beholden; feels envy for the patient's power, importance, or wealth; or feels incapable of saying no to an inappropriate request, the physician probably has been seduced. Similar to the handling of sexual behavior, prevention works quite well. Gifts can be gently refused, with the recommendation that the "grateful" patient make a charitable contribution. Acknowledging the patient's "specialness" is what the patient desires; accepting anything from the patient is not necessary to accomplish this goal.

[edit] Suspiciousness

Physicians assume they are trusted and dislike the experience of a patient who confronts them with, "I don't think you are doing the best for me," or, "I don't believe you are telling me the truth." Although antisocial, borderline, paranoid, and schizoid personality styles are most likely to take this approach, narcissistic and obsessive patients are also suspicious. The patient may be responding to the physician's discomfort with telling the patient about the illness. Patients deserve to hear the truth about their condition but do not need to be robbed of hope. In an attempt to find the right balance, the physician may convey an attitude of withholding information. Finding out what the patient already knows, what the patient thinks is occurring, and how much the patient wants to know helps guide information disclosure and prevent naturally suspicious patients from becoming more suspicious.

When patients fear they may not recover, when they find it difficult to cope with the demands of physical illness, and when the illness destabilizes their psychologic equilibrium, patients with antisocial, borderline, paranoid, and schizoid personality styles may handle their fears by regarding others as harming them. This maladaptive way of coping is psychologically easier. The suspiciousness makes the physician the enemy, an enemy who can be controlled (or so the patient believes). This replaces the fear that the illness cannot be controlled, a fear that is overwhelming for the person. Prevention is extremely useful in these situations. Recognizing which patients constantly question, never seem satisfied, and always act cheated or mistreated is a crucial preventive step for the physician. Informing these patients about tests in advance, reporting test results, and explaining the need for a procedure or treatment take extra time but are preferable to an unpleasant confrontation by the suspicious patient. The language of "entitlement" is also of great benefit when speaking with these patients. They respond to statements such as, "You deserve the best, which is why I want to do this test, to be sure we know what is going on. However, the procedure may cause you some discomfort."

[edit] TREATMENT

[edit] Referral

In general, patients with personality disorders serious enough to disrupt their lives or interfere with their health and medical care should receive careful referral to a mental health professional. Some patients will experience this referral as a rejection or as an abandonment by the physician. Reiterating the physician's intent to continue to provide medical care and providing psychologic support will aid in alleviating the patient's concerns. When patient behavior exceeds the limits of acceptability, the patient must be told that continued medical care is not possible under such circumstances. In these situations the physician should arrange a psychiatric consultation to understand the patient's behavior, and should attempt to control the behavior.

[edit] Psychotherapy

Personality disorders comprise diverse symptom clusters and ways of relating to others, and thus varied treatments can effectively target aspects of disturbance. Psychotherapy is the preferred treatment for personality disorders. Psychotherapy can be cognitive behavioral, family, or psychoanalytic in approach. Generally, psychodynamic and cognitive behavioral psychotherapy is highly effective for anxious, narcissistic, histrionic, and borderline personality disorders but less effective for paranoid, schizoid, and antisocial disorders. Dialectic behavioral therapy for borderline personality disorder is an example of specific psychotherapy. Short-term psychotherapy interventions may help patients handle specific acute stressors. Patients with personality disorders benefit most and permanently from psychotherapies lasting several years. Respectfully supporting the patient's courage in continuing such self-exploration can be invaluable to a long-term primary care relationship. The acute psychotherapeutic interventions may augment the physician's recommendation for a psychotherapy referral.

[edit] Psychopharmacology

Some aspects of personality disorders respond to psychopharmacologic treatment. Psychopharmacology is targeted to specific symptom clusters. The perceptual and cognitive distortions seen in borderline, schizotypal, and paranoid personalities may respond to low doses of neuroleptics such as haloperidol (Haldol), risperidone (Risperdal), or olanzapine (Zyprexa). Atypical presentations of depression, as well as more typical forms, can be treated with antidepressants. The decision regarding which medication to use is often dictated by side effects or drug interactions.^[13] The impulsive behavior seen in antisocial and borderline personalities often responds to anticonvulsants (e.g., carbamazepine, gabapentin, valproic acid). Benzodiazepines are not recommended for long-term treatment but may be useful in acutely stressful situations. Care should be taken in prescribing benzodiazepines to borderline and antisocial patients due to the risk of substance abuse. Buspirone is useful for patients with persistent anxiety, without the addiction concerns associated with the benzodiazepines. The antianxiety effect does not develop for several weeks. Pharmacologic treatment is best undertaken in consultation with a psychiatrist.

[edit] SUMMARY

The "difficult" patient may have a personality disorder that intrudes into all aspects of life, including the medical relationship. The person's typical style of behavior may not be an everyday problem but is causing a problem in the patient-physician relationship. The vast majority of these problem patients are dealt with effectively in the primary care setting by knowledgeable and compassionate physicians with the routine skills needed to deliver effective medical care.

[edit] REFERENCES

[edit] ADDITIONAL READINGS

• T Karasu, L Bellak: Brief psychotherapy of stress response syndromes. T Karasu Specialized techniques in individualized psychotherapy. New York: Brunner/Mazel; 1980:
• F Kass, A Skodol, E Charles,et al.: Scaled ratings of DSM-III personality disorder. Am J Psychiatry 1985; 142:627.
• JM Oldham: Personality disorders: current perspectives. JAMA 1994; 272:1770.
• JC Perry, SH Cooper: Empirical studies of psychological defense mechanisms. R Michelset al.: Psychiatry. New York: Lippincott-Raven; 1997:
• RA Sansone, MW Wiederman, LA Sansone,et al.: Early onset dysthymia and personality disturbance in a primary care setting. J Nerv Ment Dis 1998; 186:57.
• KR Silk: Biology of personality disorders. JM Oldham MD Riba Review of psychiatry series. Chicago: American Psychiatric Press; 1998:
• LF Sparr, JK Boehnlein, TG Cooney: The medical management of the paranoid patient. Gen Hosp Psychiatry 1996; 8:49.