Personality disorders are psychiatric disorders characterized by chronic patterns of inner experience and behavior that are inflexible and present across a broad range of situations. They have a marked impact on patients’ interpersonal relationships, and social and occupational functioning, and can lead to problematic interactions in the medical setting. By definition, the symptoms of personality disorders cannot be caused by a major psychiatric disorder as diagnosed in the Diagnostic and Statistical Manual of Mental Disorders, 4th ed. (DSM-IV), axis I,1 a medical disorder, or the effects of a substance. These disorders are coded on DSM-IV axis II, which is used to record personality disorders, personality traits, and mental retardation. This separate axis exists to ensure that appropriate attention is paid to these clinically significant disorders when a comprehensive psychiatric assessment is performed (Table 1).^1,2

Personality disorders are heterogeneous in their clinical features and etiology (Table 2).² Their symptom complexes are caused by combinations of hereditary temperamental traits, and environmental and developmental events. The relative percentages of genetic and environmental factors vary with each specific disorder.³

The lifetime prevalence of personality disorders in the general population is an estimated 10 to 13 percent.⁴ Based on structured surveys, the prevalence rates of personality disorders in primary care outpatient settings may be as high as 20 to 30 percent.^5–7 The treatment of medical and psychiatric disorders is more complicated in patients with comorbid personality disorders. Studies have documented poorer treatment outcomes and health status, and higher rates of health care use and costs in patients with comorbid personality disorders.^6,8–14 Many patients with whom physicians experience problematic relationships, and who have been referred to in the literature as patients who are “difficult” have personality disorders.^15,16

Diagnosis

The diagnosis of a personality disorder is based on the patient’s behavior over time in a variety of situations. In the primary care setting, many potential sources of diagnostic data are available. Some personality disorders may be readily apparent, while others may be noted only in the course of time, or by elicitation of a formal psychiatric and social history.²

In the clinical setting, the patient’s style of engagement may be inappropriate to the situation (e.g., distant, hostile, overly intimate, seductive, anxious). The interpersonal behavior of the patient also may elicit strong emotional reactions in the physician. There may be unrealistic expectations for the physician’s availability, time, and ability to help the patient. Medical and psychiatric illnesses may present in an atypical fashion, and may not respond as expected to treatment. Reactions to illness may exacerbate and intensify the patient’s personality characteristics, further hampering his or her ability to obtain proper care. The patient’s insight into the presence of these disorders is usually limited or absent.

The psychosocial functioning of patients with personality disorders can vary widely. These patients’ history of interpersonal relationships, educational and work history, psychiatric and substance abuse history, and legal history are important areas to review. Usually, marked impairments exist in significant areas of the patient’s life, such as intimate relationships or occupational functioning. Some patients are globally impaired and function marginally overall.

Patients may meet the criteria for more than one personality disorder. Comorbid mood, anxiety, and substance abuse disorders are common, and should be identified and treated. When symptoms that may indicate a personality disorder, such as increased dependency, social isolation, obsessions, or poor impulse control, are identified, it is important to view them within the context of the patient’s psychiatric and medical history.

Personality disorders are, by definition, chronic conditions. Patients with these disorders generally exhibit consistent patterns of behavior and coping throughout their adult lives. Axis I psychiatric disorders can present with patterns of symptoms similar to those of a personality disorder, but these symptoms usually have an identifiable onset, and remit or improve with appropriate treatment. A change in personality from baseline at any time, but particularly in adults and elderly persons, may indicate the onset of an axis I psychiatric disorder or a potentially serious underlying organic disorder.

When a personality change occurs, it is crucial to identify the new-onset condition that has precipitated the change (Table 3).¹ This includes conditions such as psychiatric disorders (e.g., depression), substance abuse disorders (e.g., alcohol dependence), medical disorders (e.g., hyperthyroidism), and neurologic disorders (e.g., early dementia).¹ An initial screening evaluation that includes a medical, psychiatric, and social history; mental status examination; and physical examination is necessary to help narrow the diagnostic possibilities. Further laboratory studies, central nervous system imaging, consultation, and treatment decisions are based on these data.

Characteristics and Management Strategies

Personality disorders are chronic conditions that require specific management strategies. In the primary care setting, most efforts focus on maintaining and supporting the physician-patient relationship and establishing a working alliance. The goal is to ensure that the patient is able to receive appropriate medical care despite the difficulty he or she may have in interacting with the physician and the health care system. Most primary care interventions are interpersonal, with specific management strategies depending on the disorder. In some cases, psychiatric consultation, formal psychotherapy, or pharmacologic treatment may be indicated (Table 4).¹⁷

CLUSTER A—THE ODD OR ECCENTRIC

Patients in this cluster—the paranoid, schizoid, and schizotypal—are uncomfortable in interpersonal situations, emotionally distant, difficult to engage, and isolative (Table 5).¹⁸ In addition, the paranoid patient exhibits marked distrust and suspicion, and the schizotypal patient exhibits strange or quasi-delusional beliefs. Collectively, this cluster often is referred to as the “schizophrenic spectrum cluster” because of similarities to patients with schizophrenia in terms of clinical presentation, management strategies, and response to pharmacotherapy. These patients do not respond appropriately to affective cues from the physician, and are unable to form connections on a basic emotional level. When dealing with these patients, many of the strategies commonly used to establish a therapeutic alliance are ineffective or counterproductive.

In the clinical setting, these patients may be reluctant to seek care because of the necessary personal contact, they may interact in a manner that is distant and odd, and they may have bizarre ideas regarding their illness. Attempts by the physician to become emotionally close or to delve into their personal issues are seen as intrusive and tend to distance them further. When interacting with these patients, physicians should respect their need for interpersonal distance and adopt a respectful, somewhat distant professional stance. Medical information should be conveyed in a clear, straightforward fashion. Additionally, with paranoid and schizotypal patients who exhibit distrust or strange ideas, it is important not to directly challenge these ideas or become distracted by them.

CLUSTER B—THE DRAMATIC, EMOTIONAL, OR ERRATIC

Patients in this cluster can be among the most challenging patients encountered in clinical settings (Table 6).¹⁸ They can be excessively demanding, manipulative, emotionally unstable, and interpersonally inappropriate. They may attempt to create relationships that cross professional boundaries and to place physicians in difficult or compromising positions. Physicians often experience strong emotional reactions to these patients. When dealing with such patients, physicians must be keenly aware of the issues of manipulative behavior, professional boundaries, limit setting, and monitoring their own emotional state.

The antisocial patient, with a persistent pattern of deceitfulness, impulsivity, and disregard for the rights of others, may present in the context of medicolegal issues, such as disability evaluation, seeking controlled substances, or in situations involving aggressive or violent behavior. Clinical scenarios involving possible malingering or substance abuse issues may raise “red flags” for this type of behavior. There also may be inconsistencies in the patient’s presentation, history, and physical examination. If the clinical picture indicates possible antisocial behavior, a thorough review of the patient’s history, objective examination and testing, and possible consultation are necessary. Findings, assessments, recommendations, and limits must be clearly and firmly communicated to the patient. In some circumstances, it may be appropriate to obtain psychiatric or legal consultation.

Managing borderline personality disorder can be difficult and confusing. Because of their instability in the multiple areas of interpersonal relationships, self image, affects, and impulsivity, these patients can present with a wide range of symptoms, including depression, anger, paranoia, extreme dependency, self mutilation, and alternating idealization and devaluation of the physician. Their lives tend to be chaotic. They transfer many of their dysfunctional feelings and conflicts to the physician and the medical encounter. A somewhat detached professional stance and clear limit setting in terms of availability, appointment frequency, appropriate behavior, and medication use are necessary to manage these patients successfully. It is crucial to monitor one’s own feelings, and to refrain from responding inappropriately to verbal attacks and manipulation. The development of a formal behavioral treatment plan and insistence on participation in psychiatric care may be necessary to establish an effective working relationship.

Histrionic patients are uncomfortable if they are not the center of attention. They tend to be emotionally demonstrative and seductive, and use their appearance to attract the attention of others. As a result, the implications of illness and aging may have a profound impact on their psychologic functioning. The physician should maintain an awareness of these patients’ interpersonal style, and be empathetic to their issues, while at the same time avoid responding inappropriately to emotional or seductive overtures. Additionally, the cognitive processes of these patients are overly emotional and impressionistic, leading to difficulties in dealing with facts, details, and decision making. As a result, they may require extra assistance in processing medical information.

Narcissistic patients, with their grandiose sense of self-importance, tend to be demanding and insist on special status and treatment in the physician-patient relationship. They can appear haughty and self-absorbed, exhibit denial of illness, and become easily enraged by perceived slights. The physician should try not to directly challenge their sense of entitlement, or to be put off by their anger and demands. Their concerns should be acknowledged, and they should be provided reassurance that they are receiving the best care available. Strategies that help patients to take an active role in dealing with their illnesses are helpful. Tactful negotiation and limit setting around patient demands for testing, treatment, and referrals may be necessary.

CLUSTER C—THE ANXIOUS OR FEARFUL

All patients in this cluster exhibit anxiety in some form (Table 7).¹⁸ Whether it is caused by fears of evaluation by others, abandonment, or loss of order, these patients experience uncomfortable ideas and sensations that cause distress and interfere with their functioning within the physician-patient relationship. The physician must use appropriate strategies to help allay this anxiety and establish an effective working relationship with these patients.

The patient with avoidant personality is essentially a shy, inhibited person who has feelings of inadequacy and low self-esteem. These patients are hypersensitive to perceived criticism, but have the capacity to develop appropriate relationships if they feel safe and accepted. These patients appear shy and withdrawn, may withhold information that they feel is potentially embarrassing, and may be reluctant to question or disagree with their physician. In the medical encounter, the physician should approach these patients with an accepting and attentive attitude, provide ample reassurance, and encourage them to report and discuss their symptoms and concerns.

The dependent patient struggles with the self-perception that he or she is unable to function adequately without the help of others. This leads to difficulties in decision making, motivation, assumption of responsibility, and in fears of being abandoned by significant others. Dependent patients go to excessive lengths to maintain their relationships and sense of safety. In the medical setting, particularly during times of illness, these patients rely heavily on their physician for guidance and support. Physicians can provide assistance, but must monitor their level of involvement, acknowledge their limitations, and resist making major decisions for the patient. Limits on the need for time and resources should be set empathetically and openly. Alternate sources of assistance, such as a family member, member of the clergy, or a therapist can be enlisted to help manage the patient in times of increased need.

Obsessive-compulsive patients are preoccupied with orderliness and control. They tend to “miss the forest for the trees” in their concern for details, rules, and organization. In the medical setting, they expect similar characteristics in their physician. These patients need to maintain a sense of control and become particularly anxious when dealing with uncertainty and “gray areas.” The physician must be aware of the patient’s style of information processing, and present medical issues in an appropriately organized format. However, caution should be exercised to prevent discussions from being derailed by the patient’s obsessional style. An effective tactic is to provide patients with assignments such as monitoring symptoms and reading on their condition, thus increasing their participation and sense of control. Offering reassurance and setting limits on time may be necessary.

PSYCHOPHARMACOLOGY

Psychotropic medications generally are viewed as an adjunctive treatment in the management of personality disorders. They can be helpful for some symptoms in some patients. Large studies are lacking, but an emerging body of data includes some small controlled studies. Three of the disorders, the schizotypal, borderline, and avoidant personalities, have received the most attention. Medication recommendations are based on extrapolations from these three disorders to the others in their respective clusters.

Specific medication-responsive target symptoms have been identified for each cluster. If these target symptoms are identified, a carefully monitored medication trial may be considered.Table 4¹⁷ describes the basic target symptoms and medications for each of the three personality disorder clusters. Clusters A and C have fairly straight-forward and limited target symptoms and medication options. Cluster B has multiple groupings of target symptoms and more complicated medication regimens. Psychiatric consultation should be considered for patients in whom the diagnosis is unclear, for complex treatment regimens, or for refractory symptoms.¹⁷