Identifying personality disorders

An excerpt from “Psychiatry Essentials for Primary Care,”� new from ACP Press.


Most personality disorders go unrecognized or are misunderstood and misdiagnosed. The “essential” information for clinicians regarding personality disorders includes the following:

  • Knowledge and understanding of personality disorders and their different types and clusters (A, B, and C)
  • Common comorbidities found with personality disorders
  • Relative magnitude of the personality disorder and the clinician's countertransference when labeling a patient as “difficult”
  • Basic management strategies used in treating personality disorders
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The sooner clinicians realize that they are communicating with someone who has a personality disorder, the better. The interaction between the clinician and a patient with a personality disorder is frequently perceived by the clinician as awkward and uncomfortable. Communication becomes distorted by misperceptions and different expectations from both the clinician and the patient. What sustains the distorted pattern of communication is the mutual lack of awareness of the other's perception of the doctor–patient relationship. The patient with a personality disorder can only see and experience the interpersonal interactions rigidly. For the patient with a personality disorder, the communication feels “normal” (in the sense of expectable, not pleasurable) because this is what always happens. The self-aware clinician will feel uncomfortable and that something is amiss.

Though the clinician's emotional experience in relating to a patient with a personality disorder is often a negative one, positive feelings may be evoked, including paternalistic concern, pity, appreciation of being admired, and even sexual arousal. In any case, the awkward and tangled style of communication continues for as long as clinicians remain unaware that they are interacting with a patient with a personality disorder. The first step to end this dysfunctional interaction and engage in effective, healthy communication is for clinicians to realize that what they are saying is being misperceived and misunderstood by the patient and to assess the patient for a personality disorder. Maintaining clear boundaries within the clinician–patient relationship is key in the management of patients with personality disorders.

The four E's

It is easier to become aware of a personality disorder in a patient if the clinician knows the general diagnostic features that all disordered personalities possess. The DSM-IV's general diagnostic criteria for any personality disorder assume that the individual has a long-standing manner of interacting with others that produces tension and dysfunction, resulting in poor relationships and hampering work and social interactions. To aid in remembering the general criteria for any personality disorder, we use a mnemonic device, “the 4 E's”:

  • Early: The symptoms appear early in adulthood or adolescence.
  • Enduring: The symptoms endure throughout life.
  • Ego-syntonic: The manner of interacting with other people is not recognized as abnormal by the person with a personality disorder. Avoidant personality disorder is one exception because it is characterized by prominent anxiety associated with maladaptive behaviors, which frequently cause patients to feel disturbed by their own symptoms.
  • Externalization of conflict: The intensity of the maladaptive style of a patient with a personality disorder increases under stress. This increases the likelihood that people around the patient will respond in ways that reinforce the maladaptive coping strategy of the person with a personality disorder.

Externalization typically leads to a fifth “E” that stands for everyone else other than the person with the personality disorder. Everyone else is typically blamed for causing the stress experienced by the patient with a personality disorder, and everyone else experiences the discomfort that the patient avoids with his or her maladaptive behaviors.

The three clusters and the 10 personality disorders

If the patient's style of interacting meets the general diagnostic criteria (i.e., the 4 E's), then that individual most likely has a personality disorder. Of those people who meet diagnostic criteria for a personality disorder, 60% will meet criteria for at least one other personality disorder. In other words, “pure” personality disorder types are less common than a mixture of the types. With this high degree of overlap between personality disorders in mind, it is clinically more effective, efficient and important to consider which type it may be. The 10 personality disorders are divided into three clusters, and each cluster has predominant features that help distinguish it from the other clusters. Recognizing the style and predominant features of each cluster facilitates early awareness and, ultimately, recognition of the personality disorder if present. The following descriptions of each personality disorder are provided as illustrations to help clinicians recognize when they have encountered a patient with a personality disorder. Keep in mind that an individual patient may have characteristics of more than one personality disorder.

Cluster A (odd, eccentric)

Paranoid personality disorder

These individuals have pervasive distrust and suspicion of others and typically believe that others, including their treating clinician, are exploiting or deceiving them. Full disclosure about the reasons for certain tests or treatments helps minimize their tendency to search for hidden meaning in remarks or actions that others perceive as benign.

Schizoid personality disorder

Patients with schizoid personality disorder try to stay socially and emotionally detached from others, avoiding any close relationships and living their lives as much as possible in a solitary fashion. They are uncomfortable with what feels to them like the relative intimacy of medical outpatient and inpatient settings. They do not readily open up to their clinicians and so may not communicate vital information or ask important questions of their doctors. Since they are indifferent to the praise or criticism of others, it is more difficult for health care providers to influence their health behaviors.

Schizotypal personality disorder

Patients with schizotypal personality disorder have marked eccentricities that present as odd beliefs or magical thinking. Their vague and sometimes circumstantial speech may seem very anxious. However, the content of the conversation is about odd or highly idiosyncratic perceptual experiences or bodily illusions. It is best not to confront these ideas as “wrong” or “unfounded” but rather offer diagnosis and treatment in parallel with the odd beliefs. However, if the behaviors or beliefs are interfering with treatment (e.g., the patient will not take any pills that are colored, fearing “toxic reactions”) or causing significant medical problems (e.g., frequent ear infections because of cleaning with a Q-Tip dipped in bleach), then gentle confrontation and redirection are warranted. Also, make sure that the odd beliefs are not part of psychosis from another disorder (e.g., schizophrenia, depression with psychosis).

Cluster B (dramatic, emotional)

Antisocial personality disorder

Individuals with antisocial personality disorder (ASPD) demonstrate a pervasive pattern of disregard for the rights of others and the rules of society, including the rules and norms of the patient–clinician relationship. Clear, explicit communication about expectations and rules with resultant consequences for violations (e.g., no longer prescribing controlled substances, terminating treatment) is often required. Inappropriate drug seeking and disability seeking can provide early cues to ASPD.

Borderline personality disorder

Patients with borderline personality disorder have unstable and intense interpersonal relationships, including those with their health care providers, and their moods swing between overly positive idealization and angry denigration or feeling abandoned. Problems with impulse control that are potentially self-damaging (e.g., impetuous sexual activity, substance abuse, reckless driving) precipitate many of the patient's problems. Clinicians should try to provide a steady and consistent pattern of interaction, avoiding both being drawn in to “fix” the patient's problems (i.e., overinvolvement) and being driven away (i.e., abandonment). Establishment of realistic expectations, boundaries, and limits and (when the patient is willing) early referral to a mental health clinician are key in management.

Histrionic personality disorder

Histrionic patients' excessive emotionality and attention-seeking behavior are dramatic and often sexually provocative or seductive, but it is their tendency for vague, melodramatic, and impressionistic speech (e.g., “I feel like someone took a chainsaw to me”) that may lead the clinician to miss a diagnosis or misdiagnose. Dramatically expressed physical symptoms often initially lead clinicians into excessive testing, but subsequently, like the boy who cried wolf, the patient's “real” complaints may not be taken seriously. When dealing with histrionic patients the clinician should realize that what is being talked about is often not the problem. Thus the clinician should ask specific questions targeted toward likely diagnoses and be careful not to get pulled off track or into underreacting or overreacting.

Narcissistic personality disorder

The grandiose style and requirement for admiration of those with narcissistic personality disorder inspire angry reactions from others, including clinicians. The clinician's task is to not let the patient's exaggeration of his or her own talents or sense of entitlement interfere with sound medical treatment. Directly confronting the patient's inflated self-perceptions typically results in unpleasant and unproductive exchanges. Instead, an approach that includes redirection with an opening phrase like “You deserve the benefits of the best care so . . .” should yield more productive interactions.

Cluster C (anxious, fearful)

Avoidant personality disorder

The patient with avoidant personality disorder has an unreasonable fear of criticism, extreme social inhibition and feelings of inadequacy that make interactions very uncomfortable for both the patient and the clinician. The clinician should not be too aggressive but rather should be reassuring in style. Given the high degree of overlap with social phobia, exploration for additional symptoms or past mental health treatment is important.

Dependent personality disorder

The individual with dependent personality disorder has an excessive need to be taken care of, combined with a submissive nature and clinging behavior, which may ambush well-intending clinicians. Clinicians should resist assuming responsibility for making decisions for the patient despite the patient's perceived inability to do so. Rather, clinicians can offer choices between options and facilitate the patient's autonomous decision. Dependent patients resist this approach, but they also need the clinician and wish to please him or her, so they will try to make some decisions. It is a slow process but one that is far better than the needy and clingy behaviors that can also be present. Excessively gratifying the dependent patient's wishes to be taken care of can create an addiction to the doctor's attentions and acute helplessness when the clinician inevitably is no longer able or willing to continue playing that role.

Obsessive-compulsive personality disorder

Perfectionist, preoccupied with order and control and therefore inflexible, patients with obsessive-compulsive personality disorder (OCPD) often come to their medical appointments with detailed lists and notes. They are likely to interpret medical advice very literally. They become very upset over minor scheduling or billing errors. Their expectation of ideal outcomes may make them intolerant of less-than-perfect results. While a person can have both obsessive-compulsive disorder (OCD) and OCPD (though this is uncommon), OCPD is not the same as OCD; that is, patients with OCPD do not characteristically have specific obsessions and compulsions.

Personality type

Personality types or character styles are important to distinguish from personality disorders. Personality types refer to less maladaptive ways of interacting with the world that do not produce the significant functional impairment seen with personality disorders. Like personality disorders, personality types rarely exist in pure forms; instead, they combine and blend with each other. Also, personality types tend to intensify when a person becomes ill. Generally, this intensified character style is less flexible than one's more adaptive, healthy personality type.

The “difficult patient”

The term “difficult patient” is highly subjective, and its meaning can vary from clinician to clinician. Some clinicians immediately consider a difficult patient as personality disordered; other clinicians never consider personality disorder. In Groves's classic article, “Taking Care of the Hateful Patient,” which was published in the New England Journal of Medicine in 1978, “hateful” (i.e., difficult) patients are described as those patients with whom clinicians are very uncomfortable. Making the doctor uncomfortable is not synonymous with having a personality disorder. In other words, not all patients with a personality disorder are difficult for their clinicians, and not all difficult patients have personality disorders. Other types of difficult patients include, for example, the assertive patient who may make the clinician uncomfortable with strong preferences and persistent questions (not uncommonly a patient who is a nurse or doctor), noncompliant patients, patients with psychosis and drug-seeking patients with substance abuse problems. It is important not to label patients as having a personality disorder just because they are assertive, noncompliant or otherwise “difficult.”

Case-finding strategies and management

Screening for personality disorder

In most cases, screening strategies are performed to detect disorders that have known effective treatments (i.e., colon cancer, breast cancer, hypertension, diabetes, major depression). In the case of personality disorders, there is no “cure” per se, and treatments focus on minimizing or containing the maladaptive behaviors and thereby reduce the morbidity of the personality disorders for the patient and those who come in contact with the patient. The purpose of screening for personality disorders is to identify patients whose maladaptive behaviors undermine their interpersonal interactions. For the clinician this means that, by recognizing such patients with maladaptive styles of coping and relating, one can avoid being drawn into dysfunctional doctor–patient relationships. While changing personality traits is difficult at best and takes a long time, clinicians can learn to readily avoid being provoked or otherwise drawn into unhelpful, negative responses to patients with personality disorders. First of all, the clinician has to be aware that there is a dysfunctional interaction and then recognize what pattern of features is present (e.g., odd, eccentric; dramatic, emotional; anxious, fearful), keeping in mind that a patient may well have traits of more than one specific personality disorder type.

Countertransference

One important component of a difficult clinician–patient relationship (even if the patient does not have a personality disorder) is the internal reaction the clinician has toward the patient, which is based on the clinician's internal state. This is called countertransference. Countertransference can be defined as the clinician unknowingly “transferring” or displacing onto the patient his or her own feelings in reaction to the emotions, experiences or problems of a person undergoing treatment. This can express itself as a clinician disproportionately liking or disliking a particular patient. In some cases, strong countertransference reactions reflect the clinician's own background, and the patient is only an innocent prompt to the clinician's memories. For example, the patient may remind the clinician of a family member or significant other person with whom the clinician had an intense emotional relationship. It is not “bad” for a clinician to have these feelings; indeed, it is inevitable. But if the clinician remains unaware of the feelings or of their true source, those feelings can distort the clinician's perceptions of and relationship with the patient.

Countertransference reactions to patients with personality disorders are especially likely and strong because the patients' behaviors can be very frustrating, as previously illustrated. This can be a hazardous situation, both because the reactions of the patient and clinician can become mutually inflamed and because the clinician's judgment can become clouded.

When a difficult patient, or any patient, provokes an intense emotional response, the clinician should stop and assess his or her own internal state as it pertains to the patient. This entails asking oneself, What is it about this patient that is getting to me? Is it something the patient is doing, or is this something about me? Or is it both?

Management strategies

The American Psychiatric Association (APA) Practice Guideline for treating borderline personality disorder serves as a good example to guide treatment for all personality disorders. The backbone of treatment is psychotherapy. The APA guidelines do not recommend a particular type but instead cite several different effective psychotherapies. Medications are directed toward comorbid conditions and symptom reduction. No drug therapy has been proven to resolve the personality disorders themselves.

The literature emphasizes that the goal of treatment is care and not cure. Over time, where adaptive corrective interactions are repeated sufficiently, many patients will stabilize and some, particularly those with comorbid conditions that are adequately treated, will improve. Patients with personality disorders present management challenges for any clinician. Clinicians should have a low threshold for referring the patient for psychiatric consultation and psychotherapy.