The DSM-IV describes various personality disorders, clustered into these categories: cluster A, odd-eccentric disorders (paranoid, schizoid, schizotypal); cluster B, dramatic-emotional disorders (antisocial, borderline, histrionic, narcissistic); and cluster C, anxious-fearful disorders (avoidant, dependent, obsessive-compulsive). Each cluster appears to be associated with certain axis I co-morbidities. The diagnostic index of suspicion is raised by the doctor’s own discomfort, high levels of frustration with the course of care, and complaints about the patient from the office staff. A more formal diagnosis may be established by careful history-taking or the use of one of several psychological or psychiatric diagnostic tools.20
Differential diagnosis requires confirmation of longterm patterns of functioning and ruling out of substance use disorders as the underlying cause of the disordered behavior. A variety of medical conditions may cause personality changes and should be considered as well, including tumors, head trauma, cerebrovascular disease, Huntington’s disease, epilepsy, CNS infections, endocrine conditions, autoimmune conditions, and chronic toxicity such as lead poisoning.
Cluster A Disorders
Cluster A includes paranoid, schizoid, and schizotypal personality disorders. Patients often experience mistrust or interpersonal aversion. Therefore these individuals do not typically self-refer for treatment and are often resistant to psychiatric referrals.17
Paranoid Personality Disorder. Paranoid personality disorder (PPD) patients are suspicious and mistrustful. They refuse responsibility for their own feelings and are often hostile, irritable, and angry.18 Muscular tension, inability to relax, and the need to scan the environment for clues may be evident on examination. Affect is often humorless and serious. Pathologic jealousy is often present.
Psychotherapy is the treatment of choice. Antianxiety agents such as diazepam may be helpful for agitation and anxiety.
The prevalence estimate for PPD is 0.5% to 2.5% in the general population1; the prevalence may be lower in a primary care population, as these patients tend to avoid care until their problems are advanced. PPD patients may appear business-like but have an underlying expectation of harm or trickery by the clinician. There is some evidence that PPD is genetically linked to paranoid schizophrenia or delusional disorder.21
Schizoid Personality Disorder. Schizoid personality disorder (SPD) is characterized by a lifelong pattern of social withdrawal. These individuals are often seen by others as eccentric, isolated, or lonely. Prevalence may be as high as 7.5% in the general population. Patients tend to select solitary jobs. It is difficult for them to tolerate eye contact during office visits, and spontaneous conversation is avoided. They may be fascinated with inanimate objects or metaphysical constructs. They give the impression of being cold and aloof, quiet, distant, seclusive, and unsociable. They seem to have little need for sexual activity or intimacy with others. SPD patients may appear eager for medical visits to end, may give limited information in response to questions, and may delay coming for medical visits until their problems are severe. Psychotherapy appears to be the treatment of choice.
Schizotypal Personality Disorder. The prevalence of schizotypal personality disorder (SzPD) is 3% in the general population21; but the prevalence may be lower in a primary care population, as these patients have difficulty with physical examinations and with direct communication with the physician. There is fairly strong evidence of SzPD being genetically linked to the schizophrenic spectrum.21 Patients have peculiar patterns of thinking, acting, and appearance. They are highly sensitive to others’ feelings, especially negative feelings, and they may be superstitious. The presenting picture of this disorder is easily confused with that of schizophrenia. Reports of suicide rates as high as 10% among SzPD patients are also reported in the literature.22 Antipsychotic and antidepressant medication may be useful for symptomatic relief.
Cluster B Disorders
Cluster B includes histrionic, narcissistic, antisocial, and borderline personality disorders. Patients with cluster B disorders can be manipulative and drug-seeking or disability-claim-seeking, but these disorders are extremely diverse. Borderline personality disorders are the most common cluster B disorders in the general population and the most commonly encountered in primary care, perhaps because these patients experience the greatest distress and impairment.
Histrionic Personality Disorder. The prevalence of histrionic personality disorder is estimated at 2% to 3% and is more frequently diagnosed in women.1 Patients may attempt to forget unacceptable feelings, ideas, or appointments with medical providers, and they may minimize the seriousness of their health problems. Essential features include dramatic, extroverted behavior by an excitable, emotional person. There may be remarkable forgetfulness of emotionally important material. Attention-seeking behavior is common, as are exaggeration and overdramatization. Temper tantrums, tears, and accusations may be displayed if the patient is not the center of attention or is not receiving praise or approval. Seductive behavior is common despite the fact that sexual dysfunctions are common as well.
Narcissistic Personality Disorder. The prevalence of narcissistic personality disorder is estimated as less than 1% in the general population1; the prevalence may be lower in a primary care population, as admitting medical problems is incompatible with the patient’s inflated sense of self and grandiose feelings of uniqueness. These patients cannot handle criticism, may be ambitious, and may have a “sense of entitlement.” Empathy is foreign to them and interpersonal exploitiveness common. There is less impulsivity than is seen with the borderline, histrionic, and antisocial disorders. Lithium and antidepressants may be of some use in symptom management.
Antisocial Personality Disorder. The prevalence of antisocial personality disorder is 3% among men and 1% among women; onset is usually before age 15.1 The prevalence may be higher in a primary care population, as these patients are among the disability-compensation and drug seekers. There is usually a family history of antisocial disorders. Neurologic findings often show soft signs and abnormal electroencephalographic (EEG) results. Initial presentation may be normal, even charming and ingratiating. However, the history usually reveals lying, truancy, runaways, thefts, fights, substance abuse, and so on. There is a lack of anxiety or depression that seems incongruous. Suicide threats and somatic preoccupations may be common but may lack reality. During adulthood, promiscuity, spousal abuse, child abuse and drunken driving are common events. There is rarely remorse for these actions. The patient may seem to lack a conscience. Symptoms of antisocial personality disorder may be secondary to premorbid alcohol or other substance abuse. With age, somatization disorder may become more prevalent. Pharmacotherapy is of limited use, especially in light of the drug abuse often present in this patient group.
Borderline Personality Disorder. The essential characteristic of borderline personality disorder (BPD) is instability of affect, mood, behavior, object relations, and self-image. In the ICD-10, BPD is called “emotionally unstable personality disorder.” The disorder is twice as common in women as in men; and in the general population the prevalence estimate is 2%.1 The prevalence may be higher in a primary care population, as these patients are attracted to medical settings. There is some evidence, not clear-cut, for genetic aspects of BPD. BPD patients tend to give primary care providers the most difficulty; and ironically family physicians are more likely to see them than any other specialist. These patients are often demanding of their physicians and difficult to refer to psychotherapists. BPD overlaps heavily with somatization disorders (see Chapter 34).
In contrast to such disorders as depression, which can be diagnosed from a review of relatively easily reported symptoms, the diagnosis here relies heavily on observing the patient’s style of interaction with providers and family. Typically, there is a dysfunctional family background. BPD and posttraumatic stress disorder (PTSD) overlap and are difficult to distinguish. Nowlis23 noted that one informal indicator of BPD is a relationship with the provider that always seems fragile, stormy, or inappropriate. The patient may also be exquisitely sensitive to loss or change in the health care team, as they are to any changes in the family structure. For this reason referrals elicit fear of abandonment and rejection in BPD patients. Dividing the staff and polarizing them into good and bad is also characteristic of BPD. BPD underlies most cases of Munchausen syndrome and false accusations of providers’ sexual improprieties.
Life seems to be an almost constant state of crisis for these patients. Mood swings are common, and “micro- psychotic episodes” may be present. There is usually repetitive, self-destructive action. Patients often complain about chronic feelings of emptiness, boredom, and loneliness, and despite the presence of many other affective states they are depressed most of the time. Long-term studies show a high incidence of major depressive disorder episodes. Psychotherapy is the treatment of choice, and social skills training may be helpful. Brief hospitalizations may be necessary.
Physicians must maintain appropriate time and financial boundaries and a professional and objective attitude with BPD patients. This care involves limit-setting but not harshness. Developing a sturdy, workable treatment relationship is one of the most difficult aspects of caring for BPD patients. Both extremes of constant availability and harsh limit-setting are destructive to the working alliance. A team approach is needed that typically includes family practice, social work, psychology, psychiatry, and perhaps family therapy. Skillful handling of the transition between providers (e.g., when residents graduate and must transfer care) is important. Patients may respond well to kindly transmitted information about their sensitivities; analyses of their boundary problems and immature defense mechanisms should be avoided. Although it is helpful for the provider to understand the conditions that give rise to BPD, it is not always helpful to try to explain them to the patient. Fragile borderline patients often experience an explanation as criticism. Caring for BPD patients may prompt the provider to seek his or her own sources of support within the professional community, such as Balint groups, psychotherapy, or team conferences.
Cluster C Disorders
Cluster C includes avoidant, dependent, and obsessive compulsive personality disorders. Dependent and obsessive compulsive personality disorders are most common.24 Cluster C is heavily co-morbid with axis I depression and anxiety disorders. Medical help is more frequently sought by these patients because of the prominence of worry
Avoidant Personality Disorder. The prevalence estimate for avoidant personality disorder is 0.5% to 1.0% in the general population.1 The prevalence may be lower in a primary care population, as these patients may be afraid to ask questions and delay seeking medical attention. A key feature of the disorder is extreme sensitivity to rejection coupled with a strong desire for companionship. These patients are commonly referred to as having an inferiority complex. The ICD-10 classifies it as “anxious personality disorder.” Because social inhibition is present, the disorder may be difficult to distinguish from social phobia. There is also a strong overlap with dependent personality disorder. Individual and group therapy are indicated, as are social skills training and assertiveness training. Symptoms of anxiety and depression may be treated with pharmacotherapy.
Dependent Personality Disorder. The prevalence of dependent personality disorder is unknown in the general population,1 but the prevalence may be higher in a primary care population, as these patients may attempt to get the physician to make decisions for them, have endless questions (which prolongs their visits and gives them more of a sense of being cared for), and are “noncompliant” (i.e., have difficulty with self-care responsibilities). A pattern of dependent and submissive behavior is present, as is extreme difficulty making decisions without excessive amounts of advice and reassurance. These patients may tolerate abusive or otherwise difficult partners for long periods as not to be alone. It may be difficult to distinguish this disorder from schizoid and schizotypal disorders. If high levels of anxiety are present, imipramine may be helpful; otherwise antianxiety and antidepressant medication may be helpful for symptom relief. Psychotherapy is usually indicated.
Obsessive Compulsive Personality Disorder. The prevalence estimate for obsessive compulsive personality disorder is 1% in the general population,1 the prevalence may be higher in a primary care population, as these patients may seek multiple opinions about the diagnosis and may meticulously document their symptoms. Key features include emotional constrictions, stubbornness, and indecisiveness. There is also pervasive perfectionism and inflexibility. These patients are preoccupied with rules, regulations, neatness, and details. They are often formal, serious, and humorless. They do show eagerness to please those whom they see as powerful. Disruptions in the routine precipitate substantial anxiety. There may not be the specific obsession or compulsion present in the axis I obsessive compulsive disorder, although these traits may occur during the course of the axis II disorder. Late- onset depressive disorders are common features of the later course. Severe disorders seem to respond to clonazepam. Clomipramine and fluoxetine may also be useful if obsessive compulsive symptoms break through.
Other Personality Disorders of Interest
Several additional disorders are commonly diagnosed by mental health professionals but are not DSM-IV diagnoses; they may be research diagnoses. They include (1) passive- aggressive personality disorder, called “negativistic personality disorder”; (2) sadomasochistic personality disorder; (3) personality change due to general medical condition (head trauma is usually the most common cause, but anabolic steroids can cause persistent alterations of personality as well); and (4) multiple personality disorder, or dissociative identity disorder, which is overdiagnosed in certain populations (amnesia for certain periods of time is a key feature).