Personality disorders are enduring patterns of behavior, thought, and feeling that deviate markedly from those accepted by an individual’s culture. They are pervasive over time, usually beginning in early adulthood, and lead to distress or impairment. Typically they arise from insufficient emotional development as a result of genetic predisposition, deficiencies in early nurturing, or stressful life experiences. When encountered on the inpatient medical ward, individuals with personality disorders frequently exhibit behaviors or feelings that cause tension between providers and the patient or between members of the healthcare team.
II. Diagnostic Approach.
A. What is the differential diagnosis for this problem?
Often a clinician will suspect a personality disorder when a patient manifests behaviors or expresses feelings that are generally unpleasant for others to experience. Other conditions that can result in these behaviors include poor sleep, uncontrolled pain, or an emotional response to illness or hospitalization (adjustment disorder). Acute psychosis should also be suspected in patients who exhibit Cluster A tendencies, as this cluster of personality disorders is predisposed to Axis I psychotic disorders.
B. Describe a diagnostic approach/method to the patient with this problem.
A review of the patient’s psychiatric history or discussion with the patient’s primary providers (including the psychiatric provider, if possible) may reveal that a personality disorder has already been diagnosed. These disorders frequently do not appear in “medical” problem lists and may not be divulged by the patient when the medical history is taken.
1. Historical information important in the diagnosis of this problem.
The diagnostic criteria for each personality disorder are listed in the DSM IV-TR. “Red flags” in the history that suggest a personality disorder include the following:
Cluster A – The “Mad” cluster. These personality disorders encompass alterations in what is generally perceived to be real. Individuals with these disorders are often described as odd or eccentric.
◦ Paranoid Personality Disorder
▪ Suspicion, without sufficient basis, that others are exploiting, harming, or deceiving him/her.
▪ Reluctance to confide in others as a result of fear that the information will be used maliciously against him/her.
◦ Schizoid Personality Disorder
▪ Lack of interest or enjoyment in close relationships, including familial and sexual relationships.
▪ Detached or emotionally cold responses, flattened affectivity.
▪ Odd, eccentric, peculiar behaviors; magical thinking.
▪ Suspicious or paranoid ideation.
▪ Social anxiety associated with paranoid (external) fears, not with negative internal judgments about self.
Cluster B – The “Bad” cluster. These disorders are characterized by dramatic, emotional behaviors.
◦ Antisocial Personality Disorder
▪ Repeatedly performing acts that are grounds for arrest.
▪ Disregard for the safety of self or others.
▪ Frequent physical fights or assaults.
▪ Lack of remorse for the mistreatment of others.
▪ Physical abuse of animals.
◦ Borderline Personality Disorder
▪ Self-induced injury including cutting, suicide attempts.
▪ Dissociative episodes in which the patient “withdraws” from reality for seconds to minutes in the setting of emotional distress.
▪ Problems with impulse control, often resulting in sexually promiscuous behaviors, binge eating, substance abuse, spending money, reckless driving.
▪ Attention-seeking, provocative or seductive behaviors.
▪ Exaggerated or dramatic emotional expression.
▪ Need for admiration, sense of entitlement.
▪ Expanded sense of self-importance.
▪ Arrogant, haughty behaviors or attitudes.
Cluster C – The “Sad” cluster, with behaviors that appear driven by anxiety or fear.
▪ Avoidance of interpersonal relationships and interactions out of fear of shame or ridicule.
▪ Difficulty making commonplace decisions without excessive reassurance from others.
▪ Excessive fear of being left to take care of himself or herself.
▪ Preoccupation with details, rules, and orderliness to the exclusion of leisure and relationships.
▪ Miserly spending style, views money as “something to be hoarded for future catastrophes” (DSM-IV-TR).
2. Physical Examination maneuvers that are likely to be useful in diagnosing the cause of this problem.
The psychiatric interview is the most effective tool in diagnosing personality disorders. Practitioners should also monitor their own reactions to the patient; this is an effective tool in recognizing how best to approach a patient with a personality disorder or non-pathologic personality style. The reader is referred to the list of personality styles and common countertransference responses in the Management section of this article.
Physical exam findings that may suggest the presence of a personality disorder include:
In the borderline patient, evidence of self-induced injury including scars or cuts especially on the forearms.
In the schizotypal, poor grooming.
3. Laboratory, radiographic and other tests that are likely to be useful in diagnosing the cause of this problem.
Laboratory and radiographic tests are not useful in diagnosing personality disorders. There are numerous structured and validated diagnostic interviews that may be helpful though may not be of high utility on the inpatient medical ward.
Examples include the Diagnostic Interview for Borderlines, Revised (DIB-R) and the International Personality Disorder Examination (IPDE). They are most frequently administered by psychologists.
C. Criteria for Diagnosing Each Diagnosis in the Method Above.
For official diagnostic criteria for each personality disorder, see the DSM-IV-TR.
D. Over-utilized or “wasted” diagnostic tests associated with the evaluation of this problem.
III. Management while the Diagnostic Process is Proceeding.
A. Management of Clinical Problem Personality Disorders.
In the suicidal or violent patient, most typically encountered with borderline or antisocial personality disordered individuals, safety of the patient and staff is the primary concern. Eliminate access to weapons or objects that can be used for self-injurious behaviors (razors, knives, objects that can be sharpened) and consider constant observation by staff. Seek psychiatric consultation for management of acute suicidal or homicidal ideation.
Patients with Cluster A personality disorders exhibit behaviors that resemble psychosis or schizophrenia, and many patients within this cluster eventually develop schizophrenia. If acute psychosis is suspected, consider psychiatric consultation and/or antipsychotic medications.
Approach to understanding and managing the personality-disordered patient:
In general, “Understanding the defenses of another person allows us to empathize rather than condemn, to understand rather than dismiss.” (Vaillant, 1992).
The paranoid patient appears guarded or distrustful. He likely views medical illness as proof that the world is against him and may feel exploited by healthcare providers or are the subject of medical experimentation as opposed to being the recipient of well-intentioned care.
Countertransferrence responses experienced by providers include feelings of anger or defensiveness, as these patients often accuse providers of exploiting them or experimenting upon them.
Avoid taking a defensive stance. Maintain an interpersonal distance and avoid excessive warmth, as the patient may feel threatened by this. Do not confront irrational fears.
The schizoid patient may appear aloof or socially awkward. Medical illness will precipitate fears of intrusion or forced interactions with others.
Countertransference responses experienced by providers include sensing a lack of connection to the patient or frustrations that the patient is difficult to engage.
Be sure to respect the patient’s desire for privacy. Encourage a regular, predictable routine for the patient.
Borderline or Dependent:
The borderline or dependent patient appears needy, demanding, or clingy. Medical illness is perceived as a threat of abandonment.
Countertransference responses experienced by providers can be oppositional; one may feel needed and powerful, whereas another could feel overwhelmed and annoyed and may desire to avoid the patient.
Setting clear and defined limits with the patient is crucial. Establish a frequency and duration of time the patient can expect to talk with the doctor. Minimize discrepancies in what is communicated to the patient by other members of the team (nurses, therapists) by communicating regularly with these providers.
The histrionic patient may appear melodramatic or exhibit seductive behaviors. Medical illness may signify loss of love of attractiveness.
Countertransference responses include anxiety and impatience or attraction to the patient.
Set clear boundaries. Avoid confrontation. Attempt to strike a balance between warmth and formality.
The narcissistic patient can appear arrogant and vain. They can be excessively demanding and devalue others around them. Medical illness can provoke shame by threatening the self-concept of perfection and invulnerability.
Countertransference responses include anger, feelings of inferiority, or feelings of importance.
Resist the desire to challenge patient’s entitlement. Take a humble stance. Offer consultations if appropriate. Provide opportunities for patient to show off.
Patient appears meticulous and orderly. Medical illness represents loss of control over body and emotions.
Countertransference reactions may include admiration or anger.
Set routine. Provide choices to increase sense of control. Provide detailed information. Foster a collaborative approach.
Recommend psychotherapy, not medications, first to patients with personality disorders.
Psychotropic medications can be used to target symptoms associated with personality disorders, such as antipsychotics for Cluster A patients and SSRI’s for Cluster B patients, but should be avoided unless the patient will be in psychiatric or psychologic follow-up care.
Indications for psychiatry consultation:
To evaluate safety and need for inpatient psychiatric admission in the presence of suicidal, self-injurious, or homicidal/violent ideation or behaviors.
To distinguish between acute psychosis and Cluster A personality disorders.
Consider consultation for assistance in diagnosing and selecting pharmacotherapy for personality disorders.
B. Common Pitfalls and Side-Effects of Management of this Clinical Problem.
IV. What's the evidence?
Groves, MS, Muskin, PR, Levenson, JL. “Psychological Responses to Illness”. Textbook of Psychosomatic Medicine. 2004. pp. 67-88.
“Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision.”. 2000. pp. 685-730.
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- I. Problem/Condition.
- II. Diagnostic Approach.
- A. What is the differential diagnosis for this problem?
- B. Describe a diagnostic approach/method to the patient with this problem.
- 1. Historical information important in the diagnosis of this problem.
- 2. Physical Examination maneuvers that are likely to be useful in diagnosing the cause of this problem.
- 3. Laboratory, radiographic and other tests that are likely to be useful in diagnosing the cause of this problem.
- C. Criteria for Diagnosing Each Diagnosis in the Method Above.
- D. Over-utilized or “wasted” diagnostic tests associated with the evaluation of this problem.
- III. Management while the Diagnostic Process is Proceeding.
- A. Management of Clinical Problem Personality Disorders.
- B. Common Pitfalls and Side-Effects of Management of this Clinical Problem.
- IV. What's the evidence?