Nicholas Morcos, MD; Roy Morcos, MD, FAAFP Personality disorders: Department of Psychiatry, University of Michigan Health System, Ann Arbor A measured response (Dr. N. Morcos); St. Elizabeth Boardman Hospital, Mercy Health, Ohio (Dr. R. Morcos) Improving your understanding of these disorders will help you identify specific diagnoses, ensure appropriate [email protected]. edu treatment, and reduce frustration during office visits. The authors reported no potential conflict of interest relevant to this article.

ersonality disorders (PDs) are common, affecting up PRACTICE to 15% of US adults, and are associated with comorbid RECOMMENDATIONS medical and psychiatric conditions and increased utili- ❯ Maintain a high index of P 1,2 zation of health care resources. Having a basic understand- suspicion for personality ing of these patterns of thinking and behaving can help family disorders (PDs) in patients who appear to be “difficult,” physicians (FPs) identify specific PD diagnoses, ensure appro- and take care to distinguish priate treatment, and reduce the frustration that arises when these diagnoses from primary an individual is viewed as a “difficult patient.” mood, anxiety, and Here we describe the diagnostic features of the disorders psychotic disorders. C in the 3 major clusters of PDs and review an effective approach ❯ Refer patients with PDs for to the management of the most common disorder in each clus- psychotherapy, as it is ter, using a case study patient. considered the mainstay of treatment—particularly for borderline PD. B Defense mechanisms offer clues ❯ Use pharmacotherapy that your patient may have a PD judiciously as an adjunctive Personality is an enduring pattern of inner experience and treatment for PD. B behaviors that is relatively stable across time and in different situations. Such traits comprise an individual’s inherent make- Strength of recommendation (SOR) up.1 PDs are diagnosed when an individual’s personality traits A Good-quality patient-oriented evidence create significant distress or impairment in daily functioning. B Inconsistent or limited-quality Specifically, PDs have a negative impact on cognition, affect, patient-oriented evidence interpersonal relationships, and/or impulse control.1  C Consensus, usual practice, opinion, disease-oriented One of the ways people alleviate distress is by using de- evidence, case series fense mechanisms. Defense mechanisms are unconscious mental processes that individuals use to resolve conflicts, and thereby reduce anxiety and depression on a conscious level. Taken alone, defense mechanisms are not pathologic, but they may become maladaptive in certain stressful circumstances, such as when receiving medical treatment. Recognizing pat- terns of chronic use of certain defense mechanisms may be a clue that your patient has a PD. TABLE 13,4 and TABLE 23,4 provide an overview of common defense mechanisms used by patients with PDs. The American Psychiatric Association’s Diagnostic and

90 THE JOURNAL OF FAMILY PRACTICE | FEBRUARY 2016 | VOL 65, NO 2 Does your patient complain that you don't understand him "the way his other doctor did"? Or does he frequently lose his temper? Perhaps it's time to consider a personality disorder.

Statistical Manual of Mental Disorders, 5th of a statin, which he believes was adulterated edition (DSM-5) organizes PDs into 3 clus- by the government to be sold at lower cost. ters based on similar and often overlapping Mr. A demonstrates the odd and eccen- symptoms.1 TABLE 31 provides a brief sum- tric beliefs that characterize schizotypal per- mary of the characteristic features of each sonality disorder. How can his FP best help him disorder in these clusters. adhere to his medication regimen? (For the answer, go to page 96.)

Cluster A: Odd, eccentric ❚ Schizotypal personality disorder shares Patients with one of these disorders are odd, certain disturbances of thought with schizo- eccentric, or bizarre in their behavior and phrenia, and is believed to exist on a spectrum thinking. There appears to be a genetic link with other primary psychotic disorders. Sup- between cluster A PDs (especially schizotypal) port for this theory comes from the higher rates and schizophrenia.5 These patients rarely seek of schizotypal PD among family members of treatment for their disorder because they have patients with schizophrenia. There is a genetic limited insight into their maladaptive traits.5,6 component to the disorder.3,5,6 Clinically, these patients appear odd CASE 1 u Daniel A, age 57, has hypertension and eccentric with unusual beliefs. They may and hyperlipidemia and comes in to see his have a fascination with magic, clairvoyance, FP for a 6-month follow-up appointment. He telepathy, or other such notions.1,5 Although never misses appointments, but has a history of the perceptual disturbances are unusual and poor adherence with prescribed medications. often bizarre, they are not frank delusions: He enjoys his discussions with you in the office, patients with schizotypal PD are willing to although he often perseverates on conspiracy consider alternative explanations for their theories. He lives alone and has never been beliefs and can engage in rational discussion. IMAGE: ©JOE GORMAN married. He believes that some of the previ- Cognitive deficits, particularly of memory ously prescribed medications, including a statin and attention, are common and distressing to and a thiazide diuretic, were interfering with patients. Frequently, the presenting complaint the absorption of “positive nutrients” in his is depression and anxiety due to the emotional diet. He also refuses to take the generic form discord and isolation from others.1,3,5,6 CONTINUED

JFPONLINE.COM VOL 65, NO 2 | FEBRUARY 2016 | THE JOURNAL OF FAMILY PRACTICE 91 TABLE 1 How to respond when patients use these common immature defense mechanisms3,4

Defense Definition Example Management strategies Sample statements mechanism Acting out Patient is unable to A patient screams The main goal is to quickly, and “It is difficult for me contain an impulse, which at the physician and safely, de-escalate the situation. to help you when you can manifest in yelling, threatens to sue Removing oneself from the are screaming. Can we agitation, or even violence. because the patient situation may be needed if safety address your concerns did not receive a is a concern. calmly?” prescription for opioid pain medication for chronic back pain. Splitting Patient has polarized views “My nurse under- Anticipate distinct views of staff “I can see that you are of others as “all good” or stands exactly what and meet with the patient as a upset. Let’s talk about “all bad.” These extreme I am going through, group to present a unified front. how the team and I can views of idealization and but my doctors don’t Recognize that patients’ views of help you.” devaluation can apply to listen to me or their physicians will change over different individuals or understand me at time. With this in mind, do not can be used to describe all—not like at the react strongly to criticism one one individual on separate other hospital.” week and extreme praise the occasions. next. Use splitting to your advan- tage by having a well-liked team member lead discussions with the patient. Passive Patient expresses anger in A patient may stop Recognize that the patient has “What can I do to aggression the form of failure, taking medications anger or hostility and help him to ensure that you get the procrastination, or intentionally “vent” his anger. best possible care?” provocative behavior, arrive late to self-demeaning appointments statements, or because the self-sabotage. physician is perceived to have wronged the patient in some way. Somatization Patient expresses A patient presents This is very challenging to man- “It may be that we psychological distress via with pain that is age. Use empathic statements don’t arrive at a physical symptoms or out of proportion (“This must be awful to deal definitive explanation complaints. to what is found on with”), which may disarm the for your pain or examination and patient and improve rapport. completely eliminate it, studies. Somatiza- Provide evidence-based care and but in the meantime, tion may take on a don't order unnecessary testing let’s focus on ways to delusional quality. at the patient’s insistence. Provide help you manage it in frequent follow-up and your daily routine.” reassurance.

Cluster B: Dramatic, erratic lization can be substantial. Because indi- Patients with cluster B PDs are dramatic, viduals with one of these PDs sometimes excessively emotional, confrontational, exhibit reckless and impulsive behavior, erratic, and impulsive in their behaviors.1 physicians should be aware these patients They often have comorbid mood and anxi- have a high risk of physical injuries (fights, ety disorders, as well as a disproportion- accidents, self-injurious behavior), suicide ately high co-occurrence of functional attempts, risky sexual behaviors, and un- disorders.3,7 Their rates of health care uti- planned pregnancy.8,9

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TABLE 2 How to respond when patients use neurotic defense mechanisms*3,4

Management Defense mechanism Definition Example Sample statements strategies Isolation of affect Patient separates A patient may speak Provide empathy and “Many people may feel the emotional about witnessing the support, and encour- upset in your situation, response to an death of a loved one in a age patients to feel and I hope you would feel event from the calm, matter-of-fact way. comfortable sharing comfortable sharing any thoughts about that their emotions. concerns you have if they event. arise.” Rationalization Patient justifies A patient might state Engage in a factual “I can see how you might attitudes, behavior, that a 30-lb weight gain discussion with the view it that way, but I’m or emotions by in the first trimester of patient in an wondering if you can see attributing them to pregnancy is healthy empathic tone. These any “downsides” to those an incorrect reason. to ensure that the patients may be likely thoughts.” developing fetus will be to recognize that well-nourished. their behavior is not ideal and may be willing or motivated to make changes. Intellectualization Patient attempts to A patient without a Provide the “I applaud you for being control affect and medical background patient with as much so invested in your emotions about an might extensively review information as is medical care. I’m also experience by all of the literature on relevant and provide wondering how you are thinking about cardiac-bypass procedures resources for further coping with this diagnosis them instead of before having surgery. study. In this case, and treatment.” experiencing them. more knowledge may help alleviate fears and ensure ongoing adherence with treatment.

* Neurotic defense mechanisms can, at times, be adaptive or socially acceptable.

CASE 2 u Sheryl B is a 34-year-old new patient that he would have to carefully review her with a history of irritable bowel syndrome, case before continuing to prescribe benzodi- fibromyalgia, depression, and anxiety who azepines, she becomes tearful and argumenta- shows up for her appointment an hour late. tive, proclaiming, “You won’t give me the only She is upset and blames the office scheduler thing that will help me because you want me for not reminding her of the appointment. to be miserable!” She brings a list of medications from her previ- Ms. B exhibits many cluster B personal- ous physician that includes sertraline, clonaz- ity traits consistent with borderline PD. How epam, gabapentin, oxycodone, and as-needed should the FP respond to her claims? (For the alprazolam. She insists that her physician in- answer, go to page 96.) crease the dose of the benzodiazepines. A review of her medical history reveals ❚ Borderline PD is the most studied of the diagnoses of anxiety, bipolar disorder, and PDs. It can be a stigmatizing diagnosis, and posttraumatic stress disorder. Ms. B has also even experienced psychiatrists may hesitate engaged in superficial cutting since adoles- to inform patients of this diagnosis.10 Patients cence, often triggered by arguments with her with borderline PD may be erroneously di- boyfriend. Currently, she attributes her anxiety agnosed with bipolar disorder, treatment- and pain to not receiving the “correct medica- resistant depression, or posttraumatic stress tions” because of her transition from a previ- disorder because of a complicated clinical ous physician who “knew her better than any presentation, physician unfamiliarity with di- other doctor.” After the FP explains to Ms. B agnostic criteria, or the presence of genuine

JFPONLINE.COM VOL 65, NO 2 | FEBRUARY 2016 | THE JOURNAL OF FAMILY PRACTICE 93 TABLE 3 Clusters of personality disorders and characteristic features1

Cluster/disorder Features Cluster A Paranoid Excessive distrust and suspiciousness of others; pathologically jealous; interprets actions as demeaning, malevolent, threatening, or exploitative; ideas of reference (believes coincidences or innocuous events have strong personal significance) Schizoid Detachment from social interactions without a desire for close interpersonal relationships; restricted affect Schizotypal Eccentric beliefs without frank delusions; cognitive and perceptual disturbances; impaired social interactions Cluster B Antisocial Lack of empathy, with disregard for rights of others; deceitfulness, impulsivity, irresponsibility Borderline Unstable self-image; chronic feelings of emptiness; instability of interpersonal relationships; affective instability; self-harm behavior; hypersensitivity to rejection and fear of abandonment Histrionic Excessive attention-seeking behavior and emotionality; often excessively impressionistic and shallow Narcissistic Need for admiration; grandiosity in speech and behavior; lack of empathy for others, interpersonally exploitative; arrogant and haughty Cluster C Dependent Inability or extreme difficulty making own decisions; overly reliant on others; submissiveness; feelings of inadequacy; avoidance of confrontation Avoidant Feelings of inadequacy; hypersensitivity to rejection; social inhibition despite a desire to form close interpersonal relationships Obsessive-compulsive Preoccupation with details and rules; excessive organization; perfectionism, orderliness, miserliness; rigidity and stubbornness

comorbid conditions.3,11 ious, fearful, and worried. They have features The etiology of this disorder appears to be that overlap with anxiety disorders.15 multifactorial, and includes genetic predispo- sition, disruptive parent-child relationships CASE 3 u Judy C is a 40-year-old lawyer with (especially separation), and, often, past sexual a history of gastroesophageal reflux disorder, or physical trauma.9,12 hypertension, and anxiety who presents for Predominant clinical features include a 3-week follow-up visit after starting sertra- emotional lability, efforts to avoid abandon- line. The patient describes herself as a perfec- ment, extremes of idealization and devalu- tionist who has increased work-related stress ation, unstable and intense interpersonal recently because she has to “do extra work relationships, and impulsivity.1 Character- for my colleagues who don’t know how to get istically, these patients also engage in self- things done right.” She recently fired her as- injurious behaviors.13,14 Common defense sistant for “not understanding my filing sys- mechanisms used by patients with border- tem.” She appears formal and serious, often line PD include splitting (viewing others as looking at her watch during the evaluation. either all good or all bad), acting out (yelling, Ms. C demonstrates a pattern of perfec- agitation, or violence), and passive aggres- tionism, formality, and rigidity in thought and sion (TABLE 13,4). behavior characteristic of obsessive-compulsive PD. What treatment should her physician rec- ommend? (For the answer, go to page 97.) Cluster C: Anxious, fearful ❚ Obsessive-compulsive PD. Although Individuals with cluster C PDs appear anx- this disorder is associated with significant anxi-

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ety, patients often view the specific traits of ob- cumstances may allow for the judicious use sessive-compulsive PD, such as perfectionism, of medication, although prescribing strate- as desirable. Neurotic defense mechanisms are gies are based largely on clinical experience common, especially rationalization, intellec- and expert opinion. tualization, and isolation of affect TABLE( 23,4). Prescribers should emphasize a realistic These patients appear formal, rigid, and seri- perspective on treatment response, because ous, and are preoccupied with rules and order- research suggests at best a mild-moderate liness to achieve perfection.1 Significant anxiety response of some personality traits to phar- often arises from fear of making mistakes and macotherapy.11,22-25 There is no evidence ruminating on decision-making.1,11,15 for polypharmacy in treating PDs, and FPs Although some overlap exists between should allow for sufficient treatment dura- obsessive-compulsive disorder (OCD) and tion, switch medications rather than aug- obsessive-compulsive PD, patients with OCD ment ineffective treatments, and resist the exhibit distinct obsessions and associated urge to prescribe for every psychological compulsive behavior, whereas those with ob- crisis.11,22,25,26 sessive-compulsive PD do not.1 Patient safety should always be a con- In terms of treatment, it is generally ap- sideration when prescribing medication. propriate to recognize the 2 conditions as Because use of second-generation antipsy- distinct entities.15 OCD responds well to cog- chotics is associated with the metabolic nitive behavioral therapies and high-dose se- syndrome, the patient’s baseline weight and Unlike patients lective serotonin reuptake inhibitors (SSRIs).16 fasting glucose, lipids, and hemoglobin A1c with frank In contrast, there is little data that suggests levels should be obtained and monitored delusions, antidepressants are effective for obsessive- regularly. Weight gain can be particularly patients with compulsive PD, and treatment is aimed at distressing to patients, increase stress and schizotypal addressing comorbid anxiety with psycho- anxiety, and hinder the doctor-patient rela- personality therapy and pharmacotherapy, if needed.11,15 tionship.25 Finally, medications with abuse disorder are potential or that can be lethal in overdose willing to (eg, tricyclic antidepressants and benzodi- consider Psychotherapy for PD azepines) are best avoided in patients with alternative is the first-line treatment emotional lability and impulsivity.25,26 explanations for Psychotherapy is the most effective treatment their odd beliefs. for PDs.11,17,18 Several psychotherapies are used to treat these disorders, including dialecti- Tailor treatment to the specific PD cal behavioral therapy, schema therapy, and Tx for cluster A disorders. Few studies cognitive behavioral therapy (CBT). A recent have examined the effectiveness of psycho- study demonstrated the superiority of sev- therapies for cluster A disorders. Cognitive eral evidence-based psychotherapies for PD therapy may have benefit in addressing cog- compared to treatment-as-usual.17 Even more nitive distortions and social impairment in promising is that certain benefits have been schizotypal PD.11,12,22 There is little evidence demonstrated when psychotherapy is pro- supporting psychotherapy for paranoid PD, vided by clinicians without advanced mental because challenging patients’ beliefs in this health training.19-21 However, the benefits of form is likely to exacerbate paranoia. Low- therapies for specific disorders are often limit- dose risperidone has demonstrated some ed by lack of available data, patient preference, beneficial effects on perceptual disturbanc- and accessibility of resources. es; however, the adverse metabolic effects of this medication may outweigh any po- tential benefit, as these symptoms are often Limited evidence supports not distressing to patients.6,27 In comparison, pharmacotherapy patients often find deficits in memory and The use of pharmacotherapy for treating PDs attention to be more bothersome, and some is common, although there’s limited evi- data suggest that the alpha-2 agonist guanfa- dence to support the practice.11,22 Certain cir- cine may help treat these symptoms.28 CONTINUED

JFPONLINE.COM VOL 65, NO 2 | FEBRUARY 2016 | THE JOURNAL OF FAMILY PRACTICE 95 ❚ Tx for cluster B disorders. Several PDs.34 In contrast, there is little evidence to forms of psychotherapy have proven effective support the use of pharmacotherapy.35 How- in managing symptoms and improving overall ever, given the significant overlap among functioning in patients with borderline PD, in- these disorders (especially avoidant PD) cluding dialectical behavioral therapy, mental- and social phobia and generalized anxiety ization-based therapy, transference-focused disorder, effective pharmacologic strategies therapy, and schema therapy.29 Dialectical be- can be inferred based on data for those con- havioral therapy is often the initial treatment ditions.11 SSRIs, serotonin-norepinephrine because it emphasizes reducing self-harm be- reuptake inhibitors (eg, venlafaxine), and ga- haviors and emotion regulation.11,17,26 bapentin have demonstrated efficacy in anx- Gunderson19 developed a more basic iety disorders and are reasonable and safe approach to treating borderline PD that is initial treatments for patients with a cluster intended to be used by all clinicians who C PD.11,34 treat the disorder, and not just mental health professionals with advanced training in psy- CASE 1 u Mr. A’s schizotypal PD symptoms in- chotherapy. A large, multisite randomized terfere with medication adherence because of controlled trial found that the clinical efficacy his unusual belief system. Importantly, unlike of the technique, known as good psychiatric patients with frank delusions, patients with management, rivaled that of dialectical be- schizotypal PD are willing to consider alter- Patients often havioral therapy.20,21 native explanations for their unusual beliefs. view the The general premise is that clinicians Mr. A’s intense suspiciousness may indicate specific traits foster a therapeutic relationship that is sup- some degree of overlap between paranoid and of obsessive- portive, engaging, and flexible. Physicians schizotypal PDs. compulsive are encouraged to educate patients about The FP is patient and willing to listen to personality the disorder and emphasize improvement in Mr. A’s beliefs without devaluing them. To disorder, such as daily functioning. Clinicians should share the improve medication adherence, the FP offers perfectionism, diagnosis with patients, which may give pa- him reasonable alternatives with clear expla- as desirable. tients a sense of relief in having an accurate nations. (“I understand you have concerns diagnosis and allow them to fully invest in about previous medications. At the same diagnosis-specific treatments.19 time, it seems that managing your blood pres- Systematic reviews and meta-analyses sure and cholesterol is important to you. Can of studies that evaluated pharmacotherapy we discuss alternative treatments?”) for borderline PD often have had conflicting conclusions as a result of analyzing data from CASE 2 u In response to Ms. B’s borderline PD, underpowered studies with varying study de- the FP must be cautious to avoid reacting out signs.23,24,26,30,31 In targeting specific symptoms of frustration, which may upset the patient of the disorder, the most consistent evidence and validate her mistrust. The FP first reflects has supported the use of antipsychotics for her anger (“I can tell you are upset because cognitive perceptual disturbances; patients you don’t think I want to help you”), which commonly experience depersonalization or may allow her to calmly engage in a discus- out-of-body experiences.25 Additionally, the sion. He wants to recognize Ms. B’s dramatic use of antipsychotics and mood stabilizers behavior, but not reward it with added atten- (lamotrigine and topiramate) appears to be tion and unreasonable concessions. To help somewhat effective for managing emotional establish rapport, he provides a statement to lability and impulsivity.26,32,33 Despite the legitimize Ms. B’s concerns (“Many patients widespread use of SSRIs, a recent systematic would be frustrated during the process of review found the least support for these and changing physicians”). other antidepressants for management of The FP listens empathically to Ms. B, borderline PD.25 sets clear limits, and provides consistent and ❚ Tx for cluster C disorders. Some evi- evidence-based treatments. He also provides dence supports using cognitive and inter- early referral to psychotherapy, but to miti- personal psychotherapies to treat cluster C gate any perceived abandonment, he assures

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10. Vaillant GE. The beginning of wisdom is never calling a patient a Ms. B he will remain involved with her treat- borderline; or, the clinical management of immature defenses in ment. (“It sounds like managing your anxiety the treatment of individuals with personality disorders. J Psycho- ther Pract Res. 1992;1:117-134. is important to you, and often psychiatrists or 11. Bateman AW, Gunderson J, Mulder R. Treatment of personality therapists can help give additional options for disorder. Lancet. 2015;385:735-743. 12. Beck AT, Davis DD, Freeman A, eds. Cognitive therapy of person- treatment. I want you to know that I am still ality disorders. 3rd ed. New York, NY: Guilford Press, 2015. your doctor and we can review their recom- 13. O’Connor RC, Nock MK. The psychology of suicidal behaviour. Lancet Psychiatry. 2014;1:73-85. mendations together at our next visit.”) 14. Paris J. Understanding self-mutilation in borderline personality disorder. Harv Rev Psychiatry. 2005;13:179-185. CASE 3 u The FP recognizes that Ms. C’s pat- 15. Diedrich A, Voderholzer U. Obsessive-compulsive personality disorder: a current review. Curr Psychiatry Rep. 2015;17:2. tern of perfectionism, formality, and rigidity 16. Pittenger C, Bloch MH. Pharmacological treatment of obsessive- in thought and behavior are likely a manifes- compulsive disorder. Psychiatr Clin North Am. 2014;37:375-391. 17. Budge SL, Moore JT, Del Re AC, et al. The effectiveness of evi- tation of obsessive-compulsive PD, and that dence-based treatments for personality disorders when compar- ing treatment-as-usual and bona fide treatments. Clin Psychol the maladaptive psychological traits under- Rev. 2013;33:1057-1066. lying her anxiety are distinct from a primary 18. Leichsenring F, Leibing E. The effectiveness of psychody- namic therapy and cognitive behavior therapy in the treat- anxiety disorder. ment of personality disorders: a meta-analysis. Am J Psychiatry. An SSRI may be a reasonable option to 2003;160:1223-1232. 19. Gunderson JG, Links PS. Handbook of good psychiatric man- treat Ms. B’s anxiety, and the FP also refers her agement for borderline personality disorder. Washington, DC: for CBT. (“I can tell you are feeling really anx- American Psychiatric Publishing, 2014. 20. McMain SF, Links PS, Gnam WH, et al. A randomized trial of ious and many people feel that way, especially dialectical behavior therapy versus general psychiatric man- with work. I think the medication is a good agement for borderline personality disorder. Am J Psychiatry. 2009;166:1365-1374. Psychotherapy start, but I wonder if we could discuss other 21. McMain SF, Guimond T, Streiner DL, et al. Dialectical behavior can be forms of therapy to maximize your symptom therapy compared with general psychiatric management for bor- derline personality disorder: clinical outcomes and functioning beneficial for improvement.”) Because of their exacting na- over a 2-year follow-up. Am J Psychiatry. 2012;169:650-661. patients with ture, many patients with cluster C personality 22. Ripoll LH, Triebwasser J, Siever LJ. Evidence-based pharmaco- therapy for personality disorders. Int J Neuropsychopharmacol. personality traits are willing to engage in treatments, es- 2011;14:1257-1288. disorders, even pecially if they are supported by data and rec- 23. Coccaro EF. Clinical outcome of psychopharmacologic treatment of borderline and schizotypal personality disordered subjects. J when it is ommended by a knowledgeable physician. JFP Clin Psychiatry. 1998;59:30-35. provided by 24. Soloff PH. 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