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 92 THE JOURNAL OF FAMILY PRACTICE | FEBRUARY 2016 | VOL 65, NO 2 PERSONALITY DISORDERS 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.