Delineating the Interplay of Personality Disorders and Health

The nexus of personality and health is a challenging and, at times, vexing issue in behavioral medicine. While the integration of psychiatric, psychological and psychosocial factors into healthcare delivery systems is becoming normative, the incorporation of personality factors into these system is often overlooked or poorly integrated into conceptualization in our examinations of health behaviors. Understanding and predicting health promoting and risky health behaviors has long been the province of public health, behavioral medicine, and health psychology. However, personality factors are rarely incorporated into health behavior paradigms. Personality can be dismissed as the “noise” in these equations, due to the relatively immutable nature of personality and the greater challenges in addressing personality variables in large-scale behavioral health interventions.

Personality factors, conceptualized by models such as the five-factor model of personality or Millon’s personality taxonomy,^1–2 have been found to be associated with a wide range of health behaviors, including alcohol and tobacco use, risky sexual behaviors, and cardiovascular risk indices.^3–9 The Millon Behavioral Medicine Diagnostic (MBMD) specifically, assesses personality and behavioral patterns associated with health-related outcomes and attempts to systematically address the association between personality factors and health. Research using the MBMD has documented associations between personality factors and pain treatment outcomes, sensitivity to anesthesia, health related quality of life, and medication adherence.^10–13

With regard to personality disorders, there has been stringent clinical debate about measurement of this construct. Some support the use of dimensional systems which assess personality pathology on a continuum,¹⁴ while others uphold categorical classifications which are congruent with traditional diagnostic conceptualizations of personality disorders. The traditional Diagnostic and Statistical Manual of Mental Disorders taxonomy of personality disorders typically clusters personality disorders into 3 groups (1) odd and unusual (Cluster A: disorders characterized by perceptual distortions, interpersonal behavior characterized by bizarre or unusual conduct, poor self-reflection, insight and judgment); (2) dramatic and erratic (Cluster B: disorders characterized by emotional lability, limited empathy and insight, behavioral dysregulation); and (3) anxious and fearful (Cluster C: disorders characterized by interpersonal reticence and anxiety, rigidity, and diminished social efficacy).¹⁵ Regardless of the assessment system employed, these differential patterns or clusters of personality pathology can have varying impacts on health. The “Cluster B” disorders often receive the most attention because they tend to be the most interpersonally disruptive and can be the most challenging for health care professionals due to the propensity for rage, entitlement, emotional lability and behavioral dysregulation that can severely complicate behavioral, transactional, and social aspects of clinical management. However, all of these patterns can and do negatively impact a wide range of health-related factors including risk behaviors and health-enhancing behaviors, health care provider relationships, maintenance and sustenance of social support networks, and magnification of other existing comorbid psychiatric issues including depression, anxiety, and substance use.^16–19

Personality disorders can also significantly complicate clinical management of major psychopathology and comorbid substance use disorders,^16–18,20 and may also raise management challenges in health care settings.^21,22 Traditionally, these are the patients that are termed as “difficult” or “demanding,” and oftentimes, medical staff are not trained in the nuances of managing the myriad issues raised by the interpersonal, affective, and behavioral instability associated with the personality disorders or dysfunctional personality patterns.

A number of studies have variously impacted the role of personality disorders on health, with wide ranging findings. Personality disorders have been found to be associated with physical health conditions including diabetes, gastroesophageal reflux, syncope, headaches, and arthritis.^23–25 For example, while psychopathy was found to be associated with diminished life expectancy, narcissism was associated with greater life expectancy,²⁶ and these relationships may be mediated by responses to stress as well as differential coping strategies. These relationships may also manifest across the lifespan. Hampson et al²⁷ observed that lower childhood conscientiousness was associated with greater physiological dysregulation 40 years later. Other “big five” personality traits including self-discipline, imagination, and generosity have been associated with survival time in older adults.²⁸ Personality has been found to play a role in diabetes risk and inflammatory biomarkers.^29–32

Chronic disease is now the leading source of mortality and morbidity in the US and throughout the world, with nearly half of adults in the US having at least one chronic health condition.³³ As such, maintenance of long-term health care provider relationships becomes a key factor in management of health and wellness. However, it is often personality factors that can obfuscate ongoing clinical management in chronic illness, and result in poorer outcomes for patients, as well as greater potential cost to both patients and health care systems.

The evolving focus on prevention in integrated primary care also raises the issue of personality variables and personality disorders. Prevention is oft-cited as the most cost-effective method to mitigate the deleterious impacts of leading causes of health-related disability, mortality and morbidity including obesity, diabetes, cardiovascular disease, and cancer.³⁴ Risk behaviors such as condomless sex,^9,35 physical indicators such as BMI and health behaviors such as engagement in preventative care or medication adherence are also associated with personality variables hence,^36–44 enhancement and mitigation of health can be further understood through the lens of personality. Personality variables can be both enhancing or harm-inducing, and as such, personality must be conceptualized as a multifaceted prism through which to implement and monitor preventative health care and clinical management.

In addition, increased health care utilization and uptake of more expensive health care services have been associated with personality variables, implying that patients with certain personality patterns or personality pathology may generate higher health care demands and costs,^23,45–47 with specific diagnostic patterns (e.g. borderline and obsessive compulsive personality disorder) cited as contributing to higher health care demands and costs.⁴⁸

Primary care teams may often not be as skilled in identifying personality patterns, nor do they typically have the time and training to identify and tailor health care delivery on the basis of major psychopathology, let alone personality factors. Moreover, personality assessment is often quite complex, and assessment of these patterns is typically not integrated into health care delivery. While we are seeing an increasing focus on the assessment of major psychopathology (e.g., major depression, anxiety) and substance use disorders as a more consistent aspect of primary care evaluation, the role of personality is far less integrated. Increasingly, a focus on integrating brief personality screening into primary care settings with patients across the lifespan is expanding in the extant literature.^49–50

The understanding of personality and health suggests that researchers, clinicians and policy makers skirt the tensions between a focus on individuals/people and a focus populations, although these perspectives should not be in competition.⁵¹ While there may be an economy of scale offered by population based interventions, the literature on personality and health, and particularly personality disorders and health suggests the need to tailor and customize these large- scale programs for particular subgroups on the basis of personality. The elucidation of personality and health also highlights the need for health care provider training that accounts for personality patterns and the healthcare provider relationship --which can often become strained and potentially result in suboptimal delivery of health care.²¹

This special issue closely examines the influence of personality disorders on health and behavior, with a specific focus on the role that personality disorders and their associated symptomatology may play in shaping health behaviors, risk behaviors, and health care utilization. In contrast to other major psychopathology (e.g. mood disorders) and substance use, personality disorders have received relatively less attention in the ltierature on health. The chronicity, affective instability, and interpersonal challenges raised by personality disorders often result in greater long-term impact on health through a variety of mechanisms. In addition, challenges in expedient, reliable and valid assessment of personality disorders often impede this area of inquiry.

In the series of articles featured in this special issue -- a range of personality factors are examined -- including both dimensional and categorical conceptualizations of personality, in relation to a range of health behaviors health conditions comorbid conditions and also examines treatment and impacts on clinical management, across diverse populations. The first article by Kacel et al., presents two case studies of patients in psychotherapy and how treatment was implemented to address narcissistic personality disorder. This is followed by a paper examining the relationship between personality disorders, substance use, and HIV risk among adults with a history of serious mental illness by Cathryn Mainville and her colleagues., and is complemented by an article by Benotsch et al which investigates how dependency is related to condom use among women receiving care at an STI clinic. Thereafter Nicolas Holder and colleagues test the impact of cognitive processing therapy on PTSD in female victims of military sexual trauma experiencing concurrent borderline personality disorder. D’Avanzo et al. describe personality disorder characteristics in a sample of urban sexual minority men who may be at risk for HIV and other heath burdens, while Alyssa Minnick and her colleagues examine personality disorders among Latina women with eating disorders. The issues is rounded out with a manuscript by Dokyoung et al. delineating the association between borderline personality disorder and pain, and a study by Van Veen et al. describing how impulsivity may adversely affect sleep in patients with antisocial and borderline personality disorders.

Taken together, these eight manuscripts provide clear and robust evidence on the role that personality disorders may play in diminishing health across different populations. And while personality and personality disorders may raise clinical and research challenges for health care, understanding of these variables may also represent an opportunity to optimize existing evidence based practices.