Patients With Personality Disorders in Everyday Clinical Practice

Abstract

Background

Patients with difficult personalities or personality disorders are a special challenge for primary care physicians. Their style of interpersonal interaction is often difficult. As the ICD-11 classification comes into use, a new systematic approach to diagnosis is being introduced that focuses on the patient’s functional impairments in everyday life. We describe the implications for the diagnosis and treatment of patients of this type.

Methods

This review is based on pertinent publications retrieved by a selective search, with particular attention to primary care and to somatic morbidity and mortality.

Results

10–12% of the population suffers from personality disorders. A high degree of psychiatric comorbidity is typical; somatic diseases are also more than twice as common as in the general population. In emergency medicine, persons with personality disorders are more likely than others to present with a suicide attempt. Their lifetime risk of suicide is between 1.4% and 4.5% (the latter for persons with borderline personality disorder).

Conclusion

Primary care physicians have an important role in the initial diagnosis of patients with personality disorders and in the planning of their treatment. Such patients require special care and attention from their physicians in view of their elevated somatic morbidity and mortality. In everyday clinical practice, physicians who encounter patients with complex and persistent mental problems, or just with a difficult style of interpersonal interaction, should consider the possibility of a personality disorder and motivate such patients to undergo psychotherapy, if indicated.

cme plus

This article has been certified by the North Rhine Academy for Continuing Medical Education. Participation in the CME certification program is possible only over the internet: cme.aerzteblatt.de. The deadline for submission is 9 January 2023.

Patients with personality disorders confront doctors in clinical practice with a particular set of challenges. They often appear strained, do not articulate their needs adequately, and have unrealistic expectations regarding treatment (for example, in terms of available time resources). They are overly sensitive to criticism and rejection, often mistrustful, and they are prone to abrupt changes in mood and behavior. These patients stand out by a lack of stress tolerance, lacking reliability, and adherence—attributes that hamper the treatment process, but also communication during treatment. Their often arduous, occasionally chaotic, lives and their avoidant, occasionally impulsive problem solving style often lead to crisis consultants with doctors.

This review article considers the following questions: what are personality disorders, what do the typical problems of affected persons look like, and with which other mental/psychological/psychiatric and somatic disorders are they associated? What is the classification of personality disorders and their diagnostic evaluation in the ICD-11? How can doctors who have not had specialist psychiatric training shape the doctor-patient relationship in such a way that somatic treatment and psychosocial support can be successful? And, finally: how can patients—if required—be persuaded to undergo further networked healthcare with specialists for psychiatry & psychotherapy, psychosomatic medicine & psychotherapy.

Literature search

We searched PubMed in the time period from February to April 2021 for publications since 2000. In terms of the ICD-11 classification, we used the search terms “personality disorder” and “ICD-11”. Further search terms were “personality disorder” und “primary care/medicine, general/internal medicine, family care/medicine, emergency, consultation”, “comorbidity, physical health, medical illness, morbidity”, “mortality”, und “stigma/stigmatization”. We considered for our search in particular systematic reviews and meta-analyses, where available.

The clinical relevance of personality disorders

With a 12-month prevalence of 10–12% in the general population (1), personality disorders are an important factor for the health of individual people, but also for the burden of disease in the population. The health and wellbeing of such patients depends primarily on primary care doctors, as people with personality disorders tend to consult doctors frequently (2). Widespread isolation and lack of independence are also contributing factors. Patients’ relationships with their primary care physicians is therefore of the utmost importance, although this does not provide protection from conflict but can also, conversely, encourage it (3).

The group of patients with a borderline personality disorder profile stands out. A Spanish study found that primary care consultations were double those in the general population (4). The individual consultations were often more complex and took more time (5). The results of a UK study showed lower adherence to treatment recommendations and lifestyle advice (6). Those affected often use a lot of medication, although according to the guidelines the main focus of the treatment should be on psychotherapy (7). Polypharmacy with psychotropic drugs deserves a special mention. More than 80% of patients are prescribed several such medications at the same time—the average is 2.4 psychotropic drugs per patient (8). Doctors working in emergency medicine are also familiar with patients with personality disorders, in association with attempted suicides and completed suicides. According to a recently published Australian study, 8.8% of suicides are completed by patients with personality disorders (9). Studies of borderline personality disorders conclude a lifetime risk of 4.5% of dying by suicide. For other personality disorders the risk was 1.4% (10). Assessing the suicide risk is a task that not only psychiatrists are confronted with, but primary care doctors too, especially as the suicide risk in these patients is often associated with situational triggers. Retrospective studies showed that 90% of patients with personality disorders presented to their primary care physician in the weeks preceding the completion of their suicide (9).

Patients with personality disorders, especially with borderline personality disorder, were affected by a high degree of comorbidity with other psychological/psychiatric/mental impairments. Relative to their lifetimes, 70% had depression, 90% had anxiety disorders, 30% had posttraumatic stress disorder, 20% had attention deficit-hyperactivity disorder, and 50% had addiction disorders (10%). They often present to primary care physicians with pain and fatigue syndromes (11, 12). Furthermore they had higher rates of somatic disorders, especially cardiovascular disorders (odds ratio [OR] adjusted for age, sex, and sociodemographic data 2.78), arterial hypertension ()R 1.86), cerebral insult (OR 1.89), arthritis (adjusted PR 2.38), and gastrointestinal disorders (OR 2.31) than patients without borderline personality disorder (13). Their poorer physical functioning level is independent of any comorbid depression (7). For doctors it is important to be aware that the reduction in life expectancy in such patients—which amounts to 5.0–9.3 years (14)—is still mostly due to natural causes in spite of the increased suicide risk (11, 15).

Poor physical health is primarily the result of a lack of self care (among others, such patients access screening investigations far less than the general population) and unfavorable lifestyle factors. In a 6-year long-term study, patients with borderline personality disorder who were not in remission showed more unhealthy behaviors, such as excessive smoking, increased consumption of alcohol, lack of exercise, daily consumption of sleeping pills, and overdosing on analgesics, and required more diagnostic measures than patients in remission (11). People with personality disorders should therefore be examined and treated with particular attention to physical disorders and motivated to access screening investigations.

Primary care doctors in their role as family doctors are faced with particular challenges in view of the potential consequences of personality disorders for the mental and physical wellbeing of patients’ relatives and especially children. Patients’ reduced empathy and inability to handle conflict as well as their impaired ability to self-regulate often results in poor parenting behavior and in an intrusive, controlling parenting style (16). The studies relate particularly to parents with borderline personality disorder in whom clear effects are seen for the health and development of their own children (16, 17). Initial studies also give rise to the suspicion that mistreatment and abuse are more common (18, 19). Any indications of parental stress or child welfare risks should therefore urgently be explored, including home visits and by invitations to access relevant services (20).

ICD-11 classification of personality disorders

When the ICD-11 classification (table 1) came into effect on 1 January 2022, a new classification of personality disorders was introduced, which in Germany will come into force with a delay (the exact date is not yet known). The category of a “personality difficulty” as a less pronounced personality disorder can be applied by doctors from all specialties to describe problem behavior in interactions as an aggravating condition for health, but also for contact with the (somatic) healthcare system. The WHO working group on ICD-11 (21) in this way aims to achieve wider and earlier (in primary care) identification of the problem areas associated with personality disorders, as they are—as explained earlier—associated with an increased risk for other mental disorders and poorer physical health and increased mortality (7, 15). The category of the “personality difficulty” is also intended to enable doctors to code the more difficult treatment conditions—for example, the greater investment in terms of time.

Table 1. ICD-11 criteria to for assessing impaired personality functioning.

Functional level	Severity: facets of impaired functioning
Level of self functioning	● Identity: The person experiences themselves as autonomous and as having clear boundaries regarding others. – Extent to which identity or sense of self are inconstant, fragile, or inconsistent, or particularly rigid and immovable – Experience and behavior: changing goals and abrupt changes ● Self-esteem: The person has a stable and positive sense of self worth. – Extent to which an overall stable and positive sense of self worth can be maintained even in situations of hurt, defeat, etc. – Experience and behavior: avoidant behavior, dependent on others, self devaluation possibly to the point of suicidality, presumptuousness, etc. ● Self reflection: The person knows their own strengths and limitations. – Extent to which someone’s view of themselves is unrealistic and deviates from the views of others – Experience and behavior: unrealistic life plans with a tendency of asking too much of themselves, risky behavior, avoidance of challenges, unrealized potential ● Self: The person is able to plan goals and implement these. – Extent to which lacking stamina and reduced tolerance vis-a-vis frustration hampers following goals – Experience and behavior: sudden mood changes, not able to defer gratification, impulsive or aggressive behavior
Level of interpersonal functioning	● Interest in entering into interpersonal relationships: The person lives within a satisfying social network. – Extent of isolation and disinterest in others – Experience and behavior: prefers solitary behaviors, avoids social contacts, comes across as cold ● Empathy: The person is able to understand other people’s perspectives and consider those in their own actions. – Extent of egocentricity, unable to “be giving” and forge bonds – Experience and behavior: egocentric, exploitative, only focused on own advantage ● Ability to develop and sustain intimacy: The person is able to forge close, mutually satisfying relationships and sustain these. – Extent of inability to enter into a relationship that is fulfilling for both partners and stable – Experience and behavior: no relationships or unstable ones ● Ability to handle conflict: the person can resolve conflicts in a constructive manner – Extent of conflict or conflict avoidance – Experience and behavior: frequent, sometimes escalating conflict; conflict avoidance prevents achieving individual goals, submissive behavior

At the heart of the ICD-11 classification of personality disorders is the dimensional description of functional impairments that is conceived more closely in alignment with the problems and questions of the patients than the categorical diagnoses used thus far (Figure 1). On the one hand, the questions relate to the own self—such as “How do I want to live my life?”, “Do I receive enough attention and appreciation from others?”, and “Do I know my strengths and weaknesses?”. On the other hand, questions are asked regarding interpersonal relationships—for example: “Am I able to enter into satisfactory relationships and sustain these?”, “Do I empathize enough with other people and understand their perspectives?”, and “Am I able to resolve conflict?”. The diagnosis uses a three stage severity scale (mild, moderate, severe) to evaluate the extent and pervasiveness of the dysfunctions. Data are collected on how these are expressed in the behavior, emotions, and thought patterns of those affected and whether they show themselves only in circumscribed areas of life or in all of them. This kind of diagnostic evaluation, which is shown in detail in Table 1, can help destigmatize patients—in contrast to the traditional categories of personality disorder in the ICD-10, which tend to have negative associations: histrionic, narcissistic, and obsessive-compulsive personality disorder. A further step towards de-stigmatization is the loss of the stability criterion, which is replaced with the time criterion: “Disorder has been present for at least two years.” Furthermore, diagnoses of personality disorders can now be made from the 15th year of life, in order to enable early, appropriate treatment. For those affected, the opportunity for change opens up. Figure 1 shows a scheme for the diagnostic approach according to the ICD-11 diagnosis of personality disorders. The severity scale can optionally be complemented by five prominent personality traits. In detail, these are—derived from the 5-factor model of personality—“negative affect,” “detachment,” “dissociality,” “disinhibition,” and “Anankastia” (table 2).

Figure 1.

Diagnostic approach according to ICD-11

PD, personality disorder

Table 2. Characteristics of prominent personality traits according to the ICD-11.

Trait	Characteristics
Negative affectivity	● A wide range of emotions at a frequency and intensity that is situationally inappropriate (including fear, depressiveness, fear, annoyance, hostility, guilt, and shame, etc.) ● Emotional lability and problems with regulating emotions (hyperreactivity in the face of negative cognitions and external events; emotional balance regained only with difficulty, others needed for this) ● Negativistic attitudes (rejecting suggestions in the expectation of negative consequences) ● Low self esteem and low self confidence (avoidant behavior, dependence on others, self devaluation to the point of suicidality) ● Mistrustful towards others
Detachment	● Socially distanced (avoidance of social relationships, lack of friendship and intimacy) ● Emotional detachment (guardedness, aloofness, reduced expression of emotion), lack of emotional experience and joy
Dissociality	● Selfishness (being demanding; feeling deserving of only the best; expecting admiration) ● Lack of empathy (to the point of manipulative, deceitful, and exploitative behavior; aggression to the point of violence and sadism)
Disinhibition	● Impulsiveness (impulsive behavior without werigh up consequences; difficulty in deferring gratification) ● Easily distracted (little perseverance, little focus, quickly react with boredom and frustration) ● Lack of responsibility (unreliable, will not be held accountable) ● Ruthlessness (lacking cautiousness, overestimate own capabilities, disregard safety risks) ● Lack of forward planning (focus on immediate feelings, little attention given to future goals)
Anankastia	● Perfectionism (preoccupation with social rules, expectations, and norms; obsessed with detail, rigid daily routines, inflexible schedule) ● Limited feelings and behaviours (emotional expression is rigidly controlled, stubbornness, risk avoidance), perseveration and safety seeking behavior

In addition to the severity grade, borderline personality alone can be coded as a pattern with the prominent traits “affective instability,” “impulsive behavior,” “self-harming and suicidal behavior,” intense feelings and outbursts of annoyance,” “unstable sense of self,” “feelings of emptiness,” and “dissociation”—which is similar to the DSM-5 codes. This special solution was devised to ensure healthcare, because for borderline personality disorder, several effective disorder-specific psychotherapeutic treatment programs are available.

Diagnostic tools in primary care

The functional impairments for diagnosing the severity grade (table 1) can be captured precisely by using the nine items of the Standardized Assessment of Severity of Personality Disorder (SAS-PD) (22). A German version of the SAS-PD is available (23) (www.aerzteblatt-international.de/m2022.0001). However, this instrument is suitable for an initial diagnostic assessment only, owing to not quite satisfactory quality criteria, and no threshold value exists for severe personality disorder (24).

If an indication for psychotherapeutic treatment is to be approved, a more comprehensive diagnostic evaluation by specialists or psychotherapists is required, which includes the Semi-Structured Interview for Personality Functioning DSM-5 (STiP-5.1) (25). This assessment is available in a German-language version, but this hasn’t been adapted to ICD-11 and instead follows the related alternative DSM-5 model.

Particularities in the medical consultation

The interpersonal problems shown in Box 1 hamper communication in the treatment relationship. Because of their particular characteristics, people with personality disorders encounter skepticism and stigmatization not only in their own environment but also within the healthcare system. This is made worse by the pessimistic attitudes of the treating physicians vis-à-vis the effectiveness of the treatment options. Widespread prejudices are that such patients are manipulative, don’t want to let themselves be helped, are not ill, and do not require medical treatment so much (26). Termed by Ring and Lawn (27) as “diagnosis of exclusion,” such stigmatization contributes to feelings of helplessness and demoralization among treating physicians and treated patients. Furthermore, they may limit the quality and quantity of somatic treatment and therefore led to iatrogenic harm (26, 28).

In order to counteract such effects, treating physicians can contribute by checking their own attitudes towards personality disorders as a first step and to acknowledge that these are disorders. Awareness of changed stress biomarkers and deviations from the normal cerebral structure and function in those affected is helpful (10). Not disclosing the diagnosis or a sole focus on comorbidities can hinder access to treatment. For this reason, open, authentic, and empathic communication with those affected is important, in which a specific diagnosis is no longer named (such as narcissistic personality disorder) but the focus is placed on the type and severity of the effects of the patient’s personality style on themselves and on the costs that a difficult interaction style incurs for those affected.

For empathic and effective communication, developing an awareness of the typical interpersonal challenges can be helpful. The checklist in the Box provides an opportunity for comparing one’s own behavior with the recommendations. The tips listed in the Box aim to help the development of a trusting relationship, but also support self care and psycho-hygiene of the treating physician (29).

BOX. Checklist of 10 recommendations for doctors dealing with patients with personality disorders.

• Clear, authentic, non-judgmental communication from you and your therapeutic team supports the development of a trusting relationship with the patient. The team should exchange views and experiences.

• Do plan regular visits in limited time slots. These visits should be independent of whether a crisis is currently ongoing or—in case the patient tends to somatize—they are currently “ill”

• If you suspect that feelings such as fear of abandonment, anger, or shame are at the root of difficult behaviors, name these and ask whether this is the case.

• If the patients meet you with skepticism, scrutinize you, or are particularly sensitive, do remember that in their lives, they have in many cases experienced rejection, abuse, and neglect.

• Set clear boundaries at the start of the therapeutic relationship and do not react to patients’ attempts to transgress these boundaries unless there is a genuine emergency.

• If several people are involved in the treatment then make open and honest communication within the team and towards the patient a prerequisite for treatment.

• Avoid polypharmacy and large-volume prescriptions of potentially toxic (for example, tricyclic antidepressants) or addictive medications, especially tranquillizers, and inform patients about this approach early on.

• Support patients in finding solutions to problems while calmly and empathetically assigning the main responsibility for finding solutions. Encourage patients to identify manageable short term goals.

• In case of frequent crises, develop and agree a crisis management plan, if needed by involving others. Offer a sufficient degree of flexibility and avoid rigid rules.

• Don’t be impressed by excessive praise, but don’t be discouraged by excessively harsh criticism either.

A clear explanatory model for understanding the genesis and perpetuation of characteristic interpersonal problems in such patients and for being able to encounter them appropriately in the routine consultation is the motivation oriented indication and intervention model (MIIM, “motivorientiertes Indikations- und Interventionsmodell”) (30) (3). It is based on the following assumptions:

• People with personality disorders have on the basis of their life experience developed cognitive schemes with which they perceive and interpret the world. These schemes were probably functional earlier on, but over time they have developed in a dysfunctional way and are maladaptive for the current life situation.

• The cognitive schemes that are closely associated with core motivations serve as “filters” through which these persons perceive and experience their social environment. This regulates their own behavior.

• The experience of interpersonal interactions and the respective core motivations function as a regulator of actions and can explain interpersonal behaviors. Acting and behaving are determined by three crucial aspects: fundamental assumptions about the self (self image), fundamental assumptions about others (image of others), and the core motivations for interpersonal behavior (interaction). All are useful starting points for psychotherapeutic interventions. Figure 2 explains this on the basis of two personality disorders that present particular challenges to doctors.

Figure 2.

Motivation oriented indication and intervention model (MIIM) to sustain borderline personality disorder (a) and marcissistic personality disorder (b). (b from: Renneberg B, Herpertz SC: Persönlichkeitsstörungen. Göttingen: Hogrefe Verlag; 2021 [3]; reproduced with permission from Hogrefe publishers)

Therapy

The evidence base for the effectiveness of psychotherapies in people with personality disorders is overall encouraging (31). Evidence based, structured, disorder-specific psychotherapeutic programs exist, however, only for avoidant personality disorder and borderline personality disorder (3); They are lacking, for example, for narcissistic personality disorder. Psychosocial interventions in antisocial personality disorder are not backed by sufficient evidence of efficacy and clinical utility (32).

For borderline personality disorder, specific cognitive behavioral therapeutic and psychodynamic psychotherapeutic manuals are available (33). If the primary focus is on reducing self-harming and suicidal behaviors, dialectic behavioral therapy (DBT) (34) is particularly useful, as is mentalization based therapy (MBT) (35) as individual and group approaches. DBT is derived from the therapeutic intention to achieve a balance between understanding and respecting a problem and effecting change. The focus is on those problem areas that are directly associated with difficulties in behavioral control and emotional regulation. Concrete skills are rehearsed. In MBT as a psychodynamic therapy, the focus is on placing individual experience into an understanding context and to better recognize and understand the emotions, thoughts, and motivations of others.

A meta-analysis that included only randomized controlled trials found moderate effect sizes regarding borderline relevant traits for DBT (g=0.34; 95% confidence interval [0.15; 0.53) and for psychodynamic therapy (g=0.41; [0.12; 0.69) (33). Slighter greater effects were seen for the anti-suicidal effect (g=0.44; [0.15; 0.74]). As convincing evidence for the effectiveness of psychotropic medications is lacking, drug interventions are not suitable as first-line treatments (36). What might be considered is only a time-limited use of medications in order to treat specific symptoms (for example, disturbed sleep, feeling tense).

In moderate to severe personality disorders, the primary care physician should make a referral to a specialist or psychotherapeutic consultation in order to establish a detailed diagnosis and starting psychotherapy. In the setting of interdisciplinary treatment, regular exchanges between all participating doctors and psychotherapists are recommended. The primary doctor who coordinates the overall treatment should be named, especially as patients often consult several doctors simultaneously. If this is at all possible, relatives should always be included. Peers can also take on valuable tasks as part of the care team.

Conclusions

The dimensional classification of personality disorders according to ICD-11 could make communication with affected patients easier by not fixating on a diagnostic label but by making it easier to talk about patients’ own functional impairments. Non-judgmental medical communication can open a way forward that generates the motivation to change, because patients sense the personal disadvantages that their personality style entails. A trusting therapeutic relationship that considers the risk potential but also the potential for stigmatization in these patients

Questions on the article in issue 1–2/2022:

Patients With Personality Disorders in Everyday Clinical Practice—Implications of the ICD-11

The submission deadline is 9 January 2023.

Only one answer is possible per question. Please select the answer that is most appropriate.

Question 1

What percentage of the general population is affected by a personality disorder?

1. 1–2 %

2. 3–5 %

3. 7–9 %

4. 10–12 %

5. 16–20 %

Question 2

What is the lifetime risk for suicide in patients with personality disorders?

1. 0.5–1.2 %

2. 1.4–4.5 %

3. 5.5–8.4 %

4. 9.1–10.2 %

5. 12.3–15.4 %

Question 3

What did studies of the patient group with a borderline personality profile compared with the general population find?

1. They avoided consultations with the primary care physician

2. Their consultations were fleeting

3. Twice the number of primary care consultations

4. Very good adherence to their primary care physician’s treatment suggestions

5. A lower risk of suicide

Question 4

Which mental/psychological/psychiatric comorbidities are most common in patients with borderline personality disorders?

1. ADHD and antisocial personality disorders

2. Schizophrenia and bipolar disorder

3. Autism spectrum disorders and schizophrenia

4. Anxiety disorders and depression

5. Paranoid personality disorders and delusional disorders

Question 5

Which characteristics are typically associated with anankastia?

1. Lack of planning and consideration

2. Selfishness and distractibility

3. Irresponsibility and distractibility

4. Distractibility and ruthlessness

5. Perfectionism and safety seeking behavior

Question 6

Which one of the following basic assumptions about others is characteristic of patients with narcissistic personality disorder?

1. Others are a threat, reject me, and abandon me.

2. Others should submit to me, meet my needs, and admire me.

3. Others are better than me, and I am therefore worth less than everybody else

4. Others are admirable and it makes me happy to follow others

5. I am uncomfortable if others admire me.

Question 7

The ICD-11 classification includes a new category for naming milder forms of personality disorders. What is this category called?

1. Category “rare personality”

2. Category “disturbed personality”

3. Category “mild personality disorder”

4. Category “difficult personality”

5. Category “personality difficulty”

Question 8

According to the diagnostic approach according to the ICD-11, one of the basic criteria for diagnosing a personality disorder is the duration of characteristics/symptoms. What is the minimum time period for the disorder to have been present?

1. At least 2 months

2. At least 6 months

3. At least 1 year

4. At least 2 year

5. At least 5 year

Question 9

From which age can a diagnosis of a personality disorder be made?

1. From the 12^th year of life

2. From the 15^th year of life

3. From the 17^th year of life

4. From the 19^th year of life

5. From the 21^st year of life

Question 10.

Which somatic comorbidities are particularly common in patients with borderline personality disorder?

1. Cardiovascular disorders

2. Gynecological disorders

3. Allergic disorders

4. Orthopedic disorders

5. Eye disorders

Fragebogen.