Priority Topic: Difficult Patient & Priority Topic: Personality Disorder

Difficult Patient

Key Feature 1: When physician-patient interaction is deemed difficult, diagnose personality disorder when it is present in patients.
Skill: Clinical Reasoning
Phase: Diagnosis

Key Feature 2: When confronted with difficult patient interactions, seek out and update, when necessary, information about the patient’s life circumstances, current context, and functional status.
Skill: Patient Centered
Phase: History, Diagnosis

Key Feature 5: When confronted with difficult patient interactions, identify your own attitudes and your contribution to the situation.
Skill: Professionalism
Phase: Treatment, Diagnosis

Key Feature 6: When dealing with difficult patients, set clear boundaries.
Skill: Professionalism
Phase: Treatment

Personality Disorder

Key Feature 2: In a patient with a personality disorder, look for medical and psychiatric diagnoses when the patient presents for assessment of new or changed symptoms. (Patients with personality disorders develop medical and psychiatric conditions, too.)
Skill: Clinical Reasoning
Phase: Hypothesis generation

Key Feature 5: When seeing a patient whom others have previously identified as having a personality disorder, evaluate the person yourself because the diagnosis may be wrong and the label has significant repercussions.
Skill: Clinical Reasoning, Selectivity
Phase: Diagnosis, History

Today I spent the afternoon in the Acute Behavioural Stabilization Unit (aka the Psychiatry assessment area) in the St Paul's Hospital Emergency Department. After I came back from assessing a particularly challenging patient, my attending physician said to me, "How did that patient make you feel?" This reminded me of something I was once told by an attending physician in the past: when I leave a patient encounter feeling like it was just "off" or that the patient seemed strange, it is possible they have a personality disorder. I don't think this is an evidence-based screening tool for personality disorders, but I do think it is a clinical pearl. If your spidey senses are tingling, it's probably for a reason. In these settings, inquiring about what's been going on in a patient's life (aka gathering a social history) may reveal significant psychosocial stress that could be contributing to a short fuse or leading to avoidance to say much about personal issues. And although people with personality disorders may have increased psychosocial stress, it takes knowing a patient for an extended period of time (or at least gathering an extended history of an extended period of time ideally with collateral information) to make this diagnostic call. 

Despite the requirement of needing to have a strong understanding of patients' longstanding behaviours, clinicians tend to hold strong suspicions about patients having personality disorders based on initial consultations. This is particularly true when patients present with features in keeping with Borderline Personality Disorder, which we tend to see more frequently than other personality disorders in healthcare. (Note that it is important to not just take another clinician's word for a diagnosis of a personality disorder, as this diagnosis is sometimes made prematurely, and incorrectly labelling patents with personality disorders can have real and negative consequences if it is an inaccurate description for them.) Patients with this Borderline Personality Disorder can at times be manipulative, including with the assessing physician, and can cause a countertransference reaction that is what my attending physician today was referring to today. This attending went on to explain the importance of clear reasoning and firm, caring boundaries in the management of patients with this diagnosis, because otherwise you may find yourself getting pushed into providing care in a way that is not what you think is actually most suited for the circumstances. The patient today, for example, presented with thoughts about self-harm, but had a strong relationship with a psychiatrist in the community, and it was highly unlikely that an admission to hospital would've provided any benefit (in fact, more likely the opposite). When she found out the psychiatrist who did her intake consultation today deemed her fit for discharge and close follow-up care in the community, she began saying she was more suicidal than before. Hmmmm.... That being said, patients diagnosed with personality disorders tend to face much discrimination; they are often seen as frankly difficult patients with multiple complaints and issues, at times compromising thorough and indicated assessment for specific concerns. It takes a heaping amount of good intention and experienced clinical judgment, but patients with personality disorders develop other psychiatric and non-psychiatric conditions unrelated to their personality disorder. It is not always easy to have the patience or knowledge to distinguish these, as I have seen first-hand, but it is important if we value the dignity and humanism underlying good medical care.

According to the DSM-V, "A personality disorder is an enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individual’s culture, is pervasive and inflexible, has an onset in adolescence or early adulthood, is stable over time, and leads to distress or impairment... The personality disorders are grouped into three clusters based on descriptive similarities. Individuals with Cluster A personality disorders often appear odd or eccentric. Individuals with Cluster B personality disorders often appear dramatic, emotional, or erratic. Individuals with Cluster C personality disorders often appear anxious or fearful." In medical school, I was taught of these clusters as the "Mad, bad, and sad" personality disorders, respectively.

According to the DSM-V, there are 10 different diagnosable personality disorders, which are as follows:

1. Paranoid personality disorder (A)
2. Schizoid personality disorder (A)
3. Schizotypal personality disorder (A)
4. Antisocial personality disorder (B)
5. Borderline personality disorder (B)
6. Histrionic personality disorder (B)
7. Narcissistic personality disorder (B)
8. Avoidant personality disorder (C)
9. Dependent personality disorder (C)
10. Obsessive-compulsive personality disorder (C)

There is also the catch-all diagnoses of Other specified personality disorder and Unspecified personality disorder.

While I won't get into all of the details of each personality disorder, the general diagnostic criteria per the DSM-V for personality disorders is as follows:

1. An enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individual’s culture. This pattern is manifested in two (or more) of the following areas:
   1. Cognition (i.e., ways of perceiving and interpreting self, other people, and events).
   2. Affectivity (i.e., the range, intensity, lability, and appropriateness of emotional response).
   3. Interpersonal functioning.
   4. Impulse control.
2. The enduring pattern is inflexible and pervasive across a broad range of personal and social situations.
3. The enduring pattern leads to clinically significant distress or impairment in social, occupational, or other important areas of functioning.
4. The pattern is stable and of long duration, and its onset can be traced back at least to adolescence or early adulthood.
5. The enduring pattern is not better explained as a manifestation or consequence of another mental disorder.
6. The enduring pattern is not attributable to the physiological effects of a substance (ex: a drug of abuse, a medication) or another medical condition (ex: head trauma).