Approach
People with personality disorders rarely present to a primary care physician seeking relief from their personality difficulties. They may have little or no insight into their personality issues. The comorbidity of more than one personality disorder is common. The approach to diagnosis is focused on broad symptom categories. These may be observable in physician-patient encounters or present in the patient's history, whether obtained from the patient him/herself or from collateral sources of information.
Presentation in primary care
By definition, personality disorders involve significant difficulties in interpersonal interactions, with various manifestations based on the disorder type or grouping. Thus the physician-patient relationship is likely to be affected by these issues. Repeated encounters that a physician considers ‘difficult’ may warrant consideration of a personality disorder.[52][53]
Additional presentations in primary care settings that may indicate the presence of significant personality issues include:[53][54][55]
Acute stress, inappropriate demands, disproportionate anger, rapid mood changes
Scars or other markings on the skin indicative of self-mutilation
Frequent involvement in arguments or altercations
Turbulent and volatile relationships
Chronic and unremitting mood or anxiety disorder symptom complaints
Poor response to evidence-based treatments for other mental health conditions
Problematic substance use
Presence of multiple medically unexplained symptoms
Presenting issues in children that may suggest a traumatic home environment CDC: Adverse Childhood Experiences (ACE) study Opens in new window
Clinical encounter elicits strong emotional reactions in the clinician, or departure from usual clinical practice (e.g., working outside expertise, change in prescribing practice).
Many of the symptoms of personality disorders can be grouped into the categories of:
Cognitive-perceptual (rigidly held ideas, odd or strange thinking, misperceptions of others' intentions)
Affective dysregulation (mood and anxiety symptoms)
Impulse dyscontrol (aggressive or self-harm behaviours, sexual promiscuity, problematic substance use).
The various types of personality disorder are defined by the DSM-5-TR criteria. See Criteria.
Tests: screening interviews and self-report tools
Assessment of suicidality should be included in the clinical interview. Researchers have identified suicidal desire, capability, and intent, and presence of buffers as the key variables to assess.[56] Tools are available to assist primary care clinicians in the assessment of suicide. Suicide Prevention Resource Center: suicide prevention toolkit for primary care practices Opens in new window
A brief screening interview test for personality disorder, the Standardized Assessment of Personality-Abbreviated Scale (SAPAS) has been validated in psychiatric settings.[57][58] It seems to be most useful for identifying patients within clusters A and C, but less so for identifying patients within cluster B.[58] The SAPAS was used in a large-scale study examining factors related to response to antidepressant treatment, and personality dysfunction was found to have had a significant negative impact on treatment response.[59] However, the SAPAS is not recommended for routine screening in primary care settings, where prevalence of personality disorder is lower than in psychiatric settings.[57] Within the primary care setting, it may be appropriate for use with patients who have comorbid psychiatric conditions, such as anxiety or depression. The Structured Clinical Interview for DSM-5-TR Alternative Model for Personality Disorders Version (SCID-5-AMPD) is a semi-structured interview for use by trained clinicians with a basic knowledge of the concepts of personality disorders.
An analysis of three brief self-report tools concluded that the tools were strongly correlated with each other, and also were best when used with more severe levels of personality pathology in psychiatric samples.[60] The goal of a brief self-report screening tool for personality disorders may not be achievable given the factors involved (for example, overlap between personality disorders, as well as comorbidity with mood, anxiety, or psychotic disorders).[60]
Tests: screening for organic disorders
In cases when the patient presents with sudden personality changes, organic causes such as substance use disorder, malignancy, or other general medical conditions must be excluded before a diagnosis of personality disorder can be considered. Selective testing such as brain imaging (computed tomography [CT] or magnetic resonance imaging [MRI]) and urine drug testing may be helpful in initial investigation of these findings.
Tests: screening assessment for behaviours adversely affecting health and comorbid psychiatric conditions
Many personality features are stable over time but present more prominently on an intermittent basis and are considered the 'target' symptoms for treatment efforts (e.g., the self-injurious behaviour of an individual with borderline personality disorder). While a complete diagnostic assessment of specific personality disorders or traits typically occurs in specialty settings, primary care physicians can assess for behaviours adversely impacting health status, for suicidal ideation and plan, as well as for anxiety and affective symptoms that patients with personality disorders experience.[60][61] Screening instruments that may be helpful in this regard include:
Primary Care Evaluation of Mental Disorders (PRIME-MD), a screen for the presence of a variety of psychiatric disorders, including mood, anxiety, somatoform, and eating, as well as alcohol use/dependence[62]
Patient Health Questionnaire-9 (PHQ-9), which provides information on the severity of depressive symptomatology including self-harm and suicidal ideation[63] Patient Health Questionnaire PHQ-9 Opens in new window
Generalised Anxiety Disorder-7 (GAD-7), providing information on the severity of anxiety symptomatology[64][65]
Mood Disorders Questionnaire, which screens for the presence of elevated mood states, hypomania, and mania.[66]
Patients who screen positive for mood disorder, substance use disorder, history of deliberate self-harm, and/or prior suicide attempt may be at greater suicide risk.[67]
Consultant referrals
For a detailed assessment of personality disorder traits and their potential to impact the physician-patient relationship and approach to medical care, primary care physicians should consider referral to a mental health professional with specialty training in the assessment and treatment of people with personality disorders. Structured interviewing and specific diagnostic instrument administration, including the administration of psychological testing, may be carried out by such a professional. A consulting psychologist or psychiatrist may use the Millon Clinical Multiaxial Inventory-III (MCMI-III) and the Structured Clinical Interview for DSM-IV Axis II Personality Disorders instruments. Two disciplines, clinical health psychology and consultation-liaison psychiatry, are particularly concerned with the interface of mental and physical health and well-being, but many types of mental health providers are skilled in this particular field. When consulting with the evaluating clinician, it is important to obtain information on the evaluator's practice with regard to providing feedback to patients. This will allow the primary care physician to address further patient questions regarding the evaluation in a manner that avoids potential misunderstanding and miscommunication.
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