Personality disorders

Case history

A 22-year-old man presents to a family medicine center because he is concerned about feelings of dizziness and weakness. His medical history is unremarkable and this is his first visit to the clinic. During the interview, the physician notices the man's despondent facial expression and inquires about other issues. He admits that he has not slept in 2 days because of tension in his relationship with his girlfriend, who is visiting her family in another part of the country. She had seemed somewhat distant on the phone with him, and he is concerned that she is spending time with her former boyfriend, who resides in the same town as her family. He asks for medication to help him sleep and, after a few minutes, opens up to the physician about the mood swings that he has recently been experiencing. He admits that once before, when he liked a girl and discovered that she was not interested in him, he became hopeless and despondent. He acknowledged thinking that he did not want to live any more and that he would never be able to find anyone, but he did not have thoughts of ending his own life at that time. Instead, he took comfort from donating blood, as the sight of his own blood was extremely soothing to him, and he felt safe in the controlled environment of the blood donation center. However, he states that this time the intensity of his suffering is worse, and that he feels "alone in the world" and that even his friends are "out to get him."

Other presentations

The range of personality disorders is wide, and the various personality disorders differ markedly in their clinical presentations. Unlike other mental health conditions for which patients may seek assistance from a primary care physician, patients with personality difficulties are unlikely to report that their "personality" is the source of their suffering. Instead, patients with personality disorders may report symptoms of: unremitting mood or anxiety disorder; substance use disorder; multiple medically unexplained symptoms; or difficulties in interpersonal functioning. These may at times be manifest in challenging physician-patient interactions. Attention to nonverbal manifestations, such as scars from self-injurious behavior, must also be a focus of ongoing assessment. The primary care physician is unlikely to intervene directly to address personality issues, but, through the establishment of an effective therapeutic relationship, may assist the patient in improving the "index" symptoms that are causing him or her distress.

Maintaining contact with patients with a personality disorder may be challenging because of the nature of their difficulties, which undoubtedly will become salient in some way in the clinical encounter. These difficulties may include: aloofness; somewhat strange behaviors or patterns of thinking; demonstrations of affective dysregulation and self-mutilation; or clingy, anxious behavior with heavy reliance on the physician to make decisions. Over time, such an effective relationship will facilitate medical management of chronic conditions and potentially lead to improvements in health-related quality of life. It may also indirectly offer the patient the opportunity to develop different ways of relating with others and thus improve one of the core features of personality pathology.