Robert P. Roca
Concept of Personality and Personality Disorder
Definition and Methods of Classification
The enduring attitudes, behaviors, and capacities that distinguish individuals from each other are collectively called personality. Personality is commonly conceptualized categorically or dimensionally.
Categorical approaches specify qualitatively distinct personality types and classify individuals according to the type they most closely resemble. The ancient Greek typology (i.e., phlegmatic, choleric, sanguine, melancholic) is one such example. The American Psychiatric Association uses this approach in the classification of personality disorders published in the most recent Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, Text Revision (DSM-IV-TR) (see Subtyping of Personality Disorder).
Dimensional approaches view personality as a mosaic of traits, each possessed by individuals in differing quantities (1). Intelligence, as defined by the intelligence quotient (IQ), is a model of such a trait. IQ scores are normally distributed in the population and are highly correlated with academic and occupational achievement. People with above-average IQ scores tend to be successful in school and work, whereas those with below-average IQs often have difficulty meeting the demands of daily life independently. Knowledge of a person's position on the dimension of intelligence thus illuminates strengths and vulnerabilities and allows one to predict circumstances that the person might find overwhelming.
A 30-year-old man was admitted to the hospital for cellulitis of the feet. His physician discovered that he had only completed the third grade and that he was unable to read, write, or calculate. Further investigation disclosed that he had recently lost his job in a laundromat and that he had been observed walking barefoot in a dumpster looking for items he needed. His physician explained to him, carefully and repeatedly, the relationship between his infection and his behavior. A social worker was called to help him apply for financial assistance and other entitlements.
Dimensions can be translated into categorical terms, sometimes with misleading consequences. “Mental retardation,” for example, is said to be present when the IQ is lower than 70. By this definition, a man with an IQ of 68 is categorized as mentally retarded but one with an IQ of 72 is not, despite the fact that their risk of intelligence-related difficulty is essentially identical. In the latter case, a categorical approach may obscure clinically important vulnerability.
While IQ is by far the best-studied dimension of personality, other personality traits may also be described dimensionally. We use dimensional thinking informally when we recognize that some people are more meticulous, more gregarious, or more ambitious than others. Psychologists use this approach technically when they administer standardized tests to describe quantitatively how meticulous, introverted, agreeable, or conscientious someone is. At some arbitrary point, the meticulous person may be categorized as obsessional or the introverted person as schizoid and thus be said to have a categorical personality disorder; however, it is useful to recognize that certain patients are more meticulous or more introverted than
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others even when they are not categorically obsessional or schizoid. A dimensional view facilitates the recognition of such traits in every patient, and helps health care practitioners adapt assessment, relational, and management strategies to the personalities of their individual patients (see Chapters 3 and 4).
Development of Personality
Personality is believed to evolve out of interactions between constitutional, or inborn, factors and the molding influences of the environment. Constitutional factors include capacities, such as intelligence, and aspects of temperament, such as sociability and emotionality, all of which may have neurobiologic correlates and genetic determinants (2). The most important environmental influences are interpersonal relationships, particularly with parents. Many theories have been offered to account more specifically for personality development, but none has yet proved fully adequate (3).
Conceptualization of Personality Disorder
Personality disorders are among the most controversial conditions in psychiatry. There is no doubt that some people have enduring patterns of maladaptive attitudes and behaviors that interfere with their ability to work effectively and to develop and sustain gratifying interpersonal relationships. It is also clear that such people are at increased risk for long-term social impairment and for many major psychiatric illnesses (4,5). The controversy lies in how best to conceptualize and subdivide these disorders. This chapter describes three such conceptualizations.
The dominant approach in the United States—that adopted by the American Psychiatric Association in DSM-IV-TR— is categorical. In this scheme, the diagnostic criteria for the personality disorders are lists of attitudes and behaviors (e.g., self-dramatization) that, in combination, evoke an ideal prototype (e.g., the histrionic personality). Only a person exhibiting the requisite number of such attitudes and behaviors (e.g., at least five of eight, in the case of histrionic personality disorder) is said to have the condition.
Maladaptive personalities can also be conceptualized in terms of quantitative deviations from normal along specific personality dimensions. As mentioned earlier, many clinically important personality traits (e.g., meticulousness, dependency, self-confidence) can be viewed in this way. Extreme deviations from “normal” along any of these dimensions may produce special vulnerability, particularly under certain circumstances. For example, excessive meticulousness may lead to great distress when the environment is out of order, and poor self-confidence may predispose one to demoralization in response to criticism from a superior. Thus dimensional thinking about personality disturbances creates a model for understanding the interaction between environmental stresses and trait-based vulnerabilities.
Finally, personality disorders may be viewed as incomplete or atypical expressions of schizophrenia, mood disorders, or other major psychiatric illnesses.
Subtyping of Personality Disorder
The DSM-IV-TR describes ten types of personality disorders and groups them into three clusters: the dramatic (histrionic, borderline, narcissistic, and antisocial types), the anxious or fearful (obsessive-compulsive, dependent, and avoidant types), and the odd or eccentric (schizoid, schizotypal, and paranoid types) clusters. In the descriptions of the categorical disorders that follow in this chapter, it is clear that many of the disorders may be viewed as manifestations of extreme positions on dimensions of personality such as emotionality, narcissism, trust, sociability, self-esteem, and assertiveness. It is also seen that the types within each cluster tend to share traits and vulnerabilities and, therefore, implications for management. A few disorders are linked to major psychiatric illnesses. It is important to emphasize that a patient with clinically obvious disturbances involving dimensions of personality may meet criteria for several DSM-IV-TRpersonality disorders or may meet criteria for none.
Personality disorders are listed on axis II of the multiaxial assessment system that is recommended in DSM-IV-TR. Table 23.1 shows the estimated population prevalence and sex ratios for the major personality disorders.
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TABLE 23.1 Estimated Prevalence and Sex Ratios of the Major Personality Disorders |
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General Approach to Management of Personality Traits and Disorders
Several points are useful to bear in mind when dealing with patients with maladaptive traits or categorical personality disorders of any subtype. Because maladaptive traits are generally well established and deeply ingrained, it is doubtful that they will change in response to the health care practitioner's efforts. An exception to this rule is when particular aspects of temperament (e.g., harm avoidance) change in response to pharmacologic treatment of concurrent mood disorders that are making these traits more prominent (6). Otherwise, the general approach to primary care management of personality disorders is to recognize these sources of vulnerability, take them into account when interacting with the patient, and minimize their adverse impact on the provision of medical care.
Patients may become resentful when maladaptive traits are pointed out to them, and this response defeats the practitioner's purposes. Yet it is often important to call patients’ attention to ways in which they are undermining their medical care. When such action is necessary, it is usually advisable to avoid personality disorder labels, referring instead to specific problematic behaviors, and to present clinical observations plainly and without criticism (e.g., “It is difficult for us to provide you with the care you need when you curse at us and criticize every effort we make.”).
Generally, counseling by the generalist, if undertaken at all, is best when it is symptom-focused and short-term (see Chapter 20). For long-term treatment, patients with seriously disturbed personalities should be referred to a mental health professional.
Dramatic Cluster
Patients with personality disturbances in this cluster tend to occupy extreme positions on the dimensions of emotionality and self-esteem. They are intensely emotional, sometimes acting impulsively, aggressively, or self-destructively. They are also self-absorbed, lacking in empathy for others, and extreme (unrealistically high or low) in their self-regard. They tend to be demanding of others, and their relationships are unstable, tempestuous, and exploitive, qualities that may characterize their interactions with health care practitioners and complicate the provision of medical care.
Histrionic Personality
The essence of the histrionic type is excessive emotionality, self-dramatization, and attention-seeking. Patients meeting criteria for the categoric disorder are self-centered, unusually eager for approval and praise, overly concerned with physical attractiveness, and often inappropriately sexually seductive or flattering (“Of all the doctors I’ve had, you are the first to really listen to me”). Their style of speech is dramatic, impressionistic, and factually imprecise, and their expression of emotions is often exaggerated, rapidly shifting, and apparently shallow. They may manifest an unusually warm and sometimes seductive manner with the practitioner and present to the office with complaints that are dramatically expressed but vague in medically relevant detail. Histrionic patients may be especially inclined to develop somatization disorder (see Chapter 21).
Narcissistic Personality
The narcissistic personality type is characterized by an exaggerated sense of self-importance, intolerance of criticism, and insensitivity to the needs of others. Narcissistic people may exploit others for their own ends, require constant admiration and attention, believe themselves entitled to special treatment, and envy those who are more successful, attractive, intelligent, or otherwise praiseworthy. Such patients are often difficult to care for because they tend to believe that their problems are unique and can be solved only by remarkable health care providers. They may challenge the doctor's knowledge, skill, and judgment and expect that their convenience will be the prime consideration in the scheduling of tests and appointments.
Borderline Personality
Extreme instability— in mood, identity, interpersonal relationships, and self-regard—is the essence of the borderline personality. Although this condition was once believed to lie on the “border” of schizophrenia, recent data more strongly support a link with affective disorders. Substance abuse, sexual impulsiveness, poor self-esteem, self-mutilation, recurrent (often manipulative) suicidal threats, and brief bouts of intense depression and rage, superimposed on chronic feelings of emptiness or boredom, characterize the long-term functioning of these patients. A shifting tendency to view other people as all good or all bad and to react to them with extremes of idealization or devaluation creates difficulties in all interpersonal relationships, including those with health care practitioners and other caretakers, who are seen as either good or bad and are pitted against one another (staff splitting).
Antisocial Personality
The antisocial personality type is characterized by a chronic and pervasive pattern of irresponsible and socially unacceptable behavior. Truancy, vandalism, fire setting, lying, and theft in childhood give way to impulsiveness, recklessness, aggressiveness, sexual promiscuity, financial irresponsibility, and outright criminality in adulthood. Often complaining of mistreatment themselves,
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they shamelessly exploit others in their relationships. In medical settings they may be malingerers (see Chapter 21), consciously feigning disease for obvious gain; and in their dealings with medical staff they may be either demanding and abusive or flattering and ingratiating, depending on which approach they perceive to be most expedient.
Management of Dramatic Subtypes
When dealing with dramatic patients one can expect a show of emotional extremes and pressure to bestow emotional and material favors as well as medical care. It is helpful to maintain equanimity in the face of the patient's emotional excesses, to avoid defensiveness when challenged, and to give special attention to professional boundaries. Socializing or becoming unusually familiar with histrionic or borderline patients is particularly risky. Because patients with these traits lack empathy and exploit others, it is often necessary to spell out, firmly but nonpunitively, the limits of acceptable behavior with medical staff, nurses, and other members of the health care team; such limit-setting is most often needed with narcissistic and antisocial patients.
Anxious or Fearful Cluster
Patients with personality disturbances in this cluster tend to be self-doubting, timid, and tense. Lacking confidence in themselves, they may seek to avoid making decisions or taking on responsibility, preferring to have others decide or perform for them; however, they are often dissatisfied with and critical of the efforts of others. They tend to be socially unassertive, submitting to the wishes of others and even avoiding friendships in the first place for fear of ultimate rejection. Levels of generalized anxiety are chronically high.
Avoidant Personality
The avoidant person craves social contact but avoids it because of intense social discomfort related to expectations of criticism and rejection. These people often complain of loneliness, but they are too shy to make the social contacts required to solve the problem unless they are certain of acceptance. Major depression and social phobia commonly occur. Because health care practitioners are generally viewed as accepting of their patients, avoidant people may feel particularly comfortable in the presence of their practitioner and may develop symptoms justifying regular visits to alleviate their loneliness.
Dependent Personality
Dependent people lack self-confidence and go to great lengths to ensure the availability of others on whom they can depend for advice and reassurance. Because they feel uneasy and helpless when alone, they may endure abuse and perform unpleasant or demeaning tasks to preserve the dependent relationship. They are exceedingly sensitive to criticism and abandonment. Patients of this type may become quite dependent on their health care practitioners, particularly when other relationships are unsatisfactory, and may use vague, chronic complaints as a means of remaining in close touch, especially in times of stress. Such patients may also become ill before a period of planned unavailability on the part of the practitioner (e.g., a vacation).
Obsessive-Compulsive Personality
People with obsessive-compulsive personalities are rigid, parsimonious, morally scrupulous, and emotionally constricted. Exceedingly committed to work, they are reluctant to delegate duties, convinced that no one else can do things correctly, yet they are also indecisive and at times are rendered ineffective by perfectionism or preoccupation with trivial details. They tend to describe upsetting emotional experiences in a cool, detached manner (isolation of affect). When ill, they often present their health care providers with extremely detailed accounts of their symptoms and request lengthy explanations of their disease and its treatment, including very precise instructions about medication use and likely side effects. They are usually aware of hospital rules and routines and are intolerant of lateness and inefficiency. People with obsessive-compulsive personalities may be especially prone to developing hypochondriasis (see Chapter 21) and obsessive-compulsive disorder, a condition characterized by recurrent, resisted thoughts and repetitive, senseless actions (see Chapter 22).
Passive-Aggressive Personality
Although not listed in DSM-IV TR, passive-aggressive personality disorder warrants brief mention because of its potential impact on the provision of medical care. Passive-aggressive people do not want to meet the expectations of others but do not want to be held responsible for this decision. Thus they do not say “no” directly but express hostile resistance in terms of procrastination, intentional inefficiency, and feigned forgetfulness. Usually dependent and lacking in self-confidence, they seek the counsel of others, yet often paradoxically resist following the advice of those whom they consult. In medical settings they insist that they intend to comply with treatment recommendations but then, for example, forget to keep a symptom log required to assess the effectiveness of a new treatment or forget to make it to the laboratory for an important blood test.
Management of Anxious Subtypes
The general guidelines described previously are applicable. Because patients with these types of personality traits
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tend to develop anxious attachment to their health care practitioners, the management of dependency is a central issue. It may be necessary to allow patients to be excessively dependent, within manageable bounds, during times of unusual stress. It may be helpful to give them regular, brief appointments so that they do not need to develop new symptomatic complaints to gain access to attention (seeChapter 21), and it may be useful to advise them to call weekly at a specified time to provide updates on their status; this may preempt emergency calls at less convenient times. Such patients also generally benefit from advance notice about vacations and may appreciate meeting the covering practitioner ahead of time. Treatment for generalized anxiety disorder, phobias, and major depression may be indicated in selected cases (see Chapters 22 and 24).
Odd or Eccentric Cluster
Patients with disorders in this cluster occupy extreme positions on the dimensions of trust and sociability. They tend to be highly suspicious and to isolate themselves from other people due to anxious mistrust, awkwardness, or indifference.
Paranoid Personality
Patients with paranoid personalities tend to perceive threats and insults at every turn. Expecting to be exploited or harmed by others, they hear veiled threats in neutral remarks and readily question the loyalty of friends and the fidelity of spouses. They are guarded, easily slighted, defensive, and unforgiving. Although their suspiciousness does not carry the intensity or conviction of a true delusion, they have family histories of schizophrenia and delusional disorders more often than other people (2). In medical settings these patients may be reluctant to provide a complete history, especially a social history (“What does this have to do with my medical problem?”) and may balk at undergoing laboratory tests (“You doctors are just trying to make money off me”).
Schizotypal Personality
People with schizotypal personality type exhibit odd behavior, have peculiar beliefs, and suffer social isolation— as a result of their own social anxiety as well as the impact of their beliefs and behavior on others. Their affect is often constricted, their talk vague and digressive, and their appearance unkempt. They tend to be suspicious and superstitious. People with this disorder are generally severely impaired, often meeting criteria for other personality disorders simultaneously (5). There are family links with schizophrenia (7,8), and there is evidence that this disorder should be viewed as belonging to the “schizophrenia spectrum” (7). Schizotypal patients may be guarded and suspicious in medical settings but may also present to health care practitioners with unusual symptoms (e.g., “feelings of electricity in my scalp”) or idiosyncratic theories of causation (“Could my neighbors be doing this to me?”).
Schizoid Personality
The essential features of the schizoid personality are indifference to the company of others and constricted emotionality. These people are loners who seldom marry, prefer solitary activities, and appear cold and aloof. Despite its name, this disorder does not appear to be closely linked to schizophrenia. Schizoid people tend to shun contact with health care practitioners and may appear very uncomfortable when hospitalization thrusts them into close and constant proximity to others.
Management of Eccentric Subtypes
The general guidelines described previously apply here as well. The most important specific principle of management is to work gradually toward the establishment of rapport by meticulous honesty, composure in the face of the patient's suspiciousness and reserve, and a consistent demonstration of sincere concern for the patient's well-being and respect for his or her privacy.
Specific References*
For annotated General References and resources related to this chapter, visit http://www.hopkinsbayview.org/PAMreferences.