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family medicine Board Review Manual
Statement of
Editorial Purpose
The Hospital Physician Family Medicine Board
Review Manual is a study guide for residents
and practicing physicians preparing for board
examinations in family medicine. Each manual
reviews a topic essential to current practice in
the specialty of family medicine.
PUBLISHING STAFF
PRESIDENT, Group PUBLISHER
Bruce M. White
editorial director
Debra Dreger
EDITOR
Tricia Faggioli
assistant EDITOR
Farrawh Charles
executive vice president
Barbara T. White
executive director
of operations
Jean M. Gaul
PRODUCTION Director
Approach to Personality Disorders
in Primary Care
Editor:
Tsveti Markova, MD, FAAFP
Residency Director and Associate Professor, Department of
Family Medicine and Public Health Sciences, Wayne State University
School of Medicine, Detroit, MI
Contributors:
John H. Porcerelli, PhD, ABPP
Associate Professor, Department of Family Medicine and
Public Health Sciences, Wayne State University School of Medicine,
Detroit, MI
Steven K. Huprich, PhD
Assistant Professor, Department of Psychology, Eastern Michigan
University, Ypsilanti, MI
Table of Contents
Suzanne S. Banish
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
PRODUCTION associate
General Characteristics of Personality Disorders
and Principles of Diagnosis and Management. . . 2
Kathryn K. Johnson
ADVERTISING PROJECT Director
Patricia Payne Castle
Paranoid Personality Disorder. . . . . . . . . . . . . . . 4
sales & marketing manager
Antisocial Personality Disorder . . . . . . . . . . . . . . 5
Deborah D. Chavis
Borderline Personality Disorder. . . . . . . . . . . . . . 6
NOTE FROM THE PUBLISHER:
This publication has been developed with­
out involvement of or review by the Amer­­
ican Board of Family Medicine.
Endorsed by the
Association for Hospital
Medical Education
Dependent Personality Disorder . . . . . . . . . . . . . 8
Summary. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
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www.turner-white.comFamily Medicine Volume 7, Part 1 1
Family Medicine Board Review Manual
Approach to Personality Disorders
in Primary Care
John H. Porcerelli, PhD, ABPP, and Steven K. Huprich, PhD
INTRODUCTION
Primary care physicians are well aware of the frequency of depression in the general population and,
therefore, the necessity of diagnosing and treating this
disorder. In the United States, 16.2% of the population will meet diagnostic criteria for major depressive
disorder at some point in their lifetime,1 and at any
given time, approximately 5% to 10% of primary care
patients will qualify for this diagnosis.2
Recent studies indicate that nearly 50% of patients
with a depressive disorder also meet criteria for a
personality disorder (PD).3,4 PDs have an estimated
incidence as high as 24% in the primary care setting.5
These disorders may be difficult to assess, pose the
greatest threat to the development and maintenance
of good physician-patient relationships, and if unrecognized, can lead to significant functional psychosocial
impairment in patients. In addition, the presence of a
PD can impair the recovery of patients with depression
and other Axis I disorders.6 Because the diagnosis of
PD requires an evaluation of the patient’s long-term
patterns of functioning, the continuity of care provided
by primary care physicians places these physicians in an
ideal position to make a diagnosis or to recognize the
need for referral to a mental health practitioner.
This manual begins with a general description of
PDs and an overview of the clinical approach to diagnosis and management of PDs in the primary care
setting. This is followed by a review specifically focused
on 4 PDs that have the potential to cause significant
problems for both physicians and patients: paranoid
PD, antisocial PD, borderline PD, and dependent
PD. Of the many defined PDs, borderline PD and
dependent PD are more likely to be encountered in
the primary care setting.7 Paranoid PD and antisocial
PD, while perhaps less common, are associated with
profound interpersonal difficulties. For each disorder,
we describe the condition, review the prevalence data
and comorbidities, provide a case example, and discuss
treatment/management strategies.
Hospital Physician Board Review Manual
GENERAL CHARACTERISTICS OF PERSONALITY
DISORDERS AND PRINCIPLES OF DIAGNOSIS
AND MANAGEMENT
DEFINITION AND GENERAL DESCRIPTION
PDs have been described and classified in many ways
but commonly are regarded as disorders of psychopathology less severe than the major psychoses but severe
enough to impair occupational or interpersonal functioning. Common features in the various definitions of
PDs are that the characteristics must be long-standing,
persistent, and pervasive and must cause distress to the
individual or others. The current Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR) defines
PDs as “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.”8 The
DSM-IV-TR provides a general set of diagnostic criteria
applicable to all PDs (Table 1).8
The DSM-IV-TR classifies PDs as Axis II disorders.8 The
intent of placing PDs on a separate axis for diagnosis is to
encourage clinicians to diagnose not only the patient’s
immediate clinical problem (eg, a depressive episode)
but also his or her chronic maladaptive behavior and
interpersonal problems. The DSM-IV-TR further categorizes PDs into 3 clusters (A, B, and C). Knowledge of the
clinical manifestations within this cluster classification
system is critical to diagnosis. In general, individuals with
cluster A PDs (paranoid, schizoid, and schizotypal) tend
to appear odd or eccentric. Those with cluster B PDs
(antisocial, borderline, histrionic, and narcissistic) tend
to appear overly emotional, dramatic, erratic, or unstable
in their relationships. Individuals with cluster C PDs
(avoidant, dependent, and obsessive-compulsive) tend to
appear overly anxious, fearful, or needy.
DIAGNOSTIC APPROACH
Diagnosing PDs can be difficult in clinical practice,
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Approach to Personality Disorders in Primary Care
particularly when functional or organic illness coexists,
but it is important to attempt to recognize these disorders. PDs often must be taken into account when a comorbid Axis I disorder (eg, major depression, generalized anxiety disorder) is treated, because their presence
often affects the treatment response and prognosis for
the Axis I disorder. The presence of a comorbid Axis I
disorder can also complicate the assessment of Axis II
traits. The greatest challenge in diagnosing PDs lies in
the fact that affected individuals often are oblivious to
their dysfunctional personality traits and may instead
blame others for their difficulties or even deny that they
have problems.
It has been difficult for researchers to develop valid
instruments for the assessment of a PD.9,10 A number of
structured interviews and self-report questionnaires are
available, such as the Structured Clinical Interview for
DSM-IV Axis II Personality Disorders (SCID-II)11 and the
Millon Clinical Multiaxial Inventory-III (MCMI-III).12
However, despite demonstrating adequate reliability
(eg, test-retest, inter-rater), these instruments have no
clearly established validity. In addition, time constraints
limit the usefulness of these assessment instruments in a
primary care setting. Also, although PD screening tools
are available that limit the number of items a patient
must respond to, such as the Assessment of DSM-IV
Personality Disorders Questionnaire (ADP-IV),13 these
instruments tend to over-diagnose PD. Thus, the final
determination that a PD exists can be made only after
the physician or mental health professional determines
that a patient meets DSM-IV criteria.
The assessment of PDs in actual clinical practice
differs substantially from the assessment of Axis I disorders. For depressive and anxiety disorders, clinicians
tend to ask questions about specific symptoms and their
frequency, intensity, and duration. However, direct
questioning is only marginally useful in the assessment
for PDs.9 For example, directly asking a patient with
antisocial PD if he repeatedly lies or a patient with
paranoid PD if he reads hidden, threatening meanings into benign remarks is not likely to elicit useful
diagnostic information. However, catching a patient
with anti­social PD in a lie (eg, by discovering the true
reasons the patient is seeking pain medication) or
being accused of being untrustworthy by a patient with
paranoid PD (eg, who refuses to take a prescribed
medication because of mistrust) would be more useful
in diagnosing PD.
Thus, clinicians should assess PDs through close
attention to the patient’s description of past and present interpersonal interactions (eg, with family, friends,
coworkers), through observing the patient’s behavior
Table 1. DSM-IV-TR General Diagnostic Criteria for a
Personality Disorder
A.An enduring pattern of inner experience and behavior that
deviates markedly from the expectations of the individual’s
culture. This pattern must be manifested in 2 (or more) of the
following areas:
1) Cognition (ie, ways of perceiving and interpreting self,
other people, and events)
2) Affectivity (ie, the range, intensity, lability, and
appropriateness of emotional response)
3) Interpersonal functioning
4) Impulse control
B.The enduring pattern is inflexible and pervasive across a broad
range of personal and social situations.
C.The enduring pattern leads to clinically significant distress or
impairment of social, occupational, or other important areas of
functioning.
D.The pattern is stable and of long duration and its onset can be
traced back at least to adolescence or early adulthood.
E.The enduring pattern is not better accounted for as a
manifesttion or consequence of another mental disorder.
F.The enduring pattern is not due to the direct physiological
effects of a substance (eg, a drug of abuse, a medication) or a
general medical condition (eg, head trauma).
Adapted with permission from the American Psychiatric Association.
Diagnostic and statistical manual of mental disorders. 4th ed., text
revision. Arlington (VA): American Psychiatric Publishing; 2000:689.
Copyright 2000, American Psychiatric Association.
during the clinical interview, and through repeated
encounters with the patient. Special attention should
be paid to the quality of the patient’s relationships
(ie, the capacity for love, warmth, trust, and mutuality)
as well as the quality of the physician-patient relationship over time.
The physician’s self-awareness regarding potential
negative reactions to patients becomes an important
clinical tool in assessing for PDs.14 For example, subtly
hostile remarks of a patient with a cluster B PD during
the clinical encounter may not initially indicate a PD
to the physician but rather may leave the physician
feeling irritated after the encounter. A moment of selfreflection can often help to identify the source of the
hostility and can result in a more careful assessment
of the patient’s aggression during the next visit. If the
physician is alerted to the patient’s repetitive patterns of
pathological personality characteristics, traits, and/or
interpersonal behaviors during the clinical encounter,
more specific questions can be asked to assess for the
5 general diagnostic criteria for a PD (Table 1).
It should be noted that there are many more patients
who meet 2 or 3 DSM-IV-TR criteria for a PD and who
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Table 2. DSM-IV-TR Diagnostic Criteria for Paranoid
Personality Disorder
A.A pervasive distrust and suspiciousness of others such that their
motives are interpreted as malevolent, beginning by early adult­
hood and present in a variety of contexts, as indicated by
4 (or more) of the following:
1)Suspects, without sufficient basis, that others are exploiting,
harming, or deceiving him or her
2)Is preoccupied with unjust doubts about the loyalty or trust­
worthiness of friends or associates
3)Is reluctant to confide in others because of unwarranted fear
that the information will be used maliciously against him or
her
4)Reads hidden demeaning or threatening meanings into benign
remarks or events
5)Persistently bears grudges (ie, is unforgiving of insults, injuries,
or slights)
6)Perceives attacks on his or her character or reputation that
are not apparent to others and is quick to react angrily or to
counterattack
7)Has recurrent suspicions, without justification, regarding
fidelity of spouse or sexual partner
B.Does not occur exclusively during the course of schizophrenia,
a mood disorder with psychotic features, or another psychotic
disorder and is not due to the direct physiological effects of a
general medical condition.
NOTE: If criteria are met prior to the onset of schizophrenia,
add "premorbid" (eg, "paranoid personality disorder [premorbid]").
(Adapted with permission from the American Psychiatric Association.
Diagnostic and statistical manual of mental disorders. 4th ed., text
revision. Arlington (VA): American Psychiatric Publishing; 2000:694.
Copyright 2000, American Psychiatric Association.
exhibit significant interpersonal problems and functional impairment than there are patients who meet
full diagnostic criteria. Once it is determined that a
patient meets the general criteria for diagnosis of a PD
(Table 1), then identification of a more specific PD can
be assigned.
MANAGEMENT CONSIDERATIONS
Patients with PDs tend to elicit strong negative feelings in health care providers,15 noted previously as a
consideration in the diagnostic approach. These patients—with little awareness of their own contribution
to the interaction—also tend to elicit negative responses from others. Thus, it is important for the physician
to maintain an empathic and nonjudgmental yet direct
approach when interacting with such a patient.
A collaborative (patient-centered) clinical care approach is also critical to minimize possible patient fears
of being controlled or mistreated and to encourage
patients to talk about such fears when they arise. If
Hospital Physician Board Review Manual
the physician fails to discuss these fears, the physicianpatient relationship can be negatively affected. For
patients with PDs who struggle with overt hostility and
aggression, it may be necessary to establish clear limits
and boundaries for behavior at the time of the visit. For
example, a patient who yells at the physician should be
told that complaints or disagreements must be voiced
in a normal tone in order for the patient to remain in
the practice.
Before recommending psychiatric and/or psycho­
social treatments, the physician should assess the patient’s awareness of his/her problems and readiness for
change.16 Patients with PDs tend to externalize blame
for their problems or distress to others and therefore
may not be open to mental health referrals. Once
a physician feels that the patient is open to a discussion about a referral for mental health treatment, the
physician can acknowledge the patient’s strengths (eg,
the patient’s ability to verbalize concerns) and explain
specific coping skills for the patient to learn (eg, a patient with borderline PD can learn how to lessen the frequency and intensity of negative emotions). Once the
patient acknowledges his/her difficulties, a referral to
a mental health practitioner is recommended in order
for the patient to learn how to manage these difficulties.
Note that PD patients with comorbid Axis I disorders
may need more preparation before being open to a
mental health referral.
Finally, physicians should get to know the mental
health practitioners in their community who treat patients with PDs and collaborate with them in the care
of these challenging patients. In general, cognitive
behavioral and psychodynamic therapies are effective
treatments for many PDs.17 Pharmacotherapy may also
be used to lessen the effects of certain symptoms that
often coexist with many of the PDs, especially cluster B
PDs (depression, anxiety, and aggression). Additional
treatment (eg, day hospitalization) may be necessary
when patients with PDs have comorbid substance abuse
disorders, poor impulse control, or suicidal behavior.18
PARANOID PERSONALITY DISORDER
DEFINING CHARACTERISTICS
Paranoid PD is one of the more problematic PDs
because of the pervasiveness of a mistrust of others,
suspiciousness, hostility, and a need for control, as well
as the level of dysfunction associated with the disorder.19 Patients with paranoid PD often have challenging relationships and significant difficulties with close
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Approach to Personality Disorders in Primary Care
relationships. These patients may express their mis­
trust and suspiciousness through argumentativeness,
through excessive complaining, or through hostile
aloofness.8 It is useful to understand that patients with
paranoid PD are hypervigilant (ie, “paranoid”) because
of ever-present issues of being harmed by others. Addressing these issues early in an encounter may help
to ease the patient’s fears and aid in the building of a
“safe-enough” physician-patient relationship. Physicians
should be aware that members of minority groups, immigrants, political and economic refugees, and patients
from different ethnic backgrounds may exhibit behaviors consistent with paranoid PD (guardedness, suspiciousness, or anger) because of cultural or language
barriers or in response to feelings of indifference or
neglect from the dominant society. DSM-IV-TR criteria
for the diagnosis of paranoid PD are listed in Table 2.8
PREVALENCE AND COMORBIDITY
The prevalence of paranoid PD ranges between
0.5% and 2.5% in the general population, between
10% and 30% in hospitalized psychiatric cohorts, and
between 2% and 10% in outpatient psychiatric cohorts.8 Paranoid PD has a high degree of overlap with
other PDs, especially schizotypal PD (sharing traits of
suspiciousness, paranoia, and aloofness), schizoid PD
(sharing strange, eccentric, odd, and aloof behavior),
and borderline and histrionic PDs (sharing anger over
minor accurate or inaccurate slights). Paranoid PD can
be differentiated from psychotic disorders (delusional
disorder, persecutory type; schizophrenia, paranoid
type; and mood disorder with psychotic features) by
the absence of persistent psychotic symptoms such as
delusions and hallucinations.
CASE ILLUSTRATION
A divorced 37-year-old man presents for the first
time to the clinic with a complaint about “high blood
pressure” that he says his “last doctor didn’t seem to
know what to give” to control. With slight agitation, he
says that he found a lot of information on the internet
and cannot understand why his previous physician did
not help him. When asked about this point, the patient
replies, “I don't know if some doctors just have it out
for you.” When asked for further clarification, he answers angrily, “I’ll never go back there! I could barely
understand his accent—I don't even know if he got to
this country legally!”
The patient lives alone and has no children. He appears annoyed when asked about his sexual history and
refuses to answer questions about it but spontaneously
offers, “You can’t trust women these days with all the
diseases out there!” The patient works in the information technology department for a large company but
says he would like to find another job because he has
difficulty “working with idiots.” He has a younger sibling who he has not talked to in several years.
The physician notes the patient’s concern that doctors are not helping him with his hypertension. She
then tells the patient, “It must be frustrating for you not
to have received the care you were hoping for to get
your blood pressure under control. We’ll work together
on this problem and get you started on medication.
You can help us by monitoring your blood pressure at
home. Then, we’ll see you each week until we get your
blood pressure where it should be. How does this plan
sound to you?”
TREATMENT
Most treatment information for paranoid PD comes
from clinical observation—very little is known empirically.20 To maintain an optimal primary care relationship with such patients, the physician should address
the patient’s concerns as they arise in the clinical
encounter. Encouraging the patient to voice concerns
will usually prevent the magnification of the patient’s
distrust. In this case, the physician empathized with the
patient’s frustration over the care he recently received
and reassured him that they would work together to
find the right treatment for controlling his blood pressure. The patient was also asked if he agreed with the
physician’s plan in order to foster a collaborative relationship and bolster the patient’s sense of control. The
physician was direct, nonjudgmental, and empathic
and offered a collaborative approach to care.
ANTISOCIAL PERSONALITY DISORDER
Throughout recorded history, individuals have been
described whose behavior showed a persistent disregard for and violation of social rules and the rights of
others. Unlike patients with other PDs, patients with a
diagnosis of antisocial PD must be at least 18 years of
age and have a history of childhood conduct disorder
symptoms (aggression toward people or animals, damage to property, deceitfulness or stealing, or serious rule
violations) since age 15 years. Patients with antisocial
PD show a pattern of unlawful behavior; disregard feelings and rights of others; are manipulative and deceitful for purposes of personal gain, power, or pleasure;
are dishonest, impulsive, and irresponsible; and may
lack remorse for wrong-doing.8 DSM-IV-TR criteria for
the diagnosis of antisocial PD are listed in Table 3.8
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Table 3. DSM-IV-TR Diagnostic Criteria for Antisocial
Personality Disorder
A.There is a pervasive pattern of disregard for and violation of the
rights of others occurring since age 15 years, as indicated by
3 (or more) of the following:
1)Failure to conform to social norms with respect to lawful
behaviors as indicated by repeatedly performing acts that
are grounds for arrest
2)Deceitfulness, as indicated by repeated lying, use of aliases,
or conning others for personal profit or pleasure
3) Impulsivity or failure to plan ahead
4)Irritability and aggressiveness, as indicated by repeated
physical fights or assaults
5) Reckless disregard for safety of self or others
6)Consistent irresponsibility, as indicated by repeated failure
to sustain consistent work behavior or honor financial
obligation
7)Lack of remorse, as indicated by being indifferent to or
rationalizing having hurt, mistreated, or stolen from another
B. The individual is at least age 18 years.
C.There is evidence of conduct disorder with onset before age
15 years.
D.The occurrence of antisocial behavior is not exclusively during
the course of schizophrenia or a manic episode.
Adapted with permission from the American Psychiatric Association.
Diagnostic and statistical manual of mental disorders. 4th ed., text
revision. Arlington (VA): American Psychiatric Publishing; 2000:706.
Copyright 2000, American Psychiatric Association.
PREVALENCE AND COMORBIDITY
Community samples reveal that antisocial PD occurs
in approximately 3% of men and 1% of women; prevalence in psychiatric samples varies between 3% and 30%
depending on the assessment criteria used.8 Antisocial
PD is more common in first-degree relatives of individuals with the disorder than in first-degree relatives of those
without the disorder. Patients with anti­social PD often
share symptoms with, or meet full criteria for, other
cluster B PDs (narcissistic, borderline, and histrionic).21
A diagnosis of antisocial PD in a patient with a substancerelated disorder can be made only if signs of antisocial
PD in adolescence have continued into young adulthood. Although traits of antisocial PD can be found in
individuals with paranoid PD (eg, getting into physical
fights), these traits in antisocial PD are rarely motivated
by personal gain or exploitation, but rather by a desire
for revenge. Patients with antisocial PD may also pre­sent
with dysphoria, anxiety, or depression. Patients with
antisocial PD can also meet criteria for anxiety disorder,
depressive disorder, substance-related disorders, somatization disorder, or pathological gambling disorder.8
Hospital Physician Board Review Manual
CASE ILLUSTRATION
A 24-year-old man presents with injuries to his right
hand resulting from a fight the previous night while
working as a security guard at a local dance club. The
patient is quite affable during the interview and states
that he broke the same hand in a fight 2 years ago. He
lives with his girlfriend (of 3 months) and her 2-year-old
daughter. He has 1 child, a 7-year-old son, but has not
had contact with him “since his mother left the state
last year.” The patient seems perturbed when asked if
he has ever been arrested. The patient states that, at age
16 years, he was incarcerated for 6 months in a youth
facility for stealing a car. At age 21 years, he was arrested
again for assault and spent 3 months in a county jail.
He claims that he is a full-time criminal justice student
at a local community college and plans to become a
lawyer.
During the encounter, the physician feels that the
patient exhibits some antisocial PD features; however,
he chooses not to recommend psychological treatment
because the patient’s behavior/personality is not causing him any distress, and it would be unlikely that he
would accept such a recommendation. After treating
the patient’s hand injuries, the physician overhears the
patient invite the receptionist to visit the club where he
works and promise her free admission. As the patient
leaves the office, the physician’s concerns shift to the
safety of himself and the clinical staff.
TREATMENT
Antisocial PD is probably the most difficult of all PDs
to treat. Patients with antisocial PD rarely seek psychological treatment on their own and may do so only when
mandated by a court. There are no known evidencebased treatments for antisocial PD. Some patients with
antisocial PD can be quite charming before taking advantage of others. Physicians need to be respectful yet direct
and firm with such patients and give equal weight to their
own protection and that of their staff.
BORDERLINE PERSONALITY DISORDER
Perhaps no other personality disorder evokes more
reaction and has a greater stigma than borderline PD.
This disorder was first named by Grinker et al22 after
conducting a cluster analysis of 60 patients who did
not fit neatly into any diagnostic category but shared
many features, including anger as the primary affect,
problems in interpersonal relationships, a poor sense
of identity, and pervasive depression. Concurrently,
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Approach to Personality Disorders in Primary Care
Kernberg23 described individuals with borderline PD
as patients who lacked anxiety tolerance and impulse
control and demonstrated poor sublimation of impulses
into socially accepted outlets. Likewise, these patients
tended to engage in highly self-centered thinking and
lacked the capacity to tolerate frustration or ambivalent
feelings in interpersonal relationships. These patients
tended toward the use of defense mechanisms, such as
splitting (seeing others as mainly “all good” or “all bad”
without the capacity to accept the frustrating and gratifying qualities that each person has), as well as idealization, projection, denial, omnipotence, and devaluation.
These qualitative descriptions remain true today, and
many are reflected in the DSM-IV-TR criteria (Table 4).8
Patients with borderline PD are plagued with a sense
of loneliness or emptiness, despite the fact that they
are highly dependent on others to support their fragile
sense of self. This disorder also consists of affective dysregulation, with a chronic sense of anger or irritability
commonly observed in the clinical setting. Suicidal
ideation, gestures, and attempts are not uncommon.
Because of their poor impulse control, patients with
borderline PD engage in activities that could and do
lead to significant danger (eg, compulsive buying, sexual
relationships, substance abuse, physical expressions or
outbursts of anger). When distressed, patients with
borderline PD manage their frustration in diverse, mal­
adaptive ways, including self-mutilation and acting out.
Recent empirical studies of borderline PD have
found that the traits of disinhibition and negative affectivity are most strongly predictive of borderline PD
features.24,25 Other etiologic factors that have been associated with borderline PD include the presence of parental psychopathology; a history of physical, sexual, and/or
emotional abuse; and chronic negative expectations of
relationships, which lead to an underlying sense of negativity and suspiciousness of others’ intentions.24,26,27
PREVALENCE AND COMORBIDITY
Borderline PD is estimated to occur in 2% of adults,
mostly in young women.28 Borderline PD is often diagnosed with coexisting major depressive disorder, dysthymia, substance abuse disorder, and/or bipolar disorder.
The latter disorder may be inappropriately diagnosed
when the health care provider does not attend to the patient’s personality as a whole and instead focuses almost
exclusively on the affective dysregulation component. In
terms of comorbid Axis II disorders, all of the remaining cluster B PDs (antisocial, histrionic, and narcissistic)
share similar features with borderline PD, given the extent to which impulsivity, aggression, excessive self-focus,
and common defense mechanisms occur. Dependent PD
Table 4. DSM-IV-TR Diagnostic Criteria for Borderline
Personality Disorder
A pervasive pattern of instability of interpersonal relationships, selfimage, and affects, and marked impulsivity beginning by early adult­
hood and present in a variety of contexts, as indicated by
5 (or more) of the following:
1) Frantic efforts to avoid real or imagined abandonment*
2)A pattern of unstable and intense interpersonal relationships
characterized by alternating between extremes of idealization
and devaluation
3)Identity disturbance: markedly and persistently unstable selfimage or sense of self
4)Impulsivity in at least 2 areas that are potentially selfdamaging (eg, spending, sex, substance abuse, reckless driving,
binge eating)*
5)Recurrent suicidal behavior, gestures, or threats, or selfmutilating behavior
6)Affective instability due to a marked reactivity of mood (eg,
intense episodic dysphoria, irritability, or anxiety usually last­
ing a few hours and only rarely more than a few days)
7) Chronic feelings of emptiness
8)Inappropriate, intense anger or difficulty controlling anger (eg,
frequent displays of temper, constant anger, recurrent physical
fights)
9)Transient, stress-related paranoid ideation or severe dissocia­
tive symptoms
Adapted with permission from the American Psychiatric Association.
Diagnostic and statistical manual of mental disorders. 4th ed., text
revision. Arlington (VA): American Psychiatric Publishing; 2000:710.
Copyright 2000, American Psychiatric Association.
*Note: Do not include suicidal or self-mutilating behavior covered in
criterion 5.
also may coexist in patients with borderline PD because
these patients are highly dependent on others; however,
the dependent PD patient’s sense of dependency does
not wax and wane like that of the borderline PD patient,
who experiences strong dependency feelings when his/
her needs are being met and aggressive and hostile feelings toward others when these needs are not met.
CASE ILLUSTRATION
A 24-year-old woman presents with a complaint of
“migraines.” However, she says that the main reason
she made the office appointment was to “get everyone
off my back.”
When asked about her headaches, the patient describes them as pain and pressure on both sides of her
head, “like somebody grabbing my head and squeezing
it.” She says the headaches are tolerable but bothersome, “especially when they last a few hours,” and that
acetaminophen provides some relief. She denies any
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Table 5. DSM-IV-TR Diagnostic Criteria for Dependent
Personality Disorder
A pervasive and excessive need to be taken care of that leads to
submissive and clinging behavior and fears of separation, beginning by
early adulthood and present in a variety of contexts, as indicated by
5 (or more) of the following:
1)Has difficulty making everyday decisions without an excessive
amount of advice and reassurance from others
2)Needs others to assume responsibility for most major areas
of his or her life
3)Has difficulty expressing disagreement with others because of
fear of loss of support or approval*
4)Has difficulty initiating projects of doing things on his or her
own (because of a lack of self-confidence in judgment or
abilities rather than a lack of motivation)
5)Goes to excessive lengths to obtain nurturance and support
from others, to the point of volunteering to do things that
are unpleasant
6)Feels uncomfortable or helpless when alone because of exag­
gerated fears of being unable to care for himself or herself
7)Urgently seeks another relationship as a source of care and
support when a close relationship ends
8)Is unrealistically preoccupied with fears of being left to take
care of himself or herself
Adapted with permission from the American Psychiatric Association.
Diagnostic and statistical manual of mental disorders. 4th ed., text
revision. Arlington (VA): American Psychiatric Publishing; 2000:725.
Copyright 2000, American Psychiatric Association.
*Note: Do not include realistic fears of retribution.
nausea, vomiting, or changes in her vision during the
headaches.
The physician tells the patient that her “migraines”
are actually tension headaches, for which he can offer
effective treatments. He then turns the discussion to
the patient’s opening comment about why she made
the appointment to come in today.
The patient says that her friends have expressed
concern about her erratic behavior since she broke
up with her boyfriend, whom she had been dating for
3 months. She sees nothing wrong with her behavior,
which includes frequent shopping at a local mall. She
states that she spent $600 one day, which is her weekly
income. She notes that she has been eating much more
than usual and having difficulty falling asleep since the
breakup, and she admits she has even had thoughts
of suicide. However, she sees nothing unusual about
these behaviors. She describes her relationship with her
boyfriend as a “rollercoaster ride.” She says sometimes
she hates him, but other times she is convinced he is
the man of her dreams. When they argued, she found
it particularly upsetting that her boyfriend said she was
Hospital Physician Board Review Manual
“like a firecracker that could explode at any time.” After
these fights, she would find herself “spacing out,” which
was followed by numerous frantic phone calls to the
boyfriend to be assured of his interest in her.
After ruling out alcohol and substance misuse, the
physician tells the patient that the tension headaches
may be related to her difficulty in managing her feelings when things go wrong with her relationships and
that there are treatments that can help her with these
problems. The patient states that she only needs something to stop the headaches. The physician asks if she
would be willing to talk more about her relationships
and the difficulties she has managing her feelings at
her follow-up appointment, and the patient agrees.
TREATMENT
Unlike many PDs, borderline PD is often treated
with pharmacotherapy in conjunction with psychotherapy. It is preferable that an assessment for medication be made by a psychiatrist. Selective serotonin
reuptake inhibitors and anticonvulsants have been
commonly used to address the underlying affective
dysregulation and impulsivity.29–31 Dialectical behavior
therapy32 is often used in both inpatient and outpatient settings, although it is typically believed and empirically demonstrated that long-term psychotherapy
is both successful and cost-effective.33,34 Despite the
challenges of treating patients with borderline PD, it is
recommended that these patients be strongly encouraged to seek and maintain psychotherapy. In this case,
however, the physician noted that the patient was not
ready to acknowledge her problems and thus was not
ready for a recommendation for treatment of her borderline PD. In future visits, the physician should talk
with this patient about her distress, its association with
how she manages her feelings and relationships, and
how it affects her health.
DEPENDENT PERSONALITY DISORDER
DSM-IV-TR criteria for dependent PD are listed in
Table 5.8 Patients with dependent PD are excessively
reliant on others to care for them and to provide the
comfort and self-assurance that they are not able to provide for themselves. The dependent PD patient’s sense
of agency is significantly reduced, such that others take
on an important psychological role in the patient’s
pursuit of independence and self-efficacy. The patient
with dependent PD characteristically has others make
everyday decisions for him/her and requires much support before taking action.8 Contrary to what might be
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Approach to Personality Disorders in Primary Care
expected, patients with dependent PD are not passive;
they actively seek out the care of someone else when
they lose or believe they might lose their caretaker.35
To receive the care and help that they desire, patients with dependent PD often agree to conditions
or situations that most others might find aversive. For
example, it is not uncommon to find a dependent
woman married to a narcissistic man, who expects her
to submit to his idiosyncratic and self-serving requests,
which many people would find excessive, controlling,
and possibly demoralizing. In the context of primary
care, it would not be unexpected to find the patient
with dependent PD scheduling more than the usual
number of visits within a year or seeking a physician’s
support and care for minor issues.
PREVALENCE AND COMORBIDITY
Dependent PD is frequently seen in mental health
facilities.4 Dependent PD qualities and traits are often
observed as part of avoidant and borderline PDs. As
such, dependent PD may be inappropriately diagnosed
in borderline or avoidant patients or may coexist. Eating
disorders, anxiety disorders, substance abuse disorders,
and obesity are commonly observed in patients with dependent PD or in those with PDs that have dependent
features.36–40 There also are strong links between depression and dependency, and patients with dependent PD
are vulnerable to experiencing depressive episodes.8
Thus, when assessing patients with these comorbid disorders, it is helpful to evaluate for dependent personality
qualities or the conflicts that an individual feels regarding his/her sense of dependence or independence.
CASE ILLUSTRATION
A 45-year-old woman presents to the clinic for the
fifth time in 4 months. At this appointment, the patient
notes that she cannot overcome a cold, and she wants
assurance from her physician that she is going to be
fine. The patient often presents for guidance and reassurance about common maladies, and her physician
notices that these appointments tend to occur when
her husband of 18 years is out of town on business. The
patient comments how she dislikes her husband’s absence because she must manage all the responsibilities
by herself, including determining what to feed her dog
and when to go to the grocery store.
Aware of her pattern of visits, the physician treats
the patient for her cold and then discusses how her
feelings of loneliness cause her to worry about her
health. The physician reassures the patient that she will
recover from the cold, that nothing is seriously wrong
with her, and that she is able to handle the responsibili-
ties at home until her husband returns. The physician
then asks the patient if she has ever considered seeing
a therapist for help in developing strategies for coping
with her husband’s absences. The patient says she had
not considered that option but that she would think
about it. The physician makes a note in the patient’s
chart to follow up on the issue of mental health care at
the next visit.
TREATMENT
Psychotherapy is strongly recommended for patients
with dependent PD. The focus is on restoring the patient’s sense of agency and self-efficacy and on the underlying reasons maintaining the patient’s wish for a caregiver. As dependent PD patients often experience much
anxiety when faced with decision-making or the need to
be independent, attention is often devoted to reducing
anxiety and fostering a sense of safety and efficacy. In
this case, the physician reassured the patient that her
condition was not serious, acknowledged her strengths,
provided information about therapy, and suggested an
important issue for her to focus on in therapy. Physicians
should monitor their level of emotional involvement
with dependent patients, be realistic and open about
time limitations for such encounters, acknowledge limitations in solving the patient’s problems, resist the temptation to make major decisions for the patient, and help
the patient seek alternate forms of support from others
(eg, family members, member of the clergy, a therapist)
in times of increased need.41 It should be noted that increased dependency following the loss of a loved one, a
traumatic experience, or the onset of a significant illness
may be temporary and lessen with time as long as the
patient has adequate social support.
SUMMARY
PDs may be more difficult to assess than Axis I conditions such as depression. PDs can negatively affect
the physician-patient relationship, interfere with the
treatment of other medical and psychiatric disorders,
and cause significant functional impairment in patients
who struggle with them. Physicians can assess PDs by
paying close attention to patients’ descriptions of past
and present interpersonal relationships and through
observing the way the patient interact with them within
the clinical encounter. Repetitive maladaptive patterns
are likely to emerge as primary care physicians get to
know these patients and their families. In managing
patients with PDs, it is important to develop a collaborative stance and remain empathic. Before referring
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these patients to mental health providers knowledgeable in treating PDs, physicians should assess the patients’ awareness of their problems and readiness for
change. By being aware of the diagnostic criteria, diagnostic methods, and management strategies for these
more difficult PDs, primary care physicians can more
effectively care for patients with these disorders.
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Copyright 2007 by Turner White Communications Inc., Wayne, PA. All rights reserved.
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