Abstract
Personality disorders are complex to both identify and manage. All humans have a unique personality. Personality is what distinguishes us from each other and shapes our thoughts, emotions and behaviour. Personality disorders may be diagnosed when behaviour differs from expected norms, and abnormal traits in behaviour are persistent, pervasive and problematic. This article will provide an overview of the classification of personality disorders and the factors that contribute to their development. It will then consider dissocial personality disorder, the personality disorder encountered most often by GPs, in more detail. Finally, the benefits of countertransference are considered in an overview of the interaction between GPs and patients with a personality disorder.
The GP curriculum and personality disorders
Always consider the patient’s mental health during a consultation Use good communication skills, mostly listening skills and empathy Understand that mental health problems bring about co-morbidity with physical health problems Take into consideration cultural issues: physical, social and spiritual Know how to work within a multidisciplinary team
Characterisation of personality disorders
A disorder in personality is defined as being when observed behaviour persistently differs from the expected cultural norms of behaviour. Differences in behaviour are exemplified by impairments in cognition, affectivity, interpersonal functioning and impulse control. According to the International Classification of Diseases, 10th addition (ICD-10), the diagnosis of a personality disorder can be made when such behaviour traits have been present since childhood and result in personal distress and social disturbance. In addition, disturbances in personality and behaviour must not be the result of other mental health disorders, physical diseases or brain trauma (ICD-10).
The specific types of personality disorder, their characterisation and the disorder in personality as classified in ICD-10.
As these personality disorders may show similarities or share co-morbidities with other mental health disorders, each personality disorder within the ICD-10 excludes any disorder or behaviour that may resemble that personality disorder. For example, an individual with a paranoid personality must not suffer from paranoia due to psychosis, schizophrenia or a paranoid state; dissocial personality disorder excludes conduct disorder and emotionally unstable personality disorders; anakastic personality disorder excludes obsessive compulsive disorder.
Each personality disorder is defined by characteristic impairments in behaviour. Some of the differences are quite subtle and there are shared features that can make it challenging to differentiate the different personality disorders. As the behaviours need to be evident over a period of time, and in different situational contexts, it can be difficult to identify whether a particular behaviour constitutes an impairment of personality. Evidence now shows that personality disorders affect 6% of the worldwide population, and that there is no consistent variation across different countries (Tyrer et al., 2010).
A recent study conducted by Gawda and Czuback (2017) estimated the prevalence of personality disorders within the Polish population. Their sample of 1460 participants, aged between 18 and 65 years, completed the Mini International Neuropsychiatric Interview, and subsequently further demographic data was collected. The dissocial (antisocial) personality disorder was the least prevalent in the study population and was more prevalent in men (Gawda and Czuback, 2017). The authors argued that cultural and ethnic factors explain differences in prevalence between populations. Other researchers have considered that the classification and diagnosis of personality disorders is biased towards higher prevalence in North American and Western European countries.
The prevalence of personality disorder in various geographical locations.
Source: Gawda and Czuback (2017).
Aetiology of personality disorders
Research has still not determined the causes of personality disorder, but both hereditary and environmental factors play an important part. Studies on these hereditary and environmental factors have mostly focused on paranoid, schizoid, emotionally unstable and dissocial disorders (Ma et al., 2016). The genes that regulate neurotransmitters (including dopamine, norepinephrine and other amines) are likely to explain the hereditary factors responsible for personality disorders. These neurotransmitters are known for their role in mood regulation, suicidality, aggression, impulsivity and lack of empathy (Ma et al., 2016).
Other studies have found that people suffering from personality disorders show volumetric abnormalities in certain brain regions when compared with control populations (Ma et al., 2016). Adverse environmental factors have also been found to have psychopathological effects; these adverse factors include physical, sexual and emotional abuse and neglect (Nathan and Wood, 2016). Specific adverse environmental factors were found to contribute to certain personality disorders. Such adversities include neglect during childhood and harsh and inconsistent discipline. The former adverse factor was found in emotionally unstable personality disorder, whereas the latter was associated with dissocial personality disorder (Nathan and Wood, 2016).
This research suggests that both hereditary and environmental factors contribute to the characteristics of personality and may explain the development of different personality disorders. Although biological, psychological and social risk factors should be taken into consideration when assessing patients, they cannot be considered as causative in individual patients.
Patients with personality disorders often experience fluctuations in mood. This and other behaviour traits can increase the likelihood of contact with GPs. This and a relatively high prevalence may explain why it is quite common for GPs to encounter patients with personality disorders. A study by Casey and Tyler (1990) found that evidence of personality disorder was found in almost a third of the population seeking help from GPs. The Nightingale Hospital has suggested that histrionic, narcissistic, antisocial and borderline personality disorders are the most common disorders encountered by GPs (Nightingale Hospital, 2014). Dixon-Gordon et al. (2018) found that people suffering from dissocial personality disorder had a higher tendency to seek help from GPs, mostly for chronic pain.
Dissocial personality disorder
The Diagnostic Statistical Manual (5) (DSM V) supports a diagnosis of dissocial (antisocial) personality disorder in patients over the age 18 years with previous signs of deviant behaviour before the age of 15 (American Psychiatric Association, 2013). This personality disorder is mainly characterised by violation of the rights of others. Additionally, patients show lack of remorse and must not have other conditions, physical or mental, such as schizophrenia or bipolar disorder (DSM V) to explain the behaviour. As noted in Table 1, characterisation criteria for dissocial personality disorder within the ICD-10 are equivalent to those in the DSM V classification. However, the ICD-10 places emphasis on the exclusion of co-morbidity or similar traits (for example, in conduct disorder and emotionally unstable personality disorder) in making a diagnosis.
Stigma and personality disorders
Individuals who suffer from personality disorders are highly stigmatised, often due to behaviour that is manipulative and overwhelming to others. This stigma is seen from both the public and clinical practitioners. Stigma can influence how the practitioner perceives the actions, thoughts and emotional reaction of the patient suffering from a personality disorder. The public tend to shun sufferers and this abandonment may invoke high levels of distress among sufferers. This sense of abandonment can lead to not only self-harming or other problems requiring treatment, but also withdrawal from treatment or avoidance of treatment (Aviram et al., 2006). Stigma adds to the challenge of interacting with patients with personality disorders.
Patients with personality disorders and GPs
Chronic pain is commonly reported by people suffering from either dissocial personality disorder or emotionally unstable personality disorder. Recent studies have shown that people suffering from a personality disorder often report concerns about physical health. Such illness includes poor physical health, multiple illnesses, high rates of asthma and musculoskeletal problems, among others (Dixon-Gordon et al., 2018). Such chronic illnesses are often reported by people with histrionic, dissocial or emotionally unstable personality disorders. However, people suffering from paranoid or schizoid personality disorders were found to report more symptoms of gastroesophageal reflux disease, and those suffering with anxious, ankestic or dependent personality disorder are more prone to recurrent headaches. People with personality disorders also have a tendency to report problems in sleeping pattern (Dixon-Gordon et al., 2018).
Patients with a history of poor mental health and suffering from a personality disorder have been reported to be among the most difficult patients (Moukaddam et al., 2017). For example, if care is not deemed satisfactory they can threaten suicide. This is used as a technique to ultimately persuade care givers and relatives to provide the care demanded or expected (Moukaddam et al., 2017). Since not all sufferers with a personality disorder are diagnosed, it can be difficult at times for the GP to recognise and manage the presented behaviour. It is also common for some patients with a personality disorder to attend the Accident and Emergency department intoxicated, shouting at staff, using obscene language and refusing to answer questions. Once the intoxication has been resolved, the patient often refuses care and asks to for hospital admission while complaining that no one can help or adequately attend to their needs. Such patients often exhibit behaviour that is high on negative affectivity, disinhibition and antagonism.
Generally, the best way to try and manage such patients is to tackle the maladaptive areas of behaviour (Moukaddam et al., 2017). When treating people with a personality disorder, it is best to avoid situations that may lead to harmful escalations or interfere with the medical intervention. The detail of this approach depends on the type of disordered behaviour that is presented to the GP. It is important to obtain a thorough history and to allow the patient to be part of the treatment plan. Patients who suffer from paranoid or schizoid personality disorders tend not to report all of the symptoms, thus impeding medical intervention. Individuals who suffer from dissocial, histrionic, emotional unstable or narcissistic traits tend to pass dramatic comments and add superfluous and off-topic details. They tend to escalate symptoms and report tearfully that they are not being appropriately looked after by their carers. Patients suffering from anakastic, dependent or dissocial symptoms tend to be very anxious and frequently ask for reassurance.
According to Moukaddam et al., (2017), the best way to interact with these patients is to empathise and provide validation. It may also help if family members and carers are not present in the consultation room. It can also help to employ countertransference when engaging with patients suffering from personality disorders.
Countertransference
Countertransference is a concept introduced by Freud (Moukaddam et al., 2017). It refers to the influences that are transferred from the patient to the therapist’s unconscious feelings. Countertransference can be either objective or subjective. Objective countertransference is brought about by empathising with the patient and using their attitudes and behaviour to project their feelings. Another form of countertransference involves sharing personal experience with the patient and offering a subjective viewpoint.
However, GPs using countertransference with patients suffering from personality disorders have reported differences in experience depending on the personality disorder. People with traits of paranoid and schizoid personality disorder tend to invoke a feeling of mistreatment and have a habit of criticising the provider. GPs treating patients with dissocial, emotionally unstable or histrionic personally disorder have reported feeling overwhelmed, inadequate, disorganised, helpless and of being over involved with the patient. Patients suffering from anakastic, anxious avoidant or dependent personalities tend to project the feeling that they are vulnerable and need protection (Moukaddam et al., 2017).
Conclusion
It is common for GPs to encounter patients with mental health issues, and one needs the right knowledge and skill set to provide the best treatment and advice. Providing care to patients suffering with a personality disorder can be difficult, and it is often not easy to identify the precise deficits in behaviour. Patients with personality disorders may have behaviours that overlap with other personality disorders and with other mental health problems. To provide adequate care, GPs need some knowledge of personality disorders and to be able to empathise with patients. The use of medication in the management of patients suffering from personality disorders is not covered in this article.
KEY POINTS
There are a variety of different personality disorders described with, for example, the nine personality disorders within the ICD-10 classification Each personality disorder has characteristic disorders in behaviour Personality disorders are likely to have aetiological factors that are genetic and environmental Dissocial personality disorder is likely to be the personality disorder most frequently encountered by a GP It can be helpful to understand the concept of countertransference when communicating and interacting with patients suffering from personality disorders