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Personality disorders: a measured response: improving your understanding of these disorders will help you identify specific diagnoses, ensure appropriate treatment, and reduce frustration during office visits.

Personality disorders (PDs) are common, affecting up to 15% of US adults, and are associated with comorbid medical and psychiatric conditions and increased utilization of health care resources. (1,2) Having a basic understanding of these patterns of thinking and behaving can help family physicians (FPs) identify specific PD diagnoses, ensure appropriate treatment, and reduce the frustration that arises when an individual is viewed as a "difficult patient."

Here we describe the diagnostic features of the disorders in the 3 major clusters of PDs and review an effective approach to the management of the most common disorder in each cluster, using a case study patient.

Defense mechanisms offer clues that your patient may have a PD

Personality is an enduring pattern of inner experience and behaviors that is relatively stable across time and in different situations. Such traits comprise an individual's inherent makeup. (1) PDs are diagnosed when an individual's personality traits create significant distress or impairment in daily functioning. Specifically, PDs have a negative impact on cognition, affect, interpersonal relationships, and/or impulse control. (1)

One of the ways people alleviate distress is by using defense mechanisms. Defense mechanisms are unconscious mental processes that individuals use to resolve conflicts, and thereby reduce anxiety and depression on a conscious level. Taken alone, defense mechanisms are not pathologic, but they may become maladaptive in certain stressful circumstances, such as when receiving medical treatment. Recognizing patterns of chronic use of certain defense mechanisms may be a clue that your patient has a PD. TABLE 13-4 and table 23,4 provide an overview of common defense mechanisms used by patients with PDs.

The American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5) organizes PDs into 3 clusters based on similar and often overlapping symptoms. (1) TABLE 31 provides a brief summary of the characteristic features of each disorder in these clusters.

Cluster A: Odd, eccentric

Patients with one of these disorders are odd, eccentric, or bizarre in their behavior and thinking. There appears to be a genetic link between cluster A PDs (especially schizotypal) and schizophrenia. (5) These patients rarely seek treatment for their disorder because they have limited insight into their maladaptive traits. (5,6)

CASE 1 * Daniel A, age 57, has hypertension and hyperlipidemia and comes in to see his FP for a 6-month follow-up appointment. He never misses appointments, but has a history of poor adherence with prescribed medications. He enjoys his discussions with you in the office, although he often perseverates on conspiracy theories. He lives alone and has never been married. He believes that some of the previously prescribed medications, including a statin and a thiazide diuretic, were interfering with the absorption of "positive nutrients" in his diet. He also refuses to take the generic form of a statin, which he believes was adulterated by the government to be sold at lower cost.

Mr. A demonstrates the odd and eccentric beliefs that characterize schizotypal personality disorder. How can his FP best help him adhere to his medication regimen? (For the answer, go to page 96.)

* Schizotypal personality disorder shares certain disturbances of thought with schizophrenia, and is believed to exist on a spectrum with other primary psychotic disorders. Support for this theory comes from the higher rates of schizotypal PD among family members of patients with schizophrenia. There is a genetic component to the disorder. (3,5,6)

Clinically, these patients appear odd and eccentric with unusual beliefs. They may have a fascination with magic, clairvoyance, telepathy, or other such notions. (1,5) Although the perceptual disturbances are unusual and often bizarre, they are not frank delusions: patients with schizotypal PD are willing to consider alternative explanations for their beliefs and can engage in rational discussion. Cognitive deficits, particularly of memory and attention, are common and distressing to patients. Frequently, the presenting complaint is depression and anxiety due to the emotional discord and isolation from others. (1,3,5,6)

Cluster B: Dramatic, erratic

Patients with cluster B PDs are dramatic, excessively emotional, confrontational, erratic, and impulsive in their behaviors. (1) They often have comorbid mood and anxiety disorders, as well as a disproportionately high co-occurrence of functional disorders. (3,7) Their rates of health care utilization can be substantial. Because individuals with one of these PDs sometimes exhibit reckless and impulsive behavior, physicians should be aware these patients have a high risk of physical injuries (fights, accidents, self-injurious behavior), suicide attempts, risky sexual behaviors, and unplanned pregnancy. (8,9)

CASE 2 * Sheryl B is a 34-year-old new patient with a history of irritable bowel syndrome, fibromyalgia, depression, and anxiety who shows up for her appointment an hour late. She is upset and blames the office scheduler for not reminding her of the appointment. She brings a list of medications from her previous physician that includes sertraline, clonazepam, gabapentin, oxycodone, and as-needed alprazolam. She insists that her physician increase the dose of the benzodiazepines.

A review of her medical history reveals diagnoses of anxiety, bipolar disorder, and posttraumatic stress disorder. Ms. B has also engaged in superficial cutting since adolescence, often triggered by arguments with her boyfriend. Currently, she attributes her anxiety and pain to not receiving the "correct medications" because of her transition from a previous physician who "knew her better than any other doctor." After the FP explains to Ms. B that he would have to carefully review her case before continuing to prescribe benzodiazepines, she becomes tearful and argumentative, proclaiming, "You won't give me the only thing that will help me because you want me to be miserable!"

Ms. B exhibits many cluster B personality traits consistent with borderline PD. How should the FP respond to her claims? (For the answer, go to page 96.)

* Borderline PD is the most studied of the PDs. It can be a stigmatizing diagnosis, and even experienced psychiatrists may hesitate to inform patients of this diagnosis. (10) Patients with borderline PD may be erroneously diagnosed with bipolar disorder, treatment-resistant depression, or posttraumatic stress disorder because of a complicated clinical presentation, physician unfamiliarity with diagnostic criteria, or the presence of genuine comorbid conditions. (3,11)

The etiology of this disorder appears to be multifactorial, and includes genetic predisposition, disruptive parent-child relationships (especially separation), and, often, past sexual or physical trauma. (9,12)

Predominant clinical features include emotional lability, efforts to avoid abandonment, extremes of idealization and devaluation, unstable and intense interpersonal relationships, and impulsivity. (1) Characteristically, these patients also engage in self-injurious behaviors. (13,14) Common defense mechanisms used by patients with borderline PD include splitting (viewing others as either all good or all bad), acting out (yelling, agitation, or violence), and passive aggression (TABLE 1 (3,4)).

Cluster C: Anxious, fearful

Individuals with cluster C PDs appear anxious, fearful, and worried. They have features that overlap with anxiety disorders. (15)

CASE 3 * Judy C is a 40-year-old lawyer with a history of gastroesophageal reflux disorder, hypertension, and anxiety who presents for a 3-week follow-up visit after starting sertraline. The patient describes herself as a perfectionist who has increased work-related stress recently because she has to "do extra work for my colleagues who don't know how to get things done right." She recently fired her assistant for "not understanding my filing system." She appears formal and serious, often looking at her watch during the evaluation.

Ms. C demonstrates a pattern of perfectionism, formality, and rigidity in thought and behavior characteristic of obsessive-compulsive PD. What treatment should her physician recommend? (For the answer, go to page 97.)

* Obsessive-compulsive PD. Although this disorder is associated with significant anxiety, patients often view the specific traits of obsessive-compulsive PD, such as perfectionism, as desirable. Neurotic defense mechanisms are common, especially rationalization, intellectualization, and isolation of affect (TABLE 23,4). These patients appear formal, rigid, and serious, and are preoccupied with rules and orderliness to achieve perfection. (1) Significant anxiety often arises from fear of making mistakes and ruminating on decision-making. (1,11,15)

Although some overlap exists between obsessive-compulsive disorder (OCD) and obsessive-compulsive PD, patients with OCD exhibit distinct obsessions and associated compulsive behavior, whereas those with obsessive-compulsive PD do not. (1)

In terms of treatment, it is generally appropriate to recognize the 2 conditions as distinct entities. (15) OCD responds well to cognitive behavioral therapies and high-dose selective serotonin reuptake inhibitors (SSRIs). (16) In contrast, there is little data that suggests antidepressants are effective for obsessive-compulsive PD, and treatment is aimed at addressing comorbid anxiety with psychotherapy and pharmacotherapy, if needed. (11,15)

Psychotherapy for PD is the first-line treatment

Psychotherapy is the most effective treatment for PDs. (11,17,18) Several psychotherapies are used to treat these disorders, including dialectical behavioral therapy, schema therapy, and cognitive behavioral therapy (CBT). A recent study demonstrated the superiority of several evidence-based psychotherapies for PD compared to treatment-as-usual. (17) Even more promising is that certain benefits have been demonstrated when psychotherapy is provided by clinicians without advanced mental health training. (19-21_ However, the benefits of therapies for specific disorders are often limited by lack of available data, patient preference, and accessibility of resources.

Limited evidence supports pharmacotherapy

The use of pharmacotherapy for treating PDs is common, although there's limited evidence to support the practice. (11,22) Certain circumstances may allow for the judicious use of medication, although prescribing strategies are based largely on clinical experience and expert opinion.

Prescribers should emphasize a realistic perspective on treatment response, because research suggests at best a mild-moderate response of some personality traits to pharmacotherapy. (11,22-25) There is no evidence for polypharmacy in treating PDs, and FPs should allow for sufficient treatment duration, switch medications rather than augment ineffective treatments, and resist the urge to prescribe for every psychological crisis. (11,22,25,26)

Patient safety should always be a consideration when prescribing medication. Because use of second-generation antipsychotics is associated with the metabolic syndrome, the patient's baseline weight and fasting glucose, lipids, and hemoglobin Ale levels should be obtained and monitored regularly. Weight gain can be particularly distressing to patients, increase stress and anxiety, and hinder the doctor-patient relationship. (25) Finally, medications with abuse potential or that can be lethal in overdose (eg, tricyclic antidepressants and benzodiazepines) are best avoided in patients with emotional lability and impulsivity. (25,26)

Tailor treatment to the specific PD

Tx for cluster A disorders. Few studies have examined the effectiveness of psychotherapies for cluster A disorders. Cognitive therapy may have benefit in addressing cognitive distortions and social impairment in schizotypal pd. (11,12,22) There is little evidence supporting psychotherapy for paranoid PD, because challenging patients' beliefs in this form is likely to exacerbate paranoia. Low-dose risperidone has demonstrated some beneficial effects on perceptual disturbances; however, the adverse metabolic effects of this medication may outweigh any potential benefit, as these symptoms are often not distressing to patients. (6,27) In comparison, patients often find deficits in memory and attention to be more bothersome, and some data suggest that the alpha-2 agonist guanfacine may help treat these symptoms. (28)

* Tx for cluster B disorders. Several forms of psychotherapy have proven effective in managing symptoms and improving overall functioning in patients with borderline PD, including dialectical behavioral therapy, mentalization-based therapy, transference-focused therapy, and schema therapy. (29) Dialectical behavioral therapy is often the initial treatment because it emphasizes reducing self-harm behaviors and emotion regulation. (11,17,26)

Gunderson (19) developed a more basic approach to treating borderline PD that is intended to be used by all clinicians who treat the disorder, and not just mental health professionals with advanced training in psychotherapy. A large, multisite randomized controlled trial found that the clinical efficacy of the technique, known as good psychiatric management, rivaled that of dialectical behavioral therapy. (20,21)

The general premise is that clinicians foster a therapeutic relationship that is supportive, engaging, and flexible. Physicians are encouraged to educate patients about the disorder and emphasize improvement in daily functioning. Clinicians should share the diagnosis with patients, which may give patients a sense of relief in having an accurate diagnosis and allow them to fully invest in diagnosis-specific treatments. (19)

Systematic reviews and meta-analyses of studies that evaluated pharmacotherapy for borderline PD often have had conflicting conclusions as a result of analyzing data from underpowered studies with varying study designs. (23,24,26,30,31) In targeting specific symptoms of the disorder, the most consistent evidence has supported the use of antipsychotics for cognitive perceptual disturbances; patients commonly experience depersonalization or out-of-body experiences. (25) Additionally, the use of antipsychotics and mood stabilizers (lamotrigine and topiramate) appears to be somewhat effective for managing emotional lability and impulsivity. (26,32,33) Despite the widespread use of SSRIs, a recent systematic review found the least support for these and other antidepressants for management of borderline PD. (25)

* Tx for cluster C disorders. Some evidence supports using cognitive and interpersonal psychotherapies to treat cluster C PDs. (34) In contrast, there is little evidence to support the use of pharmacotherapy. (35) However, given the significant overlap among these disorders (especially avoidant PD) and social phobia and generalized anxiety disorder, effective pharmacologic strategies can be inferred based on data for those conditions. (11) SSRIs, serotonin-norepinephrine reuptake inhibitors (eg, venlafaxine), and gabapentin have demonstrated efficacy in anxiety disorders and are reasonable and safe initial treatments for patients with a cluster C PD. (11,34)

CASE 1 * Mr. A's schizotypal PD symptoms interfere with medication adherence because of his unusual belief system. Importantly, unlike patients with frank delusions, patients with schizotypal PD are willing to consider alternative explanations for their unusual beliefs. Mr. A's intense suspiciousness may indicate some degree of overlap between paranoid and schizotypal PDs.

The FP is patient and willing to listen to Mr. As beliefs without devaluing them. To improve medication adherence, the FP offers him reasonable alternatives with clear explanations. ("I understand you have concerns about previous medications. At the same time, it seems that managing your blood pressure and cholesterol is important to you. Can we discuss alternative treatments?")

CASE 2 * In response to Ms. B's borderline PD, the FP must be cautious to avoid reacting out of frustration, which may upset the patient and validate her mistrust. The FP first reflects her anger ("I can tell you are upset because you don't think I want to help you"), which may allow her to calmly engage in a discussion. He wants to recognize Ms. B's dramatic behavior, but not reward it with added attention and unreasonable concessions. To help establish rapport, he provides a statement to legitimize Ms. B's concerns ("Many patients would be frustrated during the process of changing physicians").

The FP listens empathically to Ms. B, sets clear limits, and provides consistent and evidence-based treatments. He also provides early referral to psychotherapy, but to mitigate any perceived abandonment, he assures Ms. B he will remain involved with her treatment. ("It sounds like managing your anxiety is important to you, and often psychiatrists or therapists can help give additional options for treatment. I want you to know that I am still your doctor and we can review their recommendations together at our next visit.")

CASE 3 * The FP recognizes that Ms. C's pattern of perfectionism, formality, and rigidity in thought and behavior are likely a manifestation of obsessive-compulsive PD, and that the maladaptive psychological traits underlying her anxiety are distinct from a primary anxiety disorder.

An SSRI may be a reasonable option to treat Ms. B's anxiety, and the FP also refers her for CBT. ("I can tell you are feeling really anxious and many people feel that way, especially with work. I think the medication is a good start, but I wonder if we could discuss other forms of therapy to maximize your symptom improvement.") Because of their exacting nature, many patients with cluster C personality traits are willing to engage in treatments, especially if they are supported by data and recommended by a knowledgeable physician.

PRACTICE RECOMMENDATIONS

* Maintain a high index of suspicion for personality disorders (PDs) in patients who appear to be "difficult," and take care to distinguish these diagnoses from primary mood, anxiety, and psychotic disorders. (C)

* Refer patients with PDs for psychotherapy, as it is considered the mainstay of treatment--particularly for borderline PD. (B)

* Use pharmacotherapy judiciously as an adjunctive treatment for PD. (B)

Strength of recommendation (SOR)

(A) Good-quality patient-oriented evidence

(B) Inconsistent or limited-quality patient-oriented evidence

(C) Consensus, usual practice, opinion, disease-oriented evidence, case series

CORRESPONDENCE

Nicholas Morcos, Department of Psychiatry, University of Michigan Health System, 1500 East Medical Center Drive, Ann Arbor, Ml 48109; nmorcos@med.umich.edu.

References

(1.) American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 5th ed. Arlington, VA: American Psychiatric Publishing; 2013.

(2.) Zimmerman M, Rothschild L, Chelminski I. The prevalence of DSM-IV personality disorders in psychiatric outpatients. Am J Psychiatry. 2005;162:1911-1918.

(3.) Cloninger C, Svrakie D. Personality disorders. In: Sadock BJ, Sadock VA, Ruiz P, eds. Kaplan & Sadock's synopsis of psychiatry: Behavioral sciences/clinical psychiatry. 11th ed. Philadelphia, Pa: Wolters Kluwer; 2015:2197-2240.

(4.) Bowins B. Personality disorders: a dimensional defense mechanism approach. Am J Psychother. 2010;64:153-169.

(5.) Raine A. Schizotypal personality: neurodevelopmental and psychosocial trajectories. Annu Rev Clin Psychol. 2006;2:291-326.

(6.) Rosell DR, Futterman SE, McMaster A, et al. Schizotypal personality disorder: a current review. Curr Psychiatry Rep. 2014;16:452.

(7.) Gabbard GO, Simonsen E. Complex Case: The impact of personality and personality disorders on the treatment of depression. Personal Ment Health. 2007; 1:161 -175.

(8.) Caspi A, Begg D, Dickson N, et al. Personality differences predict health-risk behaviors in young adulthood: evidence from a longitudinal study. J Pers Soc Psychol. 1997;73:1052-1063.

(9.) Tomko RL, Trull TJ, Wood PK, et al. Characteristics of borderline personality disorder in a community sample: comorbidity, treatment utilization, and general functioning. J Pers Disord. 2014;28:734-750.

(10.) Vaillant GE. The beginning of wisdom is never calling a patient a borderline; or, the clinical management of immature defenses in the treatment of individuals with personality disorders. J Psychother Pract Res. 1992;1:117-134.

(11.) Bateman AW, Gunderson J, Mulder R. Treatment of personality disorder. Lancet. 2015;385:735-743.

(12.) Beck AT, Davis DD, Freeman A, eds. Cognitive therapy of personality disorders. 3rd ed. New York, NY: Guilford Press, 2015.

(13.) O'Connor RC, Nock MK. The psychology of suicidal behaviour. Lancet Psychiatry. 2014;1:73-85.

(14.) Paris J. Understanding self-mutilation in borderline personality disorder. Harv Rev Psychiatry. 2005;13:179-185.

(15.) Diedrich A, Voderholzer U. Obsessive-compulsive personality disorder: a current review. Curr Psychiatry Rep. 2015;17:2.

(16.) Pittenger C, Bloch MH. Pharmacological treatment of obsessive-compulsive disorder. Psychiatr Clin North Am. 2014;37:375-391.

(17.) Budge SL, Moore JT, Del Re AC, et al. The effectiveness of evidence-based treatments for personality disorders when comparing treatment-as-usual and bona fide treatments. Clin Psychol Rev. 2013;33:1057-1066.

(18.) Leichsenring F, Leibing E. The effectiveness of psychodynamic therapy and cognitive behavior therapy in the treatment of personality disorders: a meta-analysis. Am J Psychiatry. 2003;160:1223-1232.

(19.) Gunderson JG, Links PS. Handbook of good psychiatric management for borderline personality disorder. Washington, DC: American Psychiatric Publishing, 2014.

(20.) McMain SF, Links PS, Gnam WH, et al. A randomized trial of dialectical behavior therapy versus general psychiatric management for borderline personality disorder. Am J Psychiatry. 2009;166:1365-1374.

(21.) McMain SF, Guimond T, Streiner DL, et al. Dialectical behavior therapy compared with general psychiatric management for borderline personality disorder: clinical outcomes and functioning over a 2-year follow-up. Am J Psychiatry. 2012;169:650-661.

(22.) Ripoll LH, Triebwasser J, Siever LJ. Evidence-based pharmacotherapy for personality disorders. Int J Neuropsychopharmacol. 2011;14:1257-1288.

(23.) Coccaro EF. Clinical outcome of psychopharmacologic treatment of borderline and schizotypal personality disordered subjects. J Clin Psychiatry. 1998;59:30-35.

(24.) Soloff PH. Algorithms for pharmacological treatment of personality dimensions: symptom-specific treatments for cognitive-perceptual, affective, and impulsive-behavioral dysregulation. Bull Menninger Clin. 1998;62:195-214.

(25.) Silk KR. The process of managing medications in patients with borderline personality disorder. J Psychiatr Pract. 2011,17:311319.

(26.) Saunders EF, Silk KR. Personality trait dimensions and the pharmacological treatment of borderline personality disorder. J Clin Psychopharmacol. 2009;29:461-467.

(27.) Koenigsberg HW, Reynolds D, Goodman M, et al. Risperidone in the treatment of schizotypal personality disorder. J Clin Psychiatry. 2003;64:628-634.

(28.) McClure MM, Barch DM, Romero MJ, et al. The effects of guanfacine on context processing abnormalities in schizotypal personality disorder. Biol Psychiatry. 2007;61:1157-1160.

(29.) Stoffers JM, Vollm BA, Rucker G, et al. Psychological therapies for people with borderline personality disorder. Cochrane Database SystRev. 2012;8:CD005652.

(30.) Siever LJ, Davis KL. A psychobiological perspective on the personality disorders. Am J Psychiatry. 1991;148:1647-1658.

(31.) Binks CA, Fenton M, McCarthy L, et al. Pharmacological interventions for people with borderline personality disorder. Cochrane Database SystRev. 2006:CD005653.

(32.) Nickel MK, Nickel C, Kaplan P, et al. Treatment of aggression with topiramate in male borderline patients: a double-blind, placebo-controlled study. Biol Psychiatry. 2005;57:495-499.

(33.) Tritt K, Nickel C, Lahmann C, et al. Lamotrigine treatment of aggression in female borderline-patients: a randomized, double-blind, placebo-controlled study. J Psychopharmacol. 2005;19:287-291.

(34.) Simon W. Follow-up psychotherapy outcome of patients with dependent, avoidant and obsessive-compulsive personality disorders: A meta-analytic review. Int J Psychiatry Clin Pract. 2009;13:153-165.

(35.) Ansseau M, Troisfontaines B, Papart P, et al. Compulsive personality as predictor of response to serotoninergic antidepressants. BMJ. 1991;303:760-761.

Nicholas Morcos, MD; Roy Morcos, MD, FAAFP Department of Psychiatry, University of Michigan Health System, Ann Arbor (Dr. N. Morcos); St. Elizabeth Boardman Hospital, Mercy Health, Ohio (Dr. R. Morcos)

nmorcos@med.umich.edu

The authors reported no potential conflict of interest relevant to this article.

TABLE 1

How to respond when patients use these common
immature defense mechanisms (3,4)

Defense        Definition                      Example
mechanism

Acting out     Patient is unable to            A patient screams
               contain an impulse, which       at the physician and
               can manifest in yelling,        threatens to sue
               agitation, or even violence.    because the patient
                                               did not receive a
                                               prescription for
                                               opioid pain
                                               medication for
                                               chronic back pain.

Splitting      Patient has polarized views     "My nurse understands
               of others as "all good" or      exactly what
               "all bad." These extreme        I am going through,
               views of idealization and       but my doctors don't
               devaluation can apply to        listen to me or
               different individuals or        understand me at
               can be used to describe         all--not like at the
               one individual on separate      other hospital."
               occasions.

Passive        Patient expresses anger in      A patient may stop
aggression     the form of failure,            taking medications
               procrastination,                or intentionally
               provocative behavior,           arrive late to
               self-demeaning                  appointments
               statements, or                  because the
               self-sabotage.                  physician is
                                               perceived to have
                                               wronged the patient
                                               in some way.

Somatization   Patient expresses               A patient presents
               psychological distress via      with pain that is
               physical symptoms or            out of proportion
               complaints.                     to what is found on
                                               examination and
                                               studies. Somatization
                                               may take on a
                                               delusional quality.

Defense        Management strategies            Sample statements
mechanism

Acting out     The main goal is to quickly,     "It is difficult for
               and safely, de-escalate the      me to help you when
               situation. Removing oneself      you are screaming. Can
               from the situation may be        we address your
               needed if safety is a concern.   concerns calmly?"

Splitting      Anticipate distinct views of     "I can see that you
               staff and meet with the          are upset. Let's talk
               patient as a group to present    about how the team and
               a unified front. Recognize       I can help you."
               that patients' views of their
               physicians will change over
               time. With this in mind, do
               not react strongly to
               criticism one week and extreme
               praise the next. Use splitting
               to your advantage by having a
               well-liked team member lead
               discussions with the patient.

Passive        Recognize that the patient has   "What can I do to
aggression     anger or hostility and help      ensure that you get
               him to "vent" his anger.         the best possible
                                                care?"

Somatization   This is very challenging to      "It may be that we
               manage. Use empathic             don't arrive at a
               statements ("This must be        definitive explanation
               awful to deal with"), which      for your pain or
               may disarm the patient and       completely eliminate
               improve rapport. Provide         it, but in the
               evidence-based care and don't    meantime, let's focus
               order unnecessary testing at     on ways to help you
               the patient's insistence.        manage it in your
               Provide frequent follow-up and   daily routine."
               reassurance.

TABLE 2

How to respond when patients use neurotic defense mechanisms * (3,4)

Defense mechanism     Definition             Example

Isolation of affect   Patient separates      A patient may speak
                      the emotional          about witnessing the
                      response to an         death of a loved one in a
                      event from the         calm, matter-of-fact way.
                      thoughts about that
                      event

Rationalization       Patient justifies      A patient might state
                      attitudes, behavior,   that a 30-lb weight gain
                      or emotions by         in the first trimester of
                      attributing them to    pregnancy is healthy
                      an incorrect reason.   to ensure that the
                                             developing fetus will be
                                             well-nourished.

Intellectualization   Patient attempts to    A patient without a
                      control affect and     medical background
                      emotions about an      might extensively review
                      experience by          all of the literature on
                      thinking about         cardiac-bypass procedures
                      them instead of        before having surgery.
                      experiencing them.

Defense mechanism     Management             Sample statements
                      strategies

Isolation of affect   Provide empathy and    "Many people may feel
                      support, and           upset in your situation,
                      encourage patients     and I hope you would feel
                      to feel comfortable    comfortable sharing any
                      sharing their          concerns you have if they
                      emotions.              arise."

Rationalization       Engage in a factual    "I can see how you might
                      discussion with the    view it that way, but I'm
                      patient in an          wondering if you can see
                      empathic tone. These   any "downsides" to those
                      patients may be        thoughts."
                      likely to recognize
                      that their behavior
                      is not ideal and may
                      be willing or
                      motivated to make
                      changes.

Intellectualization   Provide the patient    "I applaud you for being
                      with as much           so invested in your
                      information as is      medical care. I'm also
                      relevant and provide   wondering how you are
                      resources for          coping with this
                      further study. In      diagnosis and treatment."
                      this case, more
                      knowledge may help
                      alleviate fears and
                      ensure ongoing
                      adherence with
                      treatment.

* Neurotic defense mechanisms can, at times, be adaptive
or socially acceptable.

TABLE 3

Clusters of personality disorders and characteristic features (1)

Cluster/disorder       Features

Cluster A

Paranoid               Excessive distrust and suspiciousness of
                       others; pathologically jealous; interprets
                       actions as demeaning, malevolent, threatening,
                       or exploitative; ideas of reference (believes
                       coincidences or innocuous events have strong
                       personal significance)

Schizoid               Detachment from social interactions without a
                       desire for close interpersonal relationships;
                       restricted affect

Schizotypal            Eccentric beliefs without frank delusions;
                       cognitive and perceptual disturbances; impaired
                       social interactions

Cluster B

Antisocial             Lack of empathy, with disregard for rights of
                       others; deceitfulness, impulsivity,
                       irresponsibility

Borderline             Unstable self-image; chronic feelings of
                       emptiness; instability of interpersonal
                       relationships; affective instability; self-harm
                       behavior; hypersensitivity to rejection and
                       fear of abandonment

Histrionic             Excessive attention-seeking behavior and
                       emotionality; often excessively impressionistic
                       and shallow

Narcissistic           Need for admiration; grandiosity in speech and
                       behavior; lack of empathy for others,
                       interpersonally exploitative; arrogant and
                       haughty

Cluster C

Dependent              Inability or extreme difficulty making own
                       decisions; overly reliant on others;
                       submissiveness; feelings of inadequacy;
                       avoidance of confrontation

Avoidant               Feelings of inadequacy; hypersensitivity to
                       rejection; social inhibition despite a desire
                       to form close interpersonal relationships

Obsessive-compulsive   Preoccupation with details and rules; excessive
                       organization; perfectionism, orderliness,
                       miserliness; rigidity and stubbornness
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Author:Morcos, Nicholas; Morcos, Roy
Publication:Journal of Family Practice
Geographic Code:1USA
Date:Feb 1, 2016
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