“Difficult” patient? Or does he have a personality disorder?

The most reliable and useful areas to evaluate in a patient you suspect may have a PD are identity (one’s sense of who one is and can be) and interpersonal relationships, including the capacity for empathy and intimacy.^16,17 These should be considered longitudinally and in the context of the individual’s stage of development. For example, identity is generally less stable among adolescents compared to middle-aged adults.

A cohesive sense of identity allows one to embrace life’s tasks and challenges, to develop and strive toward personal goals, and to handle setbacks and disappointments. A person with a stable identity may develop a depressive reaction to difficult life circumstances, but with some assistance can generally bounce back and re-engage in his or her personal goals. By contrast, an individual with an unstable sense of self may feel chronically insecure and empty, with limited capacity to constructively deal with life’s ups and downs. Patients with borderline PD, for example, try to manage a fragmented identity by frantically clinging to others, while narcissistic patients tend to suppress a fragile sense of self by putting forth an arrogant and entitled attitude.

Determining the specific diagnosis of a patient you suspect has a personality disorder is less important than recognizing core personality impairment. How does the patient interact with others? As is the case with identity, an individual’s capacity for interpersonal functioning is developed early in life, through interactions with primary caregivers. Mental maps of who we are and what we can expect from others are formed and reinforced in attachment relationships, such as those with our parents; traumatic attachments, including abuse or neglect by a caregiver or loved one, are strongly associated with PD.^18,19 The resulting belief structures guide subsequent interpersonal functioning, and become interactively reinforced. For example, a person whose internal map of relationships includes others abandoning him might behave in a clingy manner, which may ultimately induce others to reject him, thus creating a self-fulfilling prophecy.

Distorted interpersonal expectations can impair a person’s capacity for sustained intimate connections (a troubled relationship history is characteristic of PDs) and limit empathic functioning.²⁰ Other people’s actions may be interpreted according to the patient’s belief structures rather than with an open mind about the other person’s experience.

Focus on the physician-patient relationship


The interpersonal dysfunction of patients with PDs will often surface in the physician-patient relationship, serving as a clue to broader interpersonal dysfunction. An FP’s relatively innocuous oversight, for example, might be taken as proof of suspected incompetence in the eyes of a patient with paranoid or narcissistic tendencies. Or a patient with a recurrent complaint who repeatedly rejects the physician’s interventions probably oscillates between seeking and rejecting nurturance in other relationships, as well. A patient who tends to make sarcastic remarks regarding the doctor’s earnest efforts likely holds negative views of others and sabotages potentially positive interactions.

So what strategies are best for managing these types of scenarios?

Bringing up a potential diagnosis of PD may be a delicate matter for the FP; patients might experience this as a jarring diagnosis in the absence of a thorough psychiatric evaluation. If the FP decides to explore whether the patient is open to discussing the relationship between moods, behaviors, and personality features, he or she can begin this conversation by noting that, as with physical health, we all have our vulnerabilities, and that these vulnerabilities may be strengthened through specialist consultation and support. In this way, the patient can view a referral as an opportunity to explore herself with professional support. If a psychiatrist or psychotherapist colleague does become involved, it is important to clarify the roles of treatment providers and to communicate with one another, should difficulties arise.

Evidence supports 
2 forms of psychotherapy


Treatment for PDs has seen considerable growth over the past decade, largely due to research on therapies that target the troubling self-injurious and suicidal features of borderline PD. Considerable evidence shows that specialized psychotherapy can significantly reduce suffering and improve functioning among these patients. The 2 major evidence-based treatments for patients with borderline PD are dialectical behavior therapy (DBT) and psychodynamic therapy.

DBT is an intensive cognitive-behavioral approach that teaches patients how to regulate their emotions and develop an accepting, mindful attitude toward their mental experience.²¹ Several randomized controlled trials (RCTs) have demonstrated the effectiveness of DBT in reducing hospitalizations and self-injurious and suicidal behavior in patients with borderline PD.²²

Psychodynamic therapy, which focuses on helping patients discover how unconscious conflicts influence their present moods and behaviors, has also been validated by multiple RCTs for patients with borderline PD.^23-25 Like DBT, empirically supported psychodynamic therapy tends to be structured, long-term (>12 months), and often intensively delivered in multiple sessions per week. However, a recent study found that a less-intensive, general psychodynamic therapy, along with occasional medication management, was equivalent to intensive DBT.²⁶