Clinical Review

“Difficult” Patient? Or Is It a Personality Disorder?

The patient who always seems to be in crisis may actually have a personality disorder. Employing these techniques can benefit the patient and improve your interaction.

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Bob, age 48, comes to his family practice provider (FPP) to ask for authorization for extended medical leave from his job as an electrician. He frequently misses days at work and complains of stress on the job, saying his coworkers look down on him and make cruel jokes at his expense. He reports having chronic interpersonal conflicts and no significant relationships with family members or friends. Bob refuses a referral to a psychiatrist because he fears he will be “locked up and forced to take medications.”

If Bob were your patient, how would you proceed?

Personality disorders (PDs) are patterns of inflexible and maladaptive personality traits and behaviors that cause subjective distress and significant social or occupational impairment.1 An individual with a PD tends to have a limited repertoire of responses to the rough-and-tumble of life, with coping mechanisms that often perpetuate difficulty and distress. Examples include distrust and suspiciousness of others’ motives (paranoid PD); disregard and violation of the rights of others (antisocial PD); instability in interpersonal relationships, self-image, and affect (borderline PD); and social inhibition, feelings of inadequacy, and hypersensitivity to negative evaluation (avoidant PD).1

FPPs may view patients with PDs as “difficult patients” because of their frequent crises and the interpersonal problems they bring into the clinician-patient relationship.2,3 Help, of course, can come in the way of a referral to a psychotherapist who specializes in treating PDs. But you can also make use of some evidence-based psychotherapy techniques to improve your patients’ lives and the quality of the clinician-patient relationship. This article focuses on identifying and managing PDs in family practice, using practical strategies drawn from empirically supported therapies.

Next page: How common are PDs?

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