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

PDs ARE MORE COMMON THAN YOU MIGHT SUSPECT
The overall prevalence of PD in the community ranges from 4.4% to 14.8%, with no consistent pattern of sex differences.⁴ Between 31.4% and 45.5% of psychiatric outpatients and up to 24% of primary care patients likely meet criteria for at least one PD.^5-7 PDs impede recovery from other mental disorders,⁸ increase the risk for suicide,⁹ and are associated with substance abuse, impulsivity, and violence.^10,11 Personality pathology also is associated with greater incidence of serious medical illness^12,13 and reduced social functioning.¹⁴ Not surprisingly, patients with PDs frequently use medical and social services.¹⁵

PDs tend to be underdiagnosed, perhaps partly because of concern about stigmatization, but also due to difficulties in identifying and classifying these disorders. Published in 2013, the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5) originally was to include a major revision of PDs—reflecting concern about the limitations of PD categories—but ultimately the existing categories were retained (see Table 1).¹ There is considerable overlap among PD categories; many patients meet the criteria for more than one PD, but it is unlikely that they actually have several distinct PDs. Other patients—perhaps even the majority—are best diagnosed with “unspecified personality disorder” because they do not neatly fit into one of these categories.

What to do if you suspect your patient has a PD >>