Advertisement

Personality Pathology in Primary Care: Ongoing Needs for Detection and Intervention

  • Steven K. HuprichEmail author
Article

Abstract

Recent studies demonstrate that personality disorders are prevalent within outpatient psychiatry clinics, though they also are quite common in primary care settings. Studies across multiple health care settings demonstrate that those with a known PD have higher incidences of health problems, higher utilization of the health care system, and have a life expectancy 17.7 years less than that of the population in general. Despite these data, little attention has been directed toward detecting, managing, and treating patients with personality pathology in primary care settings. Consequently, it is argued that more attention be devoted to detecting PDs in this population, training physicians and primary care professionals in the rapid screening of personality pathology, the management of patients with personality pathology, and utilizing behavioral health specialists and reliable referral sources to address these problems as part of their overall health care management. Suggestions for how to implement these ideas are offered.

Keywords

Personality disorders Primary care Personality pathology Personality and health 

Notes

Acknowledgements

Special appreciation is expressed to John H. Porcerelli, PhD, ABPP and Benjamin F. Miller, PsyD for their feedback on an earlier draft of this paper.

Compliance with Ethical Standards

Conflict of interest

Steven K. Huprich declares that he has no conflict of interest.

Human Rights and Animal Rights and Informed Consent

No human or animal research studies were conducted by the author for this article.

References

  1. American Psychiatric Association (1994). Diagnostic and statistical manual of mental disorders, (4th ed.). Author: Washington, DC.Google Scholar
  2. American Psychiatric Association (2013). Diagnostic and statistical manual of mental disorders, (5th ed.). Author: Washington, DC.CrossRefGoogle Scholar
  3. Bateman, A., & Fonagy, P. (2009). Randomized controlled trial of outpatient mentalizationbased treatment versus structured clinical management for borderline personality disorder. American Journal of Psychiatry, 166, 1355–1364.CrossRefPubMedGoogle Scholar
  4. Beckwith, H., Moran, P. F., & Reilly, J. (2014). Personality disorder prevalence in psychiatric outpatients: A systematic literature review. Personality and Mental Health, 8, 91–101.CrossRefPubMedGoogle Scholar
  5. Bender, D. S., Dolan, R. T., Skodol, A. E., Sanislow, C. A., Dyck, I. R., McGlashan, T. H., … Gunderson, J. G. (2001). Treatment utilization by patients with personality disorders. American Journal of Psychiatry, 158, 295–302.CrossRefPubMedGoogle Scholar
  6. Bount, A. (2003). Integrated primary care: Organizing the evidence. Families, Systems, & Health, 21, 121–134.CrossRefGoogle Scholar
  7. Brooks, R., Rabin, R., & deCharro, F. (2003). The measurement and valuation of health status using EQ-5D: A European perspective. London: Kluwer Academic Publishers.CrossRefGoogle Scholar
  8. Clarkin, J. F., & Huprich, S. K. (2011). Do the DSM-5 proposals for personality disorders meet the criteria for clinical utility? Journal of Personality Disorders, 25, 192–205.CrossRefPubMedGoogle Scholar
  9. Davis, K., Schoen, C., & Schoenbaum, S. C. (2000). A 2020 vision of American health care. Archives of Internal Medicine, 160, 3357–3362.CrossRefPubMedGoogle Scholar
  10. deGruy, F. (1996). Mental health care in the primary care setting. In M. S. Donaldson, K. D. Yordy, N. Lohr & N. A. Vanselow (Eds.), Primary care: America’s health in a new ear. Washington, DC: Institute of Medicine.Google Scholar
  11. Douaihy, A., Kelly, T. M., & Gold, M. A. (2015). Motivational interviewing: A guide for medical trainees. New York: Oxford.Google Scholar
  12. Dubovsky, A. N., & Kiefer, M. M. (2014). Borderline personality disorder in the primary care setting. Medical Clinics of North American, 98, 1049–1064.CrossRefGoogle Scholar
  13. Edler, N., Ricer, R., & Tobais, B. (2006). How respected family physicians manage difficult patient encounters. Journal of the American Board of Family Medicine, 19, 533–541.CrossRefGoogle Scholar
  14. El-Gabalawy, R., Katz, L. Y., & Sareen, J. (2010). Comorbidity and associated severity of borderline personality disorder and physical health conditions in a nationally representative sample. Psychosomatic Medicine, 72, 641–647.CrossRefPubMedGoogle Scholar
  15. El-Rufaie, O. E. F., Al-Sabosy, M., Abuzeid, M. S. O., & Ghubash, R. (2002). Personality profile among primary care patients: Experimenting with the Arabic IPDE ICD-10. Acta Psychiatrica Scandinavia, 105, 37–41.CrossRefGoogle Scholar
  16. Few, L. R., Miller, J. D., Rothbaum, A., Meller, S., Maples, J., Terry, D. P., … MacKillop, J. (2013). Examination of the Section III DSM-5 diagnostic system for personality disorders in an outpatient clinical sample. Journal of Abnormal Psychology, 122, 1057–1069.CrossRefPubMedPubMedCentralGoogle Scholar
  17. Fok, M. L., Hayes, R. D., Chang, C. K., Stewart, R., Callard, F. J., & Moran, P. (2012). Life expectancy at birth and all-cause mortality among people with personality disorder. Psychosomatic Medicine, 72, 104–107.CrossRefGoogle Scholar
  18. Frankenburg, F. R., & Zanarini, M. C. (2004). The association between borderline personality disorder and chronic medical illnesses, poor health-related lifestyle choices, and costly forms of health care utilization. Journal of Clinical Psychiatry, 53, 1660–1665.CrossRefGoogle Scholar
  19. Gask, L., Evans, M., & Kessler, D. (2016). Personality disorder. BMJ, 347, 28–32.Google Scholar
  20. Greenberg, R. P., & Bornstein, R. F. (1989). Length of psychiatric hospitalization and oral dependency. Journal of Personality Disorders, 3, 199–204.CrossRefGoogle Scholar
  21. Gross, R., Olfson, M., Gameroff, M., Shea, S., Feder, A., Fuentes, M., … Weissman, M. (2002). Borderline personality disorder in primary care. Archives of Internal Medicine, 162, 53–60.CrossRefPubMedGoogle Scholar
  22. Haas, L. J. (Editor) (2004). Handbook of primary care psychology. New York: Oxford.Google Scholar
  23. Hopwood, C. J., Malone, J. C., Ansell, E. B., Sanislow, C. A., Grilo, C. M., McGlashan, T. H., … Morey, L. C. (2011). Personality assessment in DSM-5: Empirical support for rating severity, style, and traits. Journal of Personality Disorders, 25, 305–320.CrossRefPubMedGoogle Scholar
  24. Hueston, W. J., Werth, J., & Mainous, A. G. (1999). Personality disorder traits: Prevalence and effects on health status in primary care patients. International Journal of Psychiatry in Medicine, 29, 63–74.CrossRefPubMedGoogle Scholar
  25. Huprich, S. K., Hoban, P., Boys, A., & Rosen, A. (2013). Healthy and unhealthy manifestations of interpersonal dependency and pain management: Interfacing personality and health status. Journal of Clinical Psychology in Medical Settings, 20, 508–514.CrossRefPubMedGoogle Scholar
  26. Huprich, S. K., Hsiao, W. C., Porcerelli, J. H., Bornstein, R. F., & Markova, T. (2010). Expanding the validity of the relationship profile test in clinical and nonclinical samples. Assessment, 17, 81–88.CrossRefPubMedGoogle Scholar
  27. Huprich, S. K., Macaluso, M., Baade, L., Zackula, R., & Jackson, J. (2017). Physician perceptions and health care outcomes associated with pathological personality traits and levels of functioning. Manuscript under review.Google Scholar
  28. Kerns, R. D., Turk, D. C., & Rudy, T. E. (1985). The West Haven-Yale Multidimensional Pain Inventory (WHYMPI). Pain, 23, 345–356.CrossRefPubMedGoogle Scholar
  29. Kessler, R., & Stafford, D. (2008). Primary care is the de facto mental health system. In R. Kessler & D. Stafford (Eds.), Collaborative medicine case studies: Evidence in practice (pp. 9–21). New York: Springer.CrossRefGoogle Scholar
  30. Kim, Y., & Pilkonis, P. A. (1999). Selecting the most informative items in the IIP scales for personality disorders: An application of item response theory. Journal of Personality Disorders, 13, 157–174.CrossRefPubMedGoogle Scholar
  31. Langbehn, D. R., Pfohl, B. M., Reynolds, S., Clark, L. W., Battaglia, M., Bellodi, L., … Links, P. (1999). The Iowa personality disorder screen: Development and preliminary evaluation of a brief screening interview. Journal of Personality Disorders, 13, 75–89.CrossRefPubMedGoogle Scholar
  32. Lee, H. B., Bienvenu, O. J., Cho, S., Ramsey, C. M., Bandeen-Roche, K., Eaton, W. W., & Nestadt, G. (2010). Personality disorders and traits as predictors of incident cardiovascular disease: Findings from the 23-year follow-up of the Baltimore ECA study. Psychosomatics, 41, 289–296.CrossRefGoogle Scholar
  33. Linehan, M. M. (1993). Cognitive-behavioral treatment of borderline personality disorder. New York: Guilford Press.Google Scholar
  34. Mathers, N., Jones, N., & Hannay, D. (1995). Heartsink patients: A study of their general practitioners. British Journal of General Practice, 45, 293–296.PubMedPubMedCentralGoogle Scholar
  35. McDaniel, S. H., & deGruy, F. V. III (2014). An introduction to primary care and psychology. American Psychologist, 69, 325–331.CrossRefPubMedGoogle Scholar
  36. Melek, S. P., Norris, D. T., & Paulus, J. (2014). Milliman American Psychiatric Association Report: Economic Impact of Integrated Medical-Behavioral Healthcare, Implications for Psychiatry. Denver, CO: Milliman, Inc.Google Scholar
  37. Miller, B. F., & Druss, B. (2013). The role of family physicians in mental health care delivery in the United State: Implications for health reform. Journal of the American Board of Family Medicine, 26, 111–113.CrossRefPubMedGoogle Scholar
  38. Miller, B. F., Brown Levey, S. M., Payne-Murphy, J. C., & Kwan, B. M. (2014). Outlining the scope of behavioral health practice in primary care: Dispelling the myth of the one-trick mental health pony. Families, Systems, & Health, 32, 338–343.CrossRefGoogle Scholar
  39. Miller, B. F., Petterson, S., Burke, B. T., Phillips, R. L. Jr., & Green, L. A. (2014). Proximity of providers: Colocating behavioral health and primary care and the prospects for an integrated workforce. American Psychologist, 69, 443–451.CrossRefPubMedGoogle Scholar
  40. Moffitt, T. E., Caspi, A., Taylor, A., Kokaua, J., Milne, B. J., Polanczyk, G., & Poulton, R. (2010). How common are common mental disorders? Evidence that lifetime prevalence rates are doubled by prospective versus retrospective ascertainment. Psychological Medicine, 40, 899–909.CrossRefPubMedGoogle Scholar
  41. Moran, P., Leese, M., Lee, T., Walters, P., Thornicroft, G., & Mann, A. (2003). Standardised Assessment of Personality Scale (SAPAS): Preliminary validation of a brief screen for personality disorder. British Journal of Psychiatry, 183, 228–232.CrossRefPubMedGoogle Scholar
  42. Moran, P., Rendu, A., Jenkins, R., Tylee, R., & Mann, A. (2001). The impact of personality disorder in UK primary-care. A 1-year follow-up of attenders. Psychological Medicine, 31, 1447–1454.CrossRefPubMedGoogle Scholar
  43. Moran, P., Steward, R., Brugha, T., Beggingont, P., Bhugra, D., Jenkins, R., & Coid, J. W. (2007). Personality disorder and cardiovascular disease: Results from a national household survey. Journal of Clinical Psychiatry, 68, 69–74.CrossRefPubMedGoogle Scholar
  44. Morey, L. C. (1997). Personality assessment screener professional manual. Odessa, FL: Psychological Assessment Resources.Google Scholar
  45. Morey, L. C. (2007). Personality assessment Inventory professional manual. Lutz, FL: Psychological Assessment Resources.Google Scholar
  46. Morey, L. C., Skodol, A. E., & Oldham, J. M. (2014). Clinician judgments of clinical utility: A comparison of DSM-IV-TR personality disorders and the alternative model for DSM-5 personality disorders. Journal of Abnormal Psychology, 123, 398–405.CrossRefPubMedGoogle Scholar
  47. Nelson, S. M., Huprich, S. K., Shankar, S., Sohnleitner, A., & Paggeot, A. V. (2017). Comparing four diagnostic methods of personality disorder diagnosis in psychology trainees and interns. Personality Disorders: Theory, Research, and Treatment, 8, 217.CrossRefGoogle Scholar
  48. Phillips, R. L. Jr., Miller, B. F., Petterson, S. M., & Teevan, B. (2011). Better integration of mental health care improves depression screening and treatment in primary care. American Family Physician, 1 84, 980.Google Scholar
  49. Pietrzak, R., Wagner, J., & Petry, N. (2007). DSM-IV personality disorders and coronary heart disease in older adults: Results from the national epidemiological survey on alcohol related questions. Journal of Gerontology, 62B, 295–299.CrossRefGoogle Scholar
  50. Porcerelli, J., Bornstein, R. F., Markova, T., & Huprich, S. K. (2009). Physical health correlates of pathological and healthy dependency in urban women. Journal of Nervous and Mental Disease, 197, 761–765.CrossRefPubMedGoogle Scholar
  51. Porcerelli, J. H., Bornstein, R. F., Porcerelli, D., & Arterbery, V. E. (2015). The complex role of personality in cancer treatment: Impact of dependency-detachment on health status, distress, and physician-patient relationship. Journal of Nervous & Mental Disease, 203, 264–268.CrossRefGoogle Scholar
  52. Porcerelli, J. H., Fowler, S., Murdoch, W., Markova, T., & Kimbrough, C. (2013). Training family medicine residents to practice collaboratively with psychology trainees. International Journal of Psychiatry in Medicine, 35, 357–365.CrossRefGoogle Scholar
  53. Porcerelli, J. H., & Huprich, S. K. (2007). Personality disorders. Hospital Physician, Family Practice Board Review Manual, 7, 2–9.Google Scholar
  54. Porcerelli, J. H., & Jones, J. R. (2017). Psychological assessment in integrated care: An overview. In M. E. Maruish (Ed.), Handbook of psychological assessment in primary care settings (2nd ed., pp. 75–94). New York: Routledge/Taylor and Francis.Google Scholar
  55. Porcerelli, J. H., Kurtz, J. E., Cogan, R., Markova, T., & Mickens, L. (2012). Personality assessment screener in a primary care sample of low-income urban women. Journal of Personality Assessment, 94, 262–266.CrossRefPubMedGoogle Scholar
  56. Powers, A. D., & Oltmanns, T. F. (2012). Personality disorders and physical health: A longitudinal examination of physical functioning, healthcare utilization, and health-related behaviors in middle-aged adults. Journal of Personality Disorders, 26, 534–538.CrossRefGoogle Scholar
  57. Powers, A. D., & Oltmanns, T. F. (2013). Borderline personality pathology and chronic health problems in later adulthood: The mediating role of obesity. Personality Disorders: Theory, Research, and Treatment, 4, 152–159.CrossRefGoogle Scholar
  58. Quirk, E. S., Berk, M., Chanen, A. M., Koivumaa-Honkanen, H., Brennan-Olsen, S. L., Pasco, J. A., & Williams, L. J. (2016). Population prevalence of personality disorder and associations with physical health comorbidities and health care service utilization: A review. Personality Disorders: Theory, Research, and Treatment, 7, 136–146.CrossRefGoogle Scholar
  59. Riihimäki, K., Vuorilehto, M., & Isometsä, E. (2014). Borderline personality disorder among primary care depressive patients: A five-year study. Journal of Affective Disorders, 155, 303–306.CrossRefPubMedGoogle Scholar
  60. Robiner, W., & Petrick, M. (2017). Managing difficult patients: Roles of psychologists in the age of interdisciplinary care. Journal of Clinical psychology in Medical Settings, 24, 27–36.CrossRefPubMedGoogle Scholar
  61. Salvador-Carulla, L., Bendeck, M., Ferrer, M., Andión, Ó., Aragonès, E., et al. (2014). Cost of borderline personality disorder in Catalonia (Spain). European Psychiatry, 29, 490–497.CrossRefPubMedGoogle Scholar
  62. Samuel, D. B., & Griffin, S. A. (2015). A critical evaluation of retaining personality categories and types. In S. K. Huprich (Ed.), Personality disorders: Toward theoretical and empirical integration in diagnosis and assessment (pp. 43–62). Washington, DC: American Psychological Association.CrossRefGoogle Scholar
  63. Sansone, R. A., Bohinc, R. J., & Widerman, M. W. (2015). Borderline personality symptomatology and compliance with general health care among internal medicine outpatient. International Journal of Psychiatry in Clinical Practice, 19, 132–136.CrossRefPubMedGoogle Scholar
  64. Sansone, R. A., Farukhi, S., & Wiederman, M. W. (2011). Utilization of primary care physicians in borderline personality. General Hospital Psychiatry, 33, 343–346.CrossRefPubMedGoogle Scholar
  65. Sansone, R. A., Tahir, N. A., Buckner, V. R., & Wiederman, M. W. (2008). The relationship between personality disorder symptomatology and somatic preoccupation among internal medicine outpatients. Primary Care Companion – Journal of Clinical Psychiatry, 10, 286–290.CrossRefGoogle Scholar
  66. Shi, L. (2012). The impact of primary care: A focused review. Scientifica, 2012, 1–22.CrossRefGoogle Scholar
  67. Siefert, C. J. (2006). Screening for personality disorders in psychiatric settings: Four recently developed screening measures. In L. Baer & M. A. Blais (Eds.), Handbook of clinical rating scales and assessment in psychiatry and mental health, current clinical psychiatry, (pp. 125–144). New York: Humana Press.Google Scholar
  68. Skodol, A. E. (2012). Personality disorders in DSM-5. Annual Review of Clinical Psychology, 8, 317–344.CrossRefPubMedGoogle Scholar
  69. Soeteman, D. I., Roijen, L. H., Verheul, R., & Busschbach, J. J. (2008). The economic burden of personality disorders in mental health care. Journal of Clinical Psychiatry, 69, 259–265.CrossRefPubMedGoogle Scholar
  70. Soeteman, D. I., Verheul, R., & Busschbach, J. J. (2008). The burden of disease in personality disorders: Diagnosis-specific quality of life. Journal of Personality Disorders, 22, 259–268.CrossRefPubMedGoogle Scholar
  71. Tyrer, P. (2005). Medical settings. In J. M. Oldham, A. E. Skodol & D. S. Bender (Eds.), The american psychiatric publishing textbook of personality disorders (pp. 607–619). Washington, DC: American Psychiatric Publishing, Inc.Google Scholar
  72. Wagner, T., Fydrich, T., Stiglmayr, C., Marschall, P., Salize, H. J., Renneberg, B., … Roepke, S. (2014). Societal cost-of-illness in patients with borderline personality disorder one year before, during, and after dialectical behavior therapy in routine outpatient care. Behaviour Research and Therapy, 61, 12–22.CrossRefPubMedGoogle Scholar
  73. Ward, R. K. (2004). Assessment and management of personality disorders. American Family Physician, 70, 1505–1512.PubMedGoogle Scholar
  74. Westphal, M., Olfson, M., Bravova, M., Gameroff, M. J., Gross, R., Wickramaratne, P., … Weissman, M. (2013). Borderline personality disorder, exposure to interpersonal trauma, and psychiatric comorbidity in urban primary care patients. Psychiatry, 76, 365–380.CrossRefPubMedGoogle Scholar
  75. Widiger, T. A. (2004). Five factor model rating form. Unpublished measure. University of Kentucky.Google Scholar
  76. Wittchen, H. U., Jacobi, F., Rehm, J., Gustavsson, A., Svensson, M., Jönsson, B., … Steinhausen, H. C. (2011). The size and burden of mental disorders and other disorders of the brain in Europe 2010. European Neuropsychopharmacology, 21, 655–679.CrossRefPubMedGoogle Scholar
  77. World Health Organization (1992). The ICD-10 classification of mental and behavioral disorders: Clinical descriptions and diagnostic guidelines. Geneva: World Health Organization.Google Scholar
  78. World Health Organization and Wonca Working Party of Mental Health (2008). What is primary care mental health? Mental Health in Family Medicine, 5, 9–13.Google Scholar
  79. Zanarini, M., Frankenburg, F., Hennen, J., Reich, J., & Silk, K. (2005). The McLean study of adult development (MSAD): Overview and implications of the first six years of prospective follow-up. Journal of Personality Disorders, 19, 505–523.CrossRefPubMedGoogle Scholar
  80. Zanarini, M., Frankenburg, F., Hennen, J., & Silk, K. R. (2004). Mental health service utilization by borderline personality disorder patients and Axis II comparison subjects followed prospectively for 6 years. Journal of Clinical Psychiatry, 65, 28–36.CrossRefPubMedGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2018

Authors and Affiliations

  1. 1.Department of PsychologyUniversity of Detroit MercyDetroitUSA

Personalised recommendations