Personality Disorders and the Bipolar Spectrum
Patients with moderate-to-severe personality disorders (PD) may wreak havoc on an unsuspecting medical office. It is increasingly important to recognize, limit, and manage those with aggressive types of PD. Likewise, it is crucial to recognize those who fit the bipolar spectrum. In particular, the mild end of the spectrum is often missed. The clinical stakes for missing bipolar are enormous, as these patients tend to bounce from antidepressant to antidepressant, with predictably poor results.
Consider the following scenario: a 28- year-old man, “Bill” presents to the pain clinic with severe low back pain. He seems angry on the first visit, and is very demanding with the front office staff. Bill is mistrustful of physicians and openly states to the doctor, “I will go back to work when you give the right amount of drugs that help.” Bill is upset with his last two health providers.
Over the next few months, the clinic bends over backwards for Bill, even though he can be abusive to the staff. Bill overuses opioids, and is manipulative. He always has a sense of entitlement. When he calls, stating, “I want to talk to Dr. Smith NOW, put me through!” the staff, out of fear, jumps and does as he asks. The physician finds himself in a subservient position, trying to appease the patient and end the confrontations.
Bill laughs at the idea of seeing a psychotherapist but, after nine months of treatment, Bill is suddenly blaming everything on the physician and clinic: his pain, his obesity, his sexual dysfunction. Bill threatens to sue and reports the doctor to the state regulatory office. What happened here?
Bill will be later diagnosed as a paranoid personality disorder. The clinic did not recognize him as such, and failed to set limits on Bill’s behavior. The disruptions in the business of the clinic, the increased stress on the staff, and the monopolization of the doctor’s time cannot be recovered. In the following, we discuss features of personality disorders that should help with identification. Better management of the problem starts with recognition. This paper delves into the recognition and management of patients whose pain treatment is complicated by psychological concerns.
Personality Disorders at a Clinic
Approximately 10-15% of people have features of a personality disorder.1 There are a number of personality disorders, and some are more dangerous and difficult than others. In general, characteristics of personality disorders include: lack of insight, poor response to psychotherapy or other therapeutic interventions, difficulty with attachments and trust, a sense of entitlement, and the creation of chaos and distress in family, friends, and co-workers. Comorbid substance abuse is common.
Personality disorders range from mild to very severe. Patients with personality disorders may take on different roles: victim, rescuer, or persecutor. When they turn persecutor, they can be dangerous to the person they have set their sights on. Seeing a therapist for a long period of time, perhaps 5-7 years, helps to some degree. However, goals and expectations must be limited. The plasticity of the brain is important, as some people can improve naturally over time. There are a number of other personality disorders which are not as dangerous for the people around them or for health care providers. Even though PD characteristics may seem extreme, they are often overlooked, and health care clinics may react by treating these patients in a dysfunctional manner. The problem begins with not recognizing the personality disorder.
The following section describes some of the more severe personality disorder types including:
- paranoid personality disorder
- antisocial personality disorder
- borderline personality disorder
- narcissistic personality disorder
However, many people do not fit neatly into any of these categories but may have features of two or three personality disorders.
Paranoid Personality Disorder. This type tends to be non-trusting, suspicious, and see the world as dangerous. They may seem secretive and reluctant to confide in others. In relationships, they view themselves as being constantly mistreated. They doubt the loyalty of everybody around them, and believe they are being exploited or harmed. These patients bear severe grudges against others. Often, they become angry easily and have a sense of entitlement. Paranoid personalities can become violent and dangerous, as most spree killers are paranoid personalities. Several notorious world leaders, such as Joseph Stalin and Saddam Hussein, were most likely paranoid personalities.2
Antisocial Personality Disorder. These people generally have no regard for the rights of others. In demeanor, they tend to be irritable and impulsive. They are exploitative, see themselves as better or superior, and can be very opportunistic in getting what they want. Antisocials are deceitful, may steal from people around them, and often have trouble with the law. They frequently engage in fraudulent activities and make very good scam artists. For example, one may take on the role of financial savior for a church and end up stealing everything. They generally have no remorse. Conduct disorder in a child often morphs into antisocial personality disorder. Examples include Tony Soprano on the TV show, and, in real life, the mafia’s “Dapper Don,” John Gotti.2
Borderline Personality Disorder (BPD). This type of personality shows instability of mood, poor self-image, and pervasive abandonment fears. There is an identity disturbance and major boundary issues. Borderlines usually demonstrate impulsiveness, and very quick shifts from depression to anxiety to irritability. There are usually chronic feelings of emptiness or severe loneliness, plus anger and temper, and even suicidal behavior. Under stress, they can become somewhat paranoid. Coexisting problems with drug abuse or other addictive behaviors may occur. There are often sleep disorders with severe insomnia. Severe borderlines will react with high drama and create chaos for everybody around them. They tend to have a split view in that they see people as wonderful or terrible, with nothing in between. Examples include Adolph Hitler, Marilyn Monroe, and Glenn Close’s character Alex, in the movie, “Fatal Attraction.” Borderline personality can vary from mild to severe, and may become better or worse over time. Suicide becomes more likely as patients age into their upper twenties and thirties.3 Suicide is also more common within a week of discharge from a psychiatric unit. .
Narcissistic Personality Disorder. This is less common, and is typified by a personality which sees itself as above others. The personality is grandiose, has a lack of empathy, and feels and acts self-important. There is a deep sense of entitlement. They may be very vain and constantly require admiration. They are envious, arrogant, exploitative, and can be very angry. Examples include General George Patton, Nicole Kidman’s character in the movie, “To Die For,” Michael Douglas’ character, Gordon Gekko, in the movie, “Wall Street.”2