Approach

People with personality disorders rarely present to a primary care physician seeking relief from their personality difficulties.[14]​ Instead, many people present first for treatment for another psychiatric disorder.[19]​ They may have little or no insight into their personality issues. The comorbidity of more than one personality disorder is common. The approach to diagnosis is focused on broad symptom categories. These may be observable in physician-patient encounters or present in the patient's history, whether obtained from the patient him/herself or from collateral sources of information.

The initial evaluation forms the foundation for a therapeutic relationship with the patient, informing the differential diagnosis and shared decision-making about treatment. A respectful and empathetic approach is key, especially given that many patients with personality disorders have had prior experiences with stigma or bias in healthcare settings.[14][56]

The American Psychiatric Association (APA) recommends that when BPD is suspected, the initial assessment should address the following points. These considerations may also apply to the assessment of other suspected personality disorders:[14]

  • The reason the person is presenting for evaluation

  • The person’s goals and preferences for treatment

  • A review of psychiatric symptoms, including core features of personality disorders and common co-occurring disorders

  • A psychiatric treatment history

  • An assessment of physical health

  • An assessment of psychosocial and cultural factors

  • A mental status examination

  • An assessment of risk of suicide, self-injury, and aggressive behaviours

Consider offering post-assessment support, particularly if sensitive issues (such as childhood trauma) have been discussed.[56]

Urgent and acute considerations: exploring suicide and aggression risk

Certain personality disorders, particularly borderline personality disorder (BPD), are associated with an elevated risk of intentional self-injury and suicide. People with antisocial personality traits, antisocial personality disorder or with a personality disorder coexisting with a substance use disorder may be at high risk of aggression to others. Identifying risk factors for both suicidal ideation and aggressive behaviour is crucial, tailored to the specific clinical context.

Assessment of suicidality should be included in the clinical interview.[14]​ Researchers have identified suicidal desire, capability, and intent, and presence of buffers as key variables to assess.[57]​ The APA recommends that clinicians ask about the following:[14]

  • Suicidal ideas or plans

  • Previous suicidal attempts, including details of each attempt and attempts which were aborted or interrupted

  • Episodes of intentional self-injury during which there was no suicidal intent

A structured approach to assessing suicide risk may be helpful; for example,

It is important to acknowledge that predicting whether a patient will engage in aggressive behaviours or attempt suicide at a given moment is not possible. Suicidal and aggressive behaviours may arise impulsively and without prior warning.[14] Given the difficulties in predicting suicidal behaviour, it is important that patients with risk factors for suicide are carefully monitored over time for suicide risk. When an individual identifies suicidal ideas, plans, or intent, the immediate next steps are to identify the optimal setting of care and to collaborate with the individual to develop an individualised crisis prevention or safety plan.[14] Consider and assess for co-occurring disorders which may increase suicide risk, for example, depression and substance use disorder.[14] See Suicide risk mitigation.

Exploration of risk of aggression includes asking about any aggressive ideas or behaviours, including:[14] 

  • Homicide

  • Domestic or workplace violence

  • Physically or aggressive threats or acts

When a person identifies aggressive ideas or behaviours, the immediate next step is to determine whether a higher level of care or hospitalisation is needed to provide more intensive evaluation, observation, and/or treatment plan adjustment.[14]

Presentation in primary care

By definition, personality disorders involve significant difficulties in interpersonal interactions, with various manifestations based on the disorder type or grouping. Thus the physician-patient relationship is likely to be affected by these issues. Repeated encounters that a physician considers ‘difficult’ may warrant consideration of a personality disorder.[58][59]

Additional presentations in primary care settings that may indicate the presence of significant personality issues include:[59][60]​​[61]

  • Acute stress, inappropriate demands, disproportionate anger, rapid mood changes

  • Scars or other markings on the skin indicative of self-mutilation

  • Frequent involvement in arguments or altercations

  • Turbulent and volatile relationships

  • Chronic and unremitting mood or anxiety disorder symptom complaints

  • Poor response to evidence-based treatments for other mental health conditions

  • Problematic substance use

  • Presence of multiple medically unexplained symptoms

  • Presenting issues in children that may suggest a traumatic home environment CDC: Adverse Childhood Experiences (ACE) study Opens in new window

  • Clinical encounter elicits strong emotional reactions in the clinician, or departure from usual clinical practice (e.g., working outside expertise, change in prescribing practice)

Many of the symptoms of personality disorders can be grouped into the categories of:

  • Cognitive-perceptual (rigidly held ideas, odd or strange thinking, misperceptions of others' intentions)

  • Affective dysregulation (mood and anxiety symptoms)

  • Impulse dyscontrol (aggressive or self-harm behaviours, sexual promiscuity, problematic substance use)

The various types of personality disorder are defined by the DSM-5-TR criteria. See Criteria.

Tests: screening interviews and self-report tools

Use of a quantitative measure to identify and determine the severity of symptoms is recommended as an adjunct to the screening and assessment of personality disorders. Such measures provide a structured and replicable way to quantify baseline symptoms, can help to determine which symptoms to target with interventions, and can also allow for tracking of symptoms over time.[14]

A brief screening interview test for personality disorder, the Standardized Assessment of Personality-Abbreviated Scale (SAPAS) has been validated in psychiatric settings.[62][63] It seems to be most useful for identifying patients within clusters A and C, but less so for identifying patients within cluster B.[63] The SAPAS was used in a large-scale study examining factors related to response to antidepressant treatment, and personality dysfunction was found to have had a significant negative impact on treatment response.[64] However, the SAPAS is not recommended for routine screening in primary care settings, where prevalence of personality disorder is lower than in psychiatric settings.[62] Within the primary care setting, it may be appropriate for use with patients who have comorbid psychiatric conditions, such as anxiety or depression. The Structured Clinical Interview for DSM-5-TR Alternative Model for Personality Disorders Version (SCID-5-AMPD) is a semi-structured interview for use by trained clinicians with a basic knowledge of the concepts of personality disorders.

An analysis of three brief self-report tools concluded that the tools were strongly correlated with each other, and also were best when used with more severe levels of personality pathology in psychiatric samples.[65] The goal of a brief self-report screening tool for personality disorders may not be achievable given the factors involved (for example, overlap between personality disorders, as well as comorbidity with mood, anxiety, or psychotic disorders).[65]

Tests: screening for organic disorders

In cases when the patient presents with sudden personality changes, exclude organic causes such as substance use disorder, malignancy, or other general medical conditions before a diagnosis of personality disorder can be considered. Selective tests may be useful in the initial investigation, such as brain imaging (usually with magnetic resonance imaging, or in certain cases where there is a head injury or suspected intracranial bleeding, with computed tomography). Urine drug testing may also be useful.

Tests: screening assessment for behaviours adversely affecting health and comorbid psychiatric conditions

Many personality features are stable over time but present more prominently on an intermittent basis and are considered the 'target' symptoms for treatment efforts (e.g., the self-injurious behaviour of an individual with BPD). While a complete diagnostic assessment of specific personality disorders or traits typically occurs in specialty settings, primary care physicians can assess for behaviours adversely impacting health status, for suicidal ideation and plan, as well as for anxiety, affective symptoms and eating disorder symptoms, that patients with personality disorders may experience.[65][66]​

Screening instruments that may be helpful in this regard include:

  • Primary Care Evaluation of Mental Disorders (PRIME-MD), a screen for the presence of a variety of psychiatric disorders, including mood, anxiety, somatoform, and eating, as well as alcohol use/dependence.[67]

  • Patient Health Questionnaire-9 (PHQ-9), which provides information on the severity of depressive symptomatology including self-harm and suicidal ideation.[68] Patient Health Questionnaire PHQ-9 Opens in new window

  • Generalised Anxiety Disorder-7 (GAD-7), providing information on the severity of anxiety symptomatology.[69][70]

  • Mood Disorders Questionnaire, which screens for the presence of elevated mood states, hypomania, and mania.[71]

Patients who screen positive for mood disorder, substance use disorder, history of deliberate self-harm, and/or prior suicide attempt may be at greater suicide risk.[72]

See Depression in adults, Generalised anxiety disorder, Bipolar disorder in adults, Bulimia nervosa.

Consultant referrals

For a detailed assessment of personality disorder traits and their potential to impact the physician-patient relationship and approach to medical care, primary care physicians should consider referral to a mental health professional with specialty training in the assessment and treatment of people with personality disorders. Repeated self-harm or persistent risk-taking behaviour may be an indication for referral for assessment for BPD.[56]​ 

Structured interviewing and specific diagnostic instrument administration, including the administration of psychological testing, may be carried out by such a professional. A consulting psychologist or psychiatrist may use the Millon Clinical Multiaxial Inventory-III (MCMI-III) and the Structured Clinical Interview for DSM-IV Axis II Personality Disorders instruments. Two disciplines, clinical health psychology and consultation-liaison psychiatry, are particularly concerned with the interface of mental and physical health and well-being, but many types of mental health providers are skilled in this particular field. When consulting with the evaluating clinician, it is important to obtain information on the evaluator's practice with regard to providing feedback to patients. This will allow the primary care physician to address further patient questions regarding the evaluation in a manner that avoids potential misunderstanding and miscommunication.

Use of this content is subject to our disclaimer