Screening Patients, Part 2: Personality Disorders

This is the second installment in a post series about screening potential new patients and the importance thereof.

As I stated in the first post of this series (but it’s an important enough statement that it bears repeating here), this isn’t meant to be judgmental, elitist, or exclusionary in any way.  What follows is strictly my personal opinion, which is an amalgam of my own clinical experience and my interpretation/opinions formed about the experiences of other doctors.  Nothing more, nothing less.

So if I’m not trying to pass judgment, cultivate elitism, or exclude anyone from getting care, what’s the point of this post series?  What’s the point of screening patients for various issues in the first place?  Why bother; why even consider it?

The point is two-fold: 1) to decide whether or not you, as a doctor, can handle working with folks with these types of issues (some doctors don’t bat an eye, while for other doctors, these can be deal-breakers), and 2) at the very least, to ensure that you’ve got a heads-up, if you decide you want or need to have one.

With that being said, I’ll continue discussing more of these heads-ups that I personally feel I need to have in my own practice and with any luck, this information might help other doctors as well, whether new to practice, or more experienced in the field.

In this post, I’m going to discuss some of the various personality disorders as categorized by the psychology/psychiatry field, how these folks might come across in “real life”, and some of the potential sticky points that you may want to be aware of–and what it might mean for your practice either way.  This is likely not a comprehensive list or discussion; that would probably be beyond the scope of this post, which is intended to cover the basics as they apply to practice from a doctor’s point of view.

The personality disorders I’ll cover in this post are:

  • Borderline Personality Disorder (BPD)
  • Narcissism
  • Antisocial Personality Disorder (APD)

Borderline Personality Disorder (BPD):

I’ll start with this one, because my educational exposure to this condition was interesting.  In (chiropractic med) school, we all had to take a Psychology course.  (Personally, I wish we would’ve had more than a three-hour course, because I’m finding that in my experience, Psychology permeates ALL aspects of practice, but that’s a topic for another post.)

Our Psychology instructor was a very mild-mannered, liberal, semi-touchy-feely, “how do you feel about that?” kind of guy.  He was soft-spoken and good-natured, with an open mind and a cheesy, campy sense of humor.  I liked him just fine, and found his information to be fairly textbook, but also relatively good quality.

He was about as far from judgmental as you can get.  In class, we discussed all of the major psychological disorders and mental illnesses, from depression to bipolar to schizophrenia.  He covered all of these with a very neutral, non-inflammatory tone, and yet…when it came to Borderline Personality Disorder, he actually said, as kindly as possible, but very clearly:

“You do not want these people in your practice.  Try to gently, professionally, encourage them to go somewhere else.”

I know that I said that this post series is not meant to be judgmental or exclusionary, and it’s probably not good form to lead off with a glaring exception, but it is what it is, and the words aren’t mine; I’m merely parroting them from a psychological professional.

I admit, I was pretty shocked when he said that.  That kind of sentiment was very uncharacteristic of him.

Since this Psychology class took place an accumulating number of years ago, my memory isn’t verbatim, and thus I’ll have to resort to paraphrasing what I can recall of his explanation.

Essentially, people with BPD tend to run “hot-cold”.  They can be extremely clingy, putting you (the doctor) on a pedestal, idolizing you and worshipping the ground you walk on….

….Until, that is, your naturally imperfect humanity shows through.

And then the BPD tendency is to react harshly, demonizing you.  Due to neurological and emotional issues that are beyond the scope of this post, there does indeed seem to be a lack of inhibition and a tendency toward over-dramatization.  It has been described elsewhere as childish or immature, because of the over-impulsivity that tends to accompany this disorder.

When they finally (choose to) see you for who you are (which probably hadn’t changed; it’s not you who betrayed them), they’ll act like you cut off their finger.  And they might even make a scene about it, whether online (think reviews) or maybe even right there in your office–or worse, your front lobby.  Whereas you could do no wrong before (to the point where it might have made you feel a little self-conscious), the tables turn suddenly and now, you can do no right.

If the drama (which often manifests as intensity, outbursts, over-emotionality, and instability) wasn’t challenging enough to deal with, consider that there’s also a penchant for manipulation.  This can manifest as trying to end-run around your policies with your staff or any practice partners in your clinic, attempting to twist your words (or even put words in your mouth), or project their inadequacies onto you.  They may attempt to make you feel like their situation is your fault.  Double-check to be sure, and never assume, but in reality, it’s probably not your fault.

BPD is surprisingly common in prevalence, affecting about 6-7% of the population, so I find it worthwhile to screen for it.

Narcissism:

This can look a lot like BPD because it indeed shares some of the same characteristics; there is some overlap between the two conditions.  And indeed, some of the factors that lie at the root of these disorders can be quite similar as well.

Narcissists, according to the textbook definitions, are said to be those who are in love with themselves.  This is not always 100% true; in fact, many narcissists actually have fairly low self-esteem, which sways them to try to overcompensate for the inferiority they feel.  Their attempt to pump themselves up can indeed be an attempt to convince everyone (although mostly themselves) that they’re just as good as everyone else.

Some narcissists really do indeed have a genuinely inflated sense of self, though; not all of them are overcompensating for an inferiority complex.

Either way, it may be impossible to tell between the two subtypes based on their outward manifestation; they may be indistinguishable, as their external presentations may be identical.

There are a few elements of narcissism to be aware of.  One is the tendency toward self-absorption; there may generally be little thought given to others.  Another is the false persona, or the attempt to create a real-life “avatar” of who they want to be, which might be wildly different from how they actually feel inside.

From the clinician’s perspective, these attributes be tough to work with.  As most doctors know, history-taking is a crucial element of providing healthcare, and practically all of the information gleaned from this process comes from the patient him/herself.  A person operating under a false persona isn’t exactly the most believable/reliable source of information and yet, that might be all you (the doctor) have to go on.  If the old adage of “80% of a patient’s diagnosis comes from a good history” is true, and a diagnosis is a starting point for rendering care and helping a patient, unreliable information given in the history, or perhaps the act of lying by omission or embellishing certain details or downplaying others, can have a real impact on the entire trajectory of care.

Additionally, the self-absorbed attitude can also be frustrating to work with, for doctors and their staff.  It’s fairly self-evident that a patient who can only think about themselves, but nothing beyond that, will fail to consider the other human beings in the equation, whether those people are the doctors trying to help those patients, the office staff supporting the doctors in trying to help those patients, or, most importantly of all, the other patients in the office, should the narcissist’s behavior spill over into their experience.

It’s also worth noting that there is a high risk of manipulation here, too, which bears all of the same cautions and explanations as given above.

Antisocial Personality Disorder (APD):

Contrary to popular belief, the term “antisocial” is not synonymous with “introverted”, “shy”, “homebody”, or “hermit”.  It does not refer to a dislike of being around people or a discomfort regarding social situations.  If you don’t want to go out on a particular night and you would rather stay home instead, that is not “antisocial”.  Better terms might include “hyposocial” (less social), “asocial” (not social), or perhaps the age-old, tried-and-true “introverted”.

Antisocial Personality Disorder is what is commonly known in popular culture as “psychopath” or “sociopath”, which in themselves are loaded and misunderstood terms.  Typically, the words “psychopath” and “sociopath” conjure up images of violent and unpredictable criminals.  This may cause the general public to miss a real “psychopath/sociopath” when they actually see one, and fail to recognize the reality of what’s in front of them.

APD is characterized by a complete disregard for other people.  They see no problem in bending or breaking rules to suit their needs, without any consideration of how that might affect someone else.  In many cases, the APD person might not even care if someone else gets hurt or inconvenienced in the process.

This next statement might not be entirely accurate, and I’m no professional or specialist in the Psychology arena, but one might think of APD as sort of a “narcissism on steroids”.

Because for the APD, it’s ALL about them.  And everything about them is excessive – their opinions, their vocal tone and volume, their actions, and their sense of self.  Much like BPD, they tend to be impulsive, acting purely on their instinctual desires and self-interest.  Also like BPD, they can display incredible irresponsibility; i.e., it’s never their fault; it’s always someone else’s.

Lying/deceit is also a common theme, similar to narcissism, but in the APD individual, the deception/dishonesty can be more devastating.  These are the people who might be more likely to run scams, and this is particular dangerous when coupled with another hallmark: a lack of remorse.  It’s not that these folks don’t know they’re doing something wrong.  They do.  They simply don’t care.  And there’s no instilling any value system in them; they simply can’t or won’t cultivate it.

This scenario can become particularly dangerous when yet another attribute is factored in: irritability.  Irritability and anger can be common in APD, which can be very intimidating, threatening, and traumatizing–and even potentially dangerous–to yourself, your staff, and/or most importantly, your other patients.  And trust me, these folks generally won’t think twice about the impact of their behavior on other patients.  In fact, they might theoretically be encouraged to affect your other patients in order to strong-arm you or your staff into complying with their demands and giving them what they want.

Much like BPD–and actually, even more so than BPD–I screen those displaying traits of APD out of our office entirely.

The next post will cover various types of “seekers”, aka people seeking something that has little to do with their actual healing.  I’ll try to write that one tomorrow.

 

 

 

 

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