The referral should be framed as support for the patient’s suffering rather than as a statement that her problems are “all in her head” (168). The mental health professional should be introduced as a member of the medical team. Some medical institutions have dedicated psychiatric consultation, medical psychiatry, or behavioral medicine services offering expertise in the psychological complications of disease and in somatization disorders. Because so-called somatic and psychological symptoms often coexist and interact, the gynecologist should work in collaboration with the mental health professional. Patients should be given a return appointment with the primary physician, or a request for a telephone contact, at the time of the original mental health referral to reassure them that they are not being dismissed and to inform the primary physician of the results of the consultation (168).
Personality disorders are pervasive, lifelong, maladaptive patterns of perception and behavior (177–179). Patients with personality disorders believe that whatever unpleasant feelings they have are caused by the behavior of others. They view their own behaviors, which can wreak havoc in the health care setting as well as in patients’ lives, as normal, expectable, inevitable reactions to these perceived circumstances. To make matters worse, their behaviors tend to provoke in others the very responses that confirm their expectations; for example, a patient who is convinced that people always abandon her will cling desperately to others, eventually driving them away.
Diagnosis Personality disorders are organized into clusters in DSM-IV (9). Patients often manifest characteristics of several disorders within a cluster and between clusters.
Individuals with Cluster A disorders are isolated, suspicious, detached, and odd. Narcissistic patients are grandiose, arrogant, envious, and entitled. Histrionic individuals are ﬂamboyant and provocative. Antisocial patients disregard laws and rules of common decency toward others. Borderline personality disorder causes patients to have difficulty controlling their impulses and maintaining stable moods and relationships (177). They engage in self-destructive behaviors. They ﬂuctuate between overvaluation and castigation of the same person or direct these feelings alternately between one person and another. When this happens on a gynecology service or in the office, it can precipitate significant tensions among the staff. There is one caveat: research reveals that many women who were abused are diagnosed as borderline when posttraumatic stress disorder more accurately fits their symptoms (175– 178). Posttraumatic stress disorder is a less stigmatizing and more treatable condition than borderline personality disorder.
Epidemiology Lifetime prevalence of personality disorders as a group is 2.5% (177–179). Cluster A disorders are more common in men. Within Cluster B disorders, 75% of cases are women; the prevalence in the general population is 2%. Personality disorders such as narcissistic personality are more common in the clinical population than in the general population. Among Cluster C disorders, dependent personality is one of the most frequently diagnosed. Obsessive-compulsive personality is twice as common in men as in women. It is important to distinguish the personality disorder from the symptomatic obsessive-compulsive disorder. There is a strong association between personality disorders and a history of childhood abuse. The possibility of an ongoing abusive situation should be considered. There is so much overlap among the clusters that the diagnostic structure may well change in the forthcoming DSM revision (179).