Assessment The impact of personality disorders ranges widely (177–179). At one end of the spectrum, the disorder is an exaggerated personality style. At the other end of the spectrum, the individual suffers terrible emotional pain and is unable to function in work roles or relationships, spending significant periods of time in psychiatric hospitals. She characterizes her symptoms of despair as inevitable responses to abandonment or other mistreatment. As the definition implies, the patient will not seek treatment for the signs and symptoms listed in the diagnostic criteria but instead will have complaints about her treatment by others, their responses to her, and the unfairness and difficulties of life in general. Taking the history, the clinician should frame questions in those same terms: How long have these troubles gone on, and how much do they interfere with her ability to work and relate to others? Personality disorders do not bring patients to gynecologists’ offices directly, but they greatly complicate things when patients arrive.
Management Intense and lengthy psychotherapy is required to effect significant improvement in patients who have personality disorders (177). There is increasing evidence that expert, targeted therapeutic interventions can be successful and that the long-term prognosis is more hopeful than previously believed. The challenge in the gynecology setting is to minimize contention and drain on medical staff while maximizing the likelihood of effective diagnosis and treatment of the patient’s medical problems. The most helpful single step is the identification of the personality disorder. Diagnosis enables the gynecologist to recognize the reasons for a patient’s problem behaviors, to avoid becoming entangled in fruitless interactions with the patient, and to set appropriate limits.
There is increasing evidence that psychotropic medications are useful adjuncts in the treatment of personality disorders (179). Treatment should be provided in consultation with a psychiatrist. The patient’s ability to use the medication can be compromised by impulsivity, self-destructive tendencies, and unstable relationships. Low doses of major tranquilizers are sometimes helpful, especially when the patient has brief psychotic episodes. Minor tranquilizers or anxiolytics pose significant risk of overdose and physical and psychological habituation (179). They can be prescribed for temporary stresses, but only in a quantity sufficient for several days and with no refill allowed. Some patients’ anxiety, demands, and power struggles are eased when they are given control over their own use of medication. Such an approach requires enough familiarity with the patient to ensure her safety and should be managed by an expert. Because the patient with a personality disorder attributes her problems to others, her symptoms cannot be adduced as reasons for psychiatric referral, but her suffering can be. If a diagnosis of a personality disorder absolutely must be noted in the patient’s chart or on insurance forms, it is essential that she be so informed. It is useful to review the DSM-IV-TR criteria with her so that she understands the basis for the diagnosis (9). All psychiatric diagnoses, but particularly personality disorders, carry a significant stigma.
Diagnosis Adjustment disorders are temporary, self-limited responses to life stressors that are part of the normative range of human experience (unlike those that precipitate posttraumatic stress disorder) (180). The patient has mood or anxiety symptoms that are sufficient to lead her to seek medical care but that do not meet criteria of sufficient quantity or quality to qualify for psychiatric diagnosis. The diagnosis requires an identifiable stressor, onset within 3 months after the stress begins, and spontaneous resolution within 6 months after the stressor ends. Obviously the latter cannot be determined until the symptoms resolve—but they do rule out the disorder if the symptoms persist beyond that time (180,181).
Adjustment disorders can be distinguished from normal grieving (180,181). Grieving produces symptoms similar to those of depression, although depression is more likely to cause guilt. Interference with function should not persist beyond several months, but some degree of sadness and preoccupation with the lost loved one often goes on for years. Patients with persistently disabling grief should be referred to a mental health professional.