The formidable cluster: The challenge of personality disorders among hospitalized patients

© 2016 Society of Hospital Medicine

All practicing hospitalists encounter challenging patient situations that stem from issues beyond medical illness. Those situations include the patient who demands to talk with the doctor repeatedly disregarding the lack of urgency, or the patient who, despite seeing multiple well‐regarded specialists, attempts to split the healthcare team by generating unwarranted praise or criticism toward individual caregivers.

Although these patients may be labeled difficult, hateful, or simply a unique patient‐management opportunity, effective care requires a more nuanced understanding of a possible underlying personality disorder that adversely affects the patientphysician relationship. In this issue of the Journal of Hospital Medicine, Riddle et al. provide an important review that outlines a framework for identifying the likely presence of a personality disorder along with practical advice for how to manage these patients.[1] As the authors point out, personality disorders are relatively common among patients seeking medical care but are challenging to diagnose, particularly in the setting of superimposed medical illness. Common to all personality disorders are difficulties forming and maintaining positive relationships with others such that care providers find themselves feeling frustrated, fearful, or inadequate. Inpatient providers typically receive very little training in how to care for patients with personality disorders.

The approach of avoiding collaborative teaching rounds, driven perhaps by a need for time efficiency, deprives learners of the chance to reflect on effective interactions with these patients.

Personality disorders result from genetic predisposition, complex brain dysfunction, and environmental influences. Social determinants also play a role, although limited social networks may simultaneously be a result of a personality disorder and a contributing factor.[2] Although there is a temptation to view personality disorders separate from medical conditions such as diabetes mellitus, diagnosing a personality disorder is far more complicated than simply checking a glycosylated hemoglobin. As Riddle et al. suggest, making a specific diagnosis from the list of 10 personality disorders is challenging in the hospital setting, even for experienced psychiatrists. Given the danger of propagating a diagnosis unabated and unquestioned through the electronic medical record, the attending hospitalist should be reluctant to include a diagnosis such as borderline personality disorder or histrionic personality disorder in the patient problem list without input from experts. Instead, it is useful to document the specific behaviors that are impacting patient care during this episode of illness.

We are concerned about the impact of personality disorders on a number of aspects of patient care, and these are areas that are potentially fertile ground for scholarship and research.


Patients with personality disorders may have difficulty assessing the severity of their own medical illnesses. Educating patients on the meaning and value of recovery may be helpful in establishing appropriate expectations of care,[3] although it is equally important to assess the value of illness from the patient's perspective. As Riddle et al. point out, the goal for the hospitalist team is to mitigate the negative impact of adverse behavior on overall care. A recent pilot study of smartphone applications for use by patients with borderline personality disorder might have utility in the inpatient setting.[4] These types of innovations provide opportunities for hospitalist research in the care of patients with personality disorders.


A recent observational study published in the Journal of Hospital Medicine identified several important attributes of a high‐functioning inpatient care team.[5] The findings reinforced the concept that patient care is a social activity. To provide high‐quality care, a high‐functioning partnership between team members is required. Riddle et al. point out that patients with personality traits and disorders can negatively impact the relationship among care team members. The hospitalist may be tempted to leave the nursing staff to handle the unwanted communication with the patient. This strategy is maladaptive and creates friction between the hospitalist and the nursing staff. In addition, it reduces an opportunity to recognize important real‐time changes in patients' clinical status that may adversely affect patient outcomes.


Clinical and diagnostic reasoning plays a central role in patient care. Hospitalists must identify key elements from empirical data and formulate their problem representation to assist in planning the next diagnostic and treatment plans. The medical literature regarding the effect of providing care to patients with maladaptive personality structures is limited. Recent literature investigating the effect of negative patient attributes on diagnostic reasoning suggests that caring for disruptive patients, such as those with maladaptive personality structures, adversely impacts the diagnostic reasoning process. In other words, we are more likely to make cognitive errors when faced with patients who foster a negative feeling. When given vignettes of the same diagnosis but prefaced with patient characteristics that would affect their likeability, trainees of both family practice and internal medicine made significantly fewer correct diagnoses in patients who were given negative connotation, such as overly demanding, a trait not uncommonly seen in patients with personality disorders/traits.[6] The diagnosis rate was more pronounced with complex cases. It is theorized that our cognitive reasoning and use of illness scripts can overcome maladaptive behavior when it comes to common presentations of common illness. However, more complex or atypical presentations require a higher level of diagnostic reasoning that may be impacted by patients who have maladaptive behaviors. The authors hypothesize a resource depletion of mental energy as a result of managing these patients.


Patients with personality disorders require increased time from healthcare providers. Burnout is a major issue for internists.[7] Any provider who has cared for patients with personality disorders can attest to the effects on emotional energy, although this effect deserves study. Without adequate coping strategies by care providers, we run the risk of depleting both our empathy and our mental resources, all of which can negatively affect patient experience and outcomes. The coping strategies that are described by Riddle et al. should be helpful in mitigating the anticipated challenges of caring for these patients and improve both our diagnostic reasoning and care‐provider resiliency.

There is still much to be learned about the long‐term effects of maladaptive personality structures on patient outcomes. We believe that is imperative to have the skills to recognize our patients with maladaptive personality traits and how the care of these patients poses challenges on the functioning of the interdisciplinary care team. Without the advanced training to make the challenging diagnosis of a personality disorder during an acute inpatient stay, it is recommended that hospitalists document the specific behaviors that are impacting patient care and the care team. It is our hope that effective coping strategies can lead to reduced risk of diagnostic errors and bolster the resiliency of the hospitalist.


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