A peer-reviewed, evidence-based journal for clinicians in the field of neuroscience
Issue link: https://innovationscns.epubxp.com/i/555782
Innovations in CLINICAL NEUROSCIENCE [ V O L U M E 1 2 , N U M B E R 7 – 8 , J U L Y – A U G U S T 2 0 1 5 ] 40 T H E I N T E R F A C E to be commonplace and have been customarily identified by clinicians in these settings as "difficult patients." To our knowledge, no extensive large-scale study has simultaneously examined prevalence rates of various personality disorders within a single large sample of primary care outpatients. However, Gross et al 1 explored the prevalence of BPD among internal medicine outpatients in a private-practice setting and determined a rate of 6.4 percent. Likewise, during several empirical endeavors, we have examined rates of BPD symptomatology among internal medicine outpatients in a resident-provider setting and encountered rates between 18 and 25 percent. 2 As for specialty medical settings, in a cardiac stress testing setting, we determined a prevalence rate for BPD of 8.8 percent among patients undergoing evaluation. 3 PATIENT BEHAVIORAL PATTERNS SUGGESTIVE OF BPD SYMPTOMATOLOGY Patients in medical settings may display various behaviors that are suggestive, but not diagnostic, of BPD. These behaviors are typically characterized by disinhibition and impulsivity, which is predictably longitudinal and pervasive in nature (i.e., repetitive longstanding patterns). Moreover, these behaviors may reflect self-regulation struggles. The following empirically confirmed behaviors are relatively commonplace among patients with BPD in the primary care setting. Aggressive or disruptive behaviors in the medical setting. A number of aggressive or disruptive behaviors are clinically associated with BPD (i.e., refusing treatment, angry outbursts that are grossly out- of-proportion to the situation, demandingness, or intimidation). To further clarify the range of poor patient conduct in medical settings, we explored, in a survey of internal medicine outpatients, the prevalence of 17 disruptive office behaviors and their relationship to BPD symptomatology. 4 In this study, the number of different disruptive office behaviors reported by participants was correlated with BPD as well as the following specific office behaviors—yelling, screaming, making verbal threats, refusing to talk to medical personnel, and talking disrespectfully about medical personnel to both family and friends. 4 Fortunately, none of the preceding behaviors are physically threatening to the clinician. The intentional sabotage of medical care. The intentional sabotage of medical care melds well with BPD as such behaviors may function as self-injury equivalents (i.e., less recognizable variants of self-harm behavior). 5 One clinical example is intentionally making medical situations worse. In support of this impression, in a compiled sample of 332 internal medicine outpatients, 6 we found that 16.7 percent of participants acknowledged intentionally making medical situations worse; in addition, this phenomenon demonstrated a statistically significant relationship with BPD. We have also examined a behavior affiliated with making medical situations worse—exercising an injury on purpose. 7 To examine this phenomenon, we compiled four databases (1,511 internal medicine outpatients) and found that 2.9 percent of participants reported intentionally exercising an injury on purpose, and this behavior was statistically associated with BPD. Another possible behavioral variation of making medical situations worse is the phenomenon of preventing wounds from healing. To explore this possibility, we examined the prevalence of this behavior in an internal medicine outpatient sample, and found that 4.2 percent of participants engaged in preventing wounds from healing. 8 We subsequently found statistical associations between preventing wounds from healing and BPD in three study samples (i.e., a sample of internal medicine outpatients, an obstetrics/gynecology sample, and a compiled sample of mixed outpatients). 5,9,10 Excessive healthcare utilization patterns. Excessive healthcare utilization and resulting high healthcare costs are ardent issues in today's fiscal climate. Not surprisingly, BPD appears to be one of the contributory variables. In support of this impression, in a study of internal medicine outpatients, we found that over the preceding five years, participants with BPD symptomatology were significantly more likely to see a greater number of primary care physicians compared to participants without this personality dysfunction. 11 In addition, we found that compared to their nonBPD peers, patients with BPD features consistently evidenced a greater number of office visits and documented prescriptions, 12,13 more contacts with the treatment facility (e.g., telephone calls), 13 and more frequent referrals to specialists 14 — i.e., an overall greater utilization of healthcare resources. SYNDROMES AND DIAGNOSES WITH POSSIBLE ASSOCIATIONS WITH BPD Beyond the preceding sampling of patient behaviors that are suggestive of BPD in primary care settings, several syndromes and diagnoses may be suggestive of or associated with BPD, as well. Importantly, not every patient who harbors these