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Journal of Clinical Psychology in Medical Settings (2018) 25:43–54 https://doi.org/10.1007/s10880-017-9525-8

Personality Pathology in Primary Care: Ongoing Needs for Detection and Intervention

Steven K. Huprich1

Published online: 10 January 2018 © Springer Science+Business Media, LLC, part of Springer Nature 2018

Abstract Recent studies demonstrate that personality disorders are prevalent within outpatient psychiatry clinics, though they also are quite common in primary care settings. Studies across multiple health care settings demonstrate that those with a known PD have higher incidences of health problems, higher utilization of the health care system, and have a life expectancy 17.7 years less than that of the population in general. Despite these data, little attention has been directed toward detecting, managing, and treating patients with personality pathology in primary care settings. Consequently, it is argued that more attention be devoted to detecting PDs in this population, training physicians and primary care professionals in the rapid screening of personality pathology, the management of patients with personality pathology, and utilizing behavioral health specialists and reliable referral sources to address these problems as part of their overall health care management. Suggestions for how to implement these ideas are offered.

Keywords Personality disorders · Primary care · Personality pathology · Personality and health

Most physicians are acutely aware of those “difficult” patients who require considerable psychological (and psy- chiatric) management as part of their overall health care (e.g., Mathers, Jones, & Hannay, 1995; Robiner & Petrick, 2017). Some of the problems encountered include exces- sive utilization of the health care system (such as frequent physician and emergency room visits, and hospitalizations), excessive risk-taking behaviors or self-defeating behaviors that are medically contraindicated, becoming emotionally dysregulated when discussing their lives or their relation- ships with others, becoming verbally combative with physi- cians and other health care providers when service is not given exactly when and how it is desired, or becoming angry with providers for not prescribing medication that is not needed or necessary.

While these challenges are faced on a daily basis by most physicians, they have not been addressed much in the clini- cal or empirical literature by way of understanding such behaviors as a personality disorder (PD), or as personal- ity pathology. Similarly, little research has been conducted

on these issues, and not many guidelines have been offered on how to help physicians rapidly screen and manage such patients. It is the purpose of this paper to review these issues, first by briefly commenting upon prevalence studies of PDs in community and outpatient psychiatry samples over the past 20 years, and reviewing the scant literature on preva- lence in primary care settings and why the prevalence in these settings might be higher than anticipated. Next, this paper will discuss mental and physical health comorbidi- ties that are associated with personality pathology. This issue is central to understanding how personality pathol- ogy is related to health care utilization, since patients with documented PDs tend to not only have significant medical problems requiring constant care, but also have a very sig- nificantly reduced life expectancy (Fok et al., 2012). Finally, this paper will describe ways to enhance care of primary care of patients who exhibit personality pathology. Address- ing personality pathology in the primary care setting holds promise to enhance the overall quality of health care and improve patients’ lives.

* Steven K. Huprich [email protected]

1 Department of Psychology, University of Detroit Mercy, 4001 W. McNichols Road, Detroit, MI 48221, USA

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Literature Review Method

PubMed and PsycInfo searches were conducted using the terms “personality disorder” and “primary care” that were in the title, abstract, or used as key words. The search was conducted on articles published between 1997 and 2017, though when selecting a final group of articles for review, the focus was on articles within the past 10 years. The reason for this emphasis is that primary care healthcare services have been evolving rapidly in recent times, espe- cially with regard to the role of mental health assessment and treatment in primary care settings. More recent arti- cles are more likely to reflect current trends concerning the role of mental health services in primary care. Thus, papers going beyond the past 10 years were included only if it was believed they provided distinctive content that was not readily available in the more recent papers. The primary function of the search was to review all papers that assessed prevalence of PDs in a primary care sam- ple during that time period, and to select papers of high relevance to major issues being raised. In addition, I carefully considered the references and major findings of three recent key papers on the topic of PDs in primary care: Beckwith, Moran, and Reilly (2014), Fok, Hayes, Chang, Stewart, Callard, and Moran (2012), and Quirk et al. (2016). These papers provided the most recent sys- tematic review of prevalence studies and the relationship of health care problems in patients with PDs. Because these systematic reviews have already been published, there was no need to duplicate them. Instead, I have con- ducted a more focused review that examines the problem of PD prevalence in primary care settings, and then offer some ideas on how to manage that problem. Finally, I included articles from my own work in primary care set- tings, which were all identified by the literature searches (described below).

The PsycInfo® search yielded 280 papers during the designated time period. Many were ruled out immedi- ately due to irrelevant content, such as the inclusion of PD as a covariate or comorbid condition, which was not central to the main question of prevalence or health care problems observed in PD patients in primary care. In addition, a few of these papers evaluated neurobiological differences in patients drawn from a primary care sample, which included PD diagnoses. Consequently, they were not included in the review either. The PubMed® search yielded only 46 papers with the same key words in the title or abstract. Many were repeated in the PsycInfo® search, and again, many of these papers were not directly related to the focus of the current paper.

Epidemiological Studies of Personality Disorders

Though a number of studies have been conducted in assessing the prevalence of PDs in psychiatric and popula- tion-derived samples, two recent papers provide excellent summaries of the current state of the field. Beckwith et al. (2014) reviewed nine papers in which prevalence studies focused on PDs were reported. Across psychiatric outpa- tient samples ranging in size from N = 72 to N = 16,118, prevalence estimates were between 40% to 92% in Europe and 45% to 51% in the United States. A more recent paper by Quirk et al. (2016) assessed the population prevalence of PD studies across the world, including samples from England, Wales, Scotland, Western Europe, Norway, Aus- tralia, and the United States. In the United States, they found the population prevalence ranged between 5.9% and 21.5%, which are higher than what is generally reported in the DSM-IV and DSM-5 (American Psychiatric Associa- tion, 1994, 2013). Despite changes in the ways in which PDs might be assessed and diagnosed (e.g., DSM-5 Sec- tion III), it is clear that PDs as presently conceptualized are prevalent throughout the world.

Interestingly, while PD prevalence is high in specialty- care treatment programs (e.g., substance abuse and foren- sic treatment facilities), fewer prevalence studies of PDs exist within the past 20 years within primary care clin- ics. By definition, primary care often focuses upon treat- ment provided by family medicine physicians and clin- ics, but more broadly speaking, primary care often refers to the first contact individuals have with the health care system, in which providers offer integrated, accessible health care services that address the majority of an indi- vidual’s  personal health care needs. Primary care  pro- viders also develop sustained partnerships with patients and practice in the context of families and communities. (Davis, Schoen, & Schoenbaum, 2000; Shi, 2012). For the purposes of this paper, primary care will refer to treatment provided by family medicine or internal medicine physi- cians and clinics, with the focus for PD treatment being on the adult population.

One of the earlier studies on prevalence in primary care was conducted by Hueston, Werth, and Mainous (1999). They surveyed 13 primary care practices in the state of Wisconsin, assessing personality disorder by self-report, as well as assessing overall levels of self-reported func- tioning. Out of 250 patients who completed the survey, 80 met the self-report threshold for at least one PD, with the most commonly occurring PDs being Borderline (n = 49), Schizoid (n = 37), Dependent (n = 22), and Schizotypal (n = 12). Thirty of the 80 patients met criteria for two or more PDs. Patients who screened positively for PDs

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had higher rates of depression, increased office visits, increased use of the emergency department, and received a higher number of medications than their control coun- terparts. They also reported lower scores on their overall mental and physical health, social functioning, sense of vitality, and reported more physical and emotional limita- tions and more bodily pain.

El-Rufaie, Al-Sabosy, Abuzeid, and Ghubash (2002) assessed 158 patients in the United Arab Emirates with a semi-structured diagnostic interview administered by pri- mary care physicians. They found that definite PD diagno- ses could be assigned for six of the ten International Clas- sification of Diseases-10th edition (ICD-10; World Health Organization, 1992) categorical PDs, and that probable ICD-10 diagnoses were assigned for seven of ten. The most commonly observed diagnoses were Schizoid, Anankastic (comparable to Obsessive–Compulsive), and Emotionally Unstable (Borderline), with prevalence in that clinic being at 12.7%.

Moran, Rendu, Jenkins, Rylee, and Mann (2001) evalu- ated 303 patients in London primary care clinics who were referred by their primary care physicians for psychologi- cal evaluation. They were assessed with a semi-structured diagnostic interview. Seventy-two (26.7%) of the patients assessed met criteria for at least one PD. Patients classified as having a PD (either by interview or subjective impression) were more likely to visit their physician, be prescribed a psychotropic mediation, be referred for secondary care, and have a chronic medical condition.

A more extensive body of research on personality pathol- ogy in primary care has been reported by Sansone, Tahir, Buckner, and Wiederman (2008), Sansone, Farukhi, and Wiederman (2011), Sansone, Bohinc, and Widerman (2015), whose focus has been exclusively upon Borderline Personal- ity Disorder (Borderline PD). In these studies, internal medi- cine outpatients completed various self-report instruments to screen for Borderline PD. Across these studies, Borderline PD prevalence rates were determined to be 10.2% to 47.1%. As will be noted below, these individuals had higher levels of health care utilization than those who did not screen posi- tive for Borderline PD.

While the studies reviewed earlier document the high prevalence of PDs in psychiatric outpatient and primary care clinics, there has never been a wide-scale, multisite study of personality pathology in primary care clinics throughout the world. Now that the DSM-5 has proposed an alternative system for identifying and classifying personality pathol- ogy, it would seem especially timely to consider that model in conjunction with the DSM-5 PD categories as part of a wide-scale study of personality pathology in primary care. In a recent study, Huprich, Macaluso, Baade, Zackula, and Jackson (2017) found that broadband personality trait domains, perceptions of the self, and perceptions about the

quality of interpersonal relationships were all negatively associated with favorable healthcare outcomes. One impor- tant question about the utility of this alternative system is whether or not it has enhanced clinical utility over the extant DSM-5 PD categories (Clarkin & Huprich, 2011). Early research on this topic suggests that some clinicians find this dimensionalized approach of traits and self/other ratings to be easier to use than that of the extant PD cat- egories (Few et al., 2013; Morey, Skodol, & Oldham, 2014; Nelson, Huprich, Shankar, Sohnleitner, & Paggeot, 2017). Nonetheless, a study of personality pathology in primary care, which includes the use of extant categories and newer models of assessment (including trait dimensions and levels of personality functioning) appears to be needed so that a more contemporary look at personality pathology in these settings can be specifically evaluated [see Skodol (2012) for a discussion of how the DSM-5 revision considered the need for assessing personality pathology in primary care].

Other Mental and Physical Health Conditions and Personality Disorders: Risks and Costs

Other Mental Health Problems and Comorbid PD in Primary Care

It is well established that most psychological disorders are treated in primary care (deGruy, 1996; Kessler & Stafford, 2008; Miller & Druss, 2013). Patients are more likely to seek out a primary care provider over a mental health pro- fessional for mental health care, with the majority of anxi- ety and depressive disorders being treated by primary care physicians (Bount, 2003; Haas, 2004; Miller, Brown Levey, Payne-Murphy, & Kwan, 2014). And when being treated for these disorders, those patients who possess comorbid PDs have treatments that usually do not proceed as efficiently as they otherwise might. While many studies have documented Axis I and Axis II comorbidity, not as many have docu- mented these findings in primary care samples. For instance, Gross et al. (2002) found that Borderline PD patients in a primary care clinic had significantly higher rates of bipolar disorder and psychotic symptoms than a psychiatric control group in the same sample. In a sample of over 1000 patients in a primary care clinic screened for major depressive dis- orders, Riihimäki, Vuorilheto, and Isometsä (2014) reported that depressed patients with a comorbid Borderline PD diag- nosis had higher rates of depressive, anxiety, and substance abuse disorders. These patients also tended to be depressed longer throughout a 5-year period, achieved a full remis- sion of symptoms more slowly than their non-Borderline PD counterparts, and experienced more chronic depres- sive symptoms. In Hueston et al.’s (1999) study of primary care patients with PDs, those having a PD diagnosis had

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higher levels of depression than those without a PD. And, in another study of 474 urban primary care patients, Westphal et al. (2013) reported that 91% of patients with a Borderline PD diagnosis met criteria for at least one DSM-IV Axis I disorder, and many reported traumatic symptoms associated with Post-Traumatic Stress Disorder.

Physical Health Problems Associated with Personality Disorders

As stated earlier, patients with PDs often have significant health problems that require chronic care and interaction with health care providers (Tyrer, 2005). The majority of research conducted on physical health and PDs has been with Borderline PD. Given their tendencies to be impulsive and self-harm, these patients are at an increased risk for requiring health care treatment (e.g., Zanarini, Frankenburg, Hennen, Reich, & Silk, 2005). In fact, Borderline PD has been associated with a number of adverse, chronic health problems. By way of summary, these include: increased risk for cardiovascular disease; hypertension; arthritis; back pain; diabetes; chronic syndromes (e.g., chronic fatigue syndrome, fibromyalgia, temporal mandibular joint syndrome); urinary incontinence; generally poor perceptions of health; limits in physical ability and one’s ability to carry out daily roles; and increased experiences of pain, substance abuse, self-mutila- tion, psychiatric hospitalization, individual/group/day treat- ments, and obesity (e.g., Bender et al., 2001; El-Gabalawy, Katz, & Sareen, 2010; Frankenburg & Zanarini, 2004; Lee et al., 2010; Moran et al., 2001, 2007; Quirk et al., 2016; Powers & Oltmanns, 2012, 2013; Zanarini et al., 2005).

There are also a number of adverse health-related behav- iors associated with Borderline PD. Sansone et al. (2015) reported in an outpatient internal medicine sample that these patients had less frequent dental check-ups, lower rates of completing their physician-ordered lab work, lower likeli- hood of following physician and nutritionist instructions, and were less likely to take all of their medication. In another paper, Sansone et al. (2011) also noted that Borderline PD patients have a greater frequency in the number of primary care physicians seen and number of specialists seen, and higher rates of non-compliance in pharmaceutical trials, substance abuse treatment, and eating disorder treatment. Borderline patients have also been shown to have higher lev- els of health care usage, take higher numbers of prescription medications, and have higher rates of hospital admissions (e.g., Bender et al., 2001; Zanarini, Frankenburg, Hennen, & Silk, 2004).

Borderline is not the only PD in which basic health prob- lems exist. Soeteman, Verheul, and Busschbach (2008) stud- ied 1708 patients across six different treatment facilities in the Netherlands. Patients were assessed with a semi-struc- tured diagnostic interview for PD and were evaluated for the

burden of disease using the EuroQual metric (Brooks, Rabin, & de Charro, 2003). The authors found that the number of PD diagnoses was more strongly associated with several negative outcomes, including limited mobility, problems with basic self-care, not completing daily activities, general pain or discomfort, and the presence of anxiety or depres- sive symptoms.

Having a PD diagnosis has been found to be associated with a number of other serious health problems. Most nota- bly, Fok et al. (2012) prospectively followed 1837 individu- als in the United Kingdom (UK) and found that the presence of any PD was associated with a decreased life expectancy of 17.7 years (men’s mean mortality age was 59.1 years, and women’s mean mortality age was 63.3 years). The authors also found that having a PD increased one’s risk for stroke by a magnitude of 2–8.5 times. Similarly, Pietrzak, Wagner, and Petry (2007) and Moran et al. (2007) reported increased risk for heart and coronary artery disease in PD samples. Notably, in both studies, the increased risk was computed while controlling for age, gender, smoking status, and alco- hol consumption.

A recent prospective study (Powers & Oltmanns, 2012) of 686 older adults screened in the community (mean age of 59.7 years) found that total scores of PD pathology and total scores across PD clusters A, B, and C were significantly cor- related at baseline and at a 6-month follow-up with generally poor health perceptions, poor physical functioning, role limi- tations, energy level, and pain. Total PD symptoms were also correlated with increased health care and medication utili- zation. Many of these outcomes remained after controlling for major depressive disorder symptoms in the regression analyses. And, in their recent review of the extant literature, Quirk et al. (2016) reported similar elevations in health care utilization, particularly for those patients with a Cluster C PD (Avoidant, Dependent, Obsessive–Compulsive). Notable was the fact that many of these patients consulted with their primary care physician for mental health issues.

One specific type of personality pathology that has much relevancy to primary care treatment is pathological depend- ency and Dependent PD. As a disorder associated with excessive help-seeking behavior and difficulties in func- tioning independently, it is particularly relevant to seeking out health treatment and compliance with medical orders. When studied dimensionally (as opposed to categorically, as described in the DSM-IV, and in earlier editions), over- dependency (as assessed as a constellation of personality traits) is associated with poorer ratings of physical health, higher outpatient costs per visit and increased utilization, the number of days spent in the hospital, number of chief complaints and physician-assigned diagnoses, functional impairment due to chronic illness, elevated blood pressure, and a higher number of chronic illnesses (Huprich, Por- cerelli, Bornstein, & Markova, 2010; Porcerelli, Bornstein,

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Markova, & Huprich, 2009). Additionally, overdepend- ency has been associated with poorer physician–patient relationships within cancer patients (Porcerelli, Bornstein, Porcerelli, & Arterbery, 2015). And, in a sample of physi- cal therapy outpatients, overdependency predicted a large percentage of variance in a number of subscale scores on the Multidimensional Pain Inventory (Kerns, Turk, & Rudy, 1985; Huprich, Hoban, Boys, & Rosen, 2013). Specifically, overdependency was associated with an increased number of physical therapy visits, high levels of self-reported pain interfering with daily life, high levels of obtaining social support, high levels of pain severity, affective distress, and engaging others to receive emotional support.

The Cost of Physical Health Problems in Patients with Personality Pathology

Another important reason to assess prevalence is to bet- ter determine the economic impact of PDs and personality pathology in the healthcare system. For instance, in 2014 the American Psychiatric Association commissioned a report prepared by Milliman, Inc. (Melek, Norris, & Paulus, 2014) that addressed the economic impact of various medical and behavioral health conditions in the health care system throughout the 2012 calendar year. That report noted that the medical costs for treating individuals with both chronic med- ical and comorbid mental health problems were two to three times higher than those who do not have a mental health issue, which were estimated to be an additional $293 billion. Excluded in this figure was an assessment of PDs, though alcoholism, anorexia/bulimia, substance abuse, depressive, and anxiety disorders were included. Commercial insurance companies reported an average cost of almost $1200/month per person for those with serious and persistent mental ill- ness, compared to $340/month for someone without a sub- stance abuse or mental health issue. The comparable Medi- care figures were $1437/month vs. $582/month, while the comparable Medicaid figures were $1301/month vs. $381/ month. Based on these figures, it is possible that the PD figures would be 2.5 to 4 times higher than those without a PD given the seriousness and degree of impairment found in a number of PDs.

There are reasons to believe that these estimates are probably accurate. Studies of Borderline PD costs in Spain (Salvador-Carulla et al., 2014) and in the Netherlands Soe- teman, Roijen, Verheul, and Busschbach (2008) estimate that the annual cost per patient is slightly over €11,000 per year. In Germany, the annual estimated societal cost in 2010 of treatment for someone with Borderline PD who was not in treatment was €28,026 (Wagner et al., 2014). And in the United States, Porcerelli et al. (2009) reported that high overdependency (similar to Dependent PD) was positively associated with higher costs for outpatient

visits, the average cost per office visit, and the number of days in the hospital—findings that were similar to a study by Greenberg and Bornstein (1989) three decades earlier.

However, there is reason to be concerned that relying on extant PD studies might not accurately estimate their economic impact. First, Moffitt et al. (2010) have found that lifetime prevalence rates of most mental disorders are approximately doubled when studies are prospective vs. retrospective. Such a finding led Wittchen et al. (2011) to conclude that “higher impact could be expected from stringent early detection and early treatment before more severe expression occurs” (p. 670), which is often the case when studying patients currently seeking treatment. Sec- ond, PD symptoms and categorical diagnoses are often found to overlap, such that pure diagnoses are not the norm (see a review by Samuel & Griffin, 2015). Hopwood et al. (2011) found that the degree of a patient’s current func- tional impairment, and at 3-years out, was best predicted by the sum of all PD symptoms. This would mean that, for those with more than one PD, or who possess features of several PDs, their functional impairment is more severe than those who have just one PD, suggesting that the eco- nomic impact of treating these patients may be higher. Third, it is possible that those who do not meet criteria for any DSM categorical PD, but who yet still have many PD symptoms, are being underdetected in studies assess- ing the relationship of PD with health care outcome. Now that Section III of DSM-5 offers a more dimensionalized method of assessing personality pathology, it is important to verify the extent to which PD impairment and cost are associated with this dimensionalized system. Given the concerns above, it is possible that the costs of having high personality pathology may be more substantial than what has been reported above.

In sum, this brief review of the mental and physical health comorbidities found in patients with PDs or per- sonality pathology clearly demonstrates that these patients have a number of serious medical problems, including a sizeable increase in risk for early death, and increased health care utilization and costs. By not addressing the problem of personality pathology or PDs in primary care, it is likely that costs will continue to be high and possi- bly increase, due to the chronic and unremitting nature of much personality pathology.

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Improving Care for Patients with Personality Pathology in Primary Care

Interpersonal Challenges and Guidelines for Providers when Directly Dealing with Patients with Personality Pathology

As noted earlier, for a number of decades, a literature has existed on “difficult” patients; they have been said to evoke a “heartsinking” feeling in their physicians (Mathers et al., 1995). Even when these patients’ medical problems are minimal, they are described by physicians as: non-com- pliant, overly dependent, demanding specific or special treatment that is not warranted, whining or complaining frequently, having considerable family conflict, coming in with “hidden” agendas, seeking medications or drugs that are not warranted, requesting disability or workman’s compensation, experiencing chronic pain, or having sig- nificant psychiatric issues, such as unipolar or bipolar dis- orders, attention-deficit hyperactivity disorder, substance abuse, and Borderline PD (Elder, Ricer, & Tobias, 2006; Hass, 2004). Patients with Borderline PD are especially challenging, due to their affective instability, tendency to rapidly change opinions about people in their life, impul- sivity, potential for self-harm, and their difficulties with empathy and maintaining intimacy. Dubovsky and Kiefer (2014) offer important pharmacological guidelines for managing the affective dysregulation and impulsivity of Borderline PD patients, but add that a multi-level approach is often needed. They suggest that the primary care physi- cian validates the patient’s emotions and perceptions prior to addressing issues that need clinical attention. They also recommend setting clear boundaries about what is to be discussed and addressed in a particular appointment, and to not reinforce patients’ demands for contact by increas- ing the time spent. Porcerelli and Huprich (2007) note that physicians might want to link PD patients’ somatic com- plaints with their interpersonal and behavioral problems, so to increase their awareness of how the somatic domains and interpersonal/behavioral domain are related to one another. For instance, a patient might complain about her boyfriend upon first entering the treatment room, but later, when she discusses her presenting problem, migraines, she describes as being “like a firecracker that could explode at anytime” (p. S9). By linking the physical and psycho- logical problems together, physicians and health care pro- viders can increase patients’ awareness of how these two are related and that the need for treatment might extend beyond just a medical or biological intervention.

Though most primary care providers are familiar with the DSM classification of PDs, it would be especially helpful to review this material with an emphasis on how

different PD types present interpersonally and within a health care environment. Porcerelli and Huprich (2007) note that many patients’ medical symptoms are embedded within the context of an interpersonal conflict, such as the one described above. Likewise, the physician–patient relationship can also provide useful data for considering whether a patient has a PD. For instance, the narcissistic patient with gastric pain might devalue the physician for incompetency and poor business practice after waiting to be seen for an hour, and then only to be told that a simple diet change would be useful (vs. being prescribed a series of tests). Porcerelli and Huprich (2007) note that patients with Paranoid PD will struggle to find a “safe-enough” physician–patient relationship and will be hypersensitive to the possibility that their physician might actually harm them. They describe the case of a 37-year-old single male who lives alone and who left his other physician because he could not understand the physician’s accent, and took that to mean that the physician really did not care about him. Ward (2004) adds that empathic support and not chal- lenging the paranoid patient’s suspiciousness are impor- tant management strategies, along with being very clear about what plan of action is to occur and why it might occur.

A number of guidelines have been published about how to manage PDs in primary care settings (e.g., Porcerelli & Huprich, 2007; Dubovsky & Kiefer, 2014; Ward, 2004; Gask, Evan, & Kessler, 2016). As noted above, Porcerelli and Huprich (2007) provide descriptions of how to iden- tify and address interpersonal manifestations of patients who have a PD. Ward (2004) offers examples of how each DSM-IV PD might be manifested in medical symptoms. For instance, the patient with Schizoid PD might avoid seeking care and appear unappreciative of help that is given, often because of anxiety surrounding contact with others. Dubos- vky and Kiefer (2014) focus upon treatment modalities for Borderline PD, including suggested pharmacotherapies. Alternatively, Gask et al. (2016) review all PDs, including a summary of evidence-based psychotherapies for Borderline PD, broad guidelines for non-mental health specialists, and practice management guidelines.

In addition, helping physicians and other health care workers identify these kinds of patients and how to talk with them could be useful. For instance, training could occur with online instructional materials, grand rounds presentations, and/or having mental healthcare workers alongside of physicians to help assess and demonstrate communication and behavioral case management skills. Especially important is helping physicians talk to patients about symptoms as manifestations of underlying compo- nents of a patient’s personality. For instance, after this kind of training, a physician might state, “Your anxiety over your wife’s insensitivity to your hypertension is

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probably not helping you manage the disease. Maybe if you focused on this concern and your response to her, you might feel a bit better. I know behavioral health pro- fessionals who are especially useful with these kinds of problems.”

Empirically, little exists by way of studying the effect of a patient’s personality pathology on providers. Elder et al. (2006) identified strategies used by expert family practice physicians on how to manage difficult patients. These include priority setting, coaching, enhanced deci- sion-making, setting clinical management rules, setting boundaries and limits within the clinical encounter, and enhancing empathy. In a more recent study, Huprich et al. (2017) assessed 57 internal medicine outpatients and their providers. The authors asked providers to rate the fol- lowing items: how likeable is the patient, how well does the patient comply with my instructions, how well is the patient making positive strides in their treatment, how much does the patient abuse the system, and how much does the patient abuse me. Physicians also rated patients on DSM-5 Section III personality pathology dimensions. These included pathological personality trait domains, the patient’s sense of him/herself, and the patient’s capacity for interpersonal relatedness. Across all five personality trait domains (Negative Affectivity, Detachment, Antago- nism, Disinhibition, and Psychoticism), and across two ratings of self-functioning (an established sense of iden- tity, a clear sense of self-directedness) and interpersonal functioning (capacity for intimacy, capacity for empa- thy), there were significant correlations with providers’ perceptions of  patients’ likeability and treatment pro- gress. When providers detected pathological personality traits or problematic self and interpersonal functioning, they perceived the patient as less likeable and as not pro- gressing through treatment as well as could be expected. In the same study, 83 psychiatric outpatients were also assessed. A similar pattern between personality function- ing and trait domain and providers’ perceptions of the patients was observed, though the providers’ ratings of the patients’ abusiveness toward the provider was not sig- nificant across most of the trait, self, and other ratings.

Based upon the above review, it is apparent that PDs and personality pathology are prevalent in primary care settings, and that such pathology has adverse effects on patient outcomes and providers’ ability to provide optimal care. This finding is consistent with the already estab- lished idea that primary care is the “de facto” environ- ment in which mental health problems are likely to be observed within the health care environment (deGruy, 1996; Kessler & Stafford, 2008; Miller & Druss, 2013). Thus, it is timely for the field to begin thinking about how to best address PDs and personality pathology in the primary care setting.

Guidelines for How to Systemically Manage Patients with Personality Pathology

Revision of wording to assure clarity Screening. While major changes in measures used to assess and diagnose PDs are quite possible in the future, it certainly is the case that screening patients for personality pathology can be espe- cially useful now. Given concerns about the potential impact of a patient having a PD (or personality pathology) on that individual’s health status, mortality, and the cumulative impact on cost to the health care system, this is something that should be happening in current practice. If a physician observes relevant psychological and behavioral problems in patients that are consistent with the presence of a PD, then developing a plan of action would be the most appropriate course of clinical action. But what about a more active effort to identify personality pathology at the outset of treatment?

An essential part of this strategy is an active effort to identify personality pathology at the outset of treatment. Fortunately, there are some instruments available for screen- ing for personality disorders. Siefert (2006) reviewed the literature and reported on four instruments ranging from 8 to 30 items in length. The shortest instrument—the Stand- ardized Assessment of Personality-Abbreviated Scale (Moran, Rendu, Jenkins, Tylee, & Mann, 2003)—is an 8-item, Yes–No questionnaire, but requires clinicians to follow-up on those items that are endorsed affirmatively. The same is true for the next shortest measure—the Iowa Personality Disorder Screen (Langbehn et al., 1999). The other two instruments are: the Inventory for Interpersonal Problems 25 (Kim & Pilkonis, 1999), which has 25 items and is derived from an assessment of interpersonal function- ing and problems; and the Five Factor Model Rating Form (Widiger, 2004), which has 30 items and is derived from an assessment of the Five Factor Model of personality. Another instrument that has promise is the Personality Assessment Screener (PAS; Morey, 1997). This is a 22-item measure that is derived from the Personality Assessment Inventory (Morey, 2007). Porcerelli et al., (2012) administered the PAS to 110 women in a primary care outpatient clinic and found that PAS scores correlated with the total score of Cluster B (Antisocial, Borderline, Histrionic, Narcissistic) PD symp- toms. A PAS cutoff score of 20 or higher had an overall 77% correct classification rate, with a 0.96 sensitivity and 0.53 specificity. Including such tools in a screening battery is not difficult or novel. In fact, time efficient models of psycho- logical assessment have been developed for primary care, with particular attention devoted to understanding personal- ity processes and related levels of functioning (Porcerelli & Jones, 2017).

The instruments above offer a number of choices for PD screening; however, other instruments could be devel- oped as well. It is quite feasible within integrated health

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care settings that mental health professionals could quickly review the results of these screening devices and provide follow-up interviews as needed. In addition, a positive screening score could alert primary care physicians to the possibility that personality problems might be present, thus preparing the physician for potential challenges during the patient encounter. Primary care mental health professionals could also be available to meet with patients who screen positively, in order to identify some chief problems that might be addressed with a mental health professional. For instance, they might offer psychoeducational handouts that address issues that are relevant to a particular PD, such as relaxation or mindfulness exercises, or address depressive or anxiety symptoms that are part of the patient’s overall personality structure (e.g., anxiety over a relationship loss in a patient with Borderline PD). They could also follow-up with patients in a subsequent session or two and then make referrals to psychologists, psychiatrists, or other behavioral health experts who treat PDs.

As a beginning step, clinics that engage in regular screen- ing of personality pathology should assess the utility of the screening process for identifying and heading off problems, such as compliance with medical instructions, enhanced cooperation with medical professionals; and for improving physician and staff efficacy in managing potentially chal- lenging patients. It would not be unreasonable to expect this, given that screening for other mental health conditions (e.g., depression) has been associated with better manage- ment of that condition in the primary care setting (Phillips et al., 2011).

Effective Management Inside and Outside of Primary Care Settings

Few mental health clinicians would believe that PDs can and should be treated exclusively within a primary care environ- ment. In fact, in a recent review of the literature, Miller et al. (2014) did not find PDs as a mental health condition being treated in any primary care clinic. In part, this is due to the length of time required to effectively treat and manage PDs, which regularly lasts for months or years. Often, it is the case that PD problems, when they are detected as being clinically significant, are considered clinical challenges that should be referred out. To the extent that the patient’s personality pathology is regularly monitored depends upon the inter- est of the referring physician and the responsiveness of the mental health care provider. However, this does not mean that PDs should be relegated to a secondary problem that is not of interest to the primary care physician. As mentioned above, patients with personality pathology are disruptive and challenging to the medical staff; they do not comply well with physicians’ orders and have multiple comorbid physi- cal and psychological conditions; they utilize the health care

system more frequently and consume more resources and cost; most notably, patients with PDs have mortality rates higher than those without PDs. Stated differently, a PD is a very serious health condition that requires increased atten- tion by health care providers.

However, there are reasons to believe that some identifi- cation and treatment could occur in the primary care setting, and that an effective referral system could be established. One of the greatest limitations to treating such patients is resource driven. There are not enough providers or an effec- tive billing mechanism for psychologists to treat PDs within the primary care setting. But, by effectively using resources, there might be novel strategies to help such patients move into the type of treatment that they need. I will provide three examples of how this could occur.

First, as mentioned above, having a good screening pro- cess allows physicians to identify patients with personality pathology and to begin the management of symptoms asso- ciated with their PD (e.g., depression, anxiety, high stress). Physicians can refer patients immediately to the behavioral health specialists in the clinic, who could do some psycho- education and/or begin the referral process to PD experts with whom the office has a good working relationship. This also would alert providers to the possibility of some chal- lenges to clinical management, thus allowing them to be more prepared in their initial meeting with the patient.

Second, it is essential that primary care physicians establish close relationships with mental health provid- ers (ideally co-located in the same building or facility). This is necessary for several reasons. To begin with, bill- ing for outpatient psychotherapy in primary care is not likely an option, given the nature of the billing process (e.g., many insurances require the physician to be in the room; it is not currently standard practice for primary care physicians or mental health services to be offered beyond a few sessions in the primary care setting). With an estab- lished outpatient clinic in the same building, perhaps even in the same hallway, patients have ready access to care that is not physically removed from their provider (Miller, Petterson, Burke, Phillips, & Green, 2014). Furthermore, with these types of alliances between the primary care offices and outpatient mental health offices, it would be easy for individuals in both settings to communicate on a regular basis about patients. Developing shared databases or information about patient health care could be estab- lished, such that physicians could see how well patients are progressing in psychotherapy, while mental health professionals would be able to see what kinds of medical and compliance issues are in play with patients’ primary care physicians. Of course, this requires patient consent for shared communications under the HIPAA framework; however, it allows for more direct management of person- ality pathology as it relates to the person’s overall level

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of functioning, and in particular, with regard to his or her health care. Furthermore, follow-up communication by way of letter or email would be helpful so that primary care physicians know that the patient is engaging in treat- ment and that the process has begun. This would allow the primary care physician the opportunity to bring any addi- tional concerns to the behavioral health care provider’s attention once mental health treatment has begun and is going well.

Third, having clinical psychology doctoral student trainees working with psychologists in the primary care setting offers additional services that can be billed under the supervision of the psychologist and primary care phy- sician. Such training models are crucial for the expansion of mental health providers into primary care settings and integration (McDaniel & deGruy, 2014). A similar model for this type of work has been described by Porcerelli, Fowler, Murdoch, Markova, and Kimbrough (2013), in which primary care residents can be trained alongside psychology doctoral trainees. Here, family medicine resi- dents are trained about behavioral health issues and work alongside psychology trainees, who help provide the edu- cation to the residents. In a study of the efficacy of this model, Porcerelli et al. (2013) found that 83% of the resi- dents learned new information or techniques with regard to assessment and psychological intervention, and 89% reported that their collaboration enhanced their patient care. Follow-up interviews with the psychology trainees indicated that they, too, had learned much from the pri- mary care residents. As applied to treating PDs, it is quite likely that trainees could help residents assess and identify potential personality pathology. They also could work col- laboratively with patients to address those psychological or behavioral components that are most likely to inter- fere with the patients’ health, and utilize motivational interviewing (Douaihy, Kelly, & Gold, 2015) to prepare patients for the work of individual or group psychotherapy (e.g., dialectical behavior therapy groups).

Finally, there are some aspects of personality pathol- ogy that could be addressed briefly in primary care. For instance, there are some psychoeducational models in dia- lectical behavior therapy (Linehan, 1993) and mentaliza- tion-based therapy (Bateman & Fonagy, 2009) that might be useful for patients with certain kinds of behavioral problems (e.g., distress tolerance). Furthermore, there are established programs that demonstrate how these modules are being integrated into primary health care settings (e.g., http://uwaims.org/bhip/tools-clinicalskills.html#dbt). Cou- pling this with motivational interviewing, mental health professionals (and primary care physicians) could help patients with personality pathology to become more curi- ous about their overall functioning and consider engaging in outpatient psychotherapy.

Conclusions

This paper adopted a selective review strategy to identify key papers on the prevalence of PDs in primary care set- tings and the health problems observed among PD patients in these environments. While the review was not meant to be comprehensive, it capitalized upon some recent papers whose purpose was to cast a wider net in a review of the literature. Thus, the comprehensiveness of the relevant studies was limited. Nonetheless, a review of this selected literature makes it clear that patients with PDs have con- siderable risks for high psychological and physical comor- bidities, as well as increased odds for early mortality. This makes PDs and personality pathology a significant health problem that requires additional attention. At the same time, the field is not well aware of how pervasive person- ality pathology is in primary care; thus, a comprehensive prevalence study of these pathologies is needed in pri- mary care clinics. Suggestions have been offered for how to train physicians to identify PDs more readily, how to rapidly assess for personality pathology, and how to effec- tively initiate treatment for patients who need it. Integrated health care seeks to treat the whole person, and treatment of acute psychiatric symptoms is just one component of effective mental health care. Focusing upon the personal- ity of patients is needed if integrated health care truly is to become integrated. Though these problems are often pervasive and challenging to remit, attention to them is required. In doing so, the underlying conflicts, dynamics, relationship patterns, and schema that drive so much of one’s behavior can be further understood and modified, thus improving the health and life of the entire person.

Acknowledgements Special appreciation is expressed to John H. Por- cerelli, PhD, ABPP and Benjamin F. Miller, PsyD for their feedback on an earlier draft of this paper.

Compliance with Ethical Standards

Conflict of interest Steven K. Huprich declares that he has no conflict of interest.

Human Rights and Animal Rights and Informed Consent No human or animal research studies were conducted by the author for this article.

References

American Psychiatric Association (1994). Diagnostic and statistical manual of mental disorders, (4th ed.). Author: Washington, DC.

American Psychiatric Association (2013). Diagnostic and statistical manual of mental disorders, (5th ed.). Author: Washington, DC.

Bateman, A., & Fonagy, P. (2009). Randomized controlled trial of outpatient mentalizationbased treatment versus structured

52 Journal of Clinical Psychology in Medical Settings (2018) 25:43–54

1 3

clinical management for borderline personality disorder. Ameri- can Journal of Psychiatry, 166, 1355–1364.

Beckwith, H., Moran, P. F., & Reilly, J. (2014). Personality disorder prevalence in psychiatric outpatients: A systematic literature review. Personality and Mental Health, 8, 91–101.

Bender, D. S., Dolan, R. T., Skodol, A. E., Sanislow, C. A., Dyck, I. R., McGlashan, T. H., … Gunderson, J. G. (2001). Treatment utilization by patients with personality disorders. American Journal of Psychiatry, 158, 295–302.

Bount, A. (2003). Integrated primary care: Organizing the evidence. Families, Systems, & Health, 21, 121–134.

Brooks, R., Rabin, R., & deCharro, F. (2003). The measurement and valuation of health status using EQ-5D: A European perspec- tive. London: Kluwer Academic Publishers.

Clarkin, J. F., & Huprich, S. K. (2011). Do the DSM-5 proposals for personality disorders meet the criteria for clinical utility? Journal of Personality Disorders, 25, 192–205.

Davis, K., Schoen, C., & Schoenbaum, S. C. (2000). A 2020 vision of American health care. Archives of Internal Medicine, 160, 3357–3362.

deGruy, F. (1996). Mental health care in the primary care setting. In M. S. Donaldson, K. D. Yordy, N. Lohr & N. A. Vanselow (Eds.), Primary care: America’s health in a new ear. Washing- ton, DC: Institute of Medicine.

Douaihy, A., Kelly, T. M., & Gold, M. A. (2015). Motivational inter- viewing: A guide for medical trainees. New York: Oxford.

Dubovsky, A. N., & Kiefer, M. M. (2014). Borderline personality disorder in the primary care setting. Medical Clinics of North American, 98, 1049–1064.

Edler, N., Ricer, R., & Tobais, B. (2006). How respected family physicians manage difficult patient encounters. Journal of the American Board of Family Medicine, 19, 533–541.

El-Gabalawy, R., Katz, L. Y., & Sareen, J. (2010). Comorbidity and associated severity of borderline personality disorder and physical health conditions in a nationally representative sample. Psychosomatic Medicine, 72, 641–647.

El-Rufaie, O. E. F., Al-Sabosy, M., Abuzeid, M. S. O., & Ghubash, R. (2002). Personality profile among primary care patients: Experimenting with the Arabic IPDE ICD-10. Acta Psychiatrica Scandinavia, 105, 37–41.

Few, L. R., Miller, J. D., Rothbaum, A., Meller, S., Maples, J., Terry, D. P., … MacKillop, J. (2013). Examination of the Section III DSM-5 diagnostic system for personality disorders in an out- patient clinical sample. Journal of Abnormal Psychology, 122, 1057–1069.

Fok, M. L., Hayes, R. D., Chang, C. K., Stewart, R., Callard, F. J., & Moran, P. (2012). Life expectancy at birth and all-cause mor- tality among people with personality disorder. Psychosomatic Medicine, 72, 104–107.

Frankenburg, F. R., & Zanarini, M. C. (2004). The association between borderline personality disorder and chronic medical illnesses, poor health-related lifestyle choices, and costly forms of health care utilization. Journal of Clinical Psychiatry, 53, 1660–1665.

Gask, L., Evans, M., & Kessler, D. (2016). Personality disorder. BMJ, 347, 28–32.

Greenberg, R. P., & Bornstein, R. F. (1989). Length of psychiatric hospitalization and oral dependency. Journal of Personality Dis- orders, 3, 199–204.

Gross, R., Olfson, M., Gameroff, M., Shea, S., Feder, A., Fuentes, M., … Weissman, M. (2002). Borderline personality disorder in primary care. Archives of Internal Medicine, 162, 53–60.

Haas, L. J. (Editor) (2004). Handbook of primary care psychology. New York: Oxford.

Hopwood, C. J., Malone, J. C., Ansell, E. B., Sanislow, C. A., Grilo, C. M., McGlashan, T. H., … Morey, L. C. (2011). Personality

assessment in DSM-5: Empirical support for rating severity, style, and traits. Journal of Personality Disorders, 25, 305–320.

Hueston, W. J., Werth, J., & Mainous, A. G. (1999). Personality dis- order traits: Prevalence and effects on health status in primary care patients. International Journal of Psychiatry in Medicine, 29, 63–74.

Huprich, S. K., Hoban, P., Boys, A., & Rosen, A. (2013). Healthy and unhealthy manifestations of interpersonal dependency and pain management: Interfacing personality and health status. Journal of Clinical Psychology in Medical Settings, 20, 508–514.

Huprich, S. K., Hsiao, W. C., Porcerelli, J. H., Bornstein, R. F., & Markova, T. (2010). Expanding the validity of the relationship profile test in clinical and nonclinical samples. Assessment, 17, 81–88.

Huprich, S. K., Macaluso, M., Baade, L., Zackula, R., & Jackson, J. (2017). Physician perceptions and health care outcomes associ- ated with pathological personality traits and levels of functioning. Manuscript under review.

Kerns, R. D., Turk, D. C., & Rudy, T. E. (1985). The West Haven-Yale Multidimensional Pain Inventory (WHYMPI). Pain, 23, 345–356.

Kessler, R., & Stafford, D. (2008). Primary care is the de facto mental health system. In R. Kessler & D. Stafford (Eds.), Collabora- tive medicine case studies: Evidence in practice (pp. 9–21). New York: Springer.

Kim, Y., & Pilkonis, P. A. (1999). Selecting the most informative items in the IIP scales for personality disorders: An application of item response theory. Journal of Personality Disorders, 13, 157–174.

Langbehn, D. R., Pfohl, B. M., Reynolds, S., Clark, L. W., Battaglia, M., Bellodi, L., … Links, P. (1999). The Iowa personality disor- der screen: Development and preliminary evaluation of a brief screening interview. Journal of Personality Disorders, 13, 75–89.

Lee, H. B., Bienvenu, O. J., Cho, S., Ramsey, C. M., Bandeen-Roche, K., Eaton, W. W., & Nestadt, G. (2010). Personality disorders and traits as predictors of incident cardiovascular disease: Findings from the 23-year follow-up of the Baltimore ECA study. Psycho- somatics, 41, 289–296.

Linehan, M. M. (1993). Cognitive-behavioral treatment of borderline personality disorder. New York: Guilford Press.

Mathers, N., Jones, N., & Hannay, D. (1995). Heartsink patients: A study of their general practitioners. British Journal of General Practice, 45, 293–296.

McDaniel, S. H., & deGruy, F. V. III (2014). An introduction to pri- mary care and psychology. American Psychologist, 69, 325–331.

Melek, S. P., Norris, D. T., & Paulus, J. (2014). Milliman American Psychiatric Association Report: Economic Impact of Integrated Medical-Behavioral Healthcare, Implications for Psychiatry. Denver, CO: Milliman, Inc.

Miller, B. F., & Druss, B. (2013). The role of family physicians in mental health care delivery in the United State: Implications for health reform. Journal of the American Board of Family Medicine, 26, 111–113.

Miller, B. F., Brown Levey, S. M., Payne-Murphy, J. C., & Kwan, B. M. (2014). Outlining the scope of behavioral health practice in primary care: Dispelling the myth of the one-trick mental health pony. Families, Systems, & Health, 32, 338–343.

Miller, B. F., Petterson, S., Burke, B. T., Phillips, R. L. Jr., & Green, L. A. (2014). Proximity of providers: Colocating behavioral health and primary care and the prospects for an integrated workforce. American Psychologist, 69, 443–451.

Moffitt, T. E., Caspi, A., Taylor, A., Kokaua, J., Milne, B. J., Polanc- zyk, G., & Poulton, R. (2010). How common are common mental disorders? Evidence that lifetime prevalence rates are doubled by prospective versus retrospective ascertainment. Psychological Medicine, 40, 899–909.

Moran, P., Leese, M., Lee, T., Walters, P., Thornicroft, G., & Mann, A. (2003). Standardised Assessment of Personality Scale (SAPAS):

53Journal of Clinical Psychology in Medical Settings (2018) 25:43–54

1 3

Preliminary validation of a brief screen for personality disorder. British Journal of Psychiatry, 183, 228–232.

Moran, P., Rendu, A., Jenkins, R., Tylee, R., & Mann, A. (2001). The impact of personality disorder in UK primary-care. A 1-year follow-up of attenders. Psychological Medicine, 31, 1447–1454.

Moran, P., Steward, R., Brugha, T., Beggingont, P., Bhugra, D., Jen- kins, R., & Coid, J. W. (2007). Personality disorder and cardiovas- cular disease: Results from a national household survey. Journal of Clinical Psychiatry, 68, 69–74.

Morey, L. C. (1997). Personality assessment screener professional manual. Odessa, FL: Psychological Assessment Resources.

Morey, L. C. (2007). Personality assessment Inventory professional manual. Lutz, FL: Psychological Assessment Resources.

Morey, L. C., Skodol, A. E., & Oldham, J. M. (2014). Clinician judg- ments of clinical utility: A comparison of DSM-IV-TR personality disorders and the alternative model for DSM-5 personality disor- ders. Journal of Abnormal Psychology, 123, 398–405.

Nelson, S. M., Huprich, S. K., Shankar, S., Sohnleitner, A., & Paggeot, A. V. (2017). Comparing four diagnostic methods of personality disorder diagnosis in psychology trainees and interns. Personality Disorders: Theory, Research, and Treatment, 8, 217.

Phillips, R. L. Jr., Miller, B. F., Petterson, S. M., & Teevan, B. (2011). Better integration of mental health care improves depression screening and treatment in primary care. American Family Phy- sician, 1 84, 980.

Pietrzak, R., Wagner, J., & Petry, N. (2007). DSM-IV personality dis- orders and coronary heart disease in older adults: Results from the national epidemiological survey on alcohol related questions. Journal of Gerontology, 62B, 295–299.

Porcerelli, J., Bornstein, R. F., Markova, T., & Huprich, S. K. (2009). Physical health correlates of pathological and healthy depend- ency in urban women. Journal of Nervous and Mental Disease, 197, 761–765.

Porcerelli, J. H., Bornstein, R. F., Porcerelli, D., & Arterbery, V. E. (2015). The complex role of personality in cancer treatment: Impact of dependency-detachment on health status, distress, and physician-patient relationship. Journal of Nervous & Mental Dis- ease, 203, 264–268.

Porcerelli, J. H., Fowler, S., Murdoch, W., Markova, T., & Kimbrough, C. (2013). Training family medicine residents to practice collabo- ratively with psychology trainees. International Journal of Psy- chiatry in Medicine, 35, 357–365.

Porcerelli, J. H., & Huprich, S. K. (2007). Personality disorders. Hos- pital Physician, Family Practice Board Review Manual, 7, 2–9.

Porcerelli, J. H., & Jones, J. R. (2017). Psychological assessment in integrated care: An overview. In M. E. Maruish (Ed.), Handbook of psychological assessment in primary care settings (2nd ed., pp. 75–94). New York: Routledge/Taylor and Francis.

Porcerelli, J. H., Kurtz, J. E., Cogan, R., Markova, T., & Mickens, L. (2012). Personality assessment screener in a primary care sample of low-income urban women. Journal of Personality Assessment, 94, 262–266.

Powers, A. D., & Oltmanns, T. F. (2012). Personality disorders and physical health: A longitudinal examination of physical function- ing, healthcare utilization, and health-related behaviors in middle- aged adults. Journal of Personality Disorders, 26, 534–538.

Powers, A. D., & Oltmanns, T. F. (2013). Borderline personality pathol- ogy and chronic health problems in later adulthood: The mediat- ing role of obesity. Personality Disorders: Theory, Research, and Treatment, 4, 152–159.

Quirk, E. S., Berk, M., Chanen, A. M., Koivumaa-Honkanen, H., Brennan-Olsen, S. L., Pasco, J. A., & Williams, L. J. (2016). Population prevalence of personality disorder and associations with physical health comorbidities and health care service utili- zation: A review. Personality Disorders: Theory, Research, and Treatment, 7, 136–146.

Riihimäki, K., Vuorilehto, M., & Isometsä, E. (2014). Borderline per- sonality disorder among primary care depressive patients: A five- year study. Journal of Affective Disorders, 155, 303–306.

Robiner, W., & Petrick, M. (2017). Managing difficult patients: Roles of psychologists in the age of interdisciplinary care. Journal of Clinical psychology in Medical Settings, 24, 27–36.

Salvador-Carulla, L., Bendeck, M., Ferrer, M., Andión, Ó., Aragonès, E., et al. (2014). Cost of borderline personality disorder in Cata- lonia (Spain). European Psychiatry, 29, 490–497.

Samuel, D. B., & Griffin, S. A. (2015). A critical evaluation of retain- ing personality categories and types. In S. K. Huprich (Ed.), Personality disorders: Toward theoretical and empirical integra- tion in diagnosis and assessment (pp. 43–62). Washington, DC: American Psychological Association.

Sansone, R. A., Bohinc, R. J., & Widerman, M. W. (2015). Borderline personality symptomatology and compliance with general health care among internal medicine outpatient. International Journal of Psychiatry in Clinical Practice, 19, 132–136.

Sansone, R. A., Farukhi, S., & Wiederman, M. W. (2011). Utilization of primary care physicians in borderline personality. General Hos- pital Psychiatry, 33, 343–346.

Sansone, R. A., Tahir, N. A., Buckner, V. R., & Wiederman, M. W. (2008). The relationship between personality disorder symptoma- tology and somatic preoccupation among internal medicine outpa- tients. Primary Care Companion – Journal of Clinical Psychiatry, 10, 286–290.

Shi, L. (2012). The impact of primary care: A focused review. Scien- tifica, 2012, 1–22.

Siefert, C. J. (2006). Screening for personality disorders in psychiatric settings: Four recently developed screening measures. In L. Baer & M. A. Blais (Eds.), Handbook of clinical rating scales and assessment in psychiatry and mental health, current clinical psy- chiatry, (pp. 125–144). New York: Humana Press.

Skodol, A. E. (2012). Personality disorders in DSM-5. Annual Review of Clinical Psychology, 8, 317–344.

Soeteman, D. I., Roijen, L. H., Verheul, R., & Busschbach, J. J. (2008). The economic burden of personality disorders in mental health care. Journal of Clinical Psychiatry, 69, 259–265.

Soeteman, D. I., Verheul, R., & Busschbach, J. J. (2008). The burden of disease in personality disorders: Diagnosis-specific quality of life. Journal of Personality Disorders, 22, 259–268.

Tyrer, P. (2005). Medical settings. In J. M. Oldham, A. E. Skodol & D. S. Bender (Eds.), The american psychiatric publishing textbook of personality disorders (pp. 607–619). Washington, DC: American Psychiatric Publishing, Inc.

Wagner, T., Fydrich, T., Stiglmayr, C., Marschall, P., Salize, H. J., Renneberg, B., … Roepke, S. (2014). Societal cost-of-illness in patients with borderline personality disorder one year before, dur- ing, and after dialectical behavior therapy in routine outpatient care. Behaviour Research and Therapy, 61, 12–22.

Ward, R. K. (2004). Assessment and management of personality dis- orders. American Family Physician, 70, 1505–1512.

Westphal, M., Olfson, M., Bravova, M., Gameroff, M. J., Gross, R., Wickramaratne, P., … Weissman, M. (2013). Borderline person- ality disorder, exposure to interpersonal trauma, and psychiat- ric comorbidity in urban primary care patients. Psychiatry, 76, 365–380.

Widiger, T. A. (2004). Five factor model rating form. Unpublished measure. University of Kentucky.

Wittchen, H. U., Jacobi, F., Rehm, J., Gustavsson, A., Svensson, M., Jönsson, B., … Steinhausen, H. C. (2011). The size and burden of mental disorders and other disorders of the brain in Europe 2010. European Neuropsychopharmacology, 21, 655–679.

World Health Organization (1992). The ICD-10 classification of mental and behavioral disorders: Clinical descriptions and diagnostic guidelines. Geneva: World Health Organization.

54 Journal of Clinical Psychology in Medical Settings (2018) 25:43–54

1 3

World Health Organization and Wonca Working Party of Mental Health (2008). What is primary care mental health? Mental Health in Family Medicine, 5, 9–13.

Zanarini, M., Frankenburg, F., Hennen, J., Reich, J., & Silk, K. (2005). The McLean study of adult development (MSAD): Overview and implications of the first six years of prospective follow-up. Jour- nal of Personality Disorders, 19, 505–523.

Zanarini, M., Frankenburg, F., Hennen, J., & Silk, K. R. (2004). Men- tal health service utilization by borderline personality disorder patients and Axis II comparison subjects followed prospectively for 6 years. Journal of Clinical Psychiatry, 65, 28–36.