Challenging patient behaviors: Patient red flags and personality disorders

Editor’s note: This is part two of a four-part series. Part one examined early maladaptive schemas and how they influence irrational thinking and problem behaviors in dental patients. Read part three: Effective reasoning with unreasonable patients. Read part four: Strategies for listening to difficult patients.

Personality disorders (PDs) are complex mental health conditions characterized by disrupted patterns of thinking and behavior, unstable mood regulation, and inability to relate to others. Patients with PDs do not recognize their behaviors as inappropriate or understand the negative effect that their behaviors have on others.¹ It is difficult to estimate the incidence of PDs because patients typically present for psychiatric care related to a variety of other conditions that typically accompany PDs, including eating disorders, schizophrenia, bipolar disorders, anxiety disorders, obsessive-compulsive disorder, dissociative disorders, major depressive disorder, substance abuse, or alcoholism. Many patients with PDs are undiagnosed because they have never sought psychiatric treatment.^1,2

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Within a psychiatric sample, 50% of outpatients and 75% of inpatients met criteria for diagnosis of at least one PD. As many as 30% of patients met the criteria for multiple PDs.³ In a primary care setting, one-third of patients met criteria for the diagnosis of a PD²; however, only 9% of adult Americans have been formally diagnosed with a PD. The most frequently diagnosed PDs are borderline and antisocial.¹ Even when diagnosed with a PD, many patients aren’t willing to list the diagnosis on their medical history forms.⁴

Schemas and personality disorders

It is well established in psychiatric and psychologic literature that early maladaptive schemas (EMS) in childhood contribute to the development of PDs in adulthood.³ PDs are grouped into Clusters A, B, and C based on similarities in behavior among those conditions.⁵ Cluster A PDs develop from mistrust and social isolation EMS. Cluster B PDs develop from abandonment, emotional inhibition, entitlement, social isolation, and vulnerability to harm EMS.³ Cluster C PDs develop from EMS including abandonment, embarrassment/shame, dependence, failure, self-sacrifice, and subjugation. Unrelenting standards of EMS are highly correlated with development of obsessive-compulsive personality disorder, which is different from obsessive-compulsive disorder.³ Self-sacrifice and subjugation EMS together are linked to development of avoidant or dependent PD.^3,4

Cluster A PDs are characterized by odd or eccentric behaviors that include paranoid, schizoid, and schizotypal disorders. Cluster B PDs are characterized by dramatic, emotional, and erratic behaviors, including antisocial, borderline, histrionic, and narcissistic disorders. Cluster C PDs are characterized by anxious and fearful behaviors, including avoidant, dependent, and obsessive-compulsive PDs.^3,5

Descriptions and examples of personality disorders^1,4-6

Cluster A

Paranoid:

Constant suspicions of the motives of others
Belief that others are trying to harm or deceive them

Examples:

Patient is suspicious of the need for treatment
Patient is convinced the dental provider is only taking their money

Schizoid:

Detachment from social relationships with lack of emotions
General disinterest in building relationships and are nonreactive to praise or criticism

Examples:

Patient is disinterested and disconnected during conversation
Patient is not fazed by the report of improved or worsened oral hygiene performance

Schizotypal:

Obvious discomfort with interpersonal interactions
Distorted views of reality and odd behavior/speech in social situations

Examples:

Patient is always irritable and anxious
Patient is extremely difficult to engage in conversation
Patient has dfficulty answering questions or making eye contact

Cluster B

Antisocial:

Disregard for and violation of the rights of others
Refusal to take responsibility for actions
Frequent lies and deceit of others without emotion for the feelings of others

Examples:

Patient believes that office polices do not apply to them
Patient has no conscience or regard for the safety of others
Patient blames the office staff for missed appointments
Patient may behave angrily or inappropriately with office staff, and when confronted about the behavior will blame their actions on the staff

Borderline:

Instability in moods and relationships ranging from complete dependence to intense anger
Impulsive behaviors and drastic mood swings

Examples:

Patient has drastic mood swings where they are overly appreciative one minute and threatening to sue the next
Patient has mood swings that are situationally dependent and views everything as “your fault”
Patient always raves about the practice on social media until their account is sent to collections for nonpayment; then they trash the office on social media and send threatening emails to the office.

Histrionic:

Extreme emotions and attention-seeking behaviors
Self-esteem and self-worth are directly related to the approval of and attention received from others

Examples:

Patient views the need to improve their home care as a personal attack on their self-worth
Patient is overly and unreasonably emotional and may burst into tears when told they have a cavity
Patient has frequent emotional outbursts that are not quickly resolved
Patient may injure themselves or make appointments just to be seen and gain attention from staff
Patient may request appointments when the office is closed
Patient reports that multiple professionals have attempted restorative work, yet they are still not satisfied with the outcome

Narcissistic:

Grandiose sense of self-importance and lack of empathy for others
Sense of entitlement, taking advantage of others
Need for constant praise and admiration from others

Examples:

Patient feels they do not need to abide by dental office policies
Patient demands special treatment, wants appointments when the office is closed
Patient is overly demanding in their treatment expectations
Patient uses all-or-nothing thinking
Patient frequently changes dental practices because their needs aren’t being met

Cluster C

Avoidant:

Preoccupation with criticism, rejections, and self-inadequacy
Hypersensitivity and extreme emotions related to receiving feedback

Examples:

Patient becomes overly emotional and may cry when told they need to improve home care or that they have caries or inflammation
Patient interprets “you need to improve your home care” as a personal attack on their self-worth

Dependent:

Inability or unwillingness to care for oneself or make decisions
Passive, clinging behavior and great effort exerted to please others
Cannot make decisions without constant reassurance

Examples:

Patient cannot remember to perform oral hygiene daily without being reminded
Patient takes great effort to let you know they’ve been working to improve their oral hygiene and begs for compliments about the improvement
Patient is unable to make decisions about accepting treatment

Obsessive-compulsive:

This is not to be confused with obsessive-compulsive disorder (OCD), which is classified as an anxiety disorder. People with OCD are aware of how their behaviors disrupt their function and need to change. People with OCPD have minimal or no self-awareness that their behaviors are destructive and not within social norms.

Preoccupation with orderliness, perfection, or control
Inflexibility with minor details that interfere with daily activities or relationships

Examples:

Patient is obsessed with something that’s typically harmless and then acts on a compulsion to avoid the object of the obsession. This compulsion is destructive and disruptive to their daily function.
Patient is preoccupied with minor cosmetic aspects of their mouth; multiple dentists have attempted improvements, yet the patient is never satisfied. Patient makes cosmetic requests that are not possible even with the best skills and technology.
Patient is obsessed with oral bacteria, and their compulsion is to scrub brush their teeth with a denture brush, or they use Ajax to brush their teeth or rinse with bleach. They may do this 30 times a day even though it’s damaging their oral cavity.

Treatment for personality disorders

Various psychological and psychiatric methods have been employed to treat PDs. Schema therapy has shown the most success for the management of personality disorders and helping patients improve their interpersonal interactions and relationships. Cognitive behavioral therapy and exposure-based therapy are also employed to assist the patient in managing their behaviors and emotions, especially in cases of obsessive-compulsive personality disorder. The greatest treatment success for patients with PDs is to combine therapy with long-term use of SSRIs to increase and maintain serotonin levels.^4,5

Red flags in patient behaviors

Be aware of these red flags from a patient's medical history:

If a patient reports that multiple other professionals have already attempted improvements (e.g., cosmetic improvements) and yet the patient is not still satisfied with the structurally sound results, this is a red flag that the patient will never be satisfied with any attempts at improvement.
If a patient reports that they frequently change dental practices due to dissatisfaction or conflicts with the professional staff, this is a red flag that the patient will also be dissatisfied with your practice and conflicted with its policies.
If a patient refuses to allow your practice permission to contact prior dental offices or medical providers to obtain patient records or consultations, this is a red flag that they were dismissed from the other practices (either dental or medical) due to their maladaptive behaviors.

When you encounter patients exhibiting these behaviors, consider referring them to another facility that may better suit their needs. It is highly unlikely that treatment from you and your practice will finally satisfy these patients or meet their expectations. When you attempt to meet the patient’s needs but the patient is disappointed, the situation can rapidly progress to violence.⁴

Patients who demand special treatment or refuse to abide by office or organizational policies should be referred to another facility for treatment, as their demands and disrespect toward your staff will escalate. Patients who yell or curse at staff members, display inappropriate behaviors, cannot control their emotions, or make threats against a staff member or the practice should be dismissed from the practice. Contact law enforcement if the patient makes a verbal or physically assault on a staff member or threatens harm or violence.⁴

When patients do not behave appropriately in a professional dental office, dismiss them and recommend that they seek dental care with another health-care provider. Dismissing patients may result in minimal loss of revenue, but it pays dividends in avoiding escalating aggression that can lead to violence and endanger your staff.^4,7

Also by the author … Elder abuse and mistreatment: How should dental professionals respond?

Editor’s note: This article first appeared in Through the Loupes newsletter, a publication of the Endeavor Business Media Dental Group. Read more articles and subscribe to Through the Loupes.

References

Drescher J. What are personality disorders? American Psychiatric Association. September 2022. https://www.psychiatry.org/patients_families/personality-disorders/what-are-personality-disorders.
Davison SE. Principles of managing patients with personality disorders. Adv Psychiatr Treat. 2022;8(1):1-9. doi:10.1192/apt.8.1.1
Steylarts B, Dierckx E, Schotte C. Relationships between DSM-5 Personality disorders and early maladaptive schemas from the perspective of dimensional and categorical comorbidity. Cognit Ther Res. 2023;47:454-468. doi:10.1007/s10608-023-10349-w
Shannon JW. Reasoning with unreasonable people: focus on disorders of emotional regulation. Presentation and lecture notes. Institute for Brain Potential, San Francisco, CA. June 18, 2022. https://www.ibpceu.com/content/pdf/reasoning-f14-outline.pdf
Maass VS. Personality Disorders: Elements, History, Examples, and Research. Praeger; 2019. ABC-CLIO.
Eddy W. Five Types of People Who Can Ruin Your Life. Janis Publications; 2018.
Quaranta P. Dental treatment on patients with mental disorders. Presentation and lecture notes. Dent-Ed Solutions, Clifton, NJ. October 20, 2023.

Kimberly A. Erdman, MSDH, RDH, FAADH, FADHA. is a practicing dental hygienist and public health dental hygiene practitioner. She was a civilian-dental hygienist for the U.S. Navy and spent nine years as a forensic dental technician. She has a decade of experience in higher education and administration. Kimberly has been awarded a fellowship with the American Academy of Dental Hygiene and the American Dental Hygienists’ Association.

Challenging patient behaviors: Patient red flags and personality disorders

Schemas and personality disorders