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==Overview== | ==Overview== | ||
There are no specific physical [[signs]] associated with [[personality disorders]]. The [[Physical Examination|physical]] exam is essential to rule out [[organic disorders]] and [[substance use disorders]]. [[Depression and anxiety]] need to be ruled out by conducting their assessment tools. Patients with [[borderline personality disorders]] have an increased risk of [[suicide]], and they may have self-inflicted wounds on the body or signs of attempted [[Suicide attempt|suicide attempts]]. A complete [[mental status examination]] needs to be conducted. The first is to examine appearance and [[behavior]]. [[Borderline personality disorder]] patients may exhibit [[defensive]] behavior. Those with a [[paranoid personality disorder]] will fail to maintain eye contact. The second is mood and affect; [[borderline personality disorder]] may reveal fleeting mood and emotional states with different questions or scenarios. This is also vital to assess suicide risk in the patient. [[Antisocial personality disorders]] may be homicidal and display a hostile attitude. [[Cognitive]] functions like attention, memory, orientation, language, and intelligence are normal. [[Mini-mental state examination]] (MMSE) can be conducted for this. [[Histrionic]] PD may manifest a [[‘la belle indifference,’]] meaning showing an apparent lack of concern regarding their own symptoms. [[Perception]] is normal though. Moreover, the thought process is usually unremarkable. It is imperative in [[paranoid personality disorder]] to ascertain that no thoughts of harm to others are present. However, [[insight and judgment]] may be affected depending on different scenarios in patients with variable personality disorders. | |||
The | |||
==Physical Examination== | ==Physical Examination== | ||
There are no specific physical signs associated with personality disorders. However, the [[physical exam]] is essential to rule out [[organic disorders]] and [[substance use disorders]]. [[Depression and anxiety]] need to be ruled out by conducting their assessment tools. | |||
===Appearance of the Patient=== | ===Appearance of the Patient=== | ||
*Patients with PD usually appear normal. Patients with [[borderline personality disorders]] have an increased risk of [[suicide]], and they may have self-inflicted [[wounds]] on the body or signs of attempted [[Suicide attempt|suicide]] attempts. Moreover, complications of PDs may reveal certain findings. | |||
* | |||
=== | ===Physical Examination=== | ||
Each person with suspected PD must undergo a general [[physical examination]]. The emphasis is required on the following findings: | |||
*General appearance- checking the [[appearance]] (body habitus, [[age]], any syndromic feature, visible tattoos), [[height]], [[weight]], clothing and any abnormal movements | |||
* | *Oral and peripheral hygiene-level of grooming and presence of [[halitosis]] or body odor. | ||
*Eye contact and general attitude | |||
*[[Posture]]-open, closed, tensed or relaxed | |||
*Skin [[Examination]] including [[scar]] marks for self-inflicted [[wounds]] | |||
* | |||
* | |||
* | |||
* | |||
=== | ===Mental Status Examination=== | ||
The complete [[mental status examination]] is a requisite, when a patients presents with [[Symptoms and Signs|symptoms and signs]] suggestive for a PD. It describes the [[psychological]] condition and physical behaviours in a qualitative and quantitative manner and is a vital tool to differentiate between a number of [[Psychiatric Disorders|psychiatric]] and [[Neurological disorders|neurological]] conditions. It incorporates both general observations and specific [[clinical]] test to ascertain the cause. The general observations start with the first step of entry into the office. It comprises of following parts: | |||
#[[Appearance]] and [[Behaviour]]- It involves examining body habitus, attire, and [[interpersonal]] style and briefly describes the living conditions and [[mental]] well-being of a person.[[Borderline personality disorder]] patients may exhibit [[defensive]] behavior or emotional outbursts. Those with a [[paranoid personality disorder]] will fail to maintain eye contact. [[Schizoid]] and [[Schizotypal]] PD patients are represented by their eccentric or hostile [[behaviour]] and restricted expressions. [[Antisocial]] PD will have provocative and impulsive behaviour. [[Dependent]] PD usually show up with someone and frequently look at them for answers. [[Obsessive-Compulsive]] PD performs repetitive movements to remove obscured stuff from clothings and clean the place around them or continuously checking to ensure things in the bag. [[Histrionic]] PD patients present to the doctor office wearing an inappropriate and unbefitting seductive dress with tons of make up on face. [[Dishevelled]] appearance, fleeting [[eye contact]], [[apathy]] and [[catatonia]] may represent co-existing [[Depression (clinical)|depression]]. Abnormal [[gait]], evasive behaviour, unkempt appearance, repetitive purposeless movements or [[akathisia]] and [[bradykinesia]] or irritability may indicate the underlying substance abuse or medication affects. | |||
#[[Cognitive Functioning]]-It includes [[attention]], orientation, [[language]], [[memory]] and [[Intelligence (trait)|intelligence]]. [[Attention]] assess the ability to focus on words usually tested by asking a patient to spell a letter backwards. [[Orientation]] of a person is checked in terms of his time, place and person by asking specific questions in regards to it. [[Language]] tests the structured [[Verbal behavior|verbal]] and written communication in terms of appropriateness of speech, grammar, rate of speech (normal= >100 words/minute),and syntax skills according to literacy level. [[Short-term Memory]] defects are assessed through recent and remote events. [[Long-term memory]] constitutes declarative and procedural memories. [[Declarative]] or [[explicit]] memories are checked by recalling and retrieving important events in one's life. The [[hippocampus]] is responsible for it. [[Procedural]] or [[implicit]] memory is formulated by reinforcement and studies the performance of a person based on a learned experience. They are stored in [[basal ganglia]] and [[cerebellum]]. [[Executive functioning]] is a set of higher-level mental skills essential for self-control and pursuing goals and includes working memory, [[inhibitory]] control, and [[cognitive]] flexibility. It is checked by specific commands to patients like alternate letters and numbers or [[clock-drawing test]]. [[Cognitive]] functions in PDs are normal and are useful in patients with [[delirium]], [[dementia]] and substance abuse. | |||
#[[Mood (psychology)|Mood]] and [[Affect]]-Mood is the subjective report of a person's emotional condition. It is assessed by directly inquiring from the patient. Patient may be [[euphoric]] or [[dysphoric]] depending on co-existing [[bipolar]] or [[depression]] conditions. [[Apathy]] is seen in [[Alzeihmer's disease]] and [[anhedonia]] in [[schizophrenia]]. [[Mood disturbances]] are rarely presented by patients of PD. Affect is the objective assessment of apparent emotional state of patients as projected by hidden behavioural cues. [[Narcissitc]] PD may exhibit overly-dramatic or [[exaggerated]] affect. BPD may illustrate a [[labile]] affect throughout the clinical interview. [[Histrionic]] PD may manifest a [[‘la belle indifference,’]] meaning showing an apparent lack of concern regarding their own symptoms. A [[flat]] or [[blunt]] affect is seen if patient is suffering from underlying [[Depression (clinical)|depression]]. | |||
#[[Speech]]-It is the spontaneous [[articulation]] of words from lips. The rate, volume, quantity, [[fluency]] and latency are checked. [[Mutism]] is hallmark for [[schizophrenia]] and severe [[depression]] while [[pressured speech]] is seen in [[mania]]. [[Dysarthria]], [[echolalia]], [[palilalia]] or [[alogia]] are present in [[neurological]] deficit and substance use disorders. The abnormalities in speech are not exclusively seen in PDs. | |||
#[[Thought]] Process and content-[[Thought process]] is the organisation and coherence of thoughts inferred from patient encounter. Disorganization of thoughts includes thought blocking, thoughts fusion, or swaying away from the topic of discussion. [[Circumferential process]] is incorporating irrelevant ideas before arriving to the topic and includes flight of ideas. [[Tangential thinking]] is observed when patient relate relevant topics with inability to answer the asked question. These disturbances are seen in [[mania]], [[schizophrenia]] and [[dementia]]. [[Circumstantial thought disturbance]] may be seen with certain PDs. Thought content is crucial to evaluate for [[suicidal]] or [[Homicidal ideation|homicidal]] thoughts, [[delusions]], [[Auditory hallucinations|auditory]], [[visual]] or [[tactile]] [[hallucinations]] also called [[perception]], obsessions, and [[phobias]]. Determining [[suicidality]] is important in BPD and homicidality in cluster-A PDs. [[Perception]] is normaL. | |||
#[[Insight]] and [[Judegement]]-Insight is the person's understanding about the medical condition and assessed by the explanation and recognition of illness or treatment compliance shown by the patient. [[Anosognosia]] is found in patients with PDs who have concomitant [[substance abuse disorder]]. Judgement refers to problem-solving ability or decision-making capacity of an individual which is estimated by presenting a query and taking into account the response to it. Judgement usually remains unaffected in PDs as it represent higher cortical functioning. However, [[insight and judgment]] may be affected depending on different scenarios in patients with variable [[personality disorders]]. | |||
==References== | ==References== | ||
Latest revision as of 06:51, 7 August 2021
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Personality disorder Microchapters |
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Case Studies |
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Personality disorder physical examination On the Web |
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American Roentgen Ray Society Images of Personality disorder physical examination |
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Risk calculators and risk factors for Personality disorder physical examination |
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Ayesha Anwar, M.B.B.S[2]
Overview
There are no specific physical signs associated with personality disorders. The physical exam is essential to rule out organic disorders and substance use disorders. Depression and anxiety need to be ruled out by conducting their assessment tools. Patients with borderline personality disorders have an increased risk of suicide, and they may have self-inflicted wounds on the body or signs of attempted suicide attempts. A complete mental status examination needs to be conducted. The first is to examine appearance and behavior. Borderline personality disorder patients may exhibit defensive behavior. Those with a paranoid personality disorder will fail to maintain eye contact. The second is mood and affect; borderline personality disorder may reveal fleeting mood and emotional states with different questions or scenarios. This is also vital to assess suicide risk in the patient. Antisocial personality disorders may be homicidal and display a hostile attitude. Cognitive functions like attention, memory, orientation, language, and intelligence are normal. Mini-mental state examination (MMSE) can be conducted for this. Histrionic PD may manifest a ‘la belle indifference,’ meaning showing an apparent lack of concern regarding their own symptoms. Perception is normal though. Moreover, the thought process is usually unremarkable. It is imperative in paranoid personality disorder to ascertain that no thoughts of harm to others are present. However, insight and judgment may be affected depending on different scenarios in patients with variable personality disorders.
Physical Examination
There are no specific physical signs associated with personality disorders. However, the physical exam is essential to rule out organic disorders and substance use disorders. Depression and anxiety need to be ruled out by conducting their assessment tools.
Appearance of the Patient
- Patients with PD usually appear normal. Patients with borderline personality disorders have an increased risk of suicide, and they may have self-inflicted wounds on the body or signs of attempted suicide attempts. Moreover, complications of PDs may reveal certain findings.
Physical Examination
Each person with suspected PD must undergo a general physical examination. The emphasis is required on the following findings:
- General appearance- checking the appearance (body habitus, age, any syndromic feature, visible tattoos), height, weight, clothing and any abnormal movements
- Oral and peripheral hygiene-level of grooming and presence of halitosis or body odor.
- Eye contact and general attitude
- Posture-open, closed, tensed or relaxed
- Skin Examination including scar marks for self-inflicted wounds
Mental Status Examination
The complete mental status examination is a requisite, when a patients presents with symptoms and signs suggestive for a PD. It describes the psychological condition and physical behaviours in a qualitative and quantitative manner and is a vital tool to differentiate between a number of psychiatric and neurological conditions. It incorporates both general observations and specific clinical test to ascertain the cause. The general observations start with the first step of entry into the office. It comprises of following parts:
- Appearance and Behaviour- It involves examining body habitus, attire, and interpersonal style and briefly describes the living conditions and mental well-being of a person.Borderline personality disorder patients may exhibit defensive behavior or emotional outbursts. Those with a paranoid personality disorder will fail to maintain eye contact. Schizoid and Schizotypal PD patients are represented by their eccentric or hostile behaviour and restricted expressions. Antisocial PD will have provocative and impulsive behaviour. Dependent PD usually show up with someone and frequently look at them for answers. Obsessive-Compulsive PD performs repetitive movements to remove obscured stuff from clothings and clean the place around them or continuously checking to ensure things in the bag. Histrionic PD patients present to the doctor office wearing an inappropriate and unbefitting seductive dress with tons of make up on face. Dishevelled appearance, fleeting eye contact, apathy and catatonia may represent co-existing depression. Abnormal gait, evasive behaviour, unkempt appearance, repetitive purposeless movements or akathisia and bradykinesia or irritability may indicate the underlying substance abuse or medication affects.
- Cognitive Functioning-It includes attention, orientation, language, memory and intelligence. Attention assess the ability to focus on words usually tested by asking a patient to spell a letter backwards. Orientation of a person is checked in terms of his time, place and person by asking specific questions in regards to it. Language tests the structured verbal and written communication in terms of appropriateness of speech, grammar, rate of speech (normal= >100 words/minute),and syntax skills according to literacy level. Short-term Memory defects are assessed through recent and remote events. Long-term memory constitutes declarative and procedural memories. Declarative or explicit memories are checked by recalling and retrieving important events in one's life. The hippocampus is responsible for it. Procedural or implicit memory is formulated by reinforcement and studies the performance of a person based on a learned experience. They are stored in basal ganglia and cerebellum. Executive functioning is a set of higher-level mental skills essential for self-control and pursuing goals and includes working memory, inhibitory control, and cognitive flexibility. It is checked by specific commands to patients like alternate letters and numbers or clock-drawing test. Cognitive functions in PDs are normal and are useful in patients with delirium, dementia and substance abuse.
- Mood and Affect-Mood is the subjective report of a person's emotional condition. It is assessed by directly inquiring from the patient. Patient may be euphoric or dysphoric depending on co-existing bipolar or depression conditions. Apathy is seen in Alzeihmer's disease and anhedonia in schizophrenia. Mood disturbances are rarely presented by patients of PD. Affect is the objective assessment of apparent emotional state of patients as projected by hidden behavioural cues. Narcissitc PD may exhibit overly-dramatic or exaggerated affect. BPD may illustrate a labile affect throughout the clinical interview. Histrionic PD may manifest a ‘la belle indifference,’ meaning showing an apparent lack of concern regarding their own symptoms. A flat or blunt affect is seen if patient is suffering from underlying depression.
- Speech-It is the spontaneous articulation of words from lips. The rate, volume, quantity, fluency and latency are checked. Mutism is hallmark for schizophrenia and severe depression while pressured speech is seen in mania. Dysarthria, echolalia, palilalia or alogia are present in neurological deficit and substance use disorders. The abnormalities in speech are not exclusively seen in PDs.
- Thought Process and content-Thought process is the organisation and coherence of thoughts inferred from patient encounter. Disorganization of thoughts includes thought blocking, thoughts fusion, or swaying away from the topic of discussion. Circumferential process is incorporating irrelevant ideas before arriving to the topic and includes flight of ideas. Tangential thinking is observed when patient relate relevant topics with inability to answer the asked question. These disturbances are seen in mania, schizophrenia and dementia. Circumstantial thought disturbance may be seen with certain PDs. Thought content is crucial to evaluate for suicidal or homicidal thoughts, delusions, auditory, visual or tactile hallucinations also called perception, obsessions, and phobias. Determining suicidality is important in BPD and homicidality in cluster-A PDs. Perception is normaL.
- Insight and Judegement-Insight is the person's understanding about the medical condition and assessed by the explanation and recognition of illness or treatment compliance shown by the patient. Anosognosia is found in patients with PDs who have concomitant substance abuse disorder. Judgement refers to problem-solving ability or decision-making capacity of an individual which is estimated by presenting a query and taking into account the response to it. Judgement usually remains unaffected in PDs as it represent higher cortical functioning. However, insight and judgment may be affected depending on different scenarios in patients with variable personality disorders.