Personality disorder physical examination
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Ayesha Anwar, M.B.B.S[2]
Overview
Patients with [disease name] usually appear [general appearance]. Physical examination of patients with [disease name] is usually remarkable for [finding 1], [finding 2], and [finding 3].
OR
Common physical examination findings of [disease name] include [finding 1], [finding 2], and [finding 3].
OR
The presence of [finding(s)] on physical examination is diagnostic of [disease name].
OR
The presence of [finding(s)] on physical examination is highly suggestive of [disease name].
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.