This is very long but well worth the read (to me anyway). Although it’s about the mental health professionals, it could certainly be applied to any physician. Know anyone who fits this bill?

This article received a Thinking Blogger Award!

 This is my proposal for the DSM inclusion of a new section that outlines and categorizes the features of Mental Health Professional Personality Disorders or MHPPDs.

This proposal begins with a general definition of Mental Health Professional Personality Disorder that applies to each of the 4 specific MHPPDs. An MHPPD is an enduring pattern of inability to empathize with or understand the inner experience and behavior of certain patient populations that deviate markedly from the MHP’s own expectations, individual culture, life experience, values, and personal lifestyle preferences. MHPPD is pervasive, inflexible, prejudicial and has an onset upon reading educational psychiatric literature, engaging in disparaging prejudicial discussion with “more experienced” colleagues, may be triggered by reading a chart with which includes a previous undesirable diagnosis for a patient, is stable over time, and leads to further distress or impairment in the condition of the MHP’s patient. The Mental Health Professional Personality Disorders included in this proposal are listed below.

Mental Health Professional Paranoid Personality Disorder is a pattern of distrust and suspiciousness such that patients’ motives are interpreted as malevolent or manipulative.

Mental Health Professional Antisocial Personality Disorder is a pattern of disregard for and violation of the rights of patients.

Mental Health Professional Narcissistic Personality Disorder is a pattern of grandiosity, need for the compliance of one’s patients, and a lack of empathy for the experience or suffering of those patients.

Mental Health Professional Coercive Personality Disorder is a pattern of dominant and aggressive authoritarian behavior related to an excessive need to be in control of patient treatment decisions.

Mental Health Professional Personality Disorder Not Otherwise Specified is a category provided for two situations: 1) the MHP’s personality pattern meets the general criteria for an MHPPD and the traits of several different MHPPDs are present, but the criteria for any specific MHPPD are not met; or 2) the MHP’s personality pattern meets the general criteria for an MHPPD that is not included in the Classification (e.g., mental health professional passive-aggressive personality disorder). It should be noted that MHPs frequently present with co-occurring personality disorders.

Diagnostic Features
MHP personality traits are enduring patterns of perceiving, relating to and thinking about patient symptoms and behaviors and the subsequent diagnostic impressions that are formed within a wide range of clinical and personal contexts. Only when these traits are inflexible and maladaptive and cause significant functional impairment in the MHP’s ability to help patients or constitute subjective distress in the MHP and/or the patient do they constitute mental health professional personality disorders.

The diagnosis of MHPPD requires an evaluation of the MHP’s long-term patterns of professional functioning, and may manifest themselves early in the MHP’s professional practice. The personality traits that define these disorders must also be distinguished from characteristics that emerge in response to specific situational stressors or more transient mental states (e.g., Substance Intoxication). Although a single interview with an MHP is sometimes sufficient for making a diagnosis, it is often necessary to be treated by them on more than one occasion and to space these visits over time. Receiving appropriate treatment can also be complicated by the fact that the characteristics that define MHPPD may not be considered problematic by the MHP (i.e., the traits are often ego-syntonic). To help overcome this difficulty, supplementary information from other patients may be helpful.

301.0 MHP Paranoid Personality Disorder

Diagnostic Features The essential feature of MHPPPD is a pattern of pervasive distrust and suspiciousness of patients such that their motives are interpreted as malevolent or manipulative. This pattern may begin early in the education or professional career and is present in a variety of contexts.

MHPs with this disorder assume that patients will exploit, harm, manipulate, or deceive them, even if no evidence exists to support this expectation (Criterion 1). MHPs with this disorder are reluctant to confide in or explain a diagnosis given to their patient, because they fear that the information may be used against them or worsen the patient’s condition (Criterion 2). They may refuse to answer patient questions about the diagnosis they have given, saying that information may be “detrimental to the patient’s condition”. They read hidden meanings that are threatening into benign remarks or events (Criterion 3). For example: An MHP with this disorder may interpret the late arrival to an appointment by a patient as evidence of resistance to treatment or may view a casual humorous remark by a patient as a serious character attack. Patient compliments are often misinterpreted (e.g., an expression of gratitude for help with a particular issue that has gone unaddressed or unresolved with another MHP that is involved in the patient’s treatment may be interpreted as a manipulative attempt at “splitting”). MHPs may view any patient questions in regards to treatment approach or efficacy as criticism of their clinical skills and adequacy as a professional. This too may be interpreted in terms of resistance to treatment or an inability on the part of the patient to benefit from treatment. MHPs with this disorder persistently bear grudges and are unwilling to forgive the insults, injuries, or slights that they think they have received from patients (Criterion 4). Minor slights arouse major hostility, and the hostile feelings persist for a long time, usually resulting in a diagnosis of borderline or antisocial for the patient. They are constantly vigilant to the harmful intentions of patients. They are quick to counterattack and react with anger to perceived insults (Criterion 5). MHPs with this disorder are pathologically suspicious often believing that their patient is being manipulative without any adequate justification (Criterion 6). They may gather trivial and circumstantial “evidence” to support their suspicious beliefs. They want to maintain complete control of the patient relationship to avoid being manipulated by the suspect patient, whom the MHP believes will attempt to overstep appropriate boundaries if given a chance, and they may constantly question the meaning of patient behaviors and the validity of patient concerns.

Associated Features
MHPs with MHPPPD are generally difficult to get along with and often have problems with patient relationships. Their excessive hostility may be expressed in overt argumentativeness, in recurrent complaining about a particular patient to colleagues, or by quiet apparently hostile aloofness to the patient. Because they are hyper-vigilant for potential threats, they may act in a guarded, secretive, or devious manner and appear to be “cold” and lacking in empathic feelings. Although they may appear to be objective, rational, and unemotional, they more often display a labile range of affect, with hostile, stubborn, and sarcastic expressions predominating their conversations about patients with their colleagues. Their combative and suspicious nature may elicit a hostile response in patients, which serves then to confirm their original expectations.

301.7 MHP Antisocial Personality Disorder

Diagnostic Features The essential feature of MHPAPD is a pervasive pattern of disregard for, and violation of, the rights of their patients.

Because deceit and manipulation are central features of MHPAPD, it may be especially helpful to integrate information acquired from systematic assessment along with information collected from other patients.

MHPs with this disorder disregard the wishes, rights, or feelings of their patients. They are frequently deceitful about the possible side-effects or long-term consequences of medications and use manipulative threats of hospitalization in order to gain personal profit or pleasure (e.g., to obtain money or power) (Criterion 1). They may repeatedly lie and con patients into consenting to a certain medication regimen often in an attempt to gain compensation from pharmaceutical manufacturers, as well as for arbitrary reasons such as a personal preference or interest in the use of a particular medication (Criterion 2). Decisions are made with personal prejudice, and without consideration to the consequences for patients; this may lead to a sudden change of medication, mental hygiene arrest, or involuntary commitment of the patient. MHPs with MHPAPD tend to be irritable and aggressive and may repeatedly order staff to commit acts of physical assault and restraint on the patient (including forced medication and over-medication) (Criterion 3). Aggressive acts that are required to defend oneself or someone else from actual patient threat are not considered to be evidence for this item. These MHPs also display a reckless disregard for the safety of their patients. This may be evidenced in their treatment decisions ( prescribing off-label, ignoring data in regards to long-term effects, prescribing multiple drugs with disregard for the emergence of iatrogenic symptoms). They may engage in sexual behavior with their patients or substance use that has high risk for harmful consequences to patient care due to impaired judgment and functioning. They may neglect important treatment concerns or fail to provide care for a patient in a way that puts the patient at risk.

MHPs with MHPAPD also tend to be consistently and extremely irresponsible (Criterion 4). Irresponsible professional behavior may be indicated by significant periods of patient restraint and/or seclusion despite available alternatives, or by terminating the treatment relationship with an undesirable patient without attempting to arrange transfer of care for the patient to another MHP. There may be a pattern of unavailability to patients during crisis that results in patient over-use of emergency services and more frequent hospitalizations. Financial irresponsibility is indicated by acts such as Medicaid and Medicare fraud. MHPs with MHPAPD show little remorse for the consequences of their acts (Criterion 5). They may be indifferent to or provide a superficial rationalization for, having hurt, mistreated, or caused permanent disability to a patient(e.g., “it’s hospital policy”, “it was accepted protocol”, or “she’s a borderline”). The MHPs may blame the patients for being emotionally labile or needy; they may minimize the harmful consequences of patients past abuse experiences, and further minimize the harmful consequences of their own abusive actions; or they may simply indicate complete indifference. They generally fail to compensate or make amends for their behavior. They may believe that certain patients are “attention seekers” and that one should stop at nothing to avoid being pushed around.

Associated Features
MHPs with MHPAPD frequently lack empathy and tend to be condescending, callous, cynical and contemptuous of the feeling, rights, and sufferings of their patients. They may have an arrogant and inflated self-appraisal (e.g., they feel that patients are beneath them or lack a realistic assessment of their ability to treat patients, believing they know what is best for the patient) and may be excessively opinionated, self-assured, or cocky.They may display a glib, superficial charm and can be quite voluble and verbally facile (e.g., using technical terms or jargon that might impress a patient who is unfamiliar with the topic).

301.81 MHP Narcissistic Personality Disorder

Diagnostic Features
The essential feature of MHPNPD is a pervasive pattern of grandiosity, need for the total compliance of one’s patients, and a lack of empathy for the experience or suffering of those patients.

MHPs with this disorder have a grandiose sense of self-assurance (Critertion 1). They routinely overestimate their ability to help their patients and inflate their accomplishments often appearing boastful and pretentious to their patients. They may blithely assume that patients attribute that same value to their treatment methods and may be surprised when the praise they expect and feel they deserve is not forthcoming. Often implicit in the inflated judgments of their own abilities is an underestimation (devaluation) of the contributions and efforts of patients in their treatment.

MHPs with MHPNPD believe that they are superior, special, more educated and particularly qualified in making certain observations or judgments and expect patients to recognize them as such ( Criterion 2). They may feel that they can only be understood by, and should only associate with other MHPs or people who are of high status and may attribute “intelligent”, “educated”, or “healthy” qualities to those with whom they associate. MHPs with this disorder believe that their skills are special and that their observations and insights are beyond the ken of patients. They are unable and unwilling to relate to their patients lives, feelings and personal experiences in any way. Their own self-importance is enhanced (i.e., mirrored) by the idealized value that they assign to the colleagues with whom they associate.

MHPs with this disorder generally require total patient compliance (Criterion 3). Their self-assurance is almost invariably very fragile. They are overtly sensitive to patient criticism and in need of patient approval and compliance. They are often astonished and defensive if a patient reports dissatisfaction with treatment, or expresses a personal criticism in regards to their abilities. They may constantly fish for statements of absolution of responsibility for the negative observations made by their patients in regards to treatment, quality of care, or their own personal attributes that are interfering with patient progress.

MHPs with MHPNPD generally have a lack of empathy and have difficulty recognizing the wishes, subjective experiences, and feelings of their patients (Criterion 4). They may assume that patients are totally in agreement their treatment concerns and plans.They tend to discuss their own concerns in inappropriate and lengthy detail, while failing to recognize the patient’s feelings, concerns and needs. They are often contemptuous and dismissive with a patient who attempts to outline his/her own problems and needs that are not in line with their interpretations. These MHPs may be oblivious to the hurt their remarks may inflict (e.g., telling a patient that their diagnosis has a poor prognosis, and that the patient can only expect to manage the symptoms; berating a formerly average weight patient for severe weight gain while taking taking prescribed medications- despite no increase in food intake and dismissing also the patient’s inability to get out of bed in order to exercise due to excessive sedation). When recognized, the concerns, wishes or feelings of patients are likely to be viewed disparagingly as signs that the patient lacks a willingness to engage in treatment and that the concerns are not valid or genuine. Patients who attempt treatment with MHPs who have MHPNPD typically find an emotional coldness and lack of reciprocal interest for concerns held by the patient.

These MHPs are often judgmental of patients or believe that patients are judgmental of them (Criterion5). They may begrudge a patient his/her successes or progress, feeling that the patient is still much too unstable to engage in certain social and work activities. They may harshly devalue the progress of a patient, expressing concern that the patient will decompensate while attempting to reintegrate into work and social activities, particularly if that patient expresses a desire to discontinue treatment. Arrogant, haughty behaviors characterize these MHPs . They often display disdainful or patronizing attitudes (Criterion 6). For example, an MHP with this disorder may complain about a patient’s “lack of insight” or “intelligence” or conclude a psychiatric evaluation with a condescending evaluation of the patient.

Associated Features
Vulnerability to self-assurance makes MHPs with MHPNPD very sensitive to “injury” from criticism or disapproval by patients. Although they may not show it outwardly, criticism may haunt these MHPs and may leave them feeling unprepared, inadequate, and humiliated. They may react to the patient with disdain, rage or defiant counterattack such as entering a diagnosis that will diminish the patient’s treatability in the eyes of future treating MHPs. The MHP/patient relationship is typically impaired due to problems derived from the MHPs need for total compliance and the relative disregard for the sensitivities of the patient.

301.6 MHP Coercive Personality Disorder

Diagnostic Features
The essential feature of MHPCPD is a pervasive and excessive need to control that leads to aggressive, dominant behaviors characterized by an authoritarian approach to patient treatment. The dominant and aggressive behaviors are designed to elicit submission and compliance with treatment expectations and arise from a self-perception of being the authority on what the patient needs coupled with the idea that a patient will not be able to function adequately or maintain behavioral control without the MHP’s intervention.

MHPs with MHPCPD derive great satisfaction and power from making serious, life-altering decisions for their patients (i.e., whether to involuntarily commit or whether to seek a court order for assisted outpatient treatment) without any regard for the patient’s feelings, wishes, or treatment concerns (Criterion 1). These MHPs tend to be authoritative and refuse to allow patients to take the initiative and assume responsibility for their own treatment decisions (Criterion 2). MHPs with this disorder typically may decide whether a patient should live in the community or an institution and whether the patient is capable of working or attending school. The need to decide these things for others overrides patient requests for autonomy and personal choice in such important life matters.

Because they enjoy and feel entitled to be aggressive and domineering, MHPs with MHPCPD often have difficulty hearing, accepting and approving the wishes or needs of patients to have a say in their treatment decisions. They frequently express disagreement with patients they deem to be incompetent (Criterion 3). These MHPs are so unwilling to allow patients to make their own treatment decisions that they will use hospitalization or A.O.T. if the mere threat of such actions does not coerce the patient into complying with the MHP’s decisions. They will become inappropriately angry with patients who refuse to comply with their orders or who raise concerns about the type of treatment that is deemed necessary by the MHP(e.g., ignoring or dismissing a patient’s realistic concerns about long-term use of a medication, or permanent brain damage that may be caused by ECT).

MHPs with this disorder have difficulty working with patient concerns and allowing patients to make decisions autonomously(Criterion 4). They are dominating authoritarians who believe that patients need to be forced into treatment compliance. These MHPs believe that they are the only ones capable of making appropriate treatment decisions and describe their patients as incompetent and requiring intervention and constant assistance. Because these MHPs refuse to allow patients to have a role in treatment decisions, the patients often do not learn the skills of independent living, thus perpetuating their dependency.

MHPs with MHPCPD go to excessive lengths to dominate and control patient treatment, even to the point of obtaining a court order that will force a patient to comply with a specified treatment plan and allow for involuntary commitment if the patient breaches that order. They are unwilling to accept what a patient needs or wants even if the requests are reasonable(Criterion 5). Their need to maintain control may result in imbalanced or distorted reporting of patient symptoms to provide support for seeking approval of involuntary treatment of a non-compliant patient. They expect those patients to tolerate any psychological or physical side-effects and discomfort from prescribed treatment without complaint and describe any voiced discomfort or concerns about side-effects as being exaggerated or as being a risk that is “outweighed by the benefits”(Criterion 6). Their belief that they are the only ones capable of making these decisions for a patient motivates these MHPs to force patients into treatment compliance by seeking support from colleagues and through legal channels.

Associated Features
MHPs with MHPCPD are often characterized by over-confidence and self-assurance that causes them to dismiss their patient’s feelings and concerns as exaggerated or invalid, and to constantly refer to their patient as lacking in insight and incapable of good judgment. They aggressively seek to dominate and control their patient’s choices. Patient functioning may become more impaired if forced to comply with the MHP’s prescribed course of treatment despite patient complaints of discomfort. These MHPs seek positions of responsibility and power, and become aggressive when faced with a challenge to their “expert” authority.

301.9 Mental Health Professional Personality Disorder Not Otherwise Specified

This category is for disorders of of MHP personality functioning that do not meet criteria for any specific MHP personality disorder. An example is the presence of features of more than one specific MHPPD that do not meet the full criteria for any one specific MHPPD (”mixed MH personality”), but that together causes significant distress to the patient through the MHP’s impairment in one or more areas of functioning (e.g., clinical or personal). This category can also be used when a patient judges that a specific MHPPD that is not included in the Classification is appropriate. An example of such would be Mental Health Professional Passive-Aggressive Personality Disorder. ( Speak to other patients for suggested research criteria).