eMedicine Specialties > Psychiatry > Adult

Personality Disorders: Follow-up

Author: David Bienenfeld, MD, Vice-Chair, Program Director, Professor, Department of Psychiatry, Wright State University School of Medicine
Contributor Information and Disclosures

Updated: Jul 17, 2008

Follow-up

Further Inpatient Care

• Criteria for hospitalization of patients with personality disorders are generally the same as for patients with Axis I psychiatric disorders: imminent danger to self or others, inability to care for basic needs, or psychosocial stressors overwhelming the patient's capacity to cope.
• Because the underlying disorder remains basically unchanged by inpatient interventions, length of stay should be minimized to avoid dependency that subverts recovery from the circumstances prompting the hospitalization.
• Short stays may be used to stabilize environmental factors, adjust medication regimen, and/or implement short-term psychotherapeutic intervention.

Further Outpatient Care

• All patients hospitalized for manifestations of personality disorders should be referred for follow-up psychotherapy or counseling.
• See Medical Care.

Inpatient & Outpatient Medications

• See Medication.

Transfer

• Patients observed in the emergency department or admitted to a medical-surgical unit of a hospital without a psychiatric service may require transfer to a hospital that provides such service. Psychiatric consultation can provide guidance about whether the patient would benefit from such transfer.
• Some patients hospitalized in the psychiatric units of general hospitals, where stays are generally shorter than 2 weeks, may require transfer to psychiatric hospitals that can provide long-term care. Such cases are unusual and are limited to those patients with personality disorders whose coping capacities are so grossly impaired that they cannot maintain adequate function in the community or in a less restrictive environment.

Deterrence/Prevention

• Within the limits of contemporary medical knowledge, personality disorders cannot be prevented, although steps can be taken to prevent or deter some of the consequences and complications of personality disorders.
  • Frequent inquiries about suicidal ideation are warranted, regardless of whether the patient spontaneously raises the subject. The physician need not fear instilling the idea of suicide in a patient who is not already entertaining it. Subsequent inquiry about firearms, lethal medications, and other available means of suicide point to avenues of preventive behavior.¹⁴
  • Benzodiazepines, narcotic analgesics, and other drugs with potential for dependency should be used rarely and with great caution. Nearly all personality disorders are marked by impaired impulse control and consequent risk of addictive behavior.
  • Patients with personality disorder who have children should be asked frequently and in detail about their parenting practices. Their low frustration tolerance, externalization of blame for psychological distress, and impaired impulse control put the children of these patients at risk for neglect or abuse.

Complications

• Suicide¹⁴
• Substance abuse
• Accidental injury
• Depression
• Homicide - A potential complication, particularly in paranoid and antisocial personality disorders

Prognosis

• Personality disorders are lifelong conditions.
• Attributes of cluster A and B personality disorders tend to become less severe and intense in middle age and late life.
• Patients with cluster B personality disorders are particularly susceptible to problems of substance abuse, impulse control, and suicidal behavior, which may shorten their lives.
• Cluster C characteristics tend to become exaggerated in later life.

Patient Education

• See Medical Care.
• Patients should be advised that their patterns of perception and response are the results of some combination of inheritance and personal history, and that recovery is therefore likely to be a prolonged process, requiring effort and attention. The relevance of ongoing psychotherapy to long-standing vulnerabilities requires frequent reemphasis by the physician.
• Alcoholism and drug abuse are not merely complications of personality disorders, they are also aggravating factors. Patients need constant reminding that yielding to the temptation to drink or use drugs is likely to make their emotional distress worse and is certain to increase the risk of complications, including suicide.
• With the patient's permission, education to the family can alert them to the possibilities of disruptive and destructive behavior, and can provide guidelines for limit-setting and safety.

Miscellaneous

Medicolegal Pitfalls

• The poor impulse control of these patients, particularly those with cluster B disorders, places some degree of legal responsibility on the physician. If a patient threatens someone else with injury, the physician may have a duty to warn the intended victim, either directly or through legal authorities, under the Tarasoff ruling.
• Caregivers should be vigilant about suicidal potential and should document their assessments in the medical record at each visit.
• If patients without true psychotic conditions are treated with antipsychotic agents, the physician may be liable for serious neurologic effects such as tardive dyskinesia and neuroleptic malignant syndrome. The physician should carefully document the indication for the use of such agents, and these agents should be discontinued as soon as possible.
• It can be difficult to accurately diagnose an Axis II disorder in the context of acute and severe Axis I symptoms unless the clinician is very familiar with the patient's long-term history. For example, signs and symptoms of individuals with major depression, mania, panic attacks, obsessive-compulsive disorder, or substance abuse may resolve with successful treatment. Examples may include dependent or avoidant features in major depression or obsessive-compulsive disorder, antisocial behaviors in substance abuse, or histrionic or narcissistic features in mania.

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