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Personality Disorders Treatment & Management

  • Author: David Bienenfeld, MD; Chief Editor: Iqbal Ahmed, MBBS, FRCPsych(UK)  more...
 
Updated: Feb 15, 2016
 

Approach Considerations

Caregivers should be vigilant about suicidal potential and should document their assessments in the medical record at each visit.

Poor impulse control in patients with a personality disorder, particularly those with a cluster B disorder, 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.

Medications

Medications are in no way curative for any personality disorder. They should be viewed as an adjunct to psychotherapy so that the patient may productively engage in psychotherapy.

If patients without a true psychotic condition are treated with antipsychotic agents, serious neurologic effects, such as tardive dyskinesia or neuroleptic malignant syndrome, can result. The physician should carefully document the indication for the use of such agents, and these drugs should be discontinued as soon as possible.

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Physician-Patient Interactions

Cluster A

These patients rarely seek treatment. When treatment is sought, the physician should be respectful and honest and should provide clear explanations.

Cluster B

Antisocial personality disorder

Set behavioral limits when necessary. Portray a streetwise approach without being punitive.

Borderline personality disorder

Explain care truthfully and simply. Remove anxiety. Frequently, these patients use the defense mechanism of "splitting," describing individuals as all good or all bad. In the emergency department (ED), such patients may be expert at manipulating staffers and may divide caregivers against each other. Be especially sure to have clear communication lines among ED caregivers.

Be aware that emotional volatility in the patient may be precipitated by the news that a requested treatment or disposition is not possible or appropriate. Involve the patient in his or her evaluation by asking the patient to specify the treatment results that he or she expects or hopes to achieve.

With complaints that are hard to characterize, such as weakness, headaches, or dizziness, it may be helpful to ask the patient to keep a diary of his or her symptoms, including date, time, and precipitants. The goal is to have the patient take ownership of his or her presenting symptoms, rather than transferring the responsibility for all solutions to the health care provider.

Histrionic personality disorder

Provide emotional support to the patient but resist a close, interpersonal relationship.

Narcissistic personality disorder

The health care provider must deal with emotional transitions by the patient, from overidealizing the provider to devaluing him or her. The provider must avoid being defensive about mistakes. There has been work done suggesting that a narcissistic personality may have qualities similar to those of an antisocial personality. The main difference appears to be in the degree of grandiosity, with narcissistic patients tending to exaggerate their talents.

Cluster C

Avoidant personality disorder

Avoid criticism of the patient. Establish the physician-patient relationship.

Dependent personality disorder

Set limits with the patient concerning the care being provided.

Obsessive-compulsive personality disorder

Share control of treatment with the patient, allowing the individual to actively participate in decisions regarding his or her care. In addition, avoid being defensive and authoritarian with the patient.

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Psychotherapy

Psychotherapy is at the core of care for personality disorders. Because personality disorders produce symptoms as a result of poor or limited coping skills, psychotherapy aims to improve perceptions of and responses to social and environmental stressors.[13]

Psychodynamic psychotherapy

Psychodynamic psychotherapy examines the ways that patients perceive events, based on the assumption that perceptions are shaped by early life experiences. Psychotherapy aims to identify perceptual distortions and their historical sources and to facilitate the development of more adaptive modes of perception and response. Treatment is usually extended over the course of several years at a frequency ranging from several times a week to once a month; it makes use of transference.[14, 15]

Cognitive therapy

Cognitive therapy (also called cognitive behavior therapy [CBT]) is based on the idea that cognitive errors stemming from long-standing beliefs influence the meaning attached to interpersonal events. It deals with how people think about their world and with their perception of it. This very active form of therapy identifies the distortions and engages the patient in efforts to reformulate perceptions and behaviors. CBT is typically limited to once-weekly treatments over a period of 6-20 weeks. In the case of personality disorders, such episodes of therapy are repeated often over the course of years.[16]

Interpersonal therapy

Interpersonal therapy (IPT) is based on the idea that patients' difficulties result from a limited range of interpersonal problems, including such issues as role definition and grief. Current problems are interpreted narrowly through the screen of these formulations, and solutions are framed in interpersonal terms. Therapy is usually weekly for a period of 6-20 sessions. Though empirically validated for anxiety and depression, IPT is not widely practiced, and therapists conversant in the technique are difficult to locate.[17]

Group psychotherapy

Group psychotherapy allows interpersonal psychopathology to display itself among peer patients, whose feedback is used by the therapist to identify and correct maladaptive ideas, communication, and behavior. Sessions are usually once weekly over a course that may range from several months to years.

Dialectic behavior therapy

Dialectic behavior therapy (DBT), a skills-based therapy (developed by Marsha Linehan, PhD) that can be used in individual and group formats, has been applied to borderline personality disorder. The emphasis of this manual-based therapy is on the development of coping skills to improve affective stability and impulse control and on reducing self-harmful behavior. This treatment is also being used with other cluster B personality disorders to reduce impulsive behavior.[9]

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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.

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Transfer

Patients observed in the ED or admitted to the 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, being limited to 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.

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Consultations and Follow-up

Consultations

The primary care physician should usually consider psychiatric consultation for patients with personality disorders, because the ongoing psychiatric care that patients require is not readily provided in the primary care setting.

Follow-up

If a patient is discharged from an ED to a safe environment, follow-up with a psychiatrist in 24-48 hours should be arranged. Developing a verbal or written contract with the patient that reflects follow-up concerns and eventualities, with expectations for the patient, is frequently helpful.

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

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Deterrence and 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.[10]

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 disorders are prone to benzodiazepine abuse.

Patients with personality disorder who have children should be asked frequently and in detail about their parenting practices. Low frustration tolerance, a tendency to externalize blame for psychological distress, and impaired impulse control in patients with a personality disorder put their children at risk for neglect or abuse.

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Contributor Information and Disclosures
Author

David Bienenfeld, MD Professor, Departments of Psychiatry and Geriatric Medicine, Wright State University, Boonshoft School of Medicine

David Bienenfeld, MD is a member of the following medical societies: American Medical Association, American Psychiatric Association, Association for Academic Psychiatry

Disclosure: Nothing to disclose.

Chief Editor

Iqbal Ahmed, MBBS, FRCPsych(UK) Faculty, Department of Psychiatry, Tripler Army Medical Center; Clinical Professor of Psychiatry, Uniformed Services University of the Health Sciences; Clinical Professor of Psychiatry, Clinical Professor of Geriatric Medicine, University of Hawaii, John A Burns School of Medicine

Iqbal Ahmed, MBBS, FRCPsych(UK) is a member of the following medical societies: Academy of Psychosomatic Medicine, American Neuropsychiatric Association, American Society of Clinical Psychopharmacology, Royal College of Psychiatrists, American Association for Geriatric Psychiatry, American Psychiatric Association

Disclosure: Nothing to disclose.

Acknowledgements

Jerry Balentine, DO Professor of Emergency Medicine, New York College of Osteopathic Medicine; Executive Vice President, Chief Medical Officer, Attending Physician in Department of Emergency Medicine, St Barnabas Hospital

Jerry Balentine, DO is a member of the following medical societies: American College of Emergency Physicians, American College of Osteopathic Emergency Physicians, American College of Physician Executives, American Osteopathic Association, and New York Academy of Medicine

Disclosure: Nothing to disclose.

Michael S Beeson, MD, MBA, FACEP Professor of Emergency Medicine, Northeastern Ohio Universities College of Medicine and Pharmacy; Attending Faculty, Akron General Medical Center

Michael S Beeson, MD, MBA, FACEP is a member of the following medical societies: American College of Emergency Physicians, Council of Emergency Medicine Residency Directors, National Association of EMS Physicians, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Barry E Brenner, MD, PhD, FACEP Professor of Emergency Medicine, Professor of Internal Medicine, Program Director, Emergency Medicine, Case Medical Center, University Hospitals, Case Western Reserve University School of Medicine

Barry E Brenner, MD, PhD, FACEP is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Chest Physicians, American College of Emergency Physicians, American College of Physicians, American Heart Association, American Thoracic Society, Arkansas Medical Society, New York Academy of Medicine, New York Academy ofSciences,and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Robert Harwood, MD, MPH, FACEP, FAAEM Program Director, Department of Emergency Medicine, Advocate Christ Medical Center; Assistant Professor, Department of Emergency Medicine, University of Illinois at Chicago College of Medicine

Robert Harwood, MD, MPH, FACEP, FAAEM is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, Council of Emergency Medicine Residency Directors, Phi Beta Kappa, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Reference Salary Employment

References
  1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Washington, DC: American Psychiatric Association; 2013. 645-684.

  2. McCrae RR, John OP. An introduction to the five-factor model and its applications. J Pers. 1992 Jun. 60(2):175-215. [Medline].

  3. American Psychiatric Association. A Message From APA President Dilip Jeste M.D. on DSM-5. Psychiatric News. December 1, 2012. Available at http://www.psychnews.org/files/DSM-message.pdf. Accessed: Dec 10, 2012.

  4. Friborg O, Martinussen M, Kaiser S, Overgård KT, Rosenvinge JH. Comorbidity of personality disorders in anxiety disorders: A meta-analysis of 30 years of research. J Affect Disord. 2012 Sep 20. [Medline].

  5. Walsh Z, Shea MT, Yen S, Ansell EB, Grilo CM, McGlashan TH, et al. Socioeconomic-Status and Mental Health in a Personality Disorder Sample: The Importance of Neighborhood Factors. J Pers Disord. 2012 Sep 17. [Medline].

  6. Raine A, Lencz T, Bihrle S, LaCasse L, Colletti P. Reduced prefrontal gray matter volume and reduced autonomic activity in antisocial personality disorder. Arch Gen Psychiatry. 2000 Feb. 57(2):119-27; discussion 128-9. [Medline].

  7. Lyons-Ruth K, Holmes BM, Sasvari-Szekely M, Ronai Z, Nemoda Z, Pauls D. Serotonin transporter polymorphism and borderline or antisocial traits among low-income young adults. Psychiatr Genet. 2007 Dec. 17(6):339-43. [Medline]. [Full Text].

  8. Stein DJ. Borderline personality disorder: toward integration. CNS Spectr. 2009 Jul. 14(7):352-6. [Medline].

  9. Samuels J. Personality disorders: epidemiology and public health issues. Int Rev Psychiatry. 2011 Jun. 23 (3):223-33. [Medline].

  10. Suominen KH, Isometsä ET, Henriksson MM, Ostamo AI, Lönnqvist JK. Suicide attempts and personality disorder. Acta Psychiatr Scand. 2000 Aug. 102(2):118-25. [Medline].

  11. Shedler J, Westen D. Refining personality disorder diagnosis: integrating science and practice. Am J Psychiatry. 2004 Aug. 161(8):1350-65. [Medline]. [Full Text].

  12. Hopwood CJ, Donnellan MB, Ackerman RA, Thomas KM, Morey LC, Skodol AE. The Validity of the Personality Diagnostic Questionnaire-4 Narcissistic Personality Disorder Scale for Assessing Pathological Grandiosity. J Pers Assess. 2012 Oct 26. [Medline].

  13. Stoffers JM, Völlm BA, Rücker G, Timmer A, Huband N, Lieb K. Psychological therapies for people with borderline personality disorder. Cochrane Database Syst Rev. 2012 Aug 15. 8:CD005652. [Medline].

  14. Britton R. Narcissistic disorders in clinical practice. J Anal Psychol. 2004 Sep. 49(4):477-90; discussion 491-3. [Medline].

  15. Goodman G, Edwards K, Chung H. Interaction structures formed in the psychodynamic therapy of five patients with borderline personality disorder in crisis. Psychol Psychother. 2012 Dec 3. [Medline].

  16. Beck AT, Freeman A. Cognitive Therapy of Personality Disorders. London, England: Guilford Press; 1990.

  17. Livesley WJ. A practical approach to the treatment of patients with borderline personality disorder. Psychiatr Clin North Am. 2000 Mar. 23(1):211-32. [Medline].

  18. Kavoussi RJ, Coccaro EF. Divalproex sodium for impulsive aggressive behavior in patients with personality disorder. J Clin Psychiatry. 1998 Dec. 59(12):676-80. [Medline].

  19. Soloff PH. Psychopharmacology of borderline personality disorder. Psychiatr Clin North Am. 2000 Mar. 23(1):169-92, ix. [Medline].

  20. Binks CA, Fenton M, McCarthy L, Lee T, Adams CE, Duggan C. Pharmacological interventions for people with borderline personality disorder. Cochrane Database Syst Rev. 2006 Jan 25. CD005653. [Medline].

  21. Simeon D, Baker B, Chaplin W, Braun A, Hollander E. An open-label trial of divalproex extended-release in the treatment of borderline personality disorder. CNS Spectr. 2007 Jun. 12(6):439-43. [Medline].

  22. Herpertz SC, Zanarini M, Schulz CS, Siever L, Lieb K, Möller HJ. World Federation of Societies of Biological Psychiatry (WFSBP) guidelines for biological treatment of personality disorders. World J Biol Psychiatry. 2007. 8(4):212-44. [Medline].

  23. Lieb K, Völlm B, Rücker G, Timmer A, Stoffers JM. Pharmacotherapy for borderline personality disorder: Cochrane systematic review of randomised trials. Br J Psychiatry. 2010 Jan. 196(1):4-12. [Medline].

 
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