Personality Disorders Treatment & Management

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.

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.

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]

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.

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.

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.

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.