Personality Disorders

Laura Artim, reviewed by Jonathan Smith and Daniel Daunis

Background

• Caring for pts with personality disorder symptoms can result in pt and provider frustration, delays in treatment and at times, sub-optimal care and AMA discharges

• An understanding of personality disorders can mitigate some of these barriers

• Can be helpful to maintain perspective that these responses to stress initially developed in order to help the person survive, may increase compassion

• How do personality disorders develop?

• Genetic/temperament component, early traumatizing and shaping experiences

• Development of maladaptive perceptions and responses to other individuals

• Pathological interaction styles and response to stressors (fear of abandonment, dependence, rejection) are developed and become self-fulfilling and re-enforced leading to pervasive interpersonal difficulties

• Many people with these maladaptive coping strategies improve greatly with time and development of more mature coping strategies. In the hospital, we are often seeing them at their most vulnerable and thus most severe.

Presentation

• Borderline Personality Disorder:

  • Unstable and intense relationships; “splitting” between idealization and devaluation

  • Frantic efforts to avoid real or imagined abandonment

  • Impulsivity: substance use, binge eating, reckless behavior

  • Recurrent suicidal behavior or gestures

  • Mood instability: quick onset and short-lived intense dysphoria, irritability, anxiety

  • Difficulty controlling anger (displays of temper, aggression)

• Narcissistic Personality Disorder:

  • Grandiosity: exaggerates achievements and expects to be recognized as superior

  • Preoccupied with unlimited power, success, brilliance

  • Sense of entitlement: expects favorable treatment and compliance with expectations

  • Exploits others and lacks empathy

• Antisocial personality disorder:

  • Failure to conform to social norms with respect to lawful behavior

  • Deceitfulness, lying, conning others for personal profit or pleasure

  • Impulsivity and reckless disregard for others

  • Irritability, aggressiveness and lack of remorse

Management

• Guidelines for managing borderline personality inpatient:

  • In crisis, name dominant emotion, validate the experience, and offer a non-medication coping strategies (deep diaphragmatic breathing) or a break in interview to facilitate affect regulation

  • Direct, clear, unambiguous communication

  • Remain consistent in treatment planning across services; if possible, have one provider identified as point person

  • Maintain clear, consistent and enforceable limits on disruptive/violent behavior

  • For personality disorders in general, create a behavioral plan

    • Outline the patient, as well as the team’s, responsibilities and goals of care with identification of the concerning behavior and a firm plan for if the agreement is broken

    • Ideally, the patient should sign this plan and consider it as a contract

    • Dot Phrase/Sample: .IMBehavioralPlan (go to dot phrases under user Joseph Quintana)

    • Adjust, add and remove content based on patient

  • Behavioral interventions:

    • Aim for consistency w/ providers & nursing; limit consultants to ↓ splitting behaviors

    • Acknowledge patient's grievance/frustrations and shift focus on how to solve the problem

    • Align goals by emphasizing common ground and find ways to make small concessions

    • Be aware of progress and know when to disengage (if behaviors are escalating)

    • Monitor countertransference (the emotions the patient is eliciting in the provider):

      • Irresponsible and child-like behavior may prompt the provider to become angry or act in ways to limit the patient's control in their care, further perpetuating the behavior

• Outpatient management

  • Gold standard = Psychotherapy

  • Dialectical Behavioral therapy, Cognitive behavioral therapy, Psychodynamic

  • If the patient is willing, SW should assist with establishing at discharge

  • Pharmacotherapy :

    • Unclear benefit in pharmacological management of Personality Disorder

    • Treatment of comorbid psychiatric disorders if present would be most appropriate, keeping in mind that those with personality disorders may also develop superimposed disorders such as PTSD or depression