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Personality Disorders

Personality Disorders – Jonathan Constant, Jonathan Smith


  • 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
  • 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


  • 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


  • Consult Psychiatry
  • Create a behavioral plan
    • Outline the pt, 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 pt 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 pt'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 pt is eliciting in the provider): irresponsible and child-like behavior may prompt the provider to become angry or act in ways to limit the pt's control in their care, further perpetuating the behavior
  • 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