Personality Disorders

Laura Artim

reviewed by Jonathan Smith and Daniel Daunis

Background 

  • Caring for patients with personality disorder symptoms can result in patient 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 the perspective that these responses to stress initially developed in order to help the person survive difficult circumstances early in life
  • 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/stressed 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)
      • In the hospital:
      • May be demanding, demeaning, overly-attached to specific care team members
      • May try to push boundaries, ask for care or accommodations outside of usual practice
      • May use threats to leave AMA, self-harm, or threaten others to achieve their goals
  • 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 o In the hospital:
      • May present as entitled, talkative, difficult to redirect, overly-focused on their specific needs/goals
      • May use either threats or praise as a means of manipulating care team members
      • May ask for special treatment, become easily angered, consider themselves as a “VIP” patient
  • 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 o Irritability, aggressiveness and lack of remorse
    • In the hospital:
      • May be aggressive, threatening, deceitful to achieve their goals
      • High rates of comorbid substance use and episodes of malingering (and at the same time may have very poor overall health and high likelihood of true medical emergencies)
      • May split staff members, use charm/be overly accommodating of some staff while demeaning and angry with others simultaneously

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
      • “I see you’re angry, you want to go smoke and we’re not letting you right now,” etc.
    • Direct, clear, unambiguous communication especially around the limits of care, boundaries of behavior, and consequences of not adhering to these expectation
      • “If you continue to scream and threaten staff, we wont be able to safely care for you and will need to move toward discharge”
    • 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
    • Projective Identification – a coping strategy in which a person creates the circumstances for another person to take blame for a feeling or behavior – i.e. provoking and insulting a physician, eliciting a defensive response, then blaming the physician for the poor relationship
  • 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
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