Personality Disorders and Communication Tips

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.
It can be helpful to think about certain behaviors as responses to stress that developed to help the person survive difficult circumstances early in life such as abuse or neglect.
Genetic/temperament component, early traumatizing and shaping experiences all play a role in the development of maladaptive social interactions and response to stressors (fear of abandonment, dependence, rejection).
Many people with these maladaptive coping strategies improve greatly with therapy, specifically Dialectic Behavioral Therapy, CBT, or psychodynamic, and development of more mature coping strategies. SW can help establishing outpatient follow up at discharge. In the hospital, they are at a vulnerable state and under a lot of stress which presents with severe personality disorder
symptoms.
Pharmacotherapy can treat comorbid conditions such as PTSD and depression but does not directly treat personality disorders.

Instability in interpersonal relationships - “splitting” (a defense mechanism) between idealization and devaluation; frantic efforts to avoid real or imagined abandonment (see: how to manage splitting below).
Instability of behaviors – impulsivity including substance use, binge eating, reckless behavior; recurrent suicidal behavior or gestures.
Instability of mood - quick onset and short-lived intense dysphoria, irritability, anxiety, displays of temper, aggression
Instability of identity – unstable self-image or sense of self.

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.

Management tips during hospitalization:

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 especially around the limits of care, boundaries of behavior, and consequences of not adhering to these expectation including discharge if safe.
Maintain clear, consistent and enforceable limits on disruptive/violent behavior.
Remain consistent in treatment planning across services; if possible, have one provider identified as point person.
See behavioral plan tips below.

Grandiosity: An inflated sense of self-importance (ex. exaggerates achievements and expects to be recognized as superior). Preoccupied with unlimited power, success, brilliance.
Exploits others and lacks empathy.
Sense of entitlement expects favorable treatment and compliance with expectations.

Behaviors and management in the hospital:

May present as entitled, talkative, difficult to redirect, overly focused on their specific needs/goals.
Likely to ask about credentials and where team members were educated. Lightly redirect saying “everyone here is credentialed to care for you” and move on.
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.
See BPD and behavioral plan for management.

Patients present with failure to conform to social norms with respect to lawful behavior. They tend to be deceitful, lying, conning others for personal profit or pleasure. Can have impulsivity and reckless disregard for others and present with 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.
See BPD and behavioral plan for management
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.
- Here is an example dot phrase that can be adjusted according to patient’s specific needs: IMBehavioralPlan (go to dot phrases under user Joseph Quintana).

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) and leave.

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.

When a pt has a very strong affect towards you, try not to take this personally as it is rarely related to you specifically. Remain calm and unflappable while in the room, even if the pt is upset. Focus on breathing deeply and pause before speaking.
Attempt to identify and verbally reflect the pt’s emotional state.
Minimize blaming and “you” statements.
Acknowledge that being in the hospital is hard work for the pt, and the team wants to work with the pt toward a common goal.
Acknowledge that the interaction/relationship is less than ideal and how that may be impacting their care.
Assist a pt in revising unrealistic expectations by providing education but always keep the reason for their expectations at the center (refusing a procedure due to fear of death or feeling out of control).
Indicate the pt’s own role and responsibilities in their care—highlight the things that they have direct control over.
Prioritize safety. If the pt is escalating to physical agitation, defer negotiations to a later time. Do not stay in the room if you feel that your physical safety is in danger or if the pt is being verbally assaultive.

Patient views different team members as “good” or “bad” due to differences in
interactions. The pt may idealize some team members and villainize others. If possible, have all team members (primary, consultants, bedside nurse) meet with the pt at the same time.
Alternatively, have all treatment plans be delivered by one central person (primary resident) with bedside nurse present.
Find ways to make small, reasonable concessions that give the pt more control over their care and day-to-day experience (e.g. shifting the timing of medications).
Set clear expectations and boundaries (e.g. team will terminate discussion and leave the room if the pt begins cursing at them) and follow-through on them.
When feeling stuck, consulting the psychiatry consultation liaison service can help address psychiatric factors that may be contributing or can play a mediating role.