Download Managing Personality Disorders in Primary Care

Managing
Personality
DisordersinPrimary
Care
LearningObjectives
• Atendofpresentation,attendeeswillbeableto:
• Classify personality disorders according to DSM-IV-TR clusters
• Describe common differential diagnosis issues with personality
disorders
• Discuss other psychiatric co-morbidity of personality disorders
• Integrate care ofpersonality disordered patients into primary care
James A. Bourgeois, O.D.,M.D.
Pre-test/post-test
• The“cluster”withthemostsignificantpsychiatriccomorbidityiscluster:
• A,B,C,D
• Asolitarypatientwithoutobviouslyeccentriccognitions
orbehaviorwhoisindifferenttoanycloserelationships
probablyhas____________personalitydisorder
• Schizoid,Schizotypal,Narcissistic,Dependent,
Avoidant
Pre/post-test,continued
• Apatient with excess fear of being alone and an inability to make
decisions regarding his/her own interests probably has _________
personality disorder?
• Obsessive-compulsive, dependent, avoidant, histrionic,
borderline
• Which personality disorder is characterized by excess grandiosity?
• Narcissistic, borderline, obsessive-compuls ive, dependent,
avoidant
• Cluster B includes all but one of the following:
• Obsessive-compulsive, narcissistic, antisocial, borderline,
histrionic
1
GeneralConsiderations
• Enduringpatternsofbehavior
• Culturallydys-synchronous
• Cognition,affectivity,interpersonalfunctioning,impulse
control
• Notduetootherpsychiatricillnessorsubstanceabuse
ClusterA
•
•
•
•
•
Paranoid
Schizoid
Schizotypal
co-morbidity:Psychoticdisorders
Extremely rare inclinicalpopulations
Classification,Coding
•
•
•
•
AxisIIdisorder(persistent,enduring)
AxisIrefersto“episodic”illnesses
ClustersA,B,C
PersonalitydisorderNOS
ParanoidPDO301.0
• Pervasivesenseofdistrust
• 4/7of:suspiciousness,preoccupationwithothers’
untrustworthiness,reluctanttoconfide,reads“threats”in
benignencounters,bearsgrudges,sensitivetoattacksand
quicktocounter,suspiciousofinfidelity
2
ParanoidPDO
• DfDx:DelusionalDisorder,Schizophrenia
• Approach:Tolerate suspiciousness,givethorough
explanations,respectprivacyrigorously,allowtoexpress
doubtsaboutcareissues,buildtrustovertime
SchizoidPDO
• DfDx:AvoidantPDO,Schizophrenia
• Approach:Tolerate reticence,expect socialanxietyin
conditionsof“forcedintimacy”(e.g.,hospitaladmission),care
throughasingletrustedphysician,buildtrustovertime,relate
ona“fact”rather than“feeling”“currency”
SchizoidPDO301.20
• Detachment andrestrictedaffect
• 4/7of:nodesireforcloserelationships,solitary,hypo-sexual,
anhedonia,noclosefriends,indifferenttofeedback,
emotionalcoldness
SchizotypalPDO301.22
• Isolation,socialanxiety,eccentricities,cognitivedistortions,
near-psychoticatbaseline
• 5/9of:IOR,oddbeliefs,unusualpercepts,odd
thinking/speech,suspiciousness,inappropriateaffect,odd
appearance/behavior, isolation,socialanxiety
3
SchizotypalPDO
• DfDx:Schizophrenia(oftenadifficultdistinction)
• Approach:Tolerate oddinteractivestyle,mayhaveaneedfor
“alternative” evaluationandtherapy,tolerateanxietyinforced
intimacysituations(aswithschizoidPDO),relationshipwith
onephysicianovertime,psychoticdecompensationlikely
AntisocialPDO301.7
• Disregard/violationofrightsofothers
• 3/6of:unlawfulbehavior,deceitfulness,impulsivity,
irritability,disregardforsafety,irresponsibility
ClusterB
Antisocial
Borderline
Histrionic
Narcissistic
Co-morbidity:Mood,anxiety(PTSD),eating
(bulimia),dissociative,somatoform,substance
abusedisorders
• Extremely commoninclinics
•
•
•
•
•
AntisocialPDO
• DfDx:BorderlineandNarcissisticPDO,ADHD
• Approach:Caution,expectdishonestreportingofsymptoms,high
riskofmalingeringandlitigiousthreats,interactwithjudicial
system,documentthoroughly,relyonobjectivefindings,don’t“go
italone”
4
BorderlinePDO301.83
• Instabilityandchaos
• 5/9of:franticeffortstoavoidabandonment,
idealization/devaluation,identitydisturbance,impulsivity,
suicidalbehavior,affectiveinstability,“emptiness,”angerdyscontrol,transientparanoiaordissociation
HistrionicPDO301.50
• Excessiveemotionalityandattentionseeking
• 5/8of:mustbecenterofattention,seductive,shallow
emotions,physicalappearancetoderiveattention,
impressionisticspeech,dramatic,suggestible,“pseudointimacy”
BorderlinePDO
• DfDx:Broadbutcasesusuallycleartoexperiencedclinician
• Approach:Limitsetting,stablerelationshipwithonephysician,
limitdoctorshopping,capitalizeon“institutional
transference,” tolerate affectsbutconfrontunsafebehavior,
useextendersappropriately,limitphonecontacts
HistrionicPDO
• DfDx:BorderlineandNarcissisticPDO
• Approach:Seekdetails,donotbasetherapeuticdecisionson
complaintsalone,astheyareinevitablyexaggerated,maybe
goodplaceboresponders,confrontbehaviorgentlyinthe
“here andnow”
5
NarcissisticPDO301.81
• Grandiosity,Grandiosity,Grandiosity
• “Legendsintheirownminds”
• 5/9of:grandiose,fantasiesofidealization,“specialness,”
requiresexcessadmiration(“mirror-hungry”),entitlement,
exploitation,“hypo-empathic,”envy,arrogance
ClusterC
•
•
•
•
Avoidant
Dependent
Obsessive-compulsive
Comorbidity:anxietyandmooddisorders,substanceuse
disordersforavoidantswithsocialphobia,eatingd/o
(avoidantandobsessive-compulsive)
NarcissisticPDO
• DfDx:Bipolard/o,antisocial,borderline,histrionicPDO
• Approach:Verychallengingpatientswholiketochallengeyou.
Aslongassafetodoso,involvethemintreatmentdecisions
(“pseudo-colleague”),capitalizeonentitlementbymobilizing
itinserviceofcare,setlimitsonactingout
AvoidantPDO 301.82
• Socialinhibitionandinadequacy
• 4/7of:socialavoidance,reticentofinvolvementwithout
reassurance, restraintwithinintimaterelationships,
preoccupationwithcriticism,self-viewassociallyinept,
reluctanttotake risks
6
AvoidantPDO
• DfDx:Socialphobia,SchizoidPDO
• Approach:Allowwarm-up,tolerateobliquestyleof
communication,moreactiveroleininterview
DependentPDO
• DfDx:BorderlineandavoidantPDO
• Approach:Allowdependencybutsetlimits,thoroughuseof
extenders to“diffuse”dependency,groupsofalmostanysort
DependentPDO301.6
• Failureofdifferentiation
• 5/8of:excessneedforadvice,deferential,inabilityto
disagree,lackofinitiative,excessneedforsupport,helpless
whenalone,urgentlyseeksnewrelationships,fearofbeing
alone
Obsessive-compulsivePDO
301.4
• Preoccupationwithorderandcontrol
• 4/8of:detailpreoccupation,perfectionism,“work-oholism,”
over-conscientiousness,hoarding,reluctanttodelegate,
parsimonious,rigidityandstubbornness
7
Obsessive-compulsivePDO
• DfDx:OCD,NarcissisticPDO
• Approach:Expecttoseearticles,internetsearches,dataofall
sorts;avoidfeelingthreatened,butappreciatethepatient’s
needfordatamorethanemotionalsupport,bequantitative,
allowthemcontrolovertreatmentoptionswheresafe
PsychiatricReferral
• Dangerousness(suicidal,homicidal,psychotic)
• Diagnosticclarification
• Management ofco-morbidpsychiatricillness,
includingsubstanceabuse
• Psychopharmacologicconsult- e.g.,somenewer
literature suggestspharmacotherapyfor
personalitydisordersdirectly
PersonalityD/ONOSand
“TraitsOnly”
• Forcaseswhoarenotaclearfitorforwhomsuspicionis
greater thantheavailabledata
Co-management
• Clearcommunicationinbothdirections,patientmustconsent
• Face-to-face meetingwithpsychiatrist/otherMHPand
primarycare physician
• Otheragenciesvery commonly involved
8
Otherconsiderations
• Many“highutilizers”arepersonalitydisorderedpatients
(oftenwithotherpsychiatricco-morbidity)withsignificant
dependencyneeds
Summary/Questions
• Discussion
• Considerconfrontingutilizationitselfasadependency
behavior
9