Download PERSONALITY DISORDERS and the “difficult patient”

PERSONALITY DISORDERS and
the “difficult patient”
“Difficult” patients : recognizing and
working with patients with personality
disorders
Objectives
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Define Personality Disorder
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Incidence of Personality Disorders in the US
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Importance of recognizing Personality Disorders
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Ways to optimize working with this growing subset
of the population
Quote of the day....
From Shakespear's Julius Caesar.....Cassius says,
“The fault, dear Brutus, is not in our stars, but in
ourselves......”
Our characters strongly influence our fate. How we
see the world and respond to it very much
determines how the world sees and responds to us
Personality versus personality
disorder (PD)
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Personality: Enduring pattern of thinking, feeling,
interacting and behaving that is who we are; it
provides the texture of our relations with other
people
Personality disorders cause vicious cycles of
negative expectation and self fulfilling prophecies
Normal personality traits become PD when they are
inflexible and make people unable to adapt to the
needs of the moment
The diagnosis is made only if the resulting problems
cause clinically significant stress or impairment
Personality Disorder, redefined
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A deeply ingrained and maladaptive pattern of
behavior—usually recognized under that person's
perception of stress
PD: subconscious emotional “safe place” for
someone who perceives an emotional and/or
physical threat
Signs of Personality Disorders
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Tend to blame others for the challenges they face.
Rarely realize they are the one with the disorder
because their way of thinking and behaving is
natural to them. Often feel like a victim
Their impulsive behavior puts them at higher risk of
physical injuries (fights, accidents, self-injurious
behavior), suicide attempts, risky sexual behavior,
unintended pregnancy, illicit drugs and addiction
Often diagnosed or misdiagnosed as anxiety,
depression, ADHD, insomnia and bipolar
Sporadic work history, numerous relationship
failures, poor adherence to medical treatments
Why do people have personality
disorders?
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Usually there were repeated incidents in their
childhood when they did not feel safe, either
physically or emotionally and they needed to find a
“safe place” or a defense mechanism to protect
themselves emotionally.
Feelings were not validated
Some genetic component for some personality
disorders
Children of PD parent(s) can learn these coping
mechanisms and the cycle repeats
Why do we need to recognize
and address the personality
disorder patient?
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Patients with personality disorders (PD) have
increased mental health problems of substance
abuse, impulsivity, violence, suicide and often have
problems in abiding by the law
They utilize an inordinate amount of health care and
social service dollars due to medical problems,
worker relations, unemployment, childcare, and
legal issues
Treatment is time intensive and they often do not
follow through
Incidence and Cost of
Personality Disorders
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10% of general population with Personality
Disorders
15%-24% of patients in Family Practice with
Personality Disorders
Estimates vary greatly, but estimated in hundreds of
millions of dollars for healthcare services,
corrections, and social services
Revolving door of medical, social and societal
needs
Nature versus Nurture
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Distraught mother: if all is nature, then what role
does parenting do?
Learn justice---punitive or forgiving. Open and safe
environment vs learn to run away from anything
that could possibly be perceived as unsafe or could
be conflict. Place blame on someone else—
avoiding responsibility
Personality disorders are a product of a perceived
unsafe environment and not typically genetic.
However, with increased unstable home
environments, it's becoming a learned behavior
Personality Disorders.....
“People come by their pathology honestly”
Julie K, psychiatric APRN
Types of Personality Disorders
Three types of Personality Disorders. Divided into
clusters based on their behaviors or symptoms:
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Cluster A: Odd, bizarre, eccentric behavior.
Subtypes: Paranoid, Schizoid, Schizotypal
Cluster B: Dramatic, overly emotional,
unpredictable thinking or behavior. Subtypes:
Antisocial, Borderline, Histrionic, Narcissistic
Cluster C: Anxious, fearful thinking or behavior.
Subtypes: Avoidant, Dependent, ObsessiveCompulsive, Passive-Aggressive
Types of personality disorders,
Cluster A
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Cluster A (Odd, bizarre, eccentric)
Paranoid, Schizoid and Schizotypal
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Paranoid: Guarded, Suspicious. Loners.
Constantly looking for clues or suggestions to
validate their fears. Keep grudges. Cold. Humorless.
Perception that innocent remarks or nonthreatening
situations are personal insults or attacks. Angry or
hostile reaction to perceived slights or insults
Schizoid: detached, aloof. Prone to introspection.
Indifferent to others. Indifferent to praise/criticism.
Inability to pick up normal social cues. Little or no
interest in having intimate relations with another
person
Types of Personality Disorders,
Cluster A, continued
Schizotypal: Have disorganized speech,
disorganized behavior and emotional blunting
without the delusions and hallucinations that would
convert the diagnosis to schizophrenia. Avoid social
interaction as fear others. Aloof. Isolated. Magical
thinking: they may be fascinated with magic,
clairvoyance and telepathy, or believe they can
influence people and events with their thoughts. The
symptoms and behaviors have an early onset and
remain stable throughout life.
Cluster A patient example
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50 year old gentleman comes in to the clinic. He
comes to his scheduled appointments and was last
seen 3 months ago. His mood and affect are
blunted and detached. He states he communicates
with satellites on a regular basis but doesn't expect
me to understand. He does not take his prescribed
antihypertensive medication as he feels it will make
him ill
Types of Personality Disorders,
Cluster B traits
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Cluster B: Dramatic, overly emotional,
unpredictable thinking or behavior
Antisocial, Borderline, Histrionic, Narcissistic
Antisocial: callous unconcern for feelings of others.
Disregards social rules and obligations—they break
the law. Lack guilt. Fail to learn from experiences.
Most closely correlated with crime. “Charming
psychopath”
Personality Disorders, Cluster
B, Borderline Personality
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Borderline Personality: Have intense and
frustrating relationships filled with high hopes that
degenerate into fierce fights and terrible
disappointments. Terrified of abandonment, they
drive people away with unrealistic demands,
unrelenting anger and self fulfilling expectations that
they will be rejected. Impulsive or risky behavior.
Suicidal behavior or threats of self injury.
Often misdiagnosed with bipolar, ADHD,
depression, anxiety and have a high utilization of
illicit drugs
Most commonly studied and very difficult to treat
Personality Disorders, Cluster
B, continued
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Histrionic: Constant need of attention and
approval of others. Dramatic. Overly charming and
inappropriately seductive. Crave excitement. Act on
impulse and place themselves at risk of accident or
exploitation. Easily influenced by others. Shallow,
rapidly changing emotions. Excessive concern with
physical appearance. Thinks relationships with
others are closer than they really are
Narcissistic: Extreme sense of self importance and
entitlement. Fantasize about power, success and
attractiveness. Failure to recognize others needs
and feelings. Envious of others and think people
envy them. Lack empathy. Use subterfuge. Cannot
apologize.
Cluster B patient
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19 year old female comes in to the clinic stating that
she has had Chlamydia for “years” and can't be
treated. No one listens to her and no one cares.
She was in previously for rib and upper abdominal
pain and was quite certain this was an ovarian
problem. She became quite emotional when it was
suggested that perhaps it wasn't an ovarian problem
since the discomfort was not located in her pelvis.
She then stated that she and her father believe she
has IBS
Types of Personality Disorders,
Cluster C traits
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Cluster C: anxious, fearful thinking or behavior
Avoidant: Feel socially inept or inferior. Too
sensitive to criticism or rejection. Social inhibition
despite a desire to form close emotional
relationships. Feel awkward in social situations.
Fear of disapproval, embarrassment or ridicule
Dependent personality: Excessive dependence
on others and feeling the need to be taken care of.
Submissive or clinging behavior; excessive need for
advice and reassurance. Lack of self confidence.
Difficulty disagreeing with others. Tolerate abusive
relationships. Urgent need to start another
relationship when a close one has ended
Personality Disorders: Cluster
C, continued
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Obsessive-Compulsive: Preoccupied with
orderliness, perfectionism, schedules and rules.
Desire to be in control of people, tasks and
situations. Inability to delegate tasks. Tend to put
relationships and enjoyable activity aside for work
Passive-Aggressive: Unreasonable to deal with,
uncomfortable to be around, rarely express their
hostility directly. Falsely elevate self by criticizing
others. Sarcasm. End hostile comments with “just
kidding”. Withhold information, procrastinate,
backstabbers
Cluster C patient
48 year old professor with multiple sclerosis comes
to your clinic. He states he enjoys his quiet lifestyle
of work and associates with colleagues only. He
does most of his own secretarial work as he is the
only one who can do it correctly. He shows me a
picture of himself with a gentle smile and proudly
states he was “really mad” when the photo was
taken. He states he was proud of being able to be
in complete control of his emotions
Neurotic defense mechanisms:
Obsessive Compulsive PD
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Isolation of affect: Separation of emotional
response of an event from the thought of the event.
ie: a patient speaks about witnessing the death of a
loved one in a matter-of-fact way. Cannot cry
Rationalization: patient justifies attitudes,
behaviors or emotions by attributing them to an
incorrect reason: a #30 weight gain in the first
trimester of pregnancy to ensure the fetus is
properly nourished
Intellectualization: Patient tries to control affect
and emotions about an experience by thinking
about it instead of experiencing actual feelings
Treatment for Personality
Disorders
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Psychotherapy is first line treatment
Dialectical behavioral therapy: Synthesizer and
integration of opposites. Acceptance versus change
Cognitive Behavioral therapy: Problem focused
and action oriented.
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Difficult to have exacting therapies for each type of
personality disorder due to lack of available data,
patient preference, accessibility of resources and
drop out rates
Specific treatments for each
cluster
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Cluster A disorders (odd, bizarre):
Cognitive Behavioral Therapy may be beneficial.
Low dose Risperidone has been helpful for
perceptual disturbances. Overall, this is a difficult
group to get impressive results, but setting clear
boundaries is helpful
Specific treatments for Cluster B
Disorders
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Cluster B ( dramatic, emotional, erratic): many
forms of psychotherapy have proven to be effective
for cluster B disorders
Dialectical behavioral therapy : first line therapy
to reduce self-harm behaviors and emotional
regulation, tolerate distress and improve
relationships
Mentalization based therapy: talk therapy that
helps you identify your own thoughts and feelings at
any given moment and creates an alternative
perspective
Scherma therapy: Helps you identify unmet
needs that have led to negative life patterns
Cluster B treatments, continued
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Many of the therapies, such as CBT, can be
accessed online. There are helpful books such as
“CBT for Dummies” with workbooks, that make
therapy available for all.
Medication: mood stabilizers such as lamotrigine
and topiramate are somewhat effective for
managing emotional lability and impulsivity.
SSRI's and other antidepressants are not helpful
for Cluster B disorders. Due to overlapping
symptoms with anxiety, depression, bipolar and
ADHD, patients are frequently prescribed these
medications
Cluster C treatment
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Cluster C ( anxious or fearful): Some success
with cognitive and interpersonal psychotherapies.
Little evidence to support the use of
pharmacotherapy
However, due to the significant overlap of anxiety
with Cluster C personality disorders, SSRI's, SNRI's
and gabapentin have demonstrated efficacy in this
group of anxiety disorders and are a reasonable and
safe way to start treatment for patients in Cluster C
personality disorders
Conclusion
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Personality disorders are more common than may
be realized in medical settings
Utilize inordinate amount of health care dollars as
well as social and community services
Difficult to treat. Making the diagnosis is the first
step. Psychotherapy is first line for most Personality
Disorders. Accessing services on line may be best
option for some
Set boundaries. Allow process. They want and
need an emotional safe place