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Personality Disorders and The Difficult Patient | Part 1

Shawn Hersevoort, MD, MPH and Mizuho Morrison, DO
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The ever-fantastic Dr. Shawn Hersevoort is back for another installment of Psychiatry Files! In this segment, he and Mizuho Morrison discuss a practical approach to understanding and managing patients with different personality disorders.

 

Pearls:

  • Personality disorders are common in primary care.

  • They are clustered into A (weird), B (wild) and C (worried). For A and B types, you may need to give less time. For C types, they may need more time to feel taken care of. In all instances, keep yourself safe (emotionally and physically) and document well.

  • Other than dialectical behavior therapy for borderline personality disorders, there is no “treatment”. Accepting and working with these patients in-house is probably the best approach.

 

  • Personality - individual pattern of thoughts, emotions and behaviors which tend to be stable over time

  • Personality disorder - markedly inflexible  deviation in personality  from cultural norms that are manifested in at least two areas (cognition, affect, interpersonal functioning and interpersonal control) and cause significant trouble/impairment, usually beginning by adolescence or early adulthood

    • About 4% in the US fit criteria for personality disorders

    • About 1% are severe

    • Up to 10% in primary care settings with variation depending on type of primary care setting

    • Up to 50% in psychiatry settings

    • Up to 70% in the prison setting

    • Generally come from neglect, abuse, especially with cluster B

  • Clusters:

    • A (weird)

      • Paranoid

      • Schizoid

      • Schizotypal

    • B (wild)

      • Histrionic - dramatic and emotional, needs to get all the attention

      • Narcissistic - grandiose, has to be the ‘most’

      • Borderline - labile and shifting mood, impulsive; often confused with bipolar disorder

      • Antisocial - love to violate rules and rights not because they’re labile

    • C (worried)

      • Avoidant

      • Dependent

      • Obsessive-compulsive

  • “Difficult Patient”

    • Research term that is essentially synonymous with those with personality disorder

    • Multiple unexplained chronic and refractory symptoms that are disproportionately disabling

    • Poor treatment adherence

    • Emotional dysregulation

    • Make us feel like bad doctors

    • Insight varies

  • Strategies for the difficult patient:

    • Get on the right side: “It’s going to be you and me versus the symptoms, the system.”

    • Acknowledge feelings without acknowledging they are right or wrong: “Wow, that sounds really frustrating. If any doctor didn’t listen to me, I’d be really angry, too.”

    • Don’t worry so much about diagnosis as patients are often in distress and not at their best. Instead, its most important to recognize something is wrong.

      • Treatment is a misnomer because mostly it is about managing and working with personality disorders

    • Make sure it is not you: are you angry about something that happened earlier? Are you tired or particularly stressed?

    • Remain calm, clear and professional

    • Avoid being abused and abusing

  • Strategies for patients in cluster A:

    • Minimize time with them because social interaction makes them extremely uncomfortable

    • Consider increasing interval follow-up slightly because pushing too far can end up pushing them away

    • Try not to go to great lengths to get them on your side or have the most detailed history. They are not going to be able to give it to you

  • Strategies for patients in cluster B:

    • Decrease contact time for self-preservation

    • Tolerate some level of rudeness but set clear boundaries/limits

    • Rely on the textbook to defend your actions: “The standard of care for the symptoms you are describing is X, so I am not going to be able to offer the treatment you’re recommending because I don’t think it is safe and it is not recommended.”

  • Strategies for patients in cluster C:

    • Increase contact time because they need to feel taken care of

    • Give them more information

    • Set limits: “Well, I’m still going to make the final recommendations here, and you can’t come in more frequently than I think is reasonable, although I’ll do my best to accommodate you.”

  • Strategies for yourself as the provider taking care of these patients:

    • Be safe - patients can be emotionally and physically dangerous

    • Document well - most litigious patients. Especially cluster B and C patients that may meticulously document everything you have done. Important to document specific examples with quotes.

    • If patient cannot stop violating you or clinic rules, they need to go. Behavioral plans are important.

  • Treatment for personality disorders:

    • Best to keep in-house and try to manage co-morbid conditions

    • Exception is borderline personality disorder where dialectical behavioral therapy is effective

 

Reference:

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), American Psychiatric Association, Arlington 2013.

 

Bateman AW, Gunderson J, Mulder R. Treatment of personality disorder. Lancet 2015; 385(9969):735-43.

 

Leichsenring F, Leibing E. The effectiveness of psychodynamic therapy and cognitive behavior therapy in the treatment of personality disorders: a meta-analysis. Am J Psychiatry 2003; 160:1223.

 

Leichsenring F, Rabung S. Effectiveness of long-term psychodynamic psychotherapy: a meta-analysis. JAMA 2008; 300:1551.

 

Tyrer P, Reed GM, Crawford MJ. Classification, assessment, prevalence, and effect of personality disorder. Lancet 2015; 385(9969):717-26.

 

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Difficult patient vs. personality disorder? Full episode audio for MD edition 187:27 min - 88 MB - M4AHippo Urgent Care RAP - May 2019 Written Summary 572 KB - PDF

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