Personality DisordersA Patient-Centered, Evidence-Based Diagnostic and Treatment Process1,2,3Kendall L. Stewart, MD, MBA, DLFAPAJanuary 11, 2013

1My aim is to offer practical clinical insights that you can use right away in caring for patients.2Please let me know whether I have succeeded on your evaluation forms.3These are complicated and exasperating patients; your gut instincts will not serve you well.

Why is this important?

• After mastering the information in this presentation, you will be able to identify– The general diagnostic criteria for a

personality disorder,– The three “clusters” of personality

disorders and the characteristics of each cluster.

– The specific diagnoses contained in each cluster,

– The diagnostic criteria for Borderline Personality Disorder (BPD),

– Some of the associated features of BPD,

– A differential diagnosis,– A typical treatment plan, and – Some expected treatment challenges.

• 10 to13-percent of the population will meet the criteria for one or more of the personality disorders during their lifetimes.

• These people often seek medical care.• They are some of the most difficult

patients you will ever attempt to serve.

• Patients with Borderline Personality Disorder (BPD) are especially challenging.1,2

• Recognizing their underlying disorders and managing these patients appropriately won’t entirely eliminate the challenges these patients pose, but it will make your professional life easier.

1When a primary care physician calls you in the afternoon, you know it’s important.2 “A patient just told me that she loves me. What do I do now?”

What are the general diagnostic criteria for a personality disorder?

• An enduring pattern of inner experience and behavior that differs from the expectations of the culture. This pattern is evident in– Ways of perceiving and interpreting things– Emotional responses– Interpersonal functioning– Impulse control

• Pattern is inflexible and pervasive• Pattern leads to distress or impairment1,2,3

• Pattern is stable and of long duration• Not due to another mental disorder• Not due to substance use

1We all have personality quirks. This is much more than that.2To make the diagnosis, you must uncover evidence of social or occupational impairment or distress.3The people in their lives finally wash their hands of them in hopeless frustration.

What specific diagnoses are included here?

• The odd or eccentric cluster of Personality Disorders– Paranoid (suspicious)– Schizoid (withdrawn)– Schizotypal (withdrawn and weird)

• The dramatic or erratic cluster– Antisocial (disregard for rights of others)– Borderline (unstable and impulsive)– Histrionic (attention-seeking)– Narcissistic (self-centered)

• The anxious or fearful cluster– Avoidant (social discomfort)– Dependent (needy)– Obsessive-Compulsive (perfectionist)

1These diagnoses frequently coexist and overlap.2It usually takes more than one interview to make the diagnosis.3Always ask screening questions.

How might a patient with Borderline Personality Disorder present?

• “I can’t stand to be with someone and I can’t stand to be without someone.”

• “I’ve been in several different graduate programs, but the faculty members never turned out to be as nurturing as they claimed.”

• “My parents divorced when I was nine, and we’ve not been close.”

• “Nothing I do will ever please my mother, and I hate her.”

• “I couldn’t get by without the money she gives me though.”

• When talking about her relationship with her boyfriend, she alternated between distraught sobbing and barely-contained rage.

• Listen to a patient here.

• This is a 25-year-old single graduate student.

• “I’ve been thinking of killing myself.”• “My boyfriend went alone on a vacation

to Europe.”• “I told him we needed some time apart.”• “We were like Siamese twins and I

couldn’t stand it.”• “But I can’t believe he would leave me

like this.”• “I feel abandoned and empty.”• “I am angry that he would make me feel

like this.”• “He should have known it was only a

test.”• “Sometimes I cut myself because that is

the only way to let the pain out.”

What associated features might you see?

• These people tend to undermine themselves and rarely achieve the level of accomplishment they might otherwise reach.

• Transient psychotic symptoms are common.1,2

• Suicide is a constant risk.• Substance abuse is common.• Physical disability from failed suicide attempts and self

mutilation is common.• Physical and sexual abuse along with conflict and

neglect are often found in their early histories.• They often also suffer from concomitant mental

disorders.

1These patients can be downright spooky.2These patients do dramatic and unexpected things.

What other disorders should you include in the differential diagnosis?

• Mood disorders1

• Other personality disorders– Dependent– Histrionic– Narcissistic

• Personality change due to a general medical condition

• Personality changes associated with chronic substance use

• The underlying personality diagnosis often only becomes clear over time.

1Episodic Axis I disorders often obscure underlying personality disorders.

What might a typical treatment plan look like?

• Medication– All medications are double-

edged swords.– Avoid sedatives altogether.– Antidepressants may be

necessary at times.– Atypical antipsychotics in

low dosages have been helpful in some cases.

– Lithium may help to prevent suicide—or it may be the instrument of the patient’s demise.

• Counseling – Long-term treatment is

generally required.– The setting and acceptance of

limits is necessary.– A recognition of pathologic

patterns of impulsive behavior is essential.

– Patience is demanded.– Boundaries must be set and

respected.– Discharge from treatment is

sometimes the most helpful therapy.1,2

1You will not be able to help everyone.2Transfer them if you can’t trust them or can’t stand them.

What are some of the treatment challenges you can expect?

• Noncompliance is the rule.• These patients will demand a special relationship with you

and special treatment from you, and they will never be satisfied.

• These patients will be exceptionally demanding.1

• You will likely feel very frustrated, helpless, resentful and angry. (And that is only the beginning.)

• They will draw you in with their need, lead you to believe no one else can help them and then devastate you with their enraged contempt.

• If you fail to set limits, they will terrorize you with their demands.

• If you fail to respect professional boundaries, they will ruin your personal and professional lives.

• But these people really need help.• If you are not up to it, find them the help they need.

1A patient once told me that it was my job to accept whatever she said and never confront her.

The Psychiatric InterviewA Patient-Centered, Evidence-Based Diagnostic and Treatment Process

• Review my laboratory data and other available records.

• Tell me what diagnoses you have made.• Reassure me.• Outline your recommended treatment

plan while making sure that I understand.• Repeatedly invite my clarifying questions.• Be patient with me.• Provide me with the appropriate

educational resources.• Invite me to call you with any additional

questions I may have.• Make a follow up appointment.• Communicate with my other physicians.

• Introduce yourself using AIDET1.• Sit down.• Make me comfortable by asking some

routine demographic questions.• Ask me to list all of problems and concerns.• Using my problem list as a guide, ask me

clarifying questions about my current illness(es).

• Using evidence-based diagnostic criteria, make accurate preliminary diagnoses.

• Ask about my past psychiatric history.• Ask about my family and social histories.• Clarify my pertinent medical history.• Perform an appropriate mental status

examination.

1Acknowledge the patient. Introduce yourself. Inform the patient about the Duration of tests or treatment. Explain what is going to happen next. Thank your patients for the opportunity to serve them.

Where can you learn more?

• American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision, 2000

• Sadock, B. J. and Sadock V. A., Concise Textbook of Clinical Psychiatry, Third Edition, 20081

• Flaherty, AH, and Rost, NS, The Massachusetts Handbook of Neurology, April 20072

• Stead, L, Stead, SM and Kaufman, M, First Aid© for the Psychiatry Clerkship, Second Edition, March 2005

• Klamen, D, and Pan, P, Psychiatry Pre Test Self-Assessment and Review, Twelfth Edition, March 20093

• Oransky, I, and Blitzstein, S, Lange Q&A: Psychiatry, March 2007• Ratey, JJ, Spark: The Revolutionary New Science of Exercise and the Brain, January

2008• Medina, John,

Brain Rules: 12 Principles for Surviving and Thriving at Home, Work and School, February 2008

• Stewart KL, “Dealing With Anxiety: A Practical Approach to Nervous Patients,” 2000

Where can you find evidence-based information about mental disorders?

• American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision, 2000

• Sadock, B. J. and Sadock V. A., Concise Textbook of Clinical Psychiatry, Third Edition, 2008• Stern, et. al., Massachusetts General Hospital Comprehensive Clinical Psychiatry, 2008.

You can read this text online here.• Flaherty, AH, and Rost, NS, The Massachusetts Handbook of Neurology, April 2007• Stead, L, Stead, SM and Kaufman, M,

First Aid© for the Psychiatry Clerkship, Second Edition, March 2005• Klamen, D, and Pan, P, Psychiatry Pre Test Self-Assessment and Review, Twelfth Edition,

March 20093

• Oransky, I, and Blitzstein, S, Lange Q&A: Psychiatry, March 2007• Ratey, JJ, Spark: The Revolutionary New Science of Exercise and the Brain, January 2008• Medina, John,

Brain Rules: 12 Principles for Surviving and Thriving at Home, Work and School, February 2008

• Stewart KL, “Dealing With Anxiety: A Practical Approach to Nervous Patients,” 2000• Order the Kindle version of the Rakel and Rakel Textbook of Family Medicine here.

Are there other questions?

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