Personality Disorders Part Deux: How to Assess, How to Manage
Why is the management of people with personality disorder complicated?
One reason is that often in an acute hospital setting, the presence of personality disorder itself is not the main focus of treatment but can be seen as a confounding factor. In such instances, the aim is often to:
- Manage the acute problem (for e.g, an episode of deliberate self-harm), and
- Refer appropriately to follow-up. (including clarification of diagnosis and plan for longer-term treatment)
A second reason is that there is generally a limited role for psychopharmacology in most people with personality disorder.
A third reason, sadly is the stigma often associated with having a personality disorder.
In this post, I’ll talk about:
- some general principles for how to approach patients with diagnosed (or suspected) personality disorder, and
- discuss the most commonly encountered personality disorder in clinical settings: borderline personality disorder
My aim is that by the end of reading this post you are a little bit more confident in your diagnosis and management and can see that there are many things that can be done to help people who have a personality disorder.
FIVE TIPS ON APPROACHING THE PATIENT WITH PERSONALITY DISORDER
So what is in fact the difference between the history and the mental state examination? Well the textbooks will tell you that the history is an account of what has happened to the patient and gives a longitudinal perspective, whereas the mental state is what is happening to the patient right now.
In point of fact, the distinction is often not so clear and another way of looking at the MSE is a way of collecting and reporting on the current symptoms of the patient some of which will have been occurring for some time, some of which maybe occurring close to or at the time of interview, others of which may be part of the current episode but perhaps not present exactly at the time of the interview.
Some of the information between history and MSE will overlap. For example, if the patient has developed delusions, the history will indicate what they are and how long they have been present, while the MSE will record the types of delusions and the patient’s reaction to them. As another example, the patient may appear tired on MSE, they may report as part of their history that they have been suffering insomnia for the last 4 weeks.
Non-verbal behaviour is generally regarded as more difficult to control consciously than verbal behaviour, so it is powerful evidence of the mental state and a major focus of the MSE.
It is particularly important to note if there is a discrepancy between what is said and the non-verbal signals. For example, the patient may be reluctant to acknowledge that they are experiencing auditory hallucinations, however, their distractibility by unseen stimuli which interrupts the conversation flow indicates that auditory hallucinations are likely present.
1. Keep calm, be emotionally prepared.
Patients with personality disorder who present to health services do so often in a highly distressed state; as a result, this can in turn be emotionally challenging for clinicians. It is sometimes possible to feel frustrated in one’s ability to help a person with personality disorder so caring for someone with a personality disorder can be anxiety-provoking and exhausting.
So be prepared. Before going into the assessment have a cup of tea, take a deep breath, mentally remind yourself what you want to achieve in the interview. Aim to be optimistic and compassionate – while it’s easy to fall into the trap of dreading talking to someone with a personality disorder, working with them is a learnable skill and can be very rewarding.
2. Build rapport
The best, most effective, most therapeutic thing you can do with these patients is engage with them. (This is also arguably the best, most effective, most therapeutic thing you can do with all psychiatric patients.)
So draw on your basic principles of communication and medical interviewing. Introduce yourself. Ask open questions. Use reflective statements.
Be warm, courteous, and emotionally sensitive (Carlat, 2012). (Being warm, courteous, and emotionally sensitive is much easier when you’re not already anxious, tired, or stressed; which is why my first suggestion is to attend to your own emotional state before starting the interview.)
3. Be aware of unconscious biases and reactions
Countertransference is a core concept in psychiatry that dates back to Freud. Just like the patient, we too have past memories; we all have particular triggers and emotional buttons. There’s a good chance that the hostile, suicidal, volatile person in front of us is going to provoke emotional reactions that affect our assessment and management decisions without our realising it.
Many therapists find awareness of countertransference a useful tool, as the feelings that a patient evokes in us can tell us important things about how a patient behaves and interacts in their relationships. However, dealing with countertransference isn’t always an easy thing, and is part of why supervision is such an important aspect of working in mental health.
In my particular program we have excellent structured supervision in junior doctor rotations; however, if that isn’t in place for you, it is important to discuss with your registrar or consultant (who will definitely recognise its importance!).
4. Treat the patient not the diagnosis
It’s a central axiom of medicine that we should treat patients, not diagnoses. With that in mind, the clinical approach should be in line with a good general psychiatric assessment:
Understand the narrative of the presenting complaint. Consider medical conditions, past psychiatric history, substance use, and medications. Assess social, legal, family, personal and developmental history. Explore the patient’s illness beliefs and what their goals and wishes are.
Don’t jump to conclusions. Personality disorders may be among the most stigmatised of all psychiatric conditions, which is why it’s important to not prematurely make a diagnosis based on patchy information.
Amongst the personality disorders, borderline personality disorder has by far and a way the most robust evidence base for effective psychological treatments, which is one reason why this is a diagnosis worth making. (Or, if suspected, worth referring to specialist services for more comprehensive diagnostic assessment.)
5. Get help, advice and refer
Comprehensive psychiatric histories are lengthy and require adequate time and appropriate setting. It is unlikely that you are going to get a thorough developmental history from a young woman sitting in an ED cubicle with bloodied lacerations all over her arms in immediate need of suture.
Patients with personality disorder often present with questions of suicide risk, violence risk, substance use problems, or refusal of medical treatment. While a number of local, state, and national guidelines address these questions, it is both appropriate and important to seek senior advice if you feel out of your depth. Your registrar or consultant can help decide whether the patient needs to be seen by a psychiatrist, what the immediate treatment priorities are, and what community follow-up is needed.
Establishing a diagnosis of personality disorder generally requires more than one assessment session and a careful consideration of a person’s longitudinal behaviour, which is why you will often see vague phrases like ‘cluster B personality traits’ on psychiatric discharge summaries. While this may seem wishy-washy, it means that inappropriate diagnosis can be avoided. An outpatient assessment a few weeks post-discharge, after a crisis is over, will yield a clearer picture of a patient’s personality patterns.
“Countertransference is now regarded as a jointly created reaction in the clinician that stems in part from contributions of the clinician’s past and in part from feelings induced by the patient’s behaviour.”
― Glen Gabbard 2015, Psychodynamic Psychiatry in Clinical Practice
Borderline Personality Disorder: the facts, the guidelines, and what we can do
BPD is characterised by poor control of emotions and impulses, unstable interpersonal relationships, and unstable self-image. Symptoms typically emerge during adolescence and early adulthood.
BPD is a common mental illness. Prevalence in the general population has been estimated at 1-4%. It has been demonstrated that sufferers of this condition disproportionately utilise mental health services – prevalence has been estimated to be as high as 43% in psychiatric inpatient populations. (NHMRC 2012)
Some important facts about BPD
- Recurrent deliberate self-harm and chronic suicidal ideation are common features. Deliberate self-harm (for instance, through cutting) is frequently used as a method of relieving painful emotions and is often not suicidal in intent; however, suicidal acts are also common and up to 10% of sufferers will die by suicide.
- A past and present history of trauma is frequent. Many people with BPD will have experienced physical or sexual abuse or neglect during childhood; and many will continue to experience domestic violence and physical, verbal or sexual abuse even as an adult. Trauma assessment should be done sensitively. See this post for more information [link to difficult questions in psychiatry post] (don’t attempt to elicit histories of past childhood sexual abuse during a crisis in ED!)
- People with BPD are sensitive to abandonment and will frantically attempt to avoid it. Suicidal acts and gestures often take place following real or perceived abandonment by a loved one; and decisions by health professionals that represent apparent abandonment (e.g discharge from hospital, stopping a medication) will provoke intense responses.
- Splitting is common in BPD. Splitting [provide a tooltip definition] occurs when a person is unable to reconcile the good and bad parts of other people. This can result in family, friends, and health professionals being alternately idealised and then devalued. The patient may decide that you are “the best doctor in the world” one day and then “the worst doctor ever” the next! The reality is that you are probably neither. It is important to recognise those relational ups and downs as being part of the mental illness.
- People with BPD are highly stigmatised. BPD is a complex illness that provokes intense emotional reactions in clinicians. In general, people with BPD are under-diagnosed, under-treated, and discriminated against. It is important to recognise that having BPD is a valid use of mental health services, and that sufferers have significant morbidity and mortality – we have an opportunity to make a real difference with treatment.
Treatment of BPD: what the guidelines say
The Australian National Health and Medical Research Council published guidelines on the treatment of BPD in 2012. You can read them here.
Assessing and managing in the emergency department, or in primary care settings.
People with BPD may present to health services during a crisis. They may exhibit or describe emotional distress, signs of recurrent self-harm, risk taking behaviour, suicidal thoughts and attempts, and relationship problems.
Initial presentation should focus on current psychosocial functioning and safety to self and others.
- address medical issues (e.g. toxicology if deliberate self-poisoning, wound management/suturing)
- assess safety to self and others, suicidal ideation/plans/access to means of harm
- assess for co-occurring substance use disorder, eating disorder, other mental illness
- assess for psychosocial and occupational functioning, including the needs of any dependent children
Depending on the presentation, referral to mental health is not always required. However, it is likely indicated if there are significant risk issues, diagnostic uncertainty, or co-morbidity. (Talk to your friendly neighbourhood on-call mental health clinician if you’re not sure.) In all cases check with your senior as many Emergency Departments require that patients presenting with acts or thoughts of suicide or self-harm are reviewed by mental health services.
Treatment options, and prognosis
Contrary to popular perception, prognosis of borderline personality disorder is good. Longitudinal studies suggest that nearly all sufferers with BPD will achieve symptomatic recovery (although some persisting impairment is common).
- Hospitalisation: The consensus is that inpatient care should be reserved for short-term crisis intervention for people at high risk of suicide or medically serious self-harm. Admissions should be brief and be directed towards achieving specific goals that are agreed before admission.
- Prolonged admission is generally ineffective – and some experts have argued that it is harmful as it may foster dependence on being in hospital and interfere with the more valid treatments (see below).
- Psychotherapy: There are a range of psychological therapies effective for BPD, with dialectic behavioural therapy (DBT) being the most widely studied.
- Psychotherapies offered should be specifically designed for BPD and delivered by appropriately trained and supervised therapists.
Care more particularly for the individual patient than for the especial features of the disease.
― William Osler
All major classes of psychiatric drugs (antidepressants, mood stabilisers, antipsychotics) have been studied in BPD populations.
In general, medication is not helpful for altering the course of the disorder. However, medication may be prescribed for treating co-morbid illnesses (for instance, SSRIs for depression or anxiety) OR alleviating distress or reducing symptoms during periods of crisis.
What is DBT?
Dialectical Behavior Therapy (DBT)was originally developed for treatment of chronically suicidal individuals who were diagnosed with borderline personality disorder (BPD). It derives from both Cognitive Behaviour Therapy as well as a number of eastern meditation techniques. DBT is now considered the gold standard psychological treatment for BPD. In addition, research has shown that DBT or components of DBT are helpful in a range of other conditions.
What are the components of DBT?
In its classical form, there are four components of DBT: skills training group, individual treatment, coaching, and a consultation team.
- Skills training focuses on enhancing individual’s capabilities by teaching behavioural skills. The group is run like a class where the group leader teaches the skills and assigns homework. Groups meet on a weekly basis for approximately 2.5 hours and it takes around 24 weeks to get through the full skills curriculum. Briefer schedules have been trialled in some groups and Skills Training has been tested as an intervention on its own.
- DBT individual therapy is focused on enhancing motivation and helping individuals to apply the skills to specific challenges and events in their lives. Normally this occurs once per week..
- DBT coaching (generally by phone) provides in-the-moment coaching on how to use skills to effectively cope with difficult situations that arise in everyday life. This can be useful in interrupting cycles of self-harm
- A DBT therapist consultation team is intended to be therapy for the therapists and to support DBT providers in their work with people who often have severe, complex, difficult-to-treat disorders.
Daniel Carlat The Psychiatric Interview: A Practical Guide (3rd ed., 2012)
Glen Gabbard. Psychodynamic Psychiatric in Clinical Practice
Philip Muskin, Lucy Epstein. Clinical guide to countertransferance: help colleagues deal with ‘difficult’ patients. Current Psychiatry, 2009 April;8(4):25-32.