Approach
Establishment of a stable, supportive physician-patient relationship lies at the core of the approach to managing patients with personality disorders in a primary care setting.[53] The use of techniques specific to the prominent personality traits demonstrated by the individual patient can assist in forming and maintaining such a relationship. Psychotherapy and other psychosocial interventions are useful treatment modalities for a great number of these patients. Such treatments can assist patients in working through relationship issues, confronting fears, coping with trauma, dealing with troubling and dysfunctional thoughts, and acquiring skills necessary to lead a more satisfying and healthy life.
Psychotropic medication treatment can be utilized selectively to address problematic thoughts, moods, and behaviors that significantly impair the patient or place those in their immediate environment at risk. Substance use disorder, particularly alcohol use, is fairly common in these patients. It needs to be identified early and addressed through specific treatment interventions, as it leads to further medical and psychiatric morbidity for these patients.
Relationship with primary care physician
Given the interpersonal concerns of patients with personality disorders, the establishment of a physician-patient relationship that is maintained over time poses a particular challenge. The primacy of the physician-patient relationship and how to establish and maintain it have been discussed in the literature.[70][71] Allowing more time for consults and seeing one clinician consistently may be beneficial.[53]
The referral to a mental health provider should be made with great care and presented to the patient as a consultation for a symptom that he/she agrees is troubling, such as anxiety, depression, a lifestyle modification concern, or a functional impairment. The physician should emphasize that the patient will continue to follow up with him or her after the consultation, and that referral to the specialist does not suggest termination of care or abandonment. The importance of the therapeutic alliance between patient and physician, and the importance of collaboration in care between treatment providers, has been emphasized.[72] The referral decision is best approached in a collaborative manner with the patient, incorporating his/her motivation, preferences, and concerns into the resulting plan of care.
Acute management
A significant challenge confronting primary care physicians in the treatment of patients with personality disorders involves management of acute/emergent situations. There is very little randomized controlled trial (RCT)‐based evidence to inform the management of acute crises in people diagnosed with borderline personality disorder (BPD).[73] However, there are general guidelines:
Self-harm, suicidal ideation, or potential for harm to children
When patients express suicidal ideation or the wish to engage in self-harm, partial hospitalization, intensive day treatment, or, in cases where imminent risk is a concern, inpatient admission (either voluntary or involuntary) are the usual treatment options. Patients in need of this high-level, structured treatment may present with: severe disturbances of thinking, mood, and/or impulse control; aggression; hopelessness; extremely poor judgment. See Suicide risk mitigation.
While most studies have focused on BPD and risk for suicide, suicidal behavior in other personality disorders has also been studied.[72][74][75][76]
It is imperative that close communication take place between providers of acute psychiatric services and the primary care physician.
Suicide risk is much higher when personality disorder is comorbid with substance use disorder and/or major depression.
Primary care providers may also be concerned about parenting skills in patients with personality disorders; significant support will be required for them to manage children. Steps must be taken within the primary care provider's legal jurisdiction in cases of suicidality and aggression to protect the children in such homes.
Substance use
Patients with acute alcohol or other substance intoxication or highly problematic substance use may require inpatient hospitalization for detoxification and subsequent monitoring. This may be particularly necessary for patients with a history of self-injurious behavior or highly impulsive behavior.
Those with histories of complicated substance withdrawal or serious comorbid medical conditions would also be considered for inpatient substance use treatment. This treatment can occur concurrently with psychiatric stabilization.
Following the period of inpatient treatment, referral to a residential or intensive outpatient substance use disorder treatment program, including a 12-step program such as Alcoholics Anonymous (AA) or Narcotics Anonymous (NA), will provide for continuity of care.
As with referral for acute psychiatric services, it is very important that clear and timely communication take place between the primary care physician and the substance use treatment program staff.
Ongoing management: physician-patient relationship
For all patients with personality disorders, the foundation of treatment is the physician-patient relationship. The interpersonal sensitivities of individuals with personality disorders varies substantially. However, all patients will benefit from a consistent and stable relationship, characterized by clear communication and well-established boundaries. Other communication strategies are recommended based on the identified personality disorder and are listed here. They can be applied in all patient interactions, whether focusing on management of disease or improvement in lifestyle.
Cluster A: odd/eccentric
Paranoid, schizoid, schizotypal personality disorders: straightforward communication, unintrusive style; display interest in those concerns patient does share.
Cluster B: dramatic
BPD: simple communication with clear and consistent boundaries, calm demeanor in response to inevitable crises, preparation of patient for any changes in care arrangements (such as coverage during vacation), coordination of care with other treatment providers in order to avoid patient use of splitting (a defense mechanism where the patient views others as all good or all bad; it can lead to disagreements among those treating the patient). In addition, consider having a practice protocol with regard to after-hours coverage and use of e-mail communication.
Antisocial personality disorder: simple, straightforward communication; clear and consistent boundaries; exercise caution when prescribing controlled substances due to the potential for illegal use. In addition, be aware of tendencies of these patients to be less than truthful and to disregard rules.
Histrionic personality disorder: maintain professional distance, provide reassurance, address seductive behaviors in straightforward manner while maintaining a professional boundary.
Narcissistic personality disorder: acknowledge the patient as special, convey self-confidence in interactions, avoid power struggles.
Cluster C: anxious
Avoidant personality disorder: avoid critical comments, reinforce appropriate help-seeking behaviors.
Dependent personality disorder: tolerate repeated requests for reassurance; provide helpful resources and support patient self-efficacy; schedule primary care visits at regular, pre-established times (such as monthly) rather than as unscheduled visits prompted by the emergence of new symptom complaints.
Obsessive-compulsive personality disorder: provide information about conditions/treatments without extended discussion; avoid power struggles. In addition, encourage limited information-seeking on the internet and through other resources while reinforcing other interests (those that support functional, non-illness-related behaviors).
Ongoing management: psychotherapy
The other standard element of treatment for personality disorders, psychotherapy, has been demonstrated to reduce symptoms of personality disorder.[69][77] Research on its effectiveness for this condition has been hampered by a number of factors, including: the use of multiple outcome measures with no recognized standard measure(s); the need to have treatment implemented by a provider other than the originator of the treatment intervention; the need for longer-term follow-up; and the primary focus on BPD.[78][79]
The following forms of psychotherapy have had positive outcomes for patients with personality disorder.
Cluster A: odd/eccentric
Due to difficulties connecting with others, patients with this type of personality disorder may be reluctant to seek treatment for emotional concerns. For patients with symptoms of substance use disorder, referral for assessment may be indicated.
Cluster B: dramatic
BPD: evidence-based treatments include (dialectical behavior therapy [DBT], mentalization-based therapy [MBT], and transference-focused psychotherapy [TFP]) and key components of effective treatment, including the need for a primary clinician who supports the patient, who addresses suicidal threats and acts, who is self-aware, and who provides a well-defined therapeutic structure.[80][81] Borderline disorder is the only personality disorder for which there is one Cochrane review concluding that despite limitations, psychotherapy is considered an effective treatment for this condition.[77]
Other promising interventions include schema-focused therapy. This is a therapy that combines cognitive behavioral therapy (CBT) techniques with dynamic psychotherapy approaches (interpreting patient thoughts and behaviors) and mindfulness skills. Manual-assisted cognitive behavioral therapy (MACT) for self-harm and suicidal ideation is also used. This is a short-term (several session) approach combining CBT techniques with relevant informational booklets that reinforce these techniques and introduce the patient to concepts used in DBT. One systematic review comparing the efficacy of four treatment models for BPD (MBT, TFP, DBT, and schema-focused therapy [SFT]) found all four models effective in treating BPD (or, at least, some aspects), with a level of efficacy that varies depending on the parameter considered. The study authors state "according to criteria of the American Psychiatric Association for empirically-validated treatments, TFP, DBT, and SFT can be considered well-established treatments for BPD, while MBT meets the criteria for probably-efficacious treatment".[81] Psychoanalytically oriented partial hospitalization may also be used.[78]
Antisocial personality disorder: contingency management treatment (a behavioral therapy where adaptive behaviors are rewarded) may be used. There is also some evidence for schema-focused therapy and DBT. Research focusing on key symptoms is needed.[82] A review concluded that cognitive behavioral therapy implemented in a residential setting was more effective at reducing criminal behavior than standard treatment, but was no more effective than other treatment modalities.[83]
For patients with symptoms of substance use disorder, referral for assessment may be indicated.
Cluster C: anxious
Personality disorder not otherwise specified (mixed personality disorder)
Short-term dynamic psychotherapy, short-term psychodynamic supportive psychotherapy plus antidepressants, or DBT may be used.[85][86] [
]
Brief adaptive psychotherapy, a dynamic approach where a therapist works with the patient to identify and change maladaptive beliefs and behaviors in the context of the therapeutic relationship, may be indicated.
For patients with symptoms of substance use disorder, referral for assessment is indicated.
These treatments will typically be delivered by those with specialized training. The primary care physician can provide significant support for the patient participating in such treatments by maintaining a high level of interest in their progress and offering supportive comments and observations during the office visit. The back-and-forth dialogue with the provider of such care can be highly informative for both professionals and help each to adjust their patient approach over time.
Ongoing management: pharmacotherapy
Research in the area of pharmacotherapy for personality disorders is fraught with difficulties. These include (but are not limited to): almost exclusive focus on BPD, with little attention to the others; and substantial deficiencies in research designs, including lack of power and limited time frame for both treatment duration and follow-up.[87] The situation is complicated by the fact that drugs are used very frequently in the treatment of BPD despite the scarcity of evidence for their use.[88][89] Many patients present with problems related to self-harm and suicidality, which makes prescribing problematic, and the side effects of drugs chosen can be substantial.
Cluster A: odd/eccentric
Overall, there is a striking paucity of pharmacotherapy studies for schizoid and paranoid personality disorders.
Similarities between schizotypal, schizoid, and paranoid personality disorders with schizophrenia-related disorders in regards to phenomenology and biology have provided the rationale for the use of antipsychotic medication in this cluster. Studies suggest that low-dose antipsychotics targeting psychotic-like symptoms and general functioning may be effective.[90][91]
An evidence-based practice requires weighing risk of extrapyramidal side effects or tardive dyskinesia with first-generation antipsychotics versus risk of metabolic syndrome with second-generation antipsychotics versus potential benefits.[89]
The clinical trials for schizotypal disorder have been complicated by comorbidity with other psychiatric disorders as well as other personality disorders. Most early RCTs on BPD have included patients with schizotypal disorder due to conceptual issues.[90][92][93]
Antidepressants may help self-injurious behavior and depressive and psychotic-like symptoms, as suggested by some open-label studies.[94][95]
Cluster B: dramatic
The majority of pharmacotherapy research on personality disorders has focused on BPD. Clinicians need to exercise caution in attempting to apply research findings to severely ill patients with BPD, because most of the studies recruit only outpatients, who were then further excluded if they were suicidal or had made a recent suicide attempt. In addition, most studies have small sample sizes and high dropout rates, particularly if the studies lasted for more than 6 months. In most of the studies, high placebo response rates occur. Therefore open-label trials need to be interpreted with great caution.
One Cochrane review found that no pharmacologic therapy seems effective in specifically treating BPD pathology.[96]
The UK NICE guidelines on BPD state that drug treatment should not be used specifically for BPD or for the individual symptoms or behavior associated with the disorder (e.g., repeated self-harm, marked emotional instability, risk-taking behavior, and transient psychotic symptoms).[97] However, the NICE guidelines also suggest that drug treatment may be considered in the overall treatment of comorbid conditions in patients with personality disorders.[97]
Mood stabilizers, such as lithium, and anticonvulsants (e.g., topiramate, divalproex sodium, lamotrigine) may have some effectiveness in treating impulsivity and aggression in BPD. Mood stabilizers and anticonvulsants have demonstrated a moderate effect in treating depression in BPD.[98][99] However, a 2018 two-arm, double-blind, placebo-controlled individually randomized trial of lamotrigine versus placebo showed that the addition of lamotrigine to the usual care of people with BPD was not clinically effective and did not provide a cost-effective use of resources.[100] Patients need to be closely monitored because many patients tolerate these medications poorly, which also limits the titration of the medications. Although impulsivity and aggression may be responsive to these treatments, there is a paucity of evidence that interpersonal and identity disturbances are improved.
Many patients presenting to the primary care physician will have BPD, and may engage in risky sexual activity and may become pregnant. Therefore, the possibility of teratogenicity should be considered.
For antisocial personality disorder, evidence-based pharmacotherapy is mostly restricted to treatment of impulsive aggression.[101] Lithium may improve serious rule infractions in prisoners.[102] Phenytoin has been associated with fewer aggressive acts and decreased tension-anxiety and depressive symptoms in prisoners.[103] Improvements in aggression appeared to be limited to impulsive not instrumental aggression. Even though there is some evidence for the usefulness of these medications, the studies are too methodologically weak to base any recommendations upon.[101] The UK NICE guidelines on antisocial personality disorder state that pharmacologic interventions should not be routinely used for the treatment of antisocial personality disorder or associated behaviors of aggression, anger, and impulsivity.[104]
There is no evidence to support any pharmacotherapy recommendations in narcissistic and histrionic personality disorders.
Cluster C: anxious
Avoidant personality disorder is a common personality disorder, and it is the disorder most studied of the cluster C personality disorders.[105] However, no RCTs have been published of drug treatment of patients satisfying the full criteria of any cluster C personality disorder. Avoidant personality disorder is often a comorbid condition in patients with a variety of axis I anxiety disorders.[106] It has been recommended that clinicians should extrapolate from data that are primarily related to anxiety disorders to apply treatment strategies that have primarily been developed for social phobia.[107] Patients with avoidant personality disorder have shown a favorable response to venlafaxine and the selective serotonin-reuptake inhibitors (SSRIs). However, sertraline may have less effectiveness if the symptoms began in childhood.[108]
Gabapentin and pregabalin have demonstrated some efficacy in social phobia and may benefit patients with avoidant personality disorder.[109][110]
Reversible monoamine oxidase inhibitors (MAOIs), such as moclobemide, have support for their use.
Phenelzine, if used, requires great caution regarding serious risks and side effects.
The other personality disorders in this cluster, obsessive-compulsive personality disorder and dependent personality disorder, have insufficient evidence to recommend any pharmacotherapy.
Multiple features of different personality disorders
Patients with mixtures of significant symptoms (cognitive-perceptual, affective-dysregulation, impulse-dyscontrol, and substance use) are commonly encountered.
Complex pharmacological interventions may be necessary to address these symptoms. Consultation with a psychiatrist is recommended if benzodiazepines, stimulants, opioids, or psychotropic drugs with lethal overdose potential (tricyclic and MAOI antidepressants, lithium) are being prescribed or considered for use.
Psychiatric consultation may also be prudent for patients with poor symptom response to initial medication interventions, those whose psychiatric symptoms are escalating in severity, and those who are on a complicated regimen incorporating multiple psychotropic agents.
Symptom-targeted psychopharmacology
DSM-5-TR has a greater emphasis on a dimensional diagnostic approach to personality disorders than did DSM-IV. This translates into an emphasis on targeting pharmacotherapeutic interventions to symptom dimensions common to a variety of current axis II diagnoses. In addition, symptom-targeted psychopharmacology has been previously recommended for the treatment of personality disorders.[87][111][112] However, a meta-analysis raised significant questions regarding previously suggested algorithms for pharmacologic treatment of severe personality disorders. It found that antipsychotics had a moderate effect on cognitive-perceptual symptoms, and a moderate-to-large effect on anger.[99] Antidepressants, however, evidenced no significant effect on impulsive-behavioral dyscontrol and depressed mood, but had a small but significant effect on anxiety and anger. Mood stabilizers had a very large effect on impulsive-behavioral dyscontrol and anger, a large effect on anxiety, but a moderate effect on depressed mood. The effect of antidepressants on global functioning was negligible.[99] One review has recommended that clinicians should use omega-3, anticonvulsants, and atypical antipsychotic agents in treating specific DSM-5 BPD traits, notably disinhibition, antagonism, and some aspects of negative affectivity.[113]
A meta-analysis found that many antidepressant agents have some evidence for effectiveness in the treatment of patients with BPD.[114] However, the available studies suffer from serious methodological limitations. Further controlled trials of antidepressant agents versus placebo or active agents are required, including larger samples and using longer durations of treatments, in order to confirm current indications for pharmacotherapy of patients with BPD.
Treatment providers should exercise caution in practicing polypharmacy and/or escalating treatment doses in patients with personality disorders due to insufficient evidence for efficacy and considerable risk of adverse effects.[79]
The possibility of teratogenicity should be considered for any of the drugs used. Of particular note, valproic acid and its derivatives may cause major congenital malformations, including neurodevelopmental disorders and neural tube defects, after in utero exposure.
These agents must not be used in female patients of childbearing potential unless other options are unsuitable, there is a pregnancy prevention program in place, and certain conditions are met
Precautionary measures may also be required in male patients owing to a potential risk that use in the 3 months leading up to conception may increase the likelihood of neurodevelopmental disorders in their children
Regulations and precautionary measures for female and male patients may vary between countries, with some countries taking a more heightened precautionary stance, and you should consult your local guidance for more information.
In some countries, it is also recommended that topiramate should only be used in women of childbearing potential if there is a pregnancy prevention program in place.
Case consultation and physician self-care
Given the many challenges posed by working with personality-disordered patients, activities for physicians such as ongoing case consultation with a colleague, or participation in a Balint group American Balint Society Opens in new window or a similar forum for providers in which difficult cases can be discussed, are likely to maintain physician well-being, improve effectiveness in working with these patients, and enhance professional quality of life.
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