Managing Learning Objectives At end of presentation, attendees will - - PDF document

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Managing Personality Disorders in Primary Care

James A. Bourgeois, O.D., M.D.

Learning Objectives

• At end of presentation, attendees will be able to:
• Classify personality disorders according to DSM-IV-TR clusters
• Describe common differential diagnosis issues with personality

disorders

• Discuss other psychiatric co-morbidity of personality disorders
• Integrate care of personality disordered patients into primary care

Pre-test/post-test

• The “cluster” with the most significant psychiatric co-

morbidity is cluster:

• A, B, C, D
• A solitary patien

t without obviously eccentric cognitions

• r behavior who is indifferent to any close relationships

probably has ____________ personality disorder

• Schizoid, Schizotypal, Narcissistic, Dependent,

Avoidant

Pre/post-test, continued

• A patient with excess fear of being alone and an inability to make

decisions regarding his/her own interests probably has _________ personality disorder?

• Obsessive-compulsive, dependent, avoidant, histrionic,

borderline

• Which personality disorder is characterized by excess grandiosity?
• Narcissistic, borderline, obsessive-compulsive, dependent,

avoidant

• Cluster B includes all but one of the following:
• Obsessive-compulsive, narcissistic, antisocial, borderline,

histrionic

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General Considerations

• Enduring patterns of behavior
• Culturally dys-synchronous
• Cognition, affectivity, interpersonal functioning, impulse

control

• Not due to other psychiatric illness or substance abuse

Classification, Coding

• Axis II disorder (persistent, enduring)
• Axis I refers to “episodic” illnesses
• Clusters A,B,C
• Personality disorder NOS

Cluster A

• Paranoid
• Schizoid
• Schizotypal
• co-morbidity: Psychotic disorders
• Extremely rare in clinical populations

Paranoid PDO 301.0

• Pervasive sense of distrust
• 4/7 of: suspiciousness, preoccupation with others’

untrustworthiness, reluctant to confide, reads “threats” in benign encounters, bears grudges, sensitive to attacks and quick to counter , suspicious of infidelity

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Paranoid PDO

• DfDx: Delusional Disorder

, Schizophrenia

• Approach: T
• lerate suspiciousness, give thorough

explanations, respect privacy rigorously, allow to express doubts about care issues, build trust over time

Schizoid PDO 301.20

• Detachment and restricted affect
• 4/7 of: no desire for close relationships, solitary, hypo-sexual,

anhedonia, no close friends, indifferent to feedback, emotional coldness

Schizoid PDO

• DfDx: Avoidant PDO, Schizophrenia
• Approach: T
• lerate reticence, expect social anxiety in

conditions of “forced intimacy” (e.g., hospital admission), car e through a single trusted physician, build trust over time, relat e

• n a “fact” rather than “feeling” “currency”

Schizotypal PDO 301.22

• Isolation, social anxiety, eccentricities, cognitive distortions,

near-psychotic at baseline

• 5/9 of: IOR, odd beliefs, unusual percepts, odd

thinking/speech, suspiciousness, inappropriate affect, odd appearance/behavior , isolation, social anxiety

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Schizotypal PDO

• DfDx: Schizophrenia (often a difficult distinction)
• Approach: T
• lerate odd interactive style, may have a need for

“alternative” evaluation and therapy, tolerate anxiety in force d intimacy situations (as with schizoid PDO), relationship with

• ne physician over time, psychotic decompensation likely

Cluster B

• Antisocial
• Borderline
• Histrionic
• Narcissistic
• Co-morbidity: Mood, anxiety (PTSD), eating

(bulimia), dissociative, somatoform, substance abuse disorders

• Extremely common in clinics

Antisocial PDO 301.7

• Disregard/violation of rights of others
• 3/6 of: unlawful behavior

, deceitfulness, impulsivity, irritability, disregard for safety, irresponsibility

Antisocial PDO

• DfDx: Borderline and Narcissistic PDO, ADHD
• Approach: Caution, expect dishonest reporting of symptoms, high

risk of malingering and litigious threats, interact with judicial system, document thoroughly, rely on objective findings, don’t “go it alone”

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Borderline PDO 301.83

• Instability and chaos
• 5/9 of: frantic efforts to avoid abandonment,

idealization/devaluation, identity disturbance, impulsivity, suicidal behavior , affective instability, “emptiness,” anger dys- control, transient paranoia or dissociation

Borderline PDO

• DfDx: Broad but cases usually clear to experienced clinician
• Approach: Limit setting, stable relationship with one physicia

n, limit doctor shopping, capitalize on “institutional transference,” tolerate affects but confront unsafe behavior , use extenders appropriately, limit phone contacts

Histrionic PDO 301.50

• Excessive emotionality and attention seeking
• 5/8 of: must be center of attention, seductive, shallow

emotions, physical appearance to derive attention, impressionistic speech, dramatic, suggestible, “pseudo- intimacy”

Histrionic PDO

• DfDx: Borderline and Narcissistic PDO
• Approach: Seek details, do not base therapeutic decisions on

complaints alone, as they are inevitably exaggerated, may be good placebo responders, confront behavior gently in the “here and now”

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Narcissistic PDO 301.81

• Grandiosity, Grandiosity, Grandiosity
• “Legends in their own minds”
• 5/9 of: grandiose, fantasies of idealization, “specialness,”

requires excess admiration (“mirror-hungry”), entitlement, exploitation, “hypo-empathic,” envy, arrogance

Narcissistic PDO

• DfDx: Bipolar d/o, antisocial, borderline, histrionic PDO
• Approach: Very challenging patients who like to challenge y
• u.

As long as safe to do so, involve them in treatment decisions (“pseudo-colleague”), capitalize on entitlement by mobilizing it in service of care, set limits on acting out

Cluster C

• Avoidant
• Dependent
• Obsessive-compulsive
• Comorbidity: anxiety and mood disorders, substance use

disorders for avoidants with social phobia, eating d/o (avoidant and obsessive-compulsive)

Avoidant PDO 301.82

• Social inhibition and inadequacy
• 4/7 of: social avoidance, reticent of involvement without

reassurance, restraint within intimate relationships, preoccupation with criticism, self-view as socially inept, reluctant to take risks

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Avoidant PDO

• DfDx: Social phobia, Schizoid PDO
• Approach: Allow warm-up, tolerate oblique style of

communication, more active role in interview

Dependent PDO 301.6

• Failure of differentiation
• 5/8 of: excess need for advice, deferential, inability to

disagree, lack of initiative, excess need for support, helpless when alone, urgently seeks new relationships, fear of being alone

Dependent PDO

• DfDx: Borderline and avoidant PDO
• Approach: Allow dependency but set limits, thorough use of

extenders to “diffuse” dependency, groups of almost any sort

Obsessive-compulsive PDO 301.4

• Preoccupation with order and control
• 4/8 of: detail preoccupation, perfectionism, “work-oholism,”
• ver-conscientiousness,hoarding, reluctant to delegate,

parsimonious, rigidity and stubbornness

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Obsessive-compulsive PDO

• DfDx: OCD, Narcissistic PDO
• Approach: Expect to see articles, internet searches, data of all

sorts; avoid feeling threatened, but appreciate the patient’s need for data more than emotional support, be quantitative, allow them control over treatment options where safe

Personality D/O NOS and “Traits Only”

• For cases who are not a clear fit or for whom suspicion is

greater than the available data

Psychiatric Referral

• Dangerousness (suicidal, homicidal, psychotic)
• Diagnostic clarification
• Management of co-morbid psychiatric illness,

including substance abuse

• Psychopharmacologic consult - e.g., some newer

literature suggests pharmacotherapy for personality disorders directly

Co-management

• Clear communication in both directions, patient must consent
• Face-to-face meeting with psychiatrist/other MHP and

primary care physician

• Other agencies very commonly involved

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Other considerations

• Many “high utilizers” are personality disordered patients

(often with other psychiatric co-morbidity) with significant dependency needs

• Consider confronting utilization itself as a dependency

behavior

Summary/Questions

• Discussion