Managing Personality Disorders in Primary Care

Transcription

1 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 comorbidity is cluster: A, B, C, D A solitary patient without obviously eccentric cognitions or 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 1

2 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 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 2

3 Paranoid PDO DfDx: Delusional Disorder, Schizophrenia Approach: Tolerate suspiciousness, give thorough explanations, respect privacy rigorously, allow to express doubts about care issues, build trust over time Schizoid PDO 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: Tolerate reticence, expect social anxiety in conditions of forced intimacy (e.g., hospital admission), care through a single trusted physician, build trust over time, relate on a fact rather than feeling currency Schizotypal PDO 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 3

4 Schizotypal PDO DfDx: Schizophrenia (often a difficult distinction) Approach: Tolerate odd interactive style, may have a need for alternative evaluation and therapy, tolerate anxiety in forced intimacy situations (as with schizoid PDO), relationship with one 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 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 4

5 Borderline PDO Instability and chaos 5/9 of: frantic efforts to avoid abandonment, idealization/devaluation, identity disturbance, impulsivity, suicidal behavior, affective instability, emptiness, anger dyscontrol, transient paranoia or dissociation Borderline PDO DfDx: Broad but cases usually clear to experienced clinician Approach: Limit setting, stable relationship with one physician, limit doctor shopping, capitalize on institutional transference, tolerate affects but confront unsafe behavior, use extenders appropriately, limit phone contacts Histrionic PDO 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, pseudointimacy 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 5

6 Narcissistic PDO 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 you. 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 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 6

7 Avoidant PDO DfDx: Social phobia, Schizoid PDO Approach: Allow warm-up, tolerate oblique style of communication, more active role in interview Dependent PDO 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 Preoccupation with order and control 4/8 of: detail preoccupation, perfectionism, work-oholism, over-conscientiousness,hoarding, reluctant to delegate, parsimonious, rigidity and stubbornness 7

8 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 8

9 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 9