Mastering Challenges in Case Management:

Transcription

1 Mastering Challenges in Case Management: Working with Clients Who Have Personality Disorders Presented by Kate Harri, MA, LP Working Solutions, LLC September 2014

2 Outline Know the six most common Personality Disorders Understand what "causes the development of these disorders Learn the best practice treatment for these conditions Enhance claim management skills to join with and work successfully with individuals who have these diagnoses impacting function

3 Characteristics Common in Personality Disorders Behaviors that are problematic are developed in late adolescence or early adulthood Behaviors are life-long and resistant to change Medications are generally ineffective The individual blames others for the problems that arise; they are unaware of their poor coping skills The behaviors result in significant disruption in the individual s personal and work life. Some behaviors can be life threatening.

4 Characteristics Continued The individual is fragile Over-reacts to normal life events and stressors Regresses easily Once regresses, challenging to get back to baseline If in treatment, any added stressor can become the focus of treatment due to the over-reaction of the patient, thus delaying recovery.

5 The Six Most Common Disorders Antisocial PD: Males 5.8% of population; females 1.2% Borderline PD: 5.9% of population (75% are female) Dependent PD: 0.5% of population (equal in males and females) Histrionic PD: 1-3% of population (females 4x more likely) Narcissistic PD:1% of PD (more prevalent in males) Obsessive Compulsive PD: 1% of population (twice as common in males) Overall prevalence of PD in the general population is 9%. -NIMH 2007

6 One Key Factor to Consider Most providers do not identify the presence of any personality disorder as part of their assessment due to stigma, or misdiagnosing Research information gathered by Pam Warren, PhD in 2009 on assessment in worker s compensation claims revealed:22% of cases had adequate evaluation, 48%, superficial, and 30% had no evaluation What does this suggest about potential accuracy of diagnosis and treatment impact?

7 Getting Stuck: Impact of All Personality Disorders Personality disorders are conditions in which people have traits that cause them to feel and behave in socially distressing ways, limiting their ability to function in relationships and in other areas of their life, such as work or school.

8 Getting Stuck What if There is More Than Just A Personality Disorder Present? Impact of personality disorder on an individual s life Impact of psychosocial stressors Impact of physical condition Impact of existing mood disorder (sub-acute) Impact of existing mood disorder (diagnosed and treating for it) Over time, all conditions get worse if not addressed and treated appropriately

9 It s Not Hopeless; It s About Knowing What to Look for And What to Do Know the diagnosis Know best practice treatment Be on the lookout for the possibility of the presence of personality disorder Be mindful of the presence of psychosocial stressors Know how to talk with patients and providers

10 The Slightly Sullied Six Diagnoses Possibly caused by Early childhood trauma (sexual or physical abuse) resulting in attachment issues (relationship problems, distortions) Pampering or neglect by adults Genetics Verbal abuse Inconsistent and unpredictable parenting Peers Negative relationship with an adult -American Psychological Association

11 Diagnosing PD Thoughts and behaviors deviate from accepted norms: Cognitive distortions Affect (labile or not appropriate to situation) Control over impulses and self-gratification lacking Poor interpersonal skills

12 Diagnosing PD The deviations are INFLEXIBLE/RIGID Maladaptive Dysfunctional across a wide range of work, personal situations

13 Diagnosing PD The deviations are LONG STANDING STABLE (enduring) Start in late adolescence or early adulthood

14 Diagnosing PD The deviations do not have another explanation such as another mental health condition or use of a substance Providers should eliminate organic brain disease, injury or dysfunction as a possible cause of the deviation

15 Fun Facts to Know and Tell A study at the University of Surrey, UK, indicated three personality disorders were more common in executives than criminals Histrionic Narcissistic Obsessive Compulsive Board, Belinda Jane; Fritzon, Katrina; Disturbed Personalities at Work, Psychology, Crime and Law, 2005.

16 The Recipe for Developing a Personality Disorder It is a disturbance of attachment Can be caused by unhealthy treatment of the child by an adult Sexual abuse Physical abuse Significant neglect Overprotective or authoritarian

17 Borderline Personality Disorder Diagnosis A pervasive pattern of instability of interpersonal relationships, self-image and affect. Marked impulsivity that begins by late adolescence or early adulthood and is present in a variety of contexts. NOTE: it is frequently mistaken for other conditions Bipolar Disorder Depression Anxiety Substance abuse/dependence

18 Borderline PD Cont. Often has mood disorder present as a secondary condition but is noted by provider as primary condition Must be very carefully assessed for accurate diagnosis!

19 Borderline PD Diagnosis Cont. Indicated by 5 or more of the following: Frantic efforts to avoid real or imagined abandonment Patterns of unstable and intense personal relationships (extremes of idealization/devaluation) Markedly and persistently unstable self-image Impulsivity in at least two areas that are potentially self-damaging such as spending, sex, substance abuse, reckless driving, binge eating

20 Borderline Cont. Recurrent suicidal gestures, threats or self-mutilating behavior Unstable mood often referred to as mood lability or dysregulation Chronic feelings of emptiness Inappropriate, intense anger; difficulty controlling anger Transient, stress-related paranoid ideation or severe dissociative symptoms

21 Treatment Considerations They fear abandonment They will alternately think others are the best thing that ever happened to them or the worst (makes developing a professional relationship very challenging!) Can accidently do serious harm or cause their own death through suicidal gestures that are meant to get your attention Moving target with both feelings and behaviors VERY difficult to treat

22 Borderline PD: Effective Treatment Dialectical Behavior Therapy (DBT) is the treatment recognized to have positive results Teaches the person how to manage their feelings without acting out their anxiety or distress in maladaptive ways Intense treatment format; includes group several times a week and weekly individual therapy over several months Participants keep a daily diary of incidents; feelings; reactions-they are taught how to RESPOND rather than REACT-this is also reflected then in the diary as they practice the skills taught in group and oneon-one

23 The Antisocial Personality Disorder Indicated by 3 or more of the following: Failure to conform to social norms with respect to lawful behaviors Deceitfulness, such as repeated lying, use of aliases, conning others Impulsivity Irritability and aggression; fights and assaults

24 Antisocial Diagnosis Cont. Reckless disregard for safety of self or others Consistent irresponsibility, repeated failure to sustain consistent work behavior or to honor financial commitments Lack of remorse Person is at least 18

25 Treatment Considerations Because they don t care about you or anyone else.they are difficult to treat It s everyone else s fault I am going to do what I want to and you can t make me do anything They don t care about you, they disregard the rights and feelings of others and are self-absorbed. Your emphasis and focus has to be on what s in it for them. Realistically, you may not see many of them; they are usually spending their time in front of judges and in jail.

26 Dependent Personality Disorder Characterized by a pervasive and excessive need to be taken care of that leads to clinging and submissive behavior and fears of separation. Indicated by 5 of the following: Difficulty making everyday decisions independently Needs others to assume responsibility for most major areas of life Has difficulty expressing disagreement-fear of loss of support or approval

27 Diagnosis Cont. Difficulty initiating projects or doing things on own Goes to excessive lengths to obtain nurturing or support Feels uncomfortable being alone Urgently seeks another relationship when a close relationship ends Unrealistically preoccupied with fears of being left to take care of self

28 Treatment Considerations They don t seek treatment of their own volition; they don t see that their behavior is problematic (true of all PDs) They often develop a mood disorder (depression) secondary to the PD and may seek treatment for that Providers may miss seeing the PD and only treat the symptoms of depression NOTE: If the person is not getting better despite several medication trials, strongly suspect the PD is primary Their overall motivation will be for you to take care of them-hence, they will react strongly to any suggestion their benefits may end

29 Treatment Considerations Cont. Best treatment should be short term; especially as they can become dependent on the providers Assertiveness training teaching them how to advocate and speak for themselves Increase independent activity such as making decisions about everyday things Teach strategies on managing anxiety Expand ability to be on their own, by themselves Teach what constitutes healthy relationship and how to manage their part in having a healthy relationship as well as the benefits (that the relationship usually lasts longer)

30 Histrionic Personality Disorder Pervasive and excessive emotionality and attentionseeking behavior. Individuals feel uncomfortable or feel unappreciated when they are not the focus/center of attention. They are commonly known as the life of the party. They are the Hey Mom, Look at me! people

31 Histrionic PD Diagnosis/Differentiation Can be confused with other diagnoses Borderline PD-differentiator is that Borderline will threaten self-harm Dependent PD- differentiator is that the dependent personality is not flamboyant Narcissistic PD-won t look fragile or dependent to get attention or to get needs met

32 Histrionic PD Diagnosis Indicated by 5 or more of the following: Uncomfortable in situations where he/she is not the center of attention Interactions with others often characterized by inappropriate sexually seductive or provocative behavior Displays labile emotions Consistently uses physical appearance to draw attention to themselves

33 Diagnosis Cont. Style of speech lacks details or is overly impressionistic Shows self-dramatization, theatricality and exaggerated expression of emotion Is suggestible (easily influenced) Considers relationships to be more intimate than they really are

34 Histrionic PD Treatment Considerations As the symptoms are similar to Borderline Personality Disorder Treatment that is most effective is DBT to positively impact: Poor judgment Mood lability Attention seeking with disregard for consequences to self and others

35 Narcissistic Personality Disorder Diagnosis A pervasive pattern of grandiosity, need for admiration and lack of empathy for others.

36 Narcissistic PD Diagnostic Criteria Indicated by 5 or more of the following: Grandiose sense of self-importance (exaggerates, feels superior and expects recognition) Preoccupied with fantasies of unlimited success, power, brilliance, beauty or ideal love Believes they are special and unique and can only be understood by others like themselves (hard to find!) Requires excessive admiration

37 Diagnosis Cont. Sense of entitlement Exploits others for their own gain Lacks empathy Envious of others or that others envy them Arrogant, haughty behaviors and attitude prevalent

38 Narcissistic Treatment Considerations Gotta be special! If they have a physical illness, this can seriously complicate things as they see themselves as perfect and this shatters that. This can delay recovery! Demand to be treated by experts -will not accept common providers Rigid and fragile-anything can upset their day or lifeputting them into a tailspin

39 Treatment Considerations Cont. Cognitive Behavior Therapy (CBT) in a group format with one-on-one individual therapy is best. Allows them to feel special with the individual sessions Allows them to gradually get feedback from others on their destructive attitudes and behaviors CBT strategies focus on changing the irrational belief that they are special to one of appreciating their uniqueness without putting down others Medications can augment depressive symptoms if present Individual does not generally want to go to treatment as they see nothing wrong with behavior; usually forced to go by others in their life

40 Obsessive-Compulsive PD A preoccupation with orderliness, perfectionism, and mental and interpersonal control, at the expense of flexibility, openness and efficiency.

41 Obsessive Compulsive PD compared to OCD The main differences between Obsessive Compulsive PD and OCD is the PD: Enjoys perfecting something They do not feel distressed during or after engaging in these behaviors They do not engage in ritualistic behaviors

42 Diagnostic Criteria Indicated by 4 or more of the following: Pre-occupied with details, rules, lists, order, organization or schedules to the extent that the major point of the activity is lost Shows perfectionism that interferes with task completion (can t get the task done because the standard they set mentally is not being met) Excessively devoted to work and productivity to the exclusion of their personal life

43 Diagnostic Criteria Cont. Over-conscientious, scrupulous and inflexible about matters of morality, ethics or values Unable to discard worn out or worthless objects regardless of value Reluctant to delegate tasks or to work with others unless they submit to exactly his or her way of doing things Adopts miserly spending style toward self and others; money is hoarded for the future Shows rigidity and stubbornness

44 Obsessive Compulsive PD Treatment Considerations Most effective is Cognitive Analytic Therapy (CAT) Focus on understanding patterns of behavior that are ineffective, help person recognize the patterns, understand origins and then to change them to other strategies that are more effective in meeting life and work goals. If CAT is not available, CBT is also recognized to be most effective Therapy is short term; average is 16 weeks This disorder does respond to antidepressant medication; Prozac is recommended Need assistance in managing feelings of depression and anxiety as they change BONUS: this PD tends not to abuse chemicals (due to rigidity/morals)

45 SO.What is Best for You to Do in Managing These Types of Individuals? Don t panic! Keep your perspective intact Remember you are not crazy (someone with a PD can make you feel that you are ) STAY CALM and STAY THE COURSE Get support from colleagues as needed!

46 Communication with the Dependent Personality Disorder They want to cling -you may need to clarify your role as many times as needed They are afraid they can t make the goals set; celebrate small steps and keep them focused on the next small step They could suck you dry; set limits on the time you spend with them! Set clear boundaries and stick to them They fear rejection and will call you and call you and call you anticipate this and call them first Do what you say you will do; be consistent (to a fault)

47 Communication with the Borderline Personality Disorder They tend to overreact to EVERYTHING; remain cool, calm and collected They look for signs you don t care about them; be consistent and reassure as needed DO NOT make a promise you can t keep DO NOT react Overall, no matter what they do, be there for them-being cool, calm and consistent Stay the course; be supportive, encouraging as well as staying focused on the goals

48 Communication with the Narcissistic Personality Disorder They are special and expect to be treated by experts!-let them know they are working with you-the BEST in the business They have fragile egos; be respectful and have lots of patience with their resistance/reluctance They are sensitive to criticism; be sure you are on solid ground with them before introducing anything that could be seen as being critical of them Find ways to compliment-be genuine As they are so special and unique, let them know the work you do with them is personalized!

49 Communication with the Antisocial Personality Disorder They are similar to the narcissistic PD; very sensitive to criticism so- BE SURE TO BE ACCEPTING without MORALIZING They have a value system that is disturbing to us; monitor your own reactions and feelings so you don t have an attitude when communicating with them They are all about themselves; no one else matters-so be sure you focus everything on THEM and what s in it for THEM They do not care about others; again, keep in mind what resonates is What s in it for me? If they see there is something in the Deal for them, they will participate.

50 Communication with the Histrionic Personality Disorder They are similar to Borderline PD Be clear Be calm Be consistent Stay focused; do not go on their emotional roller coaster with them Keep boundaries clear and consistent Let them know something they did well each time you talk

51 Communication with the Obsessive Compulsive Personality Disorder They will want to do things perfectly or not at all Stay focused on the goals in a way they see a small success is GREAT! As they accomplish things, give them positive feedback Reinforce that doing things ok is good enough; that is best-rather than trying to get it just right.

52 Summary of Strategies with all Personality Disorders Calm Consistent Follow up and follow through Celebrate small successes Stay off the emotional roller coaster If you get frustrated, talk to a colleague! Vent with them rather than with the claimant Be non-judgmental

53 Because They fear rejection They don t think they ever do anything wrong; everyone else does Not much works to improve their condition easily (they can t take a pill for their personality) They are reactive and wonder why everyone around them is going nuts They have poor judgment They have distorted thinking that leads to the inappropriate behaviors

54 Now A Note About Psychosocial Stressors- Here are Common Ones Work Family Financial Health Childcare Eldercare Legal Marital/Partner Loss of Loved One

55 Psychosocial Stressors Normal Everyone has them What are yours? Usually present with Personality Disorder They create them They overreact to ones that are present

56 Psychosocial Stressors- Stuff Happens Incident happens (divorce, assault, robbery, death in family etc.) It complicates recovery Distracts treating providers from the main focus Can actually derail treatment or interrupt progress

57 What About Being Off Work Due to Diagnoses? Providers (and case managers) are tempted to avoid talking about work Work stress probably had something to do with the patient being off work Hard to bring it up for discussionoverreaction/disengagement possible

58 Why is Return to Work Important? TIME IS TICKING Journal of Occupational Medicine in 2003 stated If someone is off work 3 months; chance they will RTW If someone is off work 6 months; 20% chance they will RTW American Psychiatric Association in 2005 stated Being off work is a crisis All resources need to be utilized to aid in recovery Work is therapeutic

59 Being Off Work Can Be Dangerous To Your Health Workplace absence = Decreased Physical Health Decreased Mental Health Decreased Financial Health Decreased Social Support RESULTING IN 50% increase in MORTALITY -P. Warren, 2009

60 Getting Back to Work is Important How do You Talk With Providers? Do your homework Know the diagnosis Know the treatment plan Know the response to medications Know the progress to date Know the inconsistencies Know the person s current level of function (vs symptom reporting) Is return to work part of the plan by the provider?

61 The Call/Common Questions to Ask MAKE A LIST OF THE QUESTIONS YOU NEED AN ANSWER TO BEFORE THE CALL Focus your questions on level of function; not symptom reporting Ask what they have talked with the patient about regarding work and return to work Ask if they are willing to make changes to the plan (if the patient is not improving) Ask what they would need to see to indicate the patient is improving to the point either volunteer work or a trial gradual return to work could be initiated Share the research about being off work and how it impacts mental health and psychosocial issues

62 The Call/Joining with the Provider Indicate you have read the medical information and You can see this is a complicated case You can see they have been trying to change things to improve the patient s status You are concerned-and you suspect they share this concern that the patient does not seem to be showing much improvement to date Ask them what they think are the barriers present impacting recovery Ask them what would help reduce or eliminate the barriers

63 The Personality Disorder Factor If the information you have suggests there may be a PD present- or at least traits of PD present impacting the duration of the claim Ask the provider if he/she has wondered if there is a PD or traits present More often than not, they will admit it if there is- Ask then what else could be done in the treatment plan to address this and reduce the impact the PD is having on recovery Maintain your focus: getting the best treatment for recovery!

64 Summary Know the diagnosis and Look for possible PD Review the treatment to date; is it getting results? Join with patients where they are if PD is present Have your questions prepared before calling the providers Join with them Know the patient s level of function Be sure to address return to work

65 Questions? Thank you for attending today! Contact information Kate Harri, MA LP