Awkward Conversations: Personality Disorders

Personality disorders are characterized by rigid ways of thinking and feeling about one’s self and others in a way that significantly and adversely affects function.

There are 10 distinct types of personality disorders (PD) including: paranoid personality disorder, schizoid personality disorder, schizotypal personality disorder, antisocial personality disorder, borderline personality disorder, histrionic personality, narcissistic personality disorder, avoidant personality disorder, dependent personality disorder, and obsessive-compulsive personality disorder. Each PD has its own diagnostic criteria and each is presumed to vary in severity along a continuum.

Although all are distinctive, they each reflect long-term patterns of unhealthy thoughts and maladaptive behaviors leaving a swath of interpersonal destruction.

THE PREVALENCE OF PERSONALITY DISORDERS

PDs are relatively uncommon in the general population (only 9.1% of people are diagnosed and treated), but they are dramatically overrepresented in healthcare settings, particularly in rheumatology. Blaney et al., writing in the January 2020 issue of Epidemiology and Psychiatric Sciences, reported that “immune-mediated inflammatory diseases (IMID) are associated with an increased incidence of personality disorders both before and after an IMID diagnosis.”¹ They found that among 19,572 cases of immune-mediated inflammatory diseases (including inflammatory bowel disease, multiple sclerosis, and rheumatoid arthritis) and a control population of more than 97,000 patients, the IMID cohort had a consistently increased incidence of PDs over time. Notably, the incidence of PDs was also elevated before IMID diagnosis relative to matched controls (Blaney et al., 2020).

PERSONALITY DISORDERS IN THE RHEUMATIC POPULATION

Swedish investigators writing in 2008 in the Archives of General Psychiatry (and republished in JAMA Psychiatry) reported that patients with rheumatoid arthritis, systemic lupus erythematosus, and ankylosing spondylitis have a higher risk of psychiatric disorders than the general population. This was a cohort study conducted between 1973 and 2004. Investigators found a high incidence of occurrence with standardized incidence ratios for rheumatoid arthritis, systemic lupus erythematosus, and ankylosing spondylitis were 1.45, 2.38, and 1.69, respectively, for men, and 1.36, 2.16, and 1.95, respectively, for women. "Systemic lupus erythematosus carried an increased risk of dementia and delirium. Only women with rheumatoid arthritis and systemic lupus erythematosus had an increased risk of psychotic disorders and severe depression," wrote Kristina Sundquist, MD, PhD, et al.²

Some studies have suggested an increase in the incidence of neuropsychiatric disorders may be due to the immunological mechanisms of the disease itself. The stress of having a rheumatic condition is a key factor as well. This study found that affective disorders, personality disorders, and neurotic disorders were among the most prevalent in the study group.

EXCESSIVE HEALTHCARE UTILIZATION

PDs are characterized by excessive healthcare utilization patterns. One study of traditional medical patients vs medical patients with borderline personality disorder (BPD) reported that patients with BPD saw twice as many primary care physicians and nearly twice as many specialists. Their increased morbidity is reflected in a life expectancy that is nearly 2 decades shorter than the general population. The life expectancy for women with a PD is 63.3 years and 59.1 for men. That mortality risk is, in part, attributable to self-harm and substance abuse but more so to conditions like obesity (4.5 times higher rate than the general public), cardiovascular diseases, and sleep disorders, all of which are harder to treat given the psychopathology that presents itself in the room. That pathology interferes with the patient’s ability to access care and to benefit from it once they do. For example, patients with PD have a harder time building rapport with providers and are more likely to be non-compliant with care recommendations. Patients with PD can be especially challenging to manage in specialty settings given their risk for self-harm and the aggressive or disruptive behaviors that are their hallmark.

On the far end of a pathology continuum, patients with PD may sabotage their own health and medical care. In one study, 16.7% of participants with PD acknowledged intentionally making medical situations worse, 2.9% of participants with PD reported intentionally exercising an injury on purpose, and 4.2% of participants with PD engaged in behavior to deliberately prevent wounds from healing. Patient with PD also often have behavioral health complications that can be especially threatening among patients with compromised immune systems in rheumatology settings. Sixty-four percent of PD patients have experienced substantial substance-use problems in their lifetime (most commonly benzodiazepines, opiates, and stimulants) and they are also more likely to misuse prescribed medication (the self-reported rate of prescription-medication misuse is 9.2% among patients with PD). Their health complaints are severe and varied and sometimes defy explanation. In fact, 36% of patients with PD will be diagnosed with somatization disorder. Patients with PD report more pain now and over the past year and they score twice as high on measures of pain catastrophizing. And the physical health fallout isn’t limited to the patients, the first-degree relatives of patients with BPD are reported to have higher-than-expected rates of somatoform pain disorder too. Caring for the sexual health of these patients is also made more challenging by higher rates of risky sexual behavior, which is reflected in earlier sexual behavior, more sexual partners, more frequent sexually transmitted diseases, and a greater likelihood of sexual coercion and date rape.

MY PRACTICE

In my own professional experience, I can attest that nearly all of the really challenging patients referred to me by my specialty physician colleagues had some manner of PD. These patients tax everyone in the system but, thankfully, there are several strategies for managing them more successfully. First, recognize and acknowledge just how challenging their presentation is and recognize how chaotic this patient’s own experience may be.

I do a lot of training on managing PD in healthcare settings. I talk about how the emotional experience of the provider is the emotional experience of their patient. If you are made to feel inept or self-conscious, likely your patient has outsourced their own experience of feeling scrutinized. If you are made to feel angry, frustrated, or resentful—that patient is outsourcing those turbulent, aversive feelings. The more powerful your own reaction is to this patient, the more severe their own turmoil. In other words, if you behave badly, so too will your patient.

In psychiatry and psychology, we talk a lot about countertransference, but this phenomenon is actually simpler than that—you are the mirror for the patient’s emotional experience. Thinking about your reactions in that way can depersonalize and destigmatize them so they can be aired out and addressed. Discussing your reactions with your peers can unify the care team so the patient can ultimately be more effectively supported.

In the room with an agitated patient with PD, an empathic response can go a long way towards de‐escalating a situation. In practice, empathy may invoke the least amount of anger in patients with PD. You will come to realize that you win by losing battles with patients. The typical power struggle a patient with PD creates is exaggerated by rigid policies, requirements, and your own judgement, which will dictate when it is safe and practical to release restrictions with any particular case.

VALUE CONSISTENCY

Another easy intervention for healthcare professionals is to keep messaging and behavior consistent.

Patients with PD will find and exploit the team member who goes off message or allows more flexibility. Meeting with the patient as a team ensures that consistency. Make a point to reinforce desired behaviors and ignore the maladaptive ones. Patients with PD often act out to get your attention. After all, when they are healthy and compliant, you are less likely to give them their desired reaction.

Give these patients attention on a time‐contingent—rather than behavior‐contingent—basis. For example, if your patient remains agitated after your brief attempt to problem solve a non-emergent issue, you can walk away withpromise to return after a specified period of time and engage in that conversation when they are calmer. In this way, you are reinforcing their calm demeanor and healthy behavior and you can do that everywhere possible. You can also make a point to suggest healthier coping strategies.

In rheumatology cases where substance abuse or medication non-compliance can be especially risky, stick to behavioral prescriptions for stress relief. Here, I like using Eriksonian suggestions, such as, “You might find that 60-second mindfulness exercise helps you regain your footing the next time someone upsets you.”

This brings me to the most important directive for healthcare professionals working with challenging patients: refer them to a mental health specialist. Obviously, you will make an emergent psychology/psychiatry consult for any patient who has threatened or engages in self‐harming behavior, or harm to others, but consider making that same referral for diagnostic clarification or to support the development of a more complex behavior management plan. My mental health colleagues are especially skilled at problem‐solving around PD patients and in addressing those problems in their own offices so that you can ultimately be more successful in yours.

References:

1. Blaney C, Sommer J, El-Gabalawy R, et al. Incidence and temporal trends of co-occurring personality disorder diagnoses in immune-mediated inflammatory diseases. Epidemiol Psychiatr Sci. 2020;29:e84. Published 2020 Jan 9. doi:10.1017/S2045796019000854
2. Sundquist K, Li X, Hemminki K, Sundquist J. Subsequent risk of hospitalization for neuropsychiatric disorders in patients with rheumatic diseases: a nationwide study from Sweden. Arch Gen Psychiatry. 2008;65(5):501-507. doi:10.1001/archpsyc.65.5.501