PERSONALITY DISORDERS

A personality disorder is a way of thinking, feeling, or behaving that deviates from the expectations of the prevailing culture and causes distress or problems functioning. Types of personality disorders include:

  • Borderline personality disorder
  • Obsessive-compulsive personality disorder
  • Histrionic personality disorder
  • Dependent personality disorder
  • Narcissistic personality disorder
  • Paranoid personality disorder
  • Schizoid personality disorder
  • Schizotypal personality disorder

Obsessive-compulsive personality disorder (OCPD) is the most prevalent, with rates around 5% of the general population. Borderline personality disorder (BPD) prevalence is estimated to be 1.6% in the general population. Personality disorders are highly comorbid with other mental health disorders, substance abuse, and medical problems such as sleep disturbance, chronic pain, and obesity (Feldman, 2021; Chapman et al., 2022).

Core features of personality disorders include:

  • Interpersonal difficulties: Stormy relationships, especially with people to whom they are close to
  • Affective dysregulation: Affective lability, excessive anger, and efforts to avoid abandonment
  • Behavior dysregulation: Impulsivity, suicidality, and self-injurious behaviors
    (Skodol, 2022)
SCREENING FOR PERSONALITY DISORDERS

While there are no specific tests that can diagnose personality disorders, there are screening instruments that can assist in identifying them. For example, a screening tool for assessing for borderline personality disorder is the McLean Screening Instrument for Borderline Personality Disorder (MSI-BPD), a 10-item measure based on the DSM-5 diagnostic criteria. It is useful for detecting individuals who may have borderline personality features and is very effective in detecting possible BPD in people who are seeking treatment or who have a history of treatment for mental health problems. However, it is not known whether it is good at detecting BPD in the general public (CAMH, 2022b).

Treatment Modalities for Personality Disorders

Treatment can be problematic, as people with personality disorders tend to externalize, seeing their problems as “out there” and not within themselves. They rarely see themselves or their behavior as problematic and tend to blame others for any failure or missteps. Various forms of psychotherapy are the first-line treatments for personality disorders, along with symptom-targeted medication treatment. Medications may include mood stabilizers, antipsychotics, and antidepressants (Skodol, 2022).

Common Symptomatic Behaviors among Persons with Borderline Personality Disorder

Patients who have this particular personality disorder have always been present in medical settings and most often are described as “hard to care for” or “difficult.” Interactions with patients who have this disorder can make most healthcare providers feel mentally exhausted. Patients may display various behaviors that are suggestive, but not diagnostic, of BPD. These may include:

  • Aggressive or disruptive behavior: Refusing treatment, angry outbursts out of proportion to the situation, demandingness, or intimidation
  • Intentional sabotage of medical care: Making medical situations worse, such as preventing wounds from healing, which may function as a means to cause self-injury
  • Excessive healthcare utilization: Seeing a great number of primary care physicians, taking more prescription medications, and being more frequently referred to specialists
  • Alcohol and substance misuse, including abuse of prescription medications
  • Multiple somatic complaints in an attempt to elicit caring responses from others
  • Chronic pain syndromes, thought to be related to the inability to self-regulate
  • Sexual impulsivity: Greater sexual preoccupation, greater number of sexual partners, and broader range of sexual experience, which may manifest in higher rates of sexually transmitted infections
  • Black-white thinking, meaning others are either 100% for them or 100% against, or “all good” or “all bad” (referred to as splitting)
    (Skodol, 2022)

How to Respond to and Care for a Patient with Borderline Personality Disorder Signs and Symptoms

The following are some important principles to keep in mind when responding to and caring for patients who have borderline personality disorder:

  • Set explicit guidelines and boundaries for expected behaviors on their part, as well as what the patient can expect from the healthcare provider, and expect the patient to test these limits repeatedly.
  • Ensure that patients are fully aware they will be held responsible for their behaviors, and that when limits or policies are not followed, consequences will be enforced in a matter-of-fact, nonjudgmental manner.
  • Be clear as to the facility policies and the consequences if policies/limits are not adhered to.
  • Approach the patient in a consistent manner in all interactions, being aware that exceptions encourage a manipulative behavioral response.
  • Monitor one’s own thoughts and feelings constantly regarding responses to the patient, as strong and intense countertransference reactions (emotional entanglement with the patient) can occur.
  • Refrain from sharing personal information with the patient, which can open up areas for manipulation.
  • Be aware that flattery is an attempt to make a caregiver feel special and can pit one staff member against another, which can undermine the patient’s need for limits.
  • Reiterate boundaries if the patient becomes seductive.
  • Be alert to the prospect of the patient engaging in “splitting” behavior among staff, making one the “good guy” and another the “bad guy.”
  • Help to minimize manipulations by developing a clear and concrete written plan of care for all staff to follow.
  • Remain neutral and calm and avoid power struggles if the patient becomes hostile or projects blame onto others.
  • Recognize that acting out behaviors often stem from underlying feelings of anger, fear, shame, insecurity, or loneliness.
  • Remain neutral but firm when patients with a personality disorder attempt to instill guilt if they do not get what they want.
  • Be aware that reinforcing positive behaviors might increase the likelihood of repetition, and ignoring negative behaviors (when feasible) deprives the patient of negative attention.
  • Assess for self-mutilating or suicidal thoughts or behaviors.
  • Observe for mood changes, as many patients with BPD suffer profound depression, sudden mood changes, increased withdrawal, and unreasonable paranoia.
    (Martin, 2022c; Belleza, 2021)
CASE

A Patient with Borderline Personality Disorder

Thaddeus is a 27-year-old patient with paraplegia and a history of borderline personality disorder who has been receiving physical therapy from the therapist Sheri. One day, Thaddeus angrily approached Ahmed, the rehab director, and complained that Sheri was being unfair and treating him badly. He insisted that Ahmed assign him to another therapist. Ahmed listened respectfully and responded by telling Thaddeus that he could not do that but that Thaddeus could bring his concerns directly to Sheri. It seemed that this was not the response Thaddeus wanted, and he left disgruntled.

Later, Ahmed approached Sheri to let her know that Thaddeus had come to him and angrily complained about her. Thaddeus didn’t say why he was angry and upset but asked to be seen by another therapist. Sheri replied that she had no inkling at all that there was anything wrong between Thaddeus and herself. He was responding well to therapy and was always pleasant. She began to feel angry herself now and said, “I didn’t do anything wrong. I don’t understand!”

Ahmed listened and then replied, “I think Thaddeus is upset about something, cannot tell you about it, and is going behind your back to me. This may be an example of splitting behavior due to his BPD history.” He told Sheri that he had informed Thaddeus to bring up any problems directly with her.

At Thaddeus’s next appointment, Sheri brought up what Ahmed had told her and asked him to talk to her about what was bothering him.

Sheri: “Thaddeus, tell me what happened that made you go to Ahmed and tell him you were upset with me.”

Thaddeus: “I bet you’re angry with me for doing that.”

Sheri: “No, I’m not angry. I just want to know how I can help you. What has happened that made you feel upset and angry?”

Thaddeus: “Well, last week you told me I wasn’t working hard enough and would never get better.”

Sheri: “I disagree.”

Thaddeus: “You’re saying you didn’t tell me that?”

Sheri (based on the element of truth): “It is true that I said we needed to add a new exercise.”

Thaddeus: “But you said I wasn’t working hard enough.”

Sheri: “I disagree. Now, let’s move on to do some more work today.”

Discussion

When Thaddeus went to Ahmed with a complaint about Sheri, Ahmed listened but did not respond and “rescue” Thaddeus, as Thaddeus was likely expecting him to do. Instead, Ahmed directed Thaddeus back to Sheri to discuss his concerns.

When Ahmed described this interaction to Sheri, she was confused, concerned, and then upset with herself, wondering what she had done to make Thaddeus angry. But when Ahmed suggested that Thaddeus may be engaging in splitting behavior due to his BPD diagnosis, making Sheri the “persecutor” (all bad) and Ahmed the “rescuer” (all good), she considered this possibility and stopped taking Thaddeus’s complaints personally.

When Sheri next met with Thaddeus, she directly confronted the issue, denied being angry, did not attempt to defend herself, remained detached, acknowledged the element of truth in what Thaddeus said, and distracted him to bring him back to the task.