We all know these patients:
The young man who, when his name shows up on the ED board, everyone lets out a little groan, knowing his hospital stay will be long and tumultuous.
The middle-aged woman who seems to do want your care and attention and yet rebuffs your attempts to help her, meanwhile, making constant demands on nursing staff.
The older man who trusts no one and will not cooperate with any of his needed care, frustrating staff and physicians alike.
Caring for the patient is integral to the art of doctoring, and yet, there are some people for whom this is incredibly hard to do. They frustrate even the most seasoned professional and work their way under our skin. While their disruptive acts may feel volitional to those of us attempting to provide care, these individuals may suffer from a personality disorder.
Dr. Megan Riddle
In the hospital, a patient must to relate to, and cooperate with, a revolving team of care providers all while under some degree of physical and emotional distress. While this can be destabilizing for even the most resilient patient, for those with personality disorders, it is nearly inevitable that conflict will arise. In a recent article in the Journal of Hospital Medicine, my colleagues and I discussed the management of such patients, with a focus on evidence-based interventions (doi: 10.1002/jhm.2643).2
While the behaviors associated with personality disorders can feel deliberate and even manipulative, research shows that these disorders arise from a complex set of genetic and environmental factors. Alterations found in the serotonin system and regions of the brain involved in emotional reactivity and social processing suggest an underlying neurophysiology contributing to difficulties with interpersonal relationships seen in these disorders.3-9
Many do not realize that having a personality disorder has real implications for an individual’s healthcare outcomes; those with a personality disorder have a life expectancy nearly two decades shorter than the general population.10 While there are a number of factors that likely contribute to the effect on mortality, it has been suggested that dysfunctional personality structures may interfere with the individual’s ability to access and utilize care, resulting in higher morbidity and mortality.11
Although it can be difficult to make a formal diagnosis of a personality disorder on the acute care unit, we provide guideline for recognizing individuals based on the way in which they interact with others. Specifically, we propose a team should consider a personality disorder when the following features are present:
The patient elicits a strong emotional reaction from providers; these may vary markedly between providers
The patient’s emotional responses may appear disproportionate to the inciting event
The patient is on a number of different psychiatric medications with little relief of symptoms
The patient takes up an disproportionate amount of providers’ time
The patient externalizes blame, seeing others as the source of discomfort or distress and therefore sees others as the solution.2
When the team suspects a patient’s behavior may be driven by an underlying dysfunctional personality structure, there are a number of steps that can be taken to help facilitate care and shape behaviors. Key among these is recognizing our own complicated responses to these individuals. These patients evoke strong responses and no team member – from nurses and aides to residents and senior attendings – is immune.12-15
Reactions can range from a need to care for and protect the patient to feelings of futility or contempt.15 Other important behavioral interventions include providing consistency, reinforcing desired behaviors, offering empathy, and providing boundaries while also recognizing the importance of picking your battles.2 Of note, while medications may offer some help, there is limited evidence for use of pharmacological interventions. Although they may be somewhat helpful in addressing particular features of these disorders, such as impulsivity, affective dysregulation or cognitive-perceptual symptoms16, many of these patients end up on a cocktail of psychotropic medications with minimal evidence for their use or efficacy. Thus behavioral management remains the cornerstone of treatment.
While care of the patient with personality disorders can present unique challenges, it offers the opportunity for therapeutic intervention. By appreciating the underlying genetic and environmental factors, we are in a better position to offer empathy and support. For these patients, managing their personality disorder can be just as important as managing any of their other medical comorbidities. By taking an approach that acknowledges the emotional responses of the team while also reinforcing and facilitating positive behaviors of the patient, the hospital stay can prove therapeutic, helping these individuals to develop new skills while also getting their physical needs addressed.
Megan Riddle, MD, PhD, is based in the department of psychiatry and behavioral sciences at the University of Washington, Seattle.
NOTES
1. Diagnostic and Statistical Manual of Mental Disorders, 5th Edition. Arlington, VA: American Psychiatric Association; 2013.
2. Riddle M, Meeks T, Alvarez C, Dubovsky A. When personality is the problem: Managing patients with difficult personalities on the acute care unit. J Hosp Med. 2016 Dec;11(12):873-878.
3. Bukh JD, Bock C, Kessing LV. Association between genetic polymorphisms in the serotonergic system and comorbid personality disorders among patients with first-episode depression. J Pers Disord. 2014 Jun;28(3):365-378.
4. Perez-Rodriguez MM, Weinstein S, New AS, et al. Tryptophan-hydroxylase 2 haplotype association with borderline personality disorder and aggression in a sample of patients with personality disorders and healthy controls. J Psychiatr Res. 2010 Nov; 44(15):1075-1081.
5. Checknita D, Maussion G, Labonte B, et al. Monoamine oxidase: A gene promoter methylation and transcriptional downregulation in an offender population with antisocial personality disorder. Br J Psychiatry. 2015 Mar;206(3):216-222.
6. Boen E, Westlye LT, Elvsashagen T, et al. Regional cortical thinning may be a biological marker for borderline personality disorder. Acta Psychiatr Scand. 2014 Sep;130(3):193-204.
7. Thoma P, Friedmann C, Suchan B. Empathy and social problem solving in alcohol dependence, mood disorders and selected personality disorders. Neurosci Biobehav Rev. 2013 Mar;37(3):448-470.
8. Liu H, Liao J, Jiang W, Wang W. Changes in low-frequency fluctuations in patients with antisocial personality disorder revealed by resting-state functional MRI. PLoS One. 2014 Mar 5;9(3):e89790.
9. Yang Y, Raine A. Prefrontal structural and functional brain imaging findings in antisocial, violent, and psychopathic individuals: A meta-analysis. Psychiatry Res. 2009 Nov 30;174(2):81-88.
10. Fok ML, Hayes RD, Chang CK, Stewart R, Callard FJ, Moran P. Life expectancy at birth and all-cause mortality among people with personality disorder. J Psychosom Res. 2012 Aug;73(2):104-107.
11. Tyrer P, Reed GM, Crawford MJ. Classification, assessment, prevalence, and effect of personality disorder. Lancet. 2015 Feb 21;385:717-726.
12. Groves JE. Taking care of the hateful patient. N Engl J Med. 1978 Apr 20; 298:883-887.
13. Groves JE. Management of the borderline patient on a medical or surgical ward: The psychiatric consultant’s role. Int J Psychiatry Med. 1975;6(3):337-348.
14. Bodner E, Cohen-Fridel S, Mashiah M, et al. The attitudes of psychiatric hospital staff toward hospitalization and treatment of patients with borderline personality disorder. BMC psychiatry. 2015 Jan 22;15:2.
15. Colli A, Tanzilli A, Dimaggio G, Lingiardi V. Patient personality and therapist response: An empirical investigation. Am J Psychiatry. 2014 Jan;171(1):102-108.
16. Ingenhoven T, Lafay P, Rinne T, Passchier J, Duivenvoorden H. Effectiveness of pharmacotherapy for severe personality disorders: Meta-analyses of randomized controlled trials. J Clin Psychiatry. 2010 Jan;71(1):14-25.