Key Feature 5: Use psychoactive medication rationally to assist patients in crisis.
Skill: Clinical Reasoning
Key Feature 9: Be careful not to cross boundaries when treating patients in crisis (ex: lending money, appointments outside regular hours).
Key Feature 1: Clearly establish and maintain limits in dealing with patients with identified personality disorders. For example, set limits for:
Key Feature 3: Look for and attempt to limit the impact of your personal feelings (ex: anger, frustration) when dealing with patients with personality disorders (ex: stay focused, do not ignore the patient’s complaint).
Skill: Professionalism, Communication
Key Feature 4: In a patient with a personality disorder, limit the use of benzodiazepines but use them judiciously when necessary.
Skill: Clinical Reasoning, Selectivity
In the past week and a half that I have been on my Psychiatry rotation, encountering patients with personality disorders has been a thing. However, I have also seen many patients in the outpatient setting with personality disorders, at times diagnosed. In patients who have been diagnosed with personality disorders, it is important to set boundaries on the physician-patient relationship, as patients with these disorders tend to stretch them however unintentionally or intentionally. In patients who are difficult but without a diagnosed personality disorder, check in with that inner voice to consider whether or not a personality disorder may be underlying the complicated interaction.
Placing limits on the therapeutic relationship for patients with personality disorders is not intended to be punitive, but rather for establishing necessary elements in the therapeutic relationship. These limits include maintaining pre-established appointment lengths, prescribing medications only in keeping with good prescribing practices (i.e., indicated, informed, and without contraindication or doing more harm than good), and maintaining boundaries in when and how one can be reached for assistance. It also goes without saying that patients with personality disorders may attempt to stretch the limits of these and other aspects of the therapeutic relationship; should these boundaries not be upheld, the therapeutic physician-patient relationship that is bounded by these limits is compromised. That being said, it is not just patients with personality disorders who may tempt a crossing of professional boundaries. Many patients I see living on the Downtown Eastside of Vancouver, for example, face excruciating primitive challenges including a lack of basic shelter and food. While reaching into my own pocket could help to alleviate suffering in a given moment, such acts are short lived, not more than a brief respite from a much larger issue. And if I do this for one patient, how would that be okay to not do it for others? The most constructive and sustainable help I can provide for these patients is to advocate for better support systems and provide treatment within the scope of professional boundaries. For all patients in crisis including those with personality disorders.
Part of my learning objectives is to understand that benzodiazepines should be prescribed with even greater precaution for patients with personality disorders than is already indicated, which is saying a lot as I am also expected to learn that benzodiazepines should only be prescribed under necessary circumstances. The UpToDate article, "Pharmacotherapy for personality disorders" shed some light on this issue by providing the following information:
"Avoid prescribing medications that can induce physiological dependence and tolerance, including benzodiazepines, which are especially toxic when combined with alcohol or opioids. An additional risk of benzodiazepines is behavioural disinhibition associated with this class of medications in patients with personality disorders.”
Furthermore, the article addresses the prescription of benzodiazepines under extenuating circumstances for patients with personality disorders as follows:
"Avoid changing medication each time there is a crisis or change in mood symptoms, which may occur frequently and suddenly, and also remit suddenly in some personality disorders. Prescribing medication at the time of crisis often lacks a specific target symptom as well as an endpoint upon which the effects of a medication can be judged... Suicidal urges or behaviour are of potential concern. To the extent the patient is willing to engage in treatment planning, clinical strategies to reduce the risk of suicide should be considered and enacted. Avoid prescribing medications that are toxic in the setting of overdose or are disinhibiting, such as benzodiazepines. In terms of selecting a medication in the setting of suicidality, in our clinical experience, medications that address the most intolerable symptoms domain are of highest yield.”
Yesterday, while on call, I almost certainly did a consultation on a patient with a personality disorder in the Emergency Department. He was challenging as heck to get a straight story from, and was, as my preceptor described, "gamesy." Nothing was clear with him. I sensed myself getting frustrated as I painfully had to reiterate myself to get sprinkles of truth, but going into the interaction having recently spent time thinking about these sorts of difficult interactions, I was able to ground myself in mindful awareness. When I do this, it frees me from the frustration I feel, because I recognize and label this frustration as being my reaction to the patient's behaviour, which is outside of myself. It creates space for me to see the behaviour adjacent to me rather than infringing upon me. The behaviour is then reframed as being well-established before I came around, and an ongoing reality long after the present conversation. With this perspective, I no longer feel an inner drive to sort everything out or fix everything there and then, which is where I think the tension originally comes from - from the desire to "fix" things in a situation in which it is extremely difficult to do so. Although I have a "problem solver personality" - as I think is the norm for physicians - I have hope that through experience and reflection I will develop the wisdom and skill to shift more effortlessly from a focus on cure to a focus on comfort, attending to the patient's greatest concerns in a more realistic capacity. I think that the more I learn to notice what the voice of my inner tension sounds like in these moments, the quicker I will be able to hear it and the quieter the volume will need to be in order to appreciate what it's telling me.
Key Feature 1: When physician-patient interaction is deemed difficult, diagnose personality disorder when it is present in patients.
Skill: Clinical Reasoning
Key Feature 2: When confronted with difficult patient interactions, seek out and update, when necessary, information about the patient’s life circumstances, current context, and functional status.
Skill: Patient Centered
Phase: History, Diagnosis
Key Feature 5: When confronted with difficult patient interactions, identify your own attitudes and your contribution to the situation.
Phase: Treatment, Diagnosis
Key Feature 6: When dealing with difficult patients, set clear boundaries.
Key Feature 2: In a patient with a personality disorder, look for medical and psychiatric diagnoses when the patient presents for assessment of new or changed symptoms. (Patients with personality disorders develop medical and psychiatric conditions, too.)
Skill: Clinical Reasoning
Phase: Hypothesis generation
Key Feature 5: When seeing a patient whom others have previously identified as having a personality disorder, evaluate the person yourself because the diagnosis may be wrong and the label has significant repercussions.
Skill: Clinical Reasoning, Selectivity
Phase: Diagnosis, History
Today I spent the afternoon in the Acute Behavioural Stabilization Unit (aka the Psychiatry assessment area) in the St Paul's Hospital Emergency Department. After I came back from assessing a particularly challenging patient, my attending physician said to me, "How did that patient make you feel?" This reminded me of something I was once told by an attending physician in the past: when I leave a patient encounter feeling like it was just "off" or that the patient seemed strange, it is possible they have a personality disorder. I don't think this is an evidence-based screening tool for personality disorders, but I do think it is a clinical pearl. If your spidey senses are tingling, it's probably for a reason. In these settings, inquiring about what's been going on in a patient's life (aka gathering a social history) may reveal significant psychosocial stress that could be contributing to a short fuse or leading to avoidance to say much about personal issues. And although people with personality disorders may have increased psychosocial stress, it takes knowing a patient for an extended period of time (or at least gathering an extended history of an extended period of time ideally with collateral information) to make this diagnostic call.
Despite the requirement of needing to have a strong understanding of patients' longstanding behaviours, clinicians tend to hold strong suspicions about patients having personality disorders based on initial consultations. This is particularly true when patients present with features in keeping with Borderline Personality Disorder, which we tend to see more frequently than other personality disorders in healthcare. (Note that it is important to not just take another clinician's word for a diagnosis of a personality disorder, as this diagnosis is sometimes made prematurely, and incorrectly labelling patents with personality disorders can have real and negative consequences if it is an inaccurate description for them.) Patients with this Borderline Personality Disorder can at times be manipulative, including with the assessing physician, and can cause a countertransference reaction that is what my attending physician today was referring to today. This attending went on to explain the importance of clear reasoning and firm, caring boundaries in the management of patients with this diagnosis, because otherwise you may find yourself getting pushed into providing care in a way that is not what you think is actually most suited for the circumstances. The patient today, for example, presented with thoughts about self-harm, but had a strong relationship with a psychiatrist in the community, and it was highly unlikely that an admission to hospital would've provided any benefit (in fact, more likely the opposite). When she found out the psychiatrist who did her intake consultation today deemed her fit for discharge and close follow-up care in the community, she began saying she was more suicidal than before. Hmmmm.... That being said, patients diagnosed with personality disorders tend to face much discrimination; they are often seen as frankly difficult patients with multiple complaints and issues, at times compromising thorough and indicated assessment for specific concerns. It takes a heaping amount of good intention and experienced clinical judgment, but patients with personality disorders develop other psychiatric and non-psychiatric conditions unrelated to their personality disorder. It is not always easy to have the patience or knowledge to distinguish these, as I have seen first-hand, but it is important if we value the dignity and humanism underlying good medical care.
According to the DSM-V, "A personality disorder is an enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individual’s culture, is pervasive and inflexible, has an onset in adolescence or early adulthood, is stable over time, and leads to distress or impairment... The personality disorders are grouped into three clusters based on descriptive similarities. Individuals with Cluster A personality disorders often appear odd or eccentric. Individuals with Cluster B personality disorders often appear dramatic, emotional, or erratic. Individuals with Cluster C personality disorders often appear anxious or fearful." In medical school, I was taught of these clusters as the "Mad, bad, and sad" personality disorders, respectively.
According to the DSM-V, there are 10 different diagnosable personality disorders, which are as follows:
While I won't get into all of the details of each personality disorder, the general diagnostic criteria per the DSM-V for personality disorders is as follows: