Personality disorders on the acute care unit
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.
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.
