Written by Julie Brown
Personality disorders are common and complex emotional difficulties that are challenging to identify, categorize, and manage. Language surrounding these often-stigmatized diagnoses is changing, as are the recommendations on treatment of individuals with personality disorders.
It’s not me, it’s you
Personality disorders are prevalent, debilitating, associated with mental and physical comorbidities and associated with an increased incidence of self-harm, suicide, and reduced life expectancy. In this Clinical Update, the authors outline several tips on how medical providers can identify, classify, and manage personality disorders from a holistic perspective. Shifting away from the classic categories of labeling personality disorders, the World Health Organization has advised providers to 1) identify a core problem in interpersonal functioning; 2) assess the functional impact and severity of this core problem; and 3) define the main traits of this disturbance. For example, instead of diagnosing Antisocial Personality Disorder, a clinician might identify an individual with a core personality dysfunction characterized by poor anger control and severe disinhibition.
There are several indicators that providers can consider in the approach to a suspected personality disorder:
- Rapid mood changes, anxiety, anger, and detachment,
- Poor impulse regulation and evidence of self-injury,
- Volatile interpersonal relationships,
- Medically unexplained symptoms.
The authors also provide several recommendations regarding the management of personality disorders:
- Utilize a curious, non-judgmental attitude, and aim to understand the individual’s circumstances (beyond a basic social history, being mindful of trauma).
- Optimize consistency with one primary managing clinician.
- Establish clear roles, negotiate plans, and discuss deviations from agreements.
- Identify and name emotions.
- Prescribe medications thoughtfully, and consider specialist referral when implementing mood-stabilizing or antipsychotic medications.
- Outline clear safety and crisis management plans.
How will this change my practice?
I plan on approaching patients with a heightened awareness of personality disorders and how they may contribute to or underlie somatic concerns. If we suspect a component of personality disturbance, we can further explore the patient’s background and requests and use this information to better understand and validate their motivations, address expectations, and offer appropriate resources.
Personality disorder. BMJ. 2023 Sep 4;382:e050290. doi: 10.1136/bmj-2019-050290.