Key Point:
Human immunodeficiency virus (HIV)-infected patients who present with maladaptive personality traits and behaviors may have other causative or co-occurring medical, mental health, and/or social disorders that require intervention.
Please refer to the original guideline document for the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR) definition of personality disorders grouped into three "clusters" based on shared descriptive features:
- Cluster A - odd, eccentric
- Cluster B - dramatic, emotional, or erratic
- Cluster C - anxious or fearful
Differential Diagnosis for Personality Disorders
Clinicians should assess patients with maladaptive behaviors for any treatable underlying medical, mental health, or social disorders that may cause or exacerbate these behaviors.
Refer to Table 2 in the original guideline document for medical, psychiatric, and social disorders that may present with maladaptive behavior.
Patients Who Are Victims of Domestic Violence
Clinicians should screen patients for domestic violence annually and when patients display inhibited, avoidant, excessively emotional, or submissive behavior.
Patients With Low or Borderline Intelligence
Clinicians should perform a mental status evaluation that includes cognitive function of patients who are suspected of having cognitive deficiencies.
Management of Patients with Personality Disorders
Primary care clinicians should consult a mental health professional when the medical staff is unsuccessful in persuading the patient to replace old, maladaptive patterns of behavior with alternative, more adaptive behaviors.
Clinicians should clearly instruct the medical support staff about how to manage crises caused by patients with personality disorders, such as isolating the patient from other patients or contacting emergency services, when a crisis arises in the waiting area, laboratory, or other patient care areas.
Key Point:
The diagnosis of a specific personality disorder may not be as important as identifying and focusing on specific personality traits that make treatment planning and provision of health care difficult. The medical staff's principal objective should be to help patients maximize health-oriented behaviors.
General Approach to Patients With Personality Disorders
Effective Communication
Clinicians should help all members of the staff develop and enhance their skills for working with patients with personality disorders.
All staff members who interact with patients who present disruptive behavior should convey the message that the staff's intent is to assist the patient in obtaining necessary medical care and to improve the patient's function.
Clinicians should clarify for the patient the role and responsibility of each staff member, as well as the patient's own responsibility for his/her treatment.
| Table. General Guidelines for Effective Communication and Establishing a Therapeutic Provider-Patient Relationship |
- Listen carefully to identify the patient's agenda
- Maintain eye contact
- Use body language that conveys support and respect; avoid abrupt movements
- Communicate in an unhurried manner
- Avoid the use of humor that may signify disrespect or lack of professionalism
- Offer choices and options whenever possible; this will involve the patient and help share responsibilities of care
|
Interdisciplinary Team
Because management of patients with personality disorders can be stressful for all staff members, a team approach that focuses on supportive, effective communication among everyone involved in the patient's treatment should be used when developing a treatment plan.
Key Point:
Some patients with severe personality disorders may have styles of interaction that could foster conflict among patients, clinicians, and other staff. A team approach that relies on supportive, effective communication among everyone involved in the patient's treatment is essential.
Approach to Specific Patient Types
| Recommended Approaches to Personality Types |
| Cluster and Patient Subtype |
Recommended Approaches |
| Cluster A -- Odd or Eccentric |
| Guarded, suspicious, argumentative patients |
Acknowledge the patient's perception of the world, without debate or agreement, and try to focus his/her attention on healthcare treatment. Maintain a respectful, professional distance; the patient may appreciate a clinician who is more formal and "business-like." |
| Aloof or uninvolved patients |
Show that the patient's style is understood and his/her privacy is respected. Explain the need for personal questions but do not push the patient to increase social involvement. |
| Idiosyncratic or eccentric patients |
Provide a consistent approach that addresses the patient's complaints and beliefs; neither challenge the patient's beliefs nor reinforce his/her perspective. |
| Cluster B -- Dramatic, Emotional, or Erratic |
| Dramatic, dependent, and overdemanding patients |
Set limits on interactions with the patient to prevent excessive and unrealistic demands from him/her. Refer the patient, if needed, to programs that extend his/her social and healthcare support networks. |
| Dramatic, emotionally involved, seductive, and captivating patients |
Demonstrate a supportive attitude toward the patient. Maintain professional boundaries to prevent the patient from provoking unhelpful responses. |
| Superior patients |
Recognize and support the patient's strengths and achievements, and show interest in the patient's opinions. Demonstrate competence without challenging the patient's need to feel superior. |
| Sociopathic patients |
Set realistic limits on patient visits; never tolerate aggressive behavior or any other behavior that creates an unsafe environment. Consider a mental health consultation, which may help with development of an appropriate treatment plan. |
| Cluster C - Anxious, Fearful |
| Orderly, controlled, and controlling patients |
Clearly state the treatment approach and give the fullest details possible, with a discussion about treatment rationale and other treatment options. Always avoid a struggle over who is in charge. |
| Anxiously avoidant patients |
Show patience and availability and express empathy toward the patient's fears. |
| Anxiously dependent and clinging patients |
Consider providing more frequent but briefer appointments; scheduling interactions with the patient may help minimize his/her excessive demands at inconvenient times. Forewarn him/her of change, such as vacations and other absences. |
| Controlling, avoidant, and dependent patients |
Directly address concerns about the patient's behavior, suggesting that it may indicate underlying feelings about his/her illness and treatment. Encourage medical staff to avoid feeling resentful toward a patient who "acts out" his/her frustration. |
Treatment of Personality Disorders
Clinicians should refer patients to mental healthcare professionals when complex mental status evaluations become necessary or when the patient's behavior leads to instability or jeopardizes effective treatment.
Clinicians should develop treatment plans that focus on helping patients with personality disorders change their behavior and style of interacting with others in the healthcare setting and, if possible, in other settings as well.
Clinicians should be aware of symptoms in these patients that suggest a comorbid psychotic disorder.
Key Point:
Although long-term intensive, individual psychotherapy is necessary for fundamental, lasting change in patients' personalities, briefer psychotherapies may help patients modify their maladaptive behaviors.
