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Personality Disorders in Patients With HIV/AIDS

Updated May 2006 — Currently Under Revision

I. INTRODUCTION

Patients with personality disorders often present challenging therapeutic situations. Because patients with mental health disorders are at high risk for HIV infection, clinicians may encounter a number of patients with mental health disorders that complicate HIV treatment. Although a significant body of research has demonstrated a high prevalence of major Axis I psychiatric disorders among HIV-infected persons, there have been relatively few studies examining the prevalence of Axis II personality disorders.1 One study indicates that people with personality disorders are at significant risk for onset of future Axis I disorders, as well as serious functional impairment, regardless of a past history of Axis I disorders.2 Personality disorders among patients infected with HIV are associated with a higher rate of depression, maladaptive coping, and other psychiatric symptoms.3,4

In comparison with the general population, patients belonging to an HIV-risk-behavior group such as injection drug users (IDUs) may also be more likely to have a personality disorder, particularly borderline personality disorder or antisocial personality.5 Antisocial and borderline personality disorders are the two most prevalent personality disorders among substance-using patients, with reported estimates of 22% for antisocial personality disorder and 18% for borderline personality disorder.1 In addition to these findings, research has shown that patients with borderline and antisocial personality disorders are more likely to participate in sexual and needle-sharing risk behaviors.6

This chapter focuses on the fixed patterns of behavior and interpersonal relationships that characterize personality disorders, particularly the ways in which these behaviors impact medical care. Because interaction with others can be challenging for patients with personality disorders, they may be averse to medical treatment.7 Patients with personality disorders may want care but may not know how to accept it. It may be difficult for them to feel comfortable within a medical setting, a context that may be confusing or stigmatizing for them. Clinicians can interact with these patients effectively with a plan that focuses on support between the patient and the care team.

Key Point:

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.

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II. DEFINITION OF PERSONALITY DISORDERS

Personality is the sum of an individual’s behavioral and emotional characteristics. Facets of personality that are particularly relevant to patient care include perception of self and others, attitudes, styles of interaction, and behaviors related to coping, moods, and temperament. A personality disorder may be present when these features persistently and significantly limit a person’s ability to adapt to his/her environment.

The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR) defines personality disorders as persistent, pervasive, and inflexible patterns of inner experience, behavior, and interpersonal relationships that have been continuously present since adolescence or early adulthood and have resulted in significant distress and/or impairment in function. Areas of function affected may include social life, occupation, and self-care. The DSM-IV-TR uses a categorical perspective to describe 10 different personality disorders (see Table 1). Each personality disorder is delineated by a defined set of specific behaviors and personality traits. By DSM-IV-TR convention, personality disorders are grouped into three “clusters” based on shared descriptive features:

Cluster A—odd, eccentric
Cluster B—dramatic, emotional, or erratic
Cluster C—anxious, fearful

Descriptions of typical personality traits and behaviors that characterize each personality disorder are found in Section IV. B: Approach to Specific Patient Types. (Also see DSM-IV-TR for a complete discussion of personality disorders and their diagnostic criteria.)

Table 1: DSM-IV-TR Axis II Disorders
Cluster A
Odd Eccentric
Cluster B
Dramatic, Emotional, Erratic
Cluster C
Anxious, Fearful
Paranoid
Schizoid
Schizotypal 
Antisocial*
Borderline*
Histrionic
Narcissistic
Avoidant
Dependent
Obsessive-Compulsive
* Although not conclusive, research suggests that borderline personality disorder and antisocial personality disorder, both Cluster B disorders, may be the most commonly occurring personality disorders among HIV-infected substance-using patients. In addition, among noninfected patients with personality disorders, those with borderline personality disorder and antisocial personality disorder are at higher risk for becoming infected with HIV.

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III. DIFFERENTIAL DIAGNOSIS FOR PERSONALITY DISORDERS

RECOMMENDATION:

Clinicians should assess patients with maladaptive behaviors for any treatable underlying medical, mental health, or social disorders that may cause or exacerbate these behaviors.

Unlike other mental health disorders for which the clinician relies on the patient’s description of symptoms to assist diagnosis, the clinical diagnosis of personality disorders may be primarily derived from observation of the patient’s behavior and style of interacting with others. Maladaptive personality traits and behaviors may be caused or exacerbated by treatable underlying medical, mental health, and/or social disorders (see Table 2). For example:

  • Disruptive behaviors may be symptoms of HIV dementia and may also mimic symptoms of personality disorders.
  • Cognitive impairment may lead to exaggeration of underlying or prior personality disorders.
  • Victims of domestic violence may appear inhibited, avoidant, excessively emotional, or submissive; however, once their safety needs are addressed, these behaviors may disappear.
  • Some patients may try to mask their inability to process information due to low or borderline intelligence. Clinicians who are unaware of the patient’s cognitive deficits may interpret these behaviors to be symptoms of a personality disorder.

If the maladaptive personality traits and behaviors persist after other treatable disorders have been excluded or adequately addressed, they may be attributes of an underlying personality disorder.

Table 2: Medical, Psychiatric, and Social Disorders The May Present With Maladaptive Behavior
• Delirium
• Dementia
• Other medical disorders of the CNS
• Mood disorders
• Anxiety disorders
• Metabolic disorders
• Malingering 
• Post-traumatic stress disorder
• Psychotic disorders
• Substance use or withdrawal
• Domestic violence*
• Low or borderline intelligence*
CNS, central nervous system.
* See Section III. A: Patients Who Are Victims of Domestic Violence for additional information.

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A. Patients Who Are Victims of Domestic Violence

RECOMMENDATION:

Clinicians should screen patients for domestic violence annually and when patients display inhibited, avoidant, excessively emotional, or submissive behavior.

Patients who are victims of domestic violence are often reluctant to discuss this problem with anyone and may actively attempt to hide any physical injuries from medical staff. The only sign that they are victims of violence at home may be indirect, through their behavior with medical clinicians. Their behavior may mimic personality traits seen in patients with personality disorders; for example, they may appear inhibited, avoidant, excessively emotional, or submissive. Once patients’ safety needs are addressed, these behaviors may disappear. When a patient with a preexisting personality disorder is also a victim of domestic violence, it is important to separate the consequences of the violence from those of the personality disorder, so that an important avenue of intervention is not overlooked. In addition, post-traumatic stress disorder and histories of childhood neglect and abuse can co-occur with domestic violence and/or personality disorders and require separate attention.

For more information on domestic violence, see Impact of HIV and HIV Care on Families, as well as the Prevention Guidelines Domestic Violence: Prevention and Intervention. For more information on post-traumatic stress disorder, see Trauma and Post-Traumatic Stress Disorders in Patients With HIV/AIDS.

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B. Patients With Low or Borderline Intelligence

RECOMMENDATION:

Clinicians should perform a mental status evaluation that includes cognitive function of patients who are suspected of having cognitive deficiencies.

Patients with low or borderline intelligence may mask their inability to process information. These patients often confuse and frustrate clinicians who are unaware of the patients’ cognitive deficits. Their behavior could resemble any of the patient types described in Section IV. Therefore, it is important for clinicians to make a differential assessment of intelligence status. Clinicians should assess how patients process information that is given to them, such as by asking them to explain in their own words what the clinician has told them. A mental status examination that includes cognitive function, along with an evaluation for history of underlying learning and developmental disorders, will also help identify these patients. Of note, mental retardation also falls under DSM-IV-TR Axis II disorders.

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IV. MANAGEMENT OF PATIENTS WITH PERSONALITY DISORDERS

RECOMMENDATIONS:

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.

In a clinical setting, patients may exhibit a range of personality traits and behaviors that seriously interfere with their ability to interact effectively with medical clinicians and staff. As a consequence, these patients may not only jeopardize their own medical care but may also disrupt overall patient care in a busy ambulatory care environment. Furthermore, individuals often present with features from more than one type of personality disorder. For example, patients may present with anger and hostility that seem unwarranted, they may present unrealistic demands for the clinician’s time and attention, and/or they may have multiple complaints yet reject the clinician’s offers of help or treatment recommendations. Section B: Approach to Specific Patient Types describes the different personality traits that a clinician is likely to encounter. A clinician’s approach and interventions flow from an understanding of the patient’s behavior.

Primary care settings that ensure consistency in care, continuity of care, ease of access to care, and shorter periods of waiting will help diminish waiting room anxieties and displays of disruptive behaviors. If waiting room times cannot be shortened, it is important that patients have activities that will help prevent anxiety and disruptive behavior. Educational videos, discussions with patient educators, printed materials, refreshments, and games help to create an environment that addresses the difficulty that some patients with anxiety disorders experience during wait times.

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.



Clinicians should instruct their staff to speak to patients in a firm but nonjudgmental manner that makes it clear what a patient needs to do in order to avoid disruptive behavior that might prevent provision of care. Furthermore, a particular staff member may be better-suited for handling a certain personality disorder, trait, or behavior; therefore, clinicians should determine who among his/her staff should be the primary person to interact with a particular patient.

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A. General Approach to Patients With Personality Disorders

The following are practical steps that clinicians can take to develop a trusting patient-provider relationship:

  • Effective communication (see Table 3)
  • Using an interdisciplinary team
  • Developing a treatment plan with goals focused on health and behavior
  • Educating support staff about engaging with patients with personality disorders

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1. Effective Communication

RECOMMENDATIONS:

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.

Effective communication is the cornerstone of good patient care. For patients with personality disorders and associated maladaptive personality traits and behaviors, establishing adequate communication is not only necessary but may also be sufficient to prevent or alleviate disruptive behavior. Everyone who interacts with patients with disruptive behavior should convey the message that the staff’s intent is to assist the patient to obtain the best medical care possible. Use of nonverbal communication skills often conveys this message as powerfully as direct verbal communication (see Table 3).

Table 3: 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



Staff members can prevent the potential chaos that these patients may create by maintaining appropriate boundaries and providing structure. For example, when a patient first arrives for his/her office visit, a staff member may explain the schedule and the role of each staff member involved. Example:

Your doctor will see you first, although you may have to wait 15 to 30 minutes because he/she is a bit backed up today. After your office visit with your doctor, he/she may then want you to speak to the nurse to review your medications, or go to the lab for blood work.

Patients are often unaware of the impact of their behavior on others and may react defensively with anger or withdrawal when confronted about the negative effect of their behavior. Clinicians should be supportive and offer patients alternative, more adaptive ways of interacting and behaving to lessen patients’ sense of feeling criticized.

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2. Interdisciplinary Team

RECOMMENDATION:

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.

The importance of using a team approach with patients with personality disorders cannot be overemphasized. The care of patients with complex medical, mental health, and social needs may not be possible without collaboration among all members of the treatment team. By definition, patients with personality disorders often evoke intense feelings that are difficult for the people around them to process. In addition, the feelings evoked in one staff member may contradict the experience of a different staff member. Consequently, staff may feel frustrated and isolated from each other and be particularly vulnerable to “burn out.” For these reasons, it is especially important that staff members who are “on the front line,” such as registration clerks and nursing aides, be involved in treatment planning. Development of a procedure that allows staff to call on a colleague for substitution or supervision can enable team members to regroup and avoid feeling overwhelmed when stress is high. The team often functions as an important source of support for staff and can significantly enhance staff morale.

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.

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3. Developing a Treatment Plan

The development of a written treatment plan that is documented in an easily accessible place for staff may be useful to members of the treatment team. Treatment planning may occur in a team meeting and may require a comprehensive conversation among all members of the treatment team. The treatment plan should clearly delineate the goals of treatment and expected behaviors for staff and patients alike. It may take the form of a treatment contract between staff and patient. Patients should participate, whenever possible, in the treatment planning process and be encouraged to describe their treatment goals. The focus of goals should be on health and behavior, such as adhering to medications, keeping appointments, and arriving to appointments on time, rather than on general demands and feelings of the patient, which may be counterproductive. If there is disagreement, the issues should be clarified and consensus reached. Behaviors that are unacceptable should be clearly delineated, along with corresponding consequences for the behavior. Staff members should be consistent in their response to unacceptable behavior and should avoid specifying consequences with which the staff is unwilling or unable to follow through. Staff should suggest alternatives to behaviors that are damaging to the patient or clinic. For example, if a patient becomes verbally aggressive or threatening and is unable to modify his/her behavior, he/she will be asked to leave the office. This treatment plan will help both staff and patients feel more secure and in control, because the limits of safe behavior are known and agreed upon by everyone.

The healthcare network of a patient may need to be broadened to alleviate excessive demands on one individual care team. Collaboration with staff from the mental healthcare team may help formulate and implement treatment plans for patients with personality disorders. Patients who refuse psychiatric referral may accept consultation with a “treatment planning consultant,” who is a mental healthcare professional, such as a psychiatrist, social worker, or nurse practitioner. The consultation can be explained to the patient as an opportunity to express his/her particular treatment needs, so that those needs can be integrated into the patient’s overall treatment plan. This interdisciplinary collaboration is particularly important for patients at risk for harming themselves or others. The mental healthcare team may also help facilitate patient referrals to specialized treatment programs for patients with personality disorders.

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4. Educating Support Staff

Support staff can diffuse some of the potential chaos by spending a little extra time to help the patient sort out what it is he/she feels is important. There is no substitute for the extra time and attention required by some patients. It is important and useful for members of the healthcare team to recognize that engaging with unfamiliar people, particularly people who are responsible for one’s health, may be one of the most stressful situations that a patient with a personality disorder may experience. However, once patients get to know and are comfortable with their clinicians and the other medical staff, much of their problematic behavior may subside.

Staff should be educated about how to identify signs of problematic behavior and emotional discomfort, and steps should be taken to intervene early. They should be prepared for what to do in the following situations:

  • When a crisis arises in the waiting area
  • When patients present with suicidal threats or para-suicidal behavior, such as self-mutilation
  • When patients are visibly intoxicated and disruptive

Crowded waiting rooms, long waits, and unscheduled acute visits can create anxiety and frustration, particularly among patients with personality disorders. Therefore, ongoing staff education is important for managing disruptions that can occur as a result of these stressful conditions. A plan that is based on available resources and expertise and that provides strategies for staff members to overcome discomfort in managing patients with personality disorders will facilitate effective responses to patients’ needs.

For more information on treating patients with suicidal or violent behavior, see Suicidality and Violence in Patients With HIV/AIDS.

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B. Approach to Specific Patient Types

Although no patient will fit exactly into any one paradigm of personality type or style presented here, clinicians will likely encounter such personality traits in the care of HIV-infected patients. The patient types described below approximate patients who present with problematic styles of behavior and personality traits commonly encountered in real-life clinical practice.

Table 4 presents approaches to problematic personality traits that characterize patients who fall within each of the three personality disorder clusters.

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1. Odd or Eccentric Patients

Guarded, suspicious, and argumentative patients are doubtful of others’ intentions and motives. They may be openly or covertly suspicious of interventions. To the extent that they are convinced that others intend to harm them, they may also be hostile or menacing. Clinicians should maintain a respectful, professional distance from patients. Example:

I understand your reasons for not wanting to take medications. If you change your mind, please let me know. I would like to continue to work with you and help you do the things that will keep you as healthy as possible for as long as possible.

Some patients who are mistrustful, or even paranoid, about medications may eventually accept treatment once they recognize trustworthiness of their clinician in other areas of concern. For this reason, it is especially important to clarify and respond to the patient’s agenda. For example, a patient may refuse ARV medication yet request help with eating a healthier diet. Once the clinician has respectfully demonstrated competence addressing this problem, the patient may trust his/her advice about other matters. Furthermore, some patients may make clinicians particularly uncomfortable because, although guarded and unwilling to reveal much about themselves, they may be aggressively intrusive and overfamiliar with their clinicians. This behavior may represent a patient’s attempt to protect him/herself from his/her own fear of being dominated and controlled.

Aloof or uninvolved patients are remote or uninterested in the details of their illness, and they have little sense of interpersonal relatedness. They may appear cold, detached, or bland and have a very restricted range of emotional responsivity. Uncomfortable with the involvement of professionals in their lives, they may miss appointments.

Idiosyncratic or eccentric patients tend to dress differently, have peculiar beliefs that can be characterized as not culturally sanctioned, and speak in constricted, loose, digressive, and/or vague ways. These patients may act guarded or may present with unusual complaints that do not have clear physiological patterns. When complaints overlap with symptoms of co-existent somatic disorders, the situation becomes even more complicated. They may use logic that is idiosyncratic and may believe that they have special or magical powers. For example, they may reason that because HIV can be a terminal illness, they are entitled to the same benefits as a dying person, even though they may be asymptomatic and healthy. Usually, idiosyncratic patients respond best to a consistent approach to their complaints and beliefs that neither challenges their truthfulness nor reinforces their perspective. Example:

Your home remedies have kept you healthy so far. These medications won’t mix with one of the home remedies. Can we find a replacement for only that specific remedy to make sure that it does not take away the treatment action of your medications? What other remedy might work for you with these medications? Let’s talk about them, so we make sure they can be of help to you.

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2. Dramatic, Emotional, or Erratic Patients

Dramatic, dependent, and overdemanding patients have increased dependency and poor tolerance for frustration. They may demand or require more time during office visits and/or may call frequently between scheduled appointments. Also, they may not view broken appointments and their demand for added attention as contradictory.

Dramatic, emotionally involved, seductive, and captivating patients develop intense, over-idealized relationships with primary care professionals. They may treat the clinician as if he/she were a close personal friend. In addition, the clinician may become the only person who understands them, the only doctor who ever really cared about them, the only doctor they ever trusted. Over-idealization may take the form of unquestioning compliance with all treatment recommendations. They may become jealous quickly when their clinician’s attention turns to other matters. They may also treat the clinician with contempt and hatred if he/she disappoints or frustrates them. Often these patients are anxious about medical interventions. They can be particularly adept at provoking clinicians to retaliate with inappropriate and unhelpful responses.

A subgroup of overdemanding and/or emotionally involved patients may attempt to manipulate or control clinicians through para-suicidal or suicidal threats or behavior. They may respond to setting limits or confrontation by acting destructively toward their treatment or becoming more labile. They may behave similarly if they perceive or fear that their clinicians are going to abandon them.

Superior patients have exaggerated self-confidence. They may be smug, vain, or arrogant. Often their mood fluctuates between demanding brilliance from clinicians and needing to devalue, degrade, or demean these same clinicians. These patients may get “pushed away” by providers who feel they are being challenged. However, clinicians should realize that these patients are easily humiliated and usually have a very fragile sense of self. Without challenging the patient’s need to feel superior, clinicians should carefully demonstrate their own competence. Example:

May I see that article you have on HIV treatment? [Clinician reviews the article, following with] This is helpful. Can I keep a copy in the file? Now, for the next month, can you try [clinician offers treatment recommendation]?

Sociopathic patients ignore the usual social rules through lying, theft, reckless behavior, and disregard for others. They usually lack empathy and may alternate between being demanding and abusive or flattering and ingratiating. Clinicians should never tolerate behavior from these patients that is aggressive or that creates an unsafe environment. A mental health consultation may help with the development of an appropriate treatment plan.

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3. Anxious or Fearful Patients

Orderly, controlled, and controlling patients use knowledge and routine to push away fear and uncertainty. They may be stubborn, rigid, and preoccupied with right and wrong. They have difficulty tolerating the “gray areas” in which so much of medical decision-making takes place. They may view a clinician’s inability to guarantee the success of a treatment as a professional shortcoming. Illness and treatment are threats to their need for control. Their obsessions, compulsions, or need for control interfere with their function and may suggest obsessive compulsive disorder (OCD).

Anxiously avoidant patients may appear shy, easily embarrassed, and hypersensitive to criticism. The shame they experience associated with HIV usually pervades many other areas of their lives. The treatment of these patients may suffer because they are fearful of disclosing their HIV diagnosis and details about treatment to others. Criticism or rejection from someone on whom they feel dependent is the worst thing that could happen to them. They may avoid anything associated with HIV, including clinicians. Many of these patients will also meet criteria for social anxiety disorder, an Axis I disorder that significantly overlaps with their avoidant behavior.

Anxiously dependent and clinging patients are submissive and indecisive and allow the clinician and others to take responsibility for making all treatment decisions for them. Similar to dramatic and emotional patients described earlier, they fear separation and abandonment. They frequently need constant reassurance about their health and their clinician’s availability. Their needs can feel unlimited and may overwhelm the medical staff. Generally, these patients respond best when their dependency is tolerated, which may, however, require that the healthcare network be broadened to alleviate excessive demands on one individual provider.

Controlling, avoidant, and dependent patients may also use passive-aggressive means to express their anger indirectly. Because they fear criticism or rejection, they may displace anger at clinicians onto other staff or “act it out.” Their behavior may alienate other members of the medical staff, who may in turn resent the clinician because he/she sees only the adherent side of the patient. Patients may also act out their anger by missing appointments, not adhering to medications without informing the clinician, or not taking responsibility for other aspects of their care.

Approaches to problematic personality traits are presented in Table 4. In all cases, when complex mental status evaluations become necessary or a patient’s behavior leads to instability or jeopardizes effective treatment, clinicians should refer patients to mental healthcare professionals.

Table 4: 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.

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C. Treatment of Personality Disorders

RECOMMENDATIONS:

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 patients with personality disorders that suggest a comorbid psychotic disorder.

The primary psychiatric treatment of personality disorders and maladaptive traits consists of psychotherapeutic and social interventions, sometimes used in combination with adjunctive pharmacotherapy. Psychotropic medications alone are rarely useful for the treatment of patients with personality disorders, but it is important to treat comorbid Axis I disorders, such as mood and anxiety disorders. Clinicians should also be aware of symptoms in these patients that suggest a comorbid psychotic disorder. In addition, evidence suggests that selective serotonin reuptake inhibitor (SSRI) antidepressants can be effective in relieving some of the depressed, anxious, and impulsive presentations in patients with personality disorders.

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.



Specialized psychiatric treatment is necessary for patients to achieve fundamental, lasting change in their personalities. However, patients with personality disorders can often be effectively managed in the HIV clinic. Staff interventions should focus on helping patients change their behavior, style of interacting with others, and understanding of themselves and others rather than on changing their feelings. They must learn to tolerate uncomfortable feelings over time and focus on successful behavioral styles.

There are several different types of individual and group psychotherapies that may be effective in the treatment of patients with personality disorders. The choice of therapy depends on factors such as patient characteristics and availability of resources. A psychiatric consultation can assist referral to specialized treatment services.

The clinician should also consider referral to HIV-specific programs. For example, patients who need more support and structure may benefit from programs such as AIDS day-treatment programs or support groups and activities offered by community-based AIDS organizations. Consultation with a mental health provider or social worker may assist referral to an appropriate HIV/AIDS-related program. For mental health resources, refer to Appendix III: Mental Health Care Resources in New York State, Appendix IV: New York City Ryan White Part A Mental Health Providers, and Appendix V: New York State Department of Health AIDS Institute Grant-Funded Mental Health Providers.

Individual and group psychotherapies used in treatment of patients with borderline personality disorders include8-12:

  • Cognitive-behavioral therapy: incorporates the theories of behaviorism, social learning theory, and cognitive theories to understand and address a patient’s behavior. Short-term treatment is intended to help people redirect destructive thoughts and habits and learn healthier ways of addressing problems. Specific skills include identification of cognitive errors and core beliefs, setting and following an agenda, exploration of underlying assumptions, and seeking alternative explanations.
  • Dialectical behavior therapy: structured in stages, and at each stage a clear hierarchy of targets is defined. Dialectical behavior therapy teaches patients the skills of mindfulness, interpersonal effectiveness, distress tolerance, and emotional regulation.
  • Transference-based therapy: a form of psychodynamic psychotherapy that draws from three major theoretical perspectives: ego psychology, object relations, and self-psychology. The therapist explores the patient’s early childhood and develops a healthy relationship with the patient in an attempt to resolve interpersonal problems. The goals of treatment include increased self-awareness, with greater impulse control and increased stability of relationships. Specific skills include clarification, confrontation, and interpretation; management of acting out; exploration of conflict; and relating past experience to present conflict.
  • Supportive therapy: less intensive than psychotherapy and may be effective for engaging many people with borderline personality disorder in treatment, developing a therapeutic alliance, and working to attain treatment goals. Unlike psychodynamic therapy, supportive therapy minimizes the exploration of transferential feelings whereby transference is addressed only in situations where the therapy is threatened. The goals of supportive therapy involve reducing anxiety, strengthening defenses, building self-esteem, and enhancing coping mechanisms.

Other psychosocial treatment modalities may be helpful, and referral to a mental health professional is recommended. A psychiatrist can assist with referral to specialized treatment services for patients with personality disorders.

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REFERENCES

1. Verheul R, van den Bosch LMC, Ball SA. Substance use. In: Oldham JM, Skodol AE, Bender DS, eds. The American Psychiatric Publishing Textbook of Personality Disorders. Washington DC: The American Psychiatric Publishing Inc.; 2005:463-475.

2. Johnson JG, Williams JB, Goetz RR, et al. Personality disorders predict onset of Axis I disorders and impaired functioning among homosexual men with and at risk of HIV infection. Arch Gen Psychiatry 1996;53:350-357.

3. Perkins DO, Davidson EJ, Leserman J, et al. Personality disorder in patients infected with HIV: a controlled study with implications for clinical care. Am J Psychiatry 1993;150:309-315.

4. Johnson JG, Williams JB, Rabkin JG, et al. Axis I psychiatric symptoms associated with HIV infection and personality disorder. Am J Psychiatry 1995;152:551-554.

5. Verheul R, Ball SA, van der Brink W. Substance abuse and personality disorders. In: Kranzler HR, Rounsavill BJ, eds. Dual Diagnosis and Treatment: Substance Abuse and Comorbid Medical and Psychiatric Disorders. New York: Marcel Dekker; 1998.

6. Kelley JL, Petry NM. HIV risk behaviors in male substance abusers with and without antisocial personality disorder. J Subst Abuse Treat 2000;19:59-66.

7. Angelino AF, Treisman GJ. Management of psychiatric disorders in patients infected with human immunodeficiency virus. Clin Infect Dis 2001;33:847-856.

8. Hellerstein DJ, Aviram R, Kotov K. Beyond ‘handholding’: Supportive therapy for patients with BPD and self-injurious behavior. Psychiatric Times 2004;Vol. XXI: Issue 8. Available at: http://www.psychiatrictimes.com/showArticle.jhtml?articleID=175802407

9. Koerner K, Linehan MM. Research on dialectical behavior therapy for patients with borderline personality disorder. Psychiatr Clin North Am 2000;23:151-167.

10. Linehan MM. Cognitive-Behavioral Treatment of Borderline Personality Disorder. New York: The Guilford Press; 1993.

11. Linehan MM. Skills Training Manual for Treating Borderline Personality Disorder. New York: The Guilford Press; 1993.

12. Linehan MM, Armstrong H, Suarez A, et al. Cognitive-behavioral treatment of chronically parasuicidal borderline patients. Arch Gen Psychiatry 1991;48:1060-1064.

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FURTHER READING

Cohen MA, Gorman JM, eds. Comprehensive Textbook of AIDS Psychiatry. New York: Oxford University Press; 2008.

Feinstein RE. Personality disorders in the primary care setting. Resid Staff Physician 2000;46:47-56.

Fernandez F, Ruiz P, eds. Psychiatric Aspects of HIV/AIDS. 1st ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2006.

Groves JE. Taking care of the hateful patient. N Engl J Med 1978;298:883-887.

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ADDITIONAL RESOURCES

 www.apa.org

www.psych.org/psych_pract/treatg/pg/Practice Guidelines8904/BorderlinePersonalityDisorder.pdf

www.nimh.nih.gov/publicat/bpd.cfm

www.apm.org/sigs/oap

www.behavioraltech.com

www.borderlinepersonality.ca

www.bpdcentral.com

http://depts.washington.edu/brtc/about/dbt

www.medwire-news.md/47/Psychiatry.html

www.tara4bpd.org

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