Sunday, 29 April 2018

Personality Disorders :Assessment, Management and Treatment

        Assessment of Personality Disorders



Personality Disorders :Assessment, Management and Treatment
  • Personality Disorder shares many common features with functional Mental Disorder. The main differentiating feature is that in Personality Disorder, the one set is early and the features have been persistent and stable, while in functional Mental Disorder, the onset is usually later and the symptoms tend to be episodic. However, this distinction is not clear.

  • Knowing the background personality in a patient with a Mental Disorder helps the Clinician be more realistic with respect to the treatment outcome expectations.

  • So, it is very important to access the patient's Personality as a part of the initial assessment(usually with extra information from another source such as Parents, Siblings, Spouse, Family, Physician, etc) who has known the patient for many years.


  •   It is generally not appropriate to make a diagnosis of a Personality Disorder after just one Assessment session. Usually, a  patient would need to be seen at least a few times.

  • Previous Medical/Psychiatric records, if available, should also be studied.

  • while the exception of Borderline Personality Disorder, most other Personality Disorders are diagnosed the only incidentally in routine psychiatric services in patients presenting with other problems like Psychosis, Depression, Anxiety, etc.

  • Patients with a Personality disorder are at higher risk of developing Mental Disorder.


Management Of Personality Disorder


Apart from the Borderline PD, the vast majority of patients with Personality Disorders(with no co-morbid Mental Disorder) do not to the attention of mental health services. Hence, most of the studies of treatment have been on Borderline PD.


The other Personality Disorders are usually incidentally diagnosed in patients presenting with the other disorders like Depression, Anxiety, Psychosis or Addiction.


 Antisocial PD is, as expected, very common in the prison/criminal justice settings. It is usually diagnosed formally only after the person has committed a crime.


Management Of Borderline Personality Disorder:

 The goals of treatment include:

  • Better management of one's emotion.

  • Avoidance of / reduction of self-harm behavior.

  • Having more clarity about one's purpose in life.

  • Building better quality relationships with others.

  • Improvement in functioning.

  • Addressing the co-morbid Psychiatric/substance misuse issues.

Psychotherapy for Borderline PD-

    • Psychodynamic Psychotherapy

    • Dialectical Behaviour Therapy (DBT)

    • Transference-Focused Psychotherapy (TFT)

    • Mentalisation -Based Therapy (MBT)

    • Emotion Regulation Training (ERT)

    • Cognitive Behaviour Therapy (CBT)

    • Schema-Focused Therapy (SFT)

    • Interpersonal Psychotherapy (IPT)

 Pharmacotherapy for Borderline PD


  • Not used as a primary treatment as it is unlikely to alter the natural course of the disorder.

  • Mainly used for symptoms management.

  • Risk of overdose needs to be borne in mind while prescribing psychotropics.

  • Drugs that may have some benefits include:
              a) Antidepressants: usually SSRIs.

              b)Antipsychotics: usually low/dose atypicals.

              c)  Mood stabilizers: e.g. Valproate, Lithium.

                     d) Others e.g. Clonidine, Omega-3 fatty acids.



Management Of Paranoid Personality Disorder-

Patient with Paranoid Personality Disorder is very difficult to treat as they are mistrustful of most people, including Psychiatrists. A patient with Paranoid PD is unlikely to present for treatment unless there are significant immediate problems. 


For examples, a patient may be at risk of losing a job because of complaints from colleagues or a wife is deciding to leave unable to tolerate suspicious nature of the husband.


Low dose Antipsychotics may be helpful.



Treatment for Personality Disorders


If the patient is willing and motivated to change, and depending on the PD, and the availability of services the following treatments may help.


  • Psychotherapies: ranging from Supportive, through CBT, to Exploratory therapies like Psychodynamic Psychotherapy.

  • Self-help: books and online support groups.

  • Treatment of any co-morbid disorders such as Depression, Anxiety, etc with Medication or Psychotherapy to optimize functioning.







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