Medical and psychiatric illnesses may present in an atypical fashion, and may not respond as expected to treatment.
The psychosocial functioning of patients with personality disorders can vary widely. Some patients are globally impaired and function marginally overall. Patients may meet the criteria for more than one personality disorder. Comorbid mood, anxiety, and substance abuse disorders are common, and should be identified and treated. Personality disorders are, by definition, chronic conditions.
ACPMH Handbook - Information for People with ASD and PTSD. Danger ideation reduction therapy (DIRT) for obsessive compulsive disorder (OCD) is a new When they begin treating patients with CBT, they soon discover that the tough part of CBT is . in adults aged 18 years and older, in primary and secondary care. For screening to be meaningful in the primary care setting, the particular problem. substance abuse screening as part of the ongoing process of primary care is that . Substance Abuse Among Older Adults (see The National Clearinghouse for a binge drinker, and/or an alcoholic, distinctions important in determining the.
Patients with these disorders generally exhibit consistent patterns of behavior and coping throughout their adult lives. Axis I psychiatric disorders can present with patterns of symptoms similar to those of a personality disorder, but these symptoms usually have an identifiable onset, and remit or improve with appropriate treatment. A change in personality from baseline at any time, but particularly in adults and elderly persons, may indicate the onset of an axis I psychiatric disorder or a potentially serious underlying organic disorder.
When a personality change occurs, it is crucial to identify the new-onset condition that has precipitated the change Table 3. Further laboratory studies, central nervous system imaging, consultation, and treatment decisions are based on these data. Diagnostic and statistical manual of mental disorders, 4th. Personality disorders are chronic conditions that require specific management strategies.
In the primary care setting, most efforts focus on maintaining and supporting the physician-patient relationship and establishing a working alliance. The goal is to ensure that the patient is able to receive appropriate medical care despite the difficulty he or she may have in interacting with the physician and the health care system. Most primary care interventions are interpersonal, with specific management strategies depending on the disorder.
In some cases, psychiatric consultation, formal psychotherapy, or pharmacologic treatment may be indicated Table 4. Patients in this cluster—the paranoid, schizoid, and schizotypal—are uncomfortable in interpersonal situations, emotionally distant, difficult to engage, and isolative Table 5. These patients do not respond appropriately to affective cues from the physician, and are unable to form connections on a basic emotional level.
When dealing with these patients, many of the strategies commonly used to establish a therapeutic alliance are ineffective or counterproductive. Adopt a professional stance, provide clear explanations, be empathetic to fears, avoid direct challenge to paranoid ideation. Adopt a professional stance, provide clear explanations, avoid overinvolvement in personal and social issues. Adopt a professional stance, provide clear explanations, tolerate odd beliefs and behaviors, avoid overinvolvement in personal and social issues.
Behavioral medicine in primary care. In the clinical setting, these patients may be reluctant to seek care because of the necessary personal contact, they may interact in a manner that is distant and odd, and they may have bizarre ideas regarding their illness. Attempts by the physician to become emotionally close or to delve into their personal issues are seen as intrusive and tend to distance them further.
When interacting with these patients, physicians should respect their need for interpersonal distance and adopt a respectful, somewhat distant professional stance. Medical information should be conveyed in a clear, straightforward fashion. Additionally, with paranoid and schizotypal patients who exhibit distrust or strange ideas, it is important not to directly challenge these ideas or become distracted by them.
Patients in this cluster can be among the most challenging patients encountered in clinical settings Table 6. They may attempt to create relationships that cross professional boundaries and to place physicians in difficult or compromising positions.
Physicians often experience strong emotional reactions to these patients. When dealing with such patients, physicians must be keenly aware of the issues of manipulative behavior, professional boundaries, limit setting, and monitoring their own emotional state. Carefully investigate concerns and motives, communicate in a clear and nonpunitive manner, set clear limits. Instability in interpersonal relationships, self image, and affects; marked impulsivity. Fear of rejection and abandonment, self-destructive acts, idealization and devaluation of physician. Avoid excessive familiarity; schedule regular visits; provide clear, nontechnical explanations; tolerate angry outbursts, but set limits; maintain awareness of personal feelings; consult psychiatrist.
Overly dramatic, attention-seeking behavior, inability to focus on facts and details, somatization. Avoid excessive familiarity, show professional concern for feelings, emphasize objective issues. Demanding, attitude of entitlement, denial of illness, alternating praise and devaluation of physician. The antisocial patient, with a persistent pattern of deceitfulness, impulsivity, and disregard for the rights of others, may present in the context of medicolegal issues, such as disability evaluation, seeking controlled substances, or in situations involving aggressive or violent behavior.
Findings, assessments, recommendations, and limits must be clearly and firmly communicated to the patient. In some circumstances, it may be appropriate to obtain psychiatric or legal consultation. Managing borderline personality disorder can be difficult and confusing. Because of their instability in the multiple areas of interpersonal relationships, self image, affects, and impulsivity, these patients can present with a wide range of symptoms, including depression, anger, paranoia, extreme dependency, self mutilation, and alternating idealization and devaluation of the physician.
Their lives tend to be chaotic. They transfer many of their dysfunctional feelings and conflicts to the physician and the medical encounter. A somewhat detached professional stance and clear limit setting in terms of availability, appointment frequency, appropriate behavior, and medication use are necessary to manage these patients successfully.
The development of a formal behavioral treatment plan and insistence on participation in psychiatric care may be necessary to establish an effective working relationship. Histrionic patients are uncomfortable if they are not the center of attention. They tend to be emotionally demonstrative and seductive, and use their appearance to attract the attention of others. As a result, the implications of illness and aging may have a profound impact on their psychologic functioning. Additionally, the cognitive processes of these patients are overly emotional and impressionistic, leading to difficulties in dealing with facts, details, and decision making.
As a result, they may require extra assistance in processing medical information. Narcissistic patients, with their grandiose sense of self-importance, tend to be demanding and insist on special status and treatment in the physician-patient relationship. They can appear haughty and self-absorbed, exhibit denial of illness, and become easily enraged by perceived slights.
The physician should try not to directly challenge their sense of entitlement, or to be put off by their anger and demands. Their concerns should be acknowledged, and they should be provided reassurance that they are receiving the best care available.
Strategies that help patients to take an active role in dealing with their illnesses are helpful. Tactful negotiation and limit setting around patient demands for testing, treatment, and referrals may be necessary. All patients in this cluster exhibit anxiety in some form Table 7.
The physician must use appropriate strategies to help allay this anxiety and establish an effective working relationship with these patients. Provide reassurance, validate concerns, encourage reporting of symptoms and concerns.
The development of a formal behavioral treatment plan and insistence on participation in psychiatric care may be necessary to establish an effective working relationship. See Chapter 1, Figure Earn up to 6 CME credits per issue. This guideline covers people whose depression occurs as the primary diagnosis. To ensure that older adults receive needed intervention services, stepped-up identification efforts by primary care clinicians are essential DeHart and Hoffmann, Odd beliefs, socially isolative. As a result, the implications of illness and aging may have a profound impact on their psychologic functioning.
Urgent demands for attention, prolongation of illness behavior to obtain attention and care. Provide reassurance, schedule regular check-ups, set realistic limits on availability, enlist others to support patient, avoid rejection of patient. Fear of relinquishing control, excessive questioning and attention to details, anger about disruption of routines. Complete thorough history and examinations, provide thorough explanations, do not overemphasize uncertainty, encourage patient participation in treatment. The patient with avoidant personality is essentially a shy, inhibited person who has feelings of inadequacy and low self-esteem.
These patients are hypersensitive to perceived criticism, but have the capacity to develop appropriate relationships if they feel safe and accepted. These patients appear shy and withdrawn, may withhold information that they feel is potentially embarrassing, and may be reluctant to question or disagree with their physician. In the medical encounter, the physician should approach these patients with an accepting and attentive attitude, provide ample reassurance, and encourage them to report and discuss their symptoms and concerns. The dependent patient struggles with the self-perception that he or she is unable to function adequately without the help of others.
This leads to difficulties in decision making, motivation, assumption of responsibility, and in fears of being abandoned by significant others. Dependent patients go to excessive lengths to maintain their relationships and sense of safety. In the medical setting, particularly during times of illness, these patients rely heavily on their physician for guidance and support.
Physicians can provide assistance, but must monitor their level of involvement, acknowledge their limitations, and resist making major decisions for the patient. Limits on the need for time and resources should be set empathetically and openly. Alternate sources of assistance, such as a family member, member of the clergy, or a therapist can be enlisted to help manage the patient in times of increased need.
Obsessive-compulsive patients are preoccupied with orderliness and control. In the medical setting, they expect similar characteristics in their physician. An effective tactic is to provide patients with assignments such as monitoring symptoms and reading on their condition, thus increasing their participation and sense of control. Offering reassurance and setting limits on time may be necessary. Psychotropic medications generally are viewed as an adjunctive treatment in the management of personality disorders. They can be helpful for some symptoms in some patients. Large studies are lacking, but an emerging body of data includes some small controlled studies.
Three of the disorders, the schizotypal, borderline, and avoidant personalities, have received the most attention. Medication recommendations are based on extrapolations from these three disorders to the others in their respective clusters. Specific medication-responsive target symptoms have been identified for each cluster. If these target symptoms are identified, a carefully monitored medication trial may be considered. Table 4 17 describes the basic target symptoms and medications for each of the three personality disorder clusters.
Clusters A and C have fairly straight-forward and limited target symptoms and medication options. Cluster B has multiple groupings of target symptoms and more complicated medication regimens. Psychiatric consultation should be considered for patients in whom the diagnosis is unclear, for complex treatment regimens, or for refractory symptoms.
Already a member or subscriber? He received his medical degree from Northwestern University Medical School, Chicago, where he also completed a residency and fellowship in psychiatry. Address correspondence to Randy K. Reprints are not available from the author. What is the best way to carry out behavioural activation? When they begin treating patients with CBT, they soon discover that the tough part of CBT is not really technique, but rather the choices the therapist makes during the therapy: Take, for example, the fiery criticism President Obama received when in when he announced that empathy was one of the main criteria by which he would select a Supreme Court nominee Baker It provides the ethical framework for Psychologists working within Australia.
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This guideline makes recommendations on the assessment and management of bedwetting in children and young people. The guidance applies to children and young people up to 19 years with the symptom of bedwetting. NICE is developing a guideline on case identification and referral for common mental health disorders that will provide further guidance on the identification and treatment of comorbid conditions. This guideline makes recommendations on the diagnosis, assessment and management of harmful drinking and alcohol dependence in adults and in young people aged 10—17 years.
This guideline covers the assessment and management of adults and young people aged 14 years and older who have a clinical diagnosis of psychosis with coexisting substance misuse.
The intention of this guideline, which is focused on primary care, is to improve access to services including primary care services themselves , improve identification and recognition, and provide advice on the principles that need to be adopted to develop appropriate referral and local care pathways.
It brings together advice from existing guidelines and combines it with new recommendations concerning access, assessment and local care pathways for common mental health disorders. This guideline covers the recognition, referral and diagnosis of autism in children and young people from birth up to 19 years. This guideline offers best practice advice on the care of adults, children and young people who self-harm. This guideline offers best practice advice on the care of children, young people and adults with epilepsy. This guideline makes recommendations on the identification, treatment and management of depression in adults aged 18 years and older, in primary and secondary care.
This guideline covers people whose depression occurs as the primary diagnosis. NICE clinical guideline 91 on depression in adults with a chronic physical health problem. This guideline makes recommendations on the identification, treatment and management of depression in adults aged 18 years and older who also have a chronic physical health problem such as cancer, heart disease, diabetes, or a musculoskeletal, respiratory or neurological disorder. Rosa and Michael J.
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