Case 15.5 – Personality Disorders

Responding to Prescribing Demands:

• Try to stay calm
• Speak in a clear and unhurried manner
• Explain you would be happy to help Jack with his symptoms, but first need to ask him a few questions to determine what is going on
• Explain that you need to do this to ensure that the treatment you provide him with is the right treatment, and will help him with his symptoms
• Explain that alprazolam can be a helpful medication for certain symptoms, however for some conditions there are more appropriate medications
• State that at the moment you are not able to write him a script for alprazolam, but perhaps after assessing him you will be able to help him

Principles of Assessment:

• Try to establish a rapport with Jack
• Try to determine what Jack's symptoms are
• Determine if Jack has any current or past substance abuse issues
• Determine if Jack has any signs of current intoxication
• If intoxicated or under the influence of a substance, ascertain what substance is involved
• Determine if Jack has had alprazolam before, and what he has used it for
• Determine if Jack has any other reasons for coming in today
• Determine whether Jack has any safety concerns (i.e., is he at risk of harm to self or others)

Safety:

• Ensure there are other staff members are aware that Jack is in your room
• Ensure there is an avenue of escape (i.e., don't allow Jack to sit between you and the door)
• Know where your duress button is

Differential Diagnosis:

• Substance misuse disorder: Possible, given his demanding behavior for benzodiazepines and vague symptom presentation
• Personality disorder: Pattern of difficult interpersonal relationships, frequent attendance, boundary violations (after-hours contact), splitting behavior with doctors
• Mood disorder: Depression or bipolar disorder should be considered
• Anxiety disorder: Generalized anxiety disorder, panic disorder
• Adjustment disorder: Related to relationship breakdown

Personality Disorders - Overview:

Personality disorders are a collection of disorders characterised by enduring maladaptive patterns of behaviour, cognition, and inner experience. These patterns develop early, are inflexible, and are associated with significant distress and impairment.

DSM-5 Classification - Three Clusters:

Cluster A (Odd/Eccentric):

• Paranoid PD: Pattern of distrust and suspiciousness
• Schizoid PD: Pattern of detachment from social relationships
• Schizotypal PD: Pattern of acute discomfort in close relationships, cognitive or perceptual distortions, eccentricities of behavior

Cluster B (Dramatic/Emotional/Erratic):

• Antisocial PD: Pattern of disregard for and violation of the rights of others
• Borderline PD: Pattern of instability in interpersonal relationships, self-image, affects, and marked impulsivity
• Histrionic PD: Pattern of excessive emotionality and attention seeking
• Narcissistic PD: Pattern of grandiosity, need for admiration, lack of empathy

Cluster C (Anxious/Fearful):

• Avoidant PD: Pattern of social inhibition, feelings of inadequacy, hypersensitivity to negative evaluation
• Dependent PD: Pattern of submissive and clinging behavior related to excessive need to be taken care of
• Obsessive-Compulsive PD: Pattern of preoccupation with orderliness, perfectionism, mental and interpersonal control

Borderline Personality Disorder - Key Features:

Most relevant to Jack's presentation. Characterized by:

• Frantic efforts to avoid real or imagined abandonment
• Pattern of unstable and intense interpersonal relationships (idealization and devaluation)
• Identity disturbance: markedly and persistently unstable self-image
• Impulsivity in at least two areas that are potentially self-damaging (e.g., spending, sex, substance abuse, reckless driving, binge eating)
• Recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior
• Affective instability due to marked reactivity of mood
• Chronic feelings of emptiness
• Inappropriate, intense anger or difficulty controlling anger
• Transient, stress-related paranoid ideation or severe dissociative symptoms

Assessment Considerations:

• Jack's behavior shows splitting (other doctors are "much better")
• Difficulty maintaining relationships (multiple GP changes)
• Boundary violations (after-hours contact)
• Impulsivity and demanding behavior
• Mention of self-harm following relationship breakdown
• These features suggest possible Cluster B personality disorder, particularly borderline PD

General Principles for Managing Difficult Patient Behaviors:

Stay Calm and Professional:

• Maintain a calm, non-confrontational demeanor
• Speak clearly and unhurriedly
• Avoid becoming defensive or argumentative
• Don't take hostile comments personally

Set Clear Boundaries:

• Explain what is and isn't acceptable behavior in your practice
• Be specific about consultation times and after-hours contact
• Outline consequences if boundaries are violated
• Be consistent in enforcing these boundaries

Active Listening and Validation:

• Listen to Jack's concerns without interruption
• Acknowledge his distress (validation doesn't mean agreement)
• Use reflective statements: "I can hear that you're frustrated"
• Show empathy while maintaining professional boundaries

Collaborative Approach:

• Involve Jack in decision-making about his care
• Explain your reasoning for treatment decisions
• Offer alternatives when appropriate
• Establish a treatment plan together

Specific Strategies for Jack:

• Address the alprazolam request: Explain why you cannot prescribe it without proper assessment
• Focus on safety: Take his mention of self-harm seriously and assess suicide risk
• Avoid splitting: Don't compare yourself to other doctors or criticize colleagues
• Time limits: Explain how much time is available for the consultation
• Document thoroughly: Record the interaction, including what was said and agreed upon
• Safety planning: If self-harm risk is present, develop a safety plan
• Follow-up: Schedule a follow-up appointment to continue assessment
• Referral: Consider referral to mental health services if appropriate

Communication with Practice Team:

• Inform receptionists and nursing staff about boundary issues
• Ensure consistent approach across the practice
• Have a practice policy for dealing with difficult patients
• Ensure staff know how to manage after-hours contact

When to Involve Others:

• Have another staff member present if you feel unsafe
• Use duress alarm if situation escalates
• Consider having practice manager involved in setting boundaries
• Involve mental health crisis team if acute risk identified

Immediate Safety Priorities:

• Your safety comes first
• Do not put yourself at risk
• Do not attempt to physically restrain or confront an aggressive patient
• Your goal is de-escalation, not confrontation

De-escalation Techniques:

• Stay calm: Maintain calm body language and tone of voice
• Give space: Don't stand too close or make threatening gestures
• Non-threatening posture: Keep hands visible, open body language
• Speak slowly and clearly: Use simple, direct statements
• Acknowledge feelings: "I can see you're upset"
• Avoid arguing: Don't debate or become defensive
• Offer choices: Give the patient some sense of control
• Set limits: "I want to help you, but I need you to sit down and stop shouting"

If De-escalation Fails:

• Use duress alarm immediately
• Move toward the exit if possible
• Call for help from colleagues
• Leave the room if you feel unsafe
• Call security or police (000) if violence is imminent or occurs

After the Incident:

• Ensure your safety and that of staff and other patients
• Seek support from colleagues
• Document the incident thoroughly
• Report to practice manager/appropriate authorities
• Consider police report if assault occurred
• Debrief with team
• Access support services if needed (e.g., counseling)

Legal Considerations:

• You have the right to terminate the doctor-patient relationship if threatened
• Document reasons clearly
• Provide written notification to patient
• Offer to transfer care appropriately (but not required if safety concern)
• Ensure other practice staff are aware

Practice Policies:

• Have clear workplace violence policy
• Regular staff training on managing aggression
• Clear procedures for using duress alarms
• Support systems for staff who experience violence
• Physical environment considerations (exit access, panic buttons, etc.)

Immediate Response to Text Messages:

• Do not respond to personal text messages
• This represents a boundary violation
• Responding encourages further inappropriate contact
• Document that you received the messages

Setting Professional Boundaries:

• Arrange a consultation to discuss the incident and ongoing care
• Explain clearly what acceptable contact methods are (e.g., calling reception during business hours)
• Inform Jack that personal text messages are not appropriate
• Explain that after-hours contact should be for emergencies only
• Outline consequences if boundaries continue to be violated

Pattern Recognition:

• Jack's behavior shows classic "splitting" - alternating between idealization ("best doctor") and devaluation (previous hostility)
• This is characteristic of borderline personality disorder
• Recognize this pattern to avoid being manipulated
• Don't accept the idealization any more than you took the criticism personally
• Maintain consistent, professional boundaries regardless of Jack's behavior

Ongoing Management Strategies:

• Consistency: Maintain same boundaries and expectations regardless of Jack's behavior
• Clear communication: Be explicit about expectations and limits
• Documentation: Keep detailed records of all interactions
• Team approach: Ensure all practice staff are aware of the situation and boundaries
• Treatment plan: Develop a clear, written treatment plan with Jack's input
• Regular appointments: Scheduled consultations rather than crisis presentations
• Mental health referral: Strongly consider referral to psychiatrist or psychologist

Consider Terminating the Doctor-Patient Relationship If:

• Boundaries continue to be violated despite clear communication
• You or staff continue to feel unsafe
• The therapeutic relationship is not viable
• Jack is unable or unwilling to engage appropriately

If Terminating Relationship:

• Provide written notification to Jack
• Clearly document reasons
• Offer to provide ongoing care for a reasonable transition period (e.g., 30 days)
• Provide list of alternative providers if possible
• Ensure all practice staff are informed
• Be prepared for possible complaint to medical board
• Seek advice from medical defense organization if needed

Referral Options:

• Psychiatrist - for assessment and management of personality disorder
• Psychologist - for evidence-based psychotherapy (e.g., Dialectical Behavior Therapy for borderline PD)
• Community mental health services
• Crisis teams if acute risk remains

Self-Care:

• Discuss challenging cases with colleagues
• Recognize your emotional response is normal
• Don't feel obligated to continue care if relationship is not therapeutic
• Access support through GP support services if needed
• Maintain professional boundaries for your own wellbeing

Learning Points:

• Personality disorders present significant management challenges
• Consistency and clear boundaries are essential
• Don't take idealization or devaluation personally
• Recognize when a therapeutic relationship is not viable
• Your safety and wellbeing matter
• Multidisciplinary approach is often needed
• Documentation protects both you and the patient