Personality Disorders

This Clinical Information Guide is one in a series of guides designed to assist caseworkers and supervisors in identifying and managing clients who need mental health services. These guides use the treatment pathways model,¹ which outlines five stages to assist you in obtaining the best possible mental health services for your clients. Each guide is designed to highlight the primary casework task that needs to be accomplished at each stage, and to address common questions that you might have as you complete each task.

What are the five stages of the Treatment Pathways Model?

In the identification stage, you gather information concerning the identified problems, consult with your supervisor and the behavioral health consultant, and decide whether or not your client needs to be referred to a mental health specialist. In the referral stage, you follow established procedure by completing required documentation and selecting the appropriate mental health specialist. In the assessment and diagnosis stage, you assist the specialist by furnishing relevant information concerning your client. In the treatment stage, you work collaboratively with the clinician to identify treatment goals and secure the most effective treatment available for your client. In the monitoring and reviewing stage, you ensure that reasonable treatment goals are achieved.

TREATMENT PATH STAGE I: IDENTIFYING PERSONALITY DISORDERS

Primary Casework Task: To gather information to decide whether or not your client exhibits the symptoms of a personality disorder and to consult with your supervisor and the behavioral health consultant to determine if a referral for an evaluation or clinical intervention is needed.

What are personality disorders?

Personality disorders are lasting and pervasive patterns of thought, emotion, interpersonal functioning, and impulse control that differ from the patterns typically found in the individual's culture. Because these personality patterns take time to develop, personality disorders are not usually diagnosed in individuals under age 18 years.

There are 10 different personality disorders grouped into three clusters. Cluster A includes odd and eccentric behaviors, such as paranoia, detachment from social relationships, and restricted emotional expression. Cluster B includes dramatic and emotional behaviors, including impulsiveness, grandiosity, excessive emotional expression, and disregard for the rights of others. Cluster C includes anxious and fearful behaviors, including extreme shyness, sensitivity to criticism, submissiveness, and perfectionism.

How common are personality disorders?

10-15% of people in the general population have at least one personality disorder. The most commonly occurring personality disorders are those in Cluster C. Overall, the frequency of occurrence of personality disorders does not differ between men and women, although specific personality disorders are more often diagnosed in one gender or the other. The frequency of diagnosis declines with age, but increases when there are problems in marital or occupational functioning.

What causes personality disorders?

The exact causes of personality disorders are not known, although they are probably the result of a combination of genes and environmental factors, such as family environment and social and emotional development.

Are there cultural differences in personality disorders?

What one society views as "normal" behavior, another may view as abnormal. Thus, it is critical for caseworkers and treatment providers to account for the unique cultural factors of members of minority groups, immigrants, refugees, and individuals from different ethnic backgrounds. For example, among some Asian cultures, passivity, strong allegiance to elders, and respect for authority are important values that may be mislabeled by Western professionals as abnormally submissive. Similarly, people of Latin or Mediterranean descent may display dramatic or emotionally expressive behavior that Western professionals may label as abnormal.

TREATMENT PATH STAGE II: REFERRAL

Primary Casework Task: To complete the required referral process, including gathering supporting documentation, and to select the appropriate mental health specialist to assess, diagnose, and treat your client.

What kinds of mental health specialists can evaluate my client?

Psychologists (Ph.D., Psy.D.), psychiatrists (MD), licensed clinical social workers (L.C.S.W.), and psychiatric nurses (R.N.) have the training and background to conduct an initial evaluation for a personality disorder. Once a personality disorder is diagnosed, your client may need to be evaluated by a physician to rule out the possibility of medical problems causing the personality disorder.

These mental health specialists can be found at community mental health agencies, the psychiatry department of hospitals or clinics, employee assistance programs, health maintenance organizations, university or medical school-affiliated programs, state hospital outpatient clinics, family service or social service agencies, or private clinics. Appendix B of this Clinical Information Guide lists providers who treat individuals with personality disorders.

TREATMENT PATH STAGE III: ASSESSING AND DIAGNOSING

PERSONALITY DISORDERS

Primary Casework Task: To assist the mental health specialist by furnishing relevant information concerning your client's mental health.

The first step to getting appropriate diagnosis and treatment for a personality disorder is a thorough diagnostic evaluation by a mental health specialist. The clinician will gather a complete history of symptoms, including when they started, how long they have lasted, how severe they are, and whether the symptoms have ever been treated. The clinician will ask about alcohol and drug use, and whether or not the patient has thoughts about death or suicide. Further, a history will include questions about whether other family members display similar symptoms or traits, and, if these have been treated, what treatments they may have received which were effective.

Once the personality disorder is diagnosed, the individual may need to be examined by a physician. Certain symptoms such as impulsiveness are sometimes caused by other conditions such as traumatic brain injury. Some symptoms of personality disorders (described in the next section) may benefit from medication. In addition, medication is sometimes needed to treat other co-occurring psychiatric disorders, such as Major Depression or Post Traumatic Stress Disorder.

What are the different personality disorders?

The American Psychiatric Association's Diagnostic and Statistical Manual - Fourth Edition (DSM-IV) outlines 10 different personality disorders grouped within three clusters. These are summarized below:

Cluster A - Odd and eccentric behaviors

1. Paranoid Personality Disorder - characterized by distrust and suspiciousness of others.

2. Schizoid Personality Disorder - characterized by detachment from social relationships and restricted emotional expression.

3. Schizotypal Personality Disorder - characterized by odd and peculiar behavior and thoughts, and extreme discomfort with close relationships.

Cluster B - Dramatic and emotional behaviors

1. Antisocial Personality Disorder - characterized by disregard and violation of the rights of others.

2. Borderline Personality Disorder - characterized by impulsiveness and instability in interpersonal relationships, self image, and emotions.

3. Histrionic Personality Disorder - characterized by excessive emotionality and attention-seeking.

4. Narcissistic Personality Disorder - characterized by grandiosity, need for admiration, and lack of empathy.

Cluster C - Anxious and fearful behaviors

1. Avoidant Personality Disorder - characterized by extreme shyness, feelings of inadequacy, and sensitivity to criticism

2. Dependent Personality Disorder - characterized by strong needs to be taken care of, submissiveness, and fears of separation.

3. Obsessive-Compulsive Personality Disorder - characterized by preoccupation with orderliness and perfectionism.

In addition to the three clusters, the DSM-IV also contains a personality disorder diagnosis "Not Otherwise Specified" for individuals whose personalities reflect traits from more than one cluster.

To diagnose a personality disorder, the individual's symptoms should not be due to a medical condition or substance abuse. The pattern of behavior must be stable and of long duration, and it must cause the individual clinically significant distress or impair his or her occupational or social functioning.

TREATMENT PATH STAGE IV: TREATING PERSONALITY DISORDERS

Primary Task: To secure the most effective treatment available for your client's personality disorder and to work collaboratively with the treating clinician to identify treatment goals and objectives.

What kinds of treatment are available?

Individual outpatient psychotherapy is the most effective treatment for most personality disorders. In addition to psychotherapy, medication is sometimes used concurrently to treat particular symptoms or behaviors, or other co-occurring psychiatric disorders.

Compared with psychotherapy for DSM-IV diagnoses such as Major Depression or Panic Disorder, there is considerably less empirical research concerning psychotherapy for personality disorders. The most widely researched treatment is Dialectical Behavior Therapy for Borderline Personality Disorder, which combines individual and group psychotherapy. Dialectical Behavior Therapy emphasizes (a) cognitive-behavioral techniques that focus on modifying negative thoughts and behaviors and learning positive coping behaviors and skills, (b) psychoeducation that teaches patients about borderline personality disorder, and (c) supportive techniques such as empathic listening and acceptance.

Most treatments for personality disorders focus on modifying the personality traits that cause the greatest impairment. For example, treatment of borderline personality disorder focuses on helping the patient create new ways to manage strong feelings and cope with urges to hurt oneself. In general, no psychotherapeutic approach to the treatment of personality disorders -- psychodynamic, interpersonal, or cognitive-behavioral -- has been shown to be more effective than any other approach. Like the treatment of most psychiatric disorders, outcome improves when the individual has a positive working relationship with the therapist.

Combining group psychotherapy with individual psychotherapy is one way to help manage particularly difficult patients, such as those with Borderline Personality Disorder who are frequently suicidal. Group psychotherapy also allows individuals who have social skill deficits or interpersonal problems to learn from their peers. Individuals with Antisocial Personality Disorder should not participate in group psychotherapy with individuals who have other psychiatric disorders, because those with Antisocial Personality Disorder may exploit more vulnerable group members.

Hospitalization or day treatment may be needed if the individual with a personality disorder is suicidal, homicidal, or psychotic (that is, hearing voices or seeing things that other people do not see).

What kinds of medication are helpful?

Medication is sometimes used in addition to concurrent psychotherapy to treat particular symptoms or behaviors that comprise personality disorders. Psychotic symptoms, which are sometimes present in Schizotypal, Paranoid, and Borderline Personality Disorders, may respond to low-dose antipsychotic medications such as Zyprexa. Impulsiveness, which is sometimes present in Borderline and Antisocial Personality Disorders, may respond to selective serotonin reuptake inhibitors (SSRIs), such as Prozac or Zoloft. Mood symptoms such as depression or mood variability, which are sometimes present in Borderline, Histrionic, and Avoidant Personality Disorders, may respond to SSRIs or mood stabilizers such as Lithium.

How do I collaborate with the mental health specialist and my client to design treatment goals?

Developing treatment goals is a critical step in the treatment process. Clear, objective treatment goals enable the client, family, and service providers to address the client's mental health needs.

There are two broad kinds of treatment goals: Administrative and clinical. Administrative goals involve the completion or non-completion of services. Examples of administrative goals include the number of psychotherapy sessions or medication monitoring sessions that a client attends. Clinical treatment goals address two domains related to a client's overall functioning: symptom or behavior change, and changes in daily functioning ability

a) Symptom change -- A change in the symptoms or behaviors associated with a personality disorder, such as a decrease in impulsive or submissive behavior.

b) Functional change -- A change in the areas of functioning that are typically affected by personality disorder. These areas include:

· home or family (for example, improved ability to get along with family members)

· work (for example, or improved performance evaluations)

· friends or community (for example, increased stability in social relationships).

You will need to collaborate with your client and the mental health specialist to create treatment goals that address your client's symptoms and the areas of functioning that are critical to your client fulfilling his or her service plan. You will need to work with the mental health specialist to determine the manner and frequency with which treatment goals will be measured.

Individuals who have severe personality disorders or additional psychiatric disorders may need help coordinating the services of different treatment providers, such as individual and group psychotherapists, as well as the physician who provides medication management.

TREATMENT PATH STAGE V: MONITORING AND REVIEWING

Primary Task: To ensure that you receive timely and appropriate documentation from the mental health specialist that reviews progress towards treatment objectives.

How do I know if treatment is working?

Approximately 50% of individuals receiving 1-2 sessions per week of psychotherapy for a year or more experience a remission of the personality disorder. If your client's treatment is working, you should notice improvement in target symptoms such as interpersonal relationships, thought, emotions, and impulsiveness. Your client's performance at work may improve. Friends, family, and employers may report improvements in the client's demeanor.

Treatment Outcomes

What role do I play in monitoring my client's treatment goals?

Usually the mental health specialist will gauge the success of intervention services by observing changes in your client's behavior and functioning, and by administering standardized rating scales if appropriate. Because of your extensive knowledge of the client's behavior, the specialist may ask you about the client's functional change in different areas. For example, the specialist may ask you about your client's ability to get along with friends or other family members.

If your client is not improving, you will want to talk with the mental health specialist or physician concerning factors in the client's life that could be complicating recovery. Perhaps after treatment began, additional life stress or change occurred in the client's life, such as the death of a loved one or a change of job. Sometimes a client in psychotherapy may not find the treatment helpful, and other forms of treatment may need to be added, such as medication.

Clients who have improved significantly may be able to discontinue treatment if the mental health specialist indicates. On the other hand, personality disorders are enduring patterns of behavior, so long-term (that is, exceeding one year) psychotherapy is usually required. Repeated courses of psychotherapy during difficult or transitional times in the individual's life may also be required. Ongoing medication management may also be needed.

What kind of documentation should I expect from the mental health specialist?

You should expect quarterly treatment summaries that highlight your client's progress toward all administrative and clinical treatment goals. If you review a treatment summary and find that it differs significantly from your observations of the client, you will want to contact the mental health specialist to discuss your concerns. You will also want to contact the specialist if you believe that new goals should be added to your client's treatment plan.

RESOURCES FOR CLIENTS

Where can my client obtain information about personality disorders?

There are numerous sources for information concerning the diagnosis and treatment of psychiatric disorders, although these sources do not contain much information regarding personality disorders. However, these sources do provide information on the treatment of symptoms and problems that frequently co-occur with personality disorders, such as depression or anxiety. Your clients can obtain information from the following sources:

National Institute of Mental Health

Office of Communications and Public Liaison

Information Resources and Inquiries Branch

6001 Executive Boulevard, Rm. 8184, MSC 9663

Bethesda, MD 20892-9663

(301) 443-4513

www.nimh.nih.gov

American Psychiatric Association

1400 K Street, N.W.

Washington, DC 20005

(202) 682-6000

www.psych.org

American Psychological Association

750 First Street, N.E.

Washington, DC 20002

(202) 336-5500

www.apa.org

Treatment Path Stage Clinical Information Casework & Administrative

Tasks

I. Identification of problem

Lasting and pervasive pattern of behavior that differs from the individual's culture in two or more of the following areas: thought, emotion, interpersonal functioning, and impulse control.

Generally not diagnosed in individuals under age 18 years.

10 different personality disorders are grouped into three clusters:

Cluster A - odd and eccentric behaviors, including paranoia, detachment from social relationships, and restricted emotional expression

Cluster B - dramatic and emotional behaviors, including impulsiveness, grandiosity, excessive emotional expression, and disregard for the rights of others.

Cluster C - anxious and fearful behaviors, including extreme shyness, sensitivity to criticism, submissiveness, and perfectionism.

Casework Tasks:

a) Obtain input from client and significant others.

b) Observe client

c) Review clinical records

d) Consult with supervisor & behavioral health team

Administrative Task:

· Document in case record

II. Referral

Licensed mental health specialists that evaluate for personality disorders are:

a) psychiatrists (M.D.)

b) psychologists (Ph.D., Psy.D.)

c) licensed clinical social workers (LCSW)

d) psychiatric nurses (RN)

Administrative Tasks:

a) Complete referral to licensed mental health specialist.

b) Include relevant clinical and case records with your referral.

c) Document in case record.

III A. Assessment

Assessment by mental health specialist must include:

a) Interview of client

b) Review of case and clinical records

Assessment may also include:

a) Interviews with significant others

b) Observation of client in different settings

a) Clinical assessment using rating scales or other psychological tests

Administrative Task:

· Ensure mental health specialist

has all relevant casework and clinical records.

III B. Diagnosis

Diagnosis must meet DSM-IV criteria. Criteria vary for each personality disorder, but include two or more of the following areas:

thought, emotion, interpersonal functioning, and impulse control.

10 personality disorders are grouped within three clusters:

Cluster A - Odd and eccentric personality disorders

1. Paranoid -- distrust, suspiciousness of others

2. Schizoid -- detachment from social relationships, restricted expression of emotion

3. Schizotypal -- odd and peculiar behavior and thoughts, extreme discomfort with close relationships

Cluster B - Dramatic and emotional personality disorders

1. Antisocial -- disregard and violation of rights of others

2. Borderline -- unstable interpersonal relationships, self-image, and emotions, and impulsivity.

3. Histrionic -- excessive emotionality, attention-seeking

4. Narcissistic -- grandiosity, need for admiration, lack of empathy.

Cluster C - Anxious and fearful personality disorders

1. Avoidant -- extremely shy, feels inadequate, sensitive to criticism.

2. Dependent -- needs to be taken care of, submissive, fears of separation

3. Obsessive-Compulsive -- preoccupation with orderliness, perfectionism.

Additional diagnostic criteria for all personality disorders:

- Symptoms are not due to substance abuse or other medical condition

- Symptoms cause clinically

significant distress or

impairment of functioning

If diagnosed, physical exam may be required to rule-out other medical conditions that exhibit the same symptoms as certain personality disorders.

Administrative Task:

· Ensure mental health specialist

has all relevant casework and

clinical records.

IV. Treatment

Individual psychotherapy is the most effective treatment.

- Dialectical Behavior Therapy is recommended for individuals with Borderline Personality Disorder.

- Individuals with Antisocial Personality Disorder should not have outpatient group psychotherapy with individuals who have other psychiatric diagnoses.

- Group therapy may be combined with individual psychotherapy for individuals with social skill deficits or interpersonal problems.

- Hospitalization may be needed for individuals who are suicidal, homicidal or psychotic (hearing voices or seeing things).

Medication may be added to treat particular symptoms or behaviors

- Psychotic symptoms may respond to low-dose antipsychotic medications such as Zyprexa.

- Impulsiveness may respond to antidepressants such as selective serotonin reuptake inhibitors (SSRIs; for example Prozac, or Zoloft).

- Emotional symptoms such as depression or mood variability may respond to SSRIs, or mood stabilizers such as Lithium.

Medications may also be used to treat other co-existing psychiatric disorders, such as Major Depression or Post Traumatic Stress Disorder.

Casework Task:

Work collaboratively with mental health specialist to establish clear, measurable administrative and clinical treatment goals that assess your client's attendance and his or her change in:

a) personality disorder symptoms

b) functioning in areas relevant to the case plan. These areas might include home, work, and relations with family and friends.

V. Monitoring & Review of

Treatment

Approximately 50% of individuals receiving 1-2 sessions of psychotherapy per week for a year or more experience a remission.

Individuals who have severe personality disorders or other psychiatric disorders may need help coordinating the services of different treatment providers, such as individual and group psychotherapists and the physician who provides medication management.

The frequency and method of

monitoring treatment goals depends on the kind of treatment:

a) Psychotherapy -- Mental health specialist collects data from client by interview and rating scales and from reports by significant others (including caseworker).

b) Medication -- Physician monitors by reports from client and significant others and by conducting laboratory tests.

Casework Tasks:

a) Work with mental health specialists and client to evaluate progress toward treatment goals.

b) If necessary, work with specialist to revise treatment goals or to consider other kinds of treatment.

Administrative Tasks:

a) Obtain copies of quarterly, written treatment summaries from mental health specialist. Summaries should document client's progress toward clinical and administrative treatment goals, using standardized measures when appropriate.

b) Document in case record.

APPENDIX B

LOCAL CLINICAL RESOURCES

1 The treatment pathway for personality disorders is summarized in Appendix A.