Describe the behavioral patterns associated with paranoid, narcissistic, antisocial, and borderline personality disorders.

Utilize the most effective communication strategies when treating patients with personality disorders.

Implement screening questions to help identify patients with eating disorders.

Detail the common signs, symptoms, and laboratory findings associated with eating disorders.

Discuss the role of medical therapy in the management of patients with personality disorders or eating disorders.

Personality Disorders: Can These Even be Treated?
Mark E. Servis MD, Professor and Vice Chair for Education, and Roy Brophy Endowed Chair, Department of Psychiatry and Behavioral Sciences, University of California, Davis, School of Medicine, Sacramento

Challenges posed by patients with personality disorders: interactions require significant time and energy; patients often use extortion and manipulation (including self-destructive behaviors and threats of self-injury); idealization and devaluation of caregivers (patients often scorn past clinicians while lavishing praise on current clinician; opinions quickly oscillate between extremes); anaclitic dependency; countertransference (patients evoke powerful feelings [eg, anger, frustration] in others)

Personality and personality disorders: personality—an individual’s behavioral patterns for managing internal and external conflicts; personality disorder—results when individual exclusively relies on one set of coping skills or defenses

General considerations: trait- vs state-dependent—behavior patterns persistent and consistent (ie, not dependent on emotional state); state-based phenomena must be ruled out before making diagnosis of personality disorder; pervasive—behavior patterns present in all situations and environments; ego-syntonic—disorder does not cause internal distress or discomfort, so patients generally do not seek help on own

Paranoid personality disorder: patients view world as hostile and dangerous, and therefore become hypervigilant, suspicious, mistrustful, and guarded; paranoid thoughts likely represent unconscious projection of own feelings or internal conflicts; thoughts not psychotic or delusional (ie, have basis in reality); management strategies in primary care—avoid ridicule or pointing out errors in patient’s thinking; maintain professional distance and neutral position; avoid befriending patient in effort to convince or direct patient; be consistent; avoid power struggles; remain genuine and truthful

Case: man, 52 yr of age, claims pharmacist intentionally switched medication prescribed for erectile dysfunction; became suspicious when pharmacist “treated him rudely”; patient guarded, suspicious, and mistrustful in relationships (personal and professional)

Approach: strategies to avoid—psychoanalysis (patients resistant to psychotherapy); lying (eg, telling patient that he is probably right); confronting patient or challenging his view; recommended strategy—remain genuine; listen attentively; circumvent problem (eg, recommend patient go to different pharmacy) without validating claim

Narcissistic personality disorder: grandiose persona but easily injured and very sensitive to criticism (individual may become suicidal in wake of harsh criticism); shallow and labile affect; grandiosity protects fragile self-esteem; limited capacity for empathy; self-absorbed, entitled attitude; management strategies in primary care—gain trust and cooperation by giving patient positive reinforcement and praise; maintain idealized transference; avoid criticism; note—depression quickly resolves when patient praised and complimented

Case: man, 57 yr of age, admitted to hospital for elective coronary artery bypass; demands special treatment and privileges and wants to know what privileges other patients have received; repeatedly boasts about career and personal importance; refuses preoperative blood work (blood work had been performed recently; patient insists that others have not needed preoperative blood work); wife reports persistence and pervasiveness of behavior

Approach: recommended strategy—praise patient for his patience and negotiate for adherence; strategies to avoid— coercing patient into adherence; changing staff or moving patient to different department; educating patient about hospital policies (ineffective)

Antisocial personality disorder: individuals lack conscience and do not experience guilt or remorse; chronically exploit others for self-gratification (possibly sadistic); approach—protect self and staff; set clear limits on behavior; provide explicit and consistent rewards and consequences, based on behavior; this approach most effective when situational variables controlled

Borderline personality disorder: arrested development of identity (patients similar to adolescents in many ways), resulting in identity diffusion and feelings of emptiness; patients often experiment with different identities; relationships unstable and characterized by manipulation and dependence; idealization and devaluation common (may occur almost simultaneously), and likely reflects dichotomous self-image (ie, “good” self and “bad” self); characterized by mood instability, aggression, and chronic depression; self-destructive behaviors—commonly used as means of manipulation (especially as response to abandonment); patients at increased risk for suicide; other common behaviors include superficial cutting (patients report feeling relief after intentionally cutting selves); dependence—patients often very social and cannot tolerate being alone; impulsivity—substance abuse and destructive sexual behaviors common; borderline psychosis—patients may become transiently psychotic when under stress; violence—typically self-directed

Management issues for patients with borderline personality disorder: comorbid axis-I disorders (eg, mood disorders, substance abuse) require treatment; medical management helps improve axis-I disorders and behaviors associated with primary personality disorder; medications—selective serotonin reuptake inhibitors (SSRIs) dampen destructive behaviors; mood stabilizers decrease impulsivity in most patients; low-dose antipsychotic agents prevent episodes of psychosis in vulnerable patients

Case: woman, 27 yr of age, reports 2-day history of depression and suicidal thoughts (incited by relationship ending); medical history includes psychiatric treatment, mood stabilizers, and antidepressants, but patient not currently taking medications (claims absence of efficacy); interview reveals tendency for idealization and devaluation; superficial lacerations on arms (only unusual finding on physical examination; patient admits self-infliction); mental status examination identifies labile mood and passive suicidal ideation, but no delusions

Approach: recommended strategy—set limits on self-destructive behavior; involve collateral caregivers to diffuse transference; strategies to avoid —using positive reinforcement to encourage patient (unlikely to have lasting effect); building intimacy in relationship to establish trust (dangerous); exploring patient’s history to identify incidence of sexual abuse (common, but should be addressed only in context of long-term psychotherapy); other management tips— establish time limits and explicit treatment plan; avoid capitulating to patient’s demands (eg, for more time); encourage patient to express feelings through words rather than behaviors; beware of idealization

Managing personality disorders: long-term psychotherapeutic approaches effective, especially in borderline and narcissistic patients; patients with certain severe disorders (eg, sociopathic, malignant narcissistic, schizotypal personality disorders) do not respond to treatment

Questions and answers: nature vs nurture—genetic and environmental factors; childhood trauma important, but increasing evidence for genetic predisposition; cure vs management—lifelong illness, but some psychotherapies very effective (especially for patients with borderline personality disorder); use of opioids—use nonopioid analgesics when possible; avoid use in patients with antisocial personality disorder

Eating Disorders: A Primer for Family Practice
Brenda K. Woods, MD, Director of Medical Services, Remuda Center for Eating Disorders, Milford, VA

Introduction: eating disorders common but often not diagnosed; diverse population, many of whom do not fit stereotypes; disorders often begin at young age; 40% of third-grade girls, and 75% of fifth-grade girls, diet to lose weight

Anorexia nervosa: low body weight (≤85th percentile), including (in growing children) failure to gain weight; intense fear of gaining weight or becoming overweight; negative body image; primary amenorrhea or ≥3 mo of secondary amenorrhea (note, patients taking oral contraceptives may continue to menstruate, despite low body mass index [BMI]); subtypes—restrictive; binge-purge

Bulimia: patient binge-eats ≥2 times/week for ≥3 mo and experiences remorse after binging; compensatory behaviors after binge (eg, vomiting, laxative abuse, compulsive exercise, fasting); negative body image

Eating disorder not otherwise specified (NOS): eating disorder significant, but falls outside definitions of anorexia and bulimia; examples—patient has very low body weight but does not exhibit amenorrhea; patient has lost large amount of weight but is not underweight

Obesity: although obese individuals often compulsively overeat, obesity not considered eating disorder in Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition

Prevalence: ≈15% of women 14 to 30 yr of age; ≈12% of all women; 4% of men; ie, 5 to 10 million women and ≈1 million men in United States have diagnosable eating disorders

Early intervention: when possible, engage and treat patients before severe emaciation occurs; important to screen, monitor, and engage patients with low or falling weight; evidence—most practice recommendations supported by level C evidence; because research requirements dictate use of populations free of comorbid psychiatric diagnoses, difficult to recruit sufficient numbers of patients for clinical trials

Diagnosis: patients rarely seek help for eating disorder; disorders surrounded by shame and denial (similar to substance abuse); screening questions—how do you feel about your weight? (often associated with strong emotions); how often do you weigh yourself? (some patients never check weight [afraid they may have gained weight]; others check weight many times each day); how much has your weight fluctuated lately? (vomiting or laxative abuse may result in wide daily fluctuations in weight); do you feel out of control when you eat? (patients with anorexia often report loss of control, even when eating very little; binge-eating defined by loss of control); do you ever do anything to eliminate or burn off what you have eaten? are other people concerned about your weight or how you eat?

Associated signs and symptoms: weight loss of uncertain etiology—rule out other causes of weight loss, but remember to screen for eating disorder; primary or secondary amenorrhea—first rule out pregnancy; chronic constipation or diarrhea—ask patients about laxative use; study showed that 20% of patients who had been referred to gastroenterologist for chronic diarrhea abused laxatives (ie, had undiagnosed eating disorder); general symptoms—dizziness; fatigue; gastrointestinal symptoms—chronic sore throat or gastroesophageal reflux (caused by vomiting); repeated vomiting increases risk for Barrett’s esophagus and other complications associated with reflux; infertility—common reason for seeking medical advice; physical findings associated with vomiting—enlarged parotid and submandibular glands (may become more pronounced 1-2 days after vomiting); cavities and eroded enamel (evident after ≈2 yr of chronic vomiting); angular cheilosis (gastric contents irritate soft tissues of mouth; may signal vitamin deficiency); energy—patients report high levels of energy despite cachectic appearance; other physical findings—growth of lanugo hair; chronic hypotension, bradycardia, and/or hypothermia; edema (caused by rebound retention of fluid after purging)

Laboratory findings: hypercholesterolemia—important to screen for eating disorder (affects management); etiology poorly understood; insufficient intake of foods that promote breakdown of cholesterol may lead to gradual increase in serum levels of cholesterol; patients need to introduce fats and proteins into diet; leukopenia—caused by bone- marrow suppression; corrected QT interval—may be prolonged; associated with disturbances in electrolytes; enzyme abnormalities—starvation associated with elevations in liver enzymes; vomiting may result in elevated levels of serum amylase; lipase levels may increase (associated with pancreatitis); electrolyte disturbances—hyponatremia (caused by increased intake of fluids; patients may drink large volumes of, eg, water, in effort to suppress hunger); hypokalemia (commonly associated with vomiting or laxative abuse); urine specific gravity may increase (ketones present) if patients restrict intake of fluid; metabolic disturbances—metabolic acidosis (caused by vomiting); elevation or suppression of thyrotropin (screen for eating disorder before treating hypothyroidism)

Medication caution: patients at risk for QT abnormalities; avoid medications that affect QT interval

Malnourishment: serum albumin—level usually normal (in contrast to patients with chronic medical conditions); diagnosis—assess body composition or BMI, and percentage of ideal body weight; may see depressed levels of prealbumin, and evidence of iron deficiency and/or neutropenia

Associated behaviors: various combinations of restriction, binging, purging (vomiting; abuse of laxatives or diuretics), stimulant abuse, and compulsive exercising; less common behaviors include chewing and spitting (ie, not swallowing food), eating nonnutritive items (eg, paper, cotton), and (in children) refusal to swallow saliva; preoccupation with food or obsessive calorie counting

Agents of abuse: ipecac—evokes vomiting; cardiotoxic and causes peripheral myopathy; available over-the-counter; prescription diet pills—easily available via Internet; stimulants—caffeine; methamphetamines; cocaine

Management approach: basic evaluation—weigh patients in hospital gown (underwear only; empty bladder); perform dual-energy x-ray absorptiometry (DXA) for patients with 6 to 12 mo of amenorrhea (patients at risk for osteoporosis); management team—physician (case manager); dietician; therapist; psychiatrist; weight gain—slowly increase intake of food (dangerous to increase intake too quickly); inpatient programs strive to increase weight by 2 to 3 lb per week; 1 lb/wk good goal in outpatient programs; therapeutic issues—eating disorders serve “purpose” by addressing unmet emotional need (ie, not directly related to food, weight, or appearance); identifying purpose and redirecting behavior important part of recovery; medical management—fluoxetine (60 mg) beneficial for treating patients with bulimia; other psychopharmacologic agents appropriate for managing comorbid psychiatric disorders