Principles of managing personality disorder

Because personality disorder is common, all clinicians are likely to encounter patients with personality disorder, and will need to employ specific skills to effectively treat them. Severe personality disorder usually requires a collaborative multidisciplinary approach. By following the key principles of working with patients with personality disorder, all clinicians can contribute positively to their care.

The therapeutic relationship between the patient and clinician is central to personality disorder management and can provide an environment that allows change. However, it can be challenging because, by definition, people with personality disorder have difficulties with interpersonal relationships (see The clinician–patient relationship in patients with a personality disorder).

When making a diagnosis of personality disorder, the clinician should openly and honestly discuss the diagnosis with the patient (see Psychoeducation for personality disorder). Clinicians also play an important role in addressing the stigma associated with personality disorder.

People with personality disorder often present during an acute crisis. Patients usually respond well to being given support and time to talk about their concerns—follow the key principles for working with a patient with personality disorder. Use simple problem-solving strategies to address immediate precipitants and involve the patient’s family, carers or significant others if possible. If these strategies are insufficient to manage the acute crisis, consider using adjunctive pharmacotherapy. Although clinicians may feel pressured by the patient to use pharmacotherapy, or compelled by a sense that alternatives are lacking, pharmacotherapy is not first line. Follow the patient’s management plan, if they have one.

If a patient with personality disorder is acutely agitated or has an acute behavioural disturbance, do not start treatment before determining that it is safe and appropriate to intervene. If possible, use nonpharmacological measures, including verbal de-escalation and psychological intervention, to reduce the risk of harm. If the patient remains acutely agitated or at risk of harming themselves or others, see Pharmacological management for acute behavioural disturbance in adults or Pharmacological management for acute behavioural disturbance in older people for advice on drug therapy.

Even if management is first initiated for an acute crisis, simultaneously plan long-term management (see Management plan for a person with personality disorder). Psychosocial interventions are the mainstay of long-term management and can include individual, group and family approaches, as well as social support and environmental modification. For many people with personality disorder, effective psychosocial interventions can be instigated in primary care, without the need for further referral. However, patients with moderate to severe personality disorder or those who do not respond to treatment should be referred to a specialist mental health service or personality disorder service¹. Pharmacological treatment has limited or no role in the management of personality disorder itself.

Treatment of personality disorder usually occurs in an outpatient setting to allow the patient to improve their management of day-to-day stressors and interpersonal relationships. Inpatient treatment is rarely indicated, but may be required to manage an acute crisis if other approaches (eg intensive outpatient treatment) have been unsuccessful—admissions are usually brief and should have specific goals. Inpatient treatment may also be required to treat co-occurring conditions (eg major depression, psychoses).

For considerations in managing personality disorder in females of childbearing potential, see here and the perinatal period, see here.