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Personality Disorders and HIV Care

Identification and Management of Personality Disordersand How They Can AffectHIV Caregiving James Satriano, Ph.D. AIDS Education and Training Center Columbia University Department of Psychiatry Disclosures "This program is supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) as part of an award totaling $3,845,677 with zero percent financed with nongovernmental sources. The contents are those of the author(s) and do not necessarily represent the official views of, nor an endorsement, by HRSA, HHS or the U.S. Government." 2 Personality Disorders and HIV Care Learning Objectives Understand the prevalence of Personality Disorders among those in HIV care Describe the hallmarks of Personality Disorders in HIV patients and best practices for treatment Appreciate how Personality Disorders can affect HIV care (engagement, adherence, retention) Review approaches to working with clients with Personality Disorders Understand conditions to rule out Personality Disorders Why is PD Identification Important in HIV Care? 20 40% of individuals with HIV have a Personality Disorder (and many others have traits associated with Personality Disorders that may be impairing) versus 9-15% in the general population. Risk factors for HIV associated Personality Disorders adverse childhood events (especially sexual traumas), impulsivity and addictions factors that could promote high risk behaviors. Management of HIV disease requires positive alliance with treatment team (engagement/retention) and adherence to treatment regimen challenging tasks for many with Personality Disorders. Perkins, Davidson et al. (1993) A J of Psychiatry Golding & Perkins (1996) Int Rev of Psychiatry Personality "Personality traits are enduring patterns of perceiving, relating to, and thinking about the environment and oneself that are exhibited in a wide range of social and personal contexts." DSM-5 Personality is the combination of behaviors, emotions, motivations, and thought patterns that define an individual. Personality traits have been the subject of much scientific research in terms, among other things, of heritability, childhood antecedents, stability over time, and functional relevance to work, well-being, and physical health. Theories of Personality Formation Psychodynamic theories symptoms reflect maladaptive "compromises" outside of awareness (i.e., unconscious). Behavioral theories focus on the interaction between the individual and the environment, and what is observable and measurable (versus internal psychic processes). Trait theories personality make up of many traits a relatively stable characteristic that causes an individual to behave in certain ways; e.g., five factor theory of personality. Humanist theories focus on free will and individual experience, emphasizing self-actualization (innate need for human growth that motivates behavior); optimistic about human nature. Five Factor Model Trait Theory Openness vs close-mindedness curious, imaginative, independent vs conventional, practical, conforming Conscientiousness vs undependable organized, hardworking, dependable vs impulsive, careless, disorganized Extraversion vs introversion sociable, adventure-seeking, affectionate vs quiet, withdrawn, reserved Agreeableness vs disagreeableness helpful, trusting, empathic vs critical, suspicious, uncooperative Emotional stability vs neuroticism calm, secure, self-satisfied vs anxious, unhappy, self-pitying Personality Disorders - DSM Categorical versus Dimensional Models Categorical approach used for other psychiatric disorders assessment of signs/symptoms (DSM criteria); one has the disorder or one does not DSM-5 criteria versus "Alternative DSM 5 Model for Personality Disorders" contained in the DSM Appendix Conditions that exist on a continuum, such as personality and personality traits might better be assessed on a dimensional model Categorical Approach - Problems Excessive diagnostic comorbidity among Personality Disorders. Heterogeneity among individuals with the same disorder. Inconsistent, unstable, arbitrary diagnostic boundaries. Inadequate coverage (Personality Disorder NOS the most frequent diagnosis). DSM-5 Alternative Model for PDs Personality Disorders characterized by impairments in personality functioning and pathological personality traits which are often maladaptive variants of non-pathological personality traits. Includes Antisocial, Avoidant, Borderline, Obsessive-Compulsive, Narcissistic and Schizotypal PDs and a Personality Disorder Trait Specified. All Personality Disorders look at disturbances in self (identity & self-direction) & interpersonal (empathy & intimacy) functioning. 25 specific traits in 5 domains negative affectivity, detachment, antagonism, disinhibition, psychoticism. DSM-5 definition of PD An enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individual's culture manifested in at least two areas (cognition, affect, interpersonal functioning, impulse control). The pattern is inflexible and pervasive. The pattern leads to significant distress. Is stable and of long duration. Not better explained by another mental disorder or attributable to substance abuse or a medical condition. DSM-5 definition of PD continued Enduring aspect in theory Personality Disorders are evident since adolescence or young adulthood and are relatively chronic and stable throughout adulthood most other disorders generally more episodic Requirement of impairment or subjective distress an important point for almost all psychiatric disorders Ruling out another psychiatric disorder particularly important when there is a seeming change in personality later in adulthood Diagnosis of Personality Disorder Several semi-structured interviews available to ensure a systematic assessment and increase reliability. Subjective assessments much more susceptible to bias (e.g., gender or culturally based) as well as incomplete assessment. Length of time for assessment can make semi-structured interviews impractical but there are self-report questionnaires that can be used as well. Patients with PDs tend to have poorer treatment outcomes, greater recurrence of other psychiatric disorders, and higher risk for suicidal behaviors. PDs among People with HIV/AIDS The National Comorbidity Study (Kessler et al., 1996) showed that substance use disorders are highly co-morbid with other psychiatric disorders including borderline personality disorder. Substance use disorders are very common among people living with HIV/AIDS. Study of incarcerated men in NC with BPD symptoms associated with multiple partners, drug use with sex partners, having sex while high, and crack/cocaine and ecstasy use. Borderline Personality Disorder Symptoms & HIV Risk Behaviors among African-American Incarcerated Men, Scheidell, Lujuez, etc. (2014). PDs among People with SUDs 40-50% of individuals with a SUD meet the criteria for ASPD and about 90% of individuals with ASPD also have a co-occurring SUD Messina, N., Wish, E., & Nemes, S. (1999). Over 50% of individuals with a lifetime diagnosis of BPD also had a SUD diagnosis in the previous 12 months Grant, B.F., Chou, S.P., Goldstein, R.B., Stinson, F.S., Saha, T.D., et al. (2008). 60% of patients with a SUD had a Personality Disorder - BPD more associated with current and ASPD with lifetime disorders Skodol, A.E., Oldham, J.M., Gallaher, P.E. (1999). Personality Disorders among IDUs Injection drug users are more likely than the general population to have Personality Disorders. Antisocial and Borderline Personality Disorders most common 22% of IDUs reported to have Antisocial Personality Disorder. 18% of IDUs reported to have Borderline Personality Disorder. Verhuel, R. et al. Substance use. In Oldham, J. Skodol, A., Bender, D. The American Psychiatric Publishing Textbook of Personality Disorders. Washington D.C. The American Psychiatric Publishing Inc.; 2005: 463-75. HIV + Psych ER Visits 58,000 consecutive ER visits 2.0% known HIV + HIV + patients more likely to be: Male Homeless African American Living with dementia Substance abusing Suicidal Diagnosed with a borderline personality disorder Murray Bennett, Joesch, Mazur & Roy-Byrne (2009) Narcissistic Personality Features 300 individuals with HIV/AIDS recruited from infectious disease clinic investigators looked at narcissistic characteristics, substance use, and sexual risk behaviors. Majority of participants (85%) reported no unprotected intercourse in previous 3 months with an HIV negative partner or partner with unknown status. Narcissistic traits strongly predicted sexual activity following substance use, more partners, more unprotected sex acts, and low intentions to use condoms in the future. Transmission Risk Behaviors in a Subset of HIV-positive Individuals: The Role of Narcissistic Personality Features, Martin, Benotsch, Lance & Green (2012) Personality Disorder Clusters Cluster A: Odd, Eccentric Cluster B: Dramatic, Emotional, Erratic Cluster C: Anxious, Fearful Cluster A Odd, Eccentric Paranoid PD "pattern of pervasive distrust and suspiciousness of others such that their motives are interpreted as malevolent . . ." (Captain Queeg) Schizoid PD "pervasive pattern of detachment from social relationships and a restricted range of expression of emotions in interpersonal settings . . ." Schizotypal PD "pervasive pattern of social and interpersonal deficits marked by acute discomfort with, and reduced capacity for, close relationships as well as by cognitive or perceptual distortions and eccentricities of behavior . . ." (Travis Bickel) Cluster C Anxious, Fearful Avoidant PD "pervasive pattern of social inhibitions, feelings of inadequacy, and hypersensitivity to negative evaluation . . ." Dependent PD "pervasive and excessive need to be taken care of that leads to submissive and clinging behavior and fear of separation . . . " Obsessive-Compulsive PD "a pervasive pattern of preoccupation with orderliness, perfectionism, and mental and interpersonal control, at the expense of flexibility, openness, and efficiency . . ." (Melvin Udall) Cluster B Dramatic, Emotional, Erratic Antisocial PD "pervasive pattern of disregard for and violation of the rights of others . . ." (Hannibal Lecter). Borderline PD "pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity . . ." (Alex Forrest, Tommy DeVito). Histrionic PD "pervasive pattern of excessive emotionality and attention seeking . . ." (Scarlett O'Hara, Derek Zoolander). Narcissistic PD "pervasive pattern of grandiosity (in fantasy or behavior), need for admiration, and lack of empathy . . ." (Walter White, Frank Underwood). Antisocial Personality Disorder Failure to comply with social norms regarding lawful behaviors Deceitfulness, as indicated by repeated lying for profit or pleasure Impulsivity or failure to plan ahead Irritability and aggressiveness, as indicated by physical fights/assaults Reckless disregard for the safety of self or others Consistent irresponsibility, as indicated by lack of consistent work, paying debts, etc. Lack of remorse, as indicated by being indifferent or rationalizing hurting, mistreating, stealing from others Antisocial Personality Disorder continued Evidence of a conduct disorder before age 15 a criterion Because of the nature of the Disorder (deceit and manipulation), collateral history especially important DSM criticized for focusing too much on behaviors rather than character traits Concept of psychopathy focusing on lack of empathy, inflated self-appraisal, superficial charm, etc.; often used in correctional and forensic settings Clinicians Reactions to ASPD Therapeutic nihilism Illusory alliance clinician being manipulated Fear of assault/harm can be warranted Denial in response to real danger Helplessness/guilt in response to lack of response Hatred and rage Case of Mr. J Mr. J was a 19 year old African American man diagnosed with HIV in September of 1996. Over the course of the next year, Mr. J . had unprotected sex with many young women in a small industrial town in a mostly rural community not known for high rates of HIV. The emergence of a cluster of new cases began an investigation. Epidemiological interviewing of the first six cases led public health officials to identify Mr. J as the source of the cluster. Case of Mr. J continued Investigators identified more than three dozen young women who admitted to having sex with Mr. J. Of this group, 16 of the women have confirmed cases of HIV. The youngest of this group was 13 years old at the time of diagnosis. Relentless and charming Menacing ; became physically abusive when threatened Sold crack and said he was a member of the Bloods; Hx incarceration Showered girls with gifts Never used condoms Claims to have had sex with over 300 women Borderline Personality Disorder Frantic efforts to avoid real or imagined abandonment Unstable and intense interpersonal relationships Chronic feelings of emptiness Markedly and persistently unstable sense of self Impulsivity in 2 areas that are potentially self-damaging spending, sex, substance abuse, binge eating, etc. Recurrent suicidal behavior/threats or self-mutilating behavior Borderline Personality Disorder continued Affective instability due to a marked reactivity of mood (intense episodic dysphoria, irritability or anxiety usually lasting a few hours & no more than a few days) Inappropriate anger or difficulty controlling anger Transient stress-related paranoid ideation or severe dissociative symptoms Frequent comorbidity other Personality Disorders, eating, substance use* and mood disorders, PTSD Natural course predicts eventual remission Case of Ms. R Ms. R was a 29 year old Caucasian woman referred for HIV care to a hospital-based outpatient clinic after testing positive. She was assigned to be seen by Dr. B, an ID physician on the team at the clinic. After routine intake and a follow-up visit with Dr. B she stated that he was the "best doctor I have ever seen." The relationship between Ms. R and Dr. B seemed to be working very well for the first few months. She reported taking her medication as prescribed and her labs showed a rise in CD4 cells and a drop in viral load. Case of Ms. R continued Encouraged by the good results, Dr. B decided to decrease the frequency of Ms. R's follow-up appointments. With the onset of less frequent appointments, Ms R began making many phone calls to Dr. B, complaining of odd symptoms and medication side effects. She stated that she would experience these side effects as soon as she put the pills in her mouth. Also at this time Ms R began missing scheduled appointments and showing up at the clinic at non-scheduled times demanding to be seen. Case of Ms. R continued Ms. R began to behave erratically in the clinic, throwing a tantrum when told that Dr. B was running behind and would be a half-hour late. The nursing staff and support staff did not want to interact with her because she seemed so volatile. During one unscheduled visit, when the receptionist told her that she could not be seen that day and to please schedule an appointment, Ms. R threatened to hurt herself and raised the sleeve on her blouse to show the receptionist several dozen razor cuts up and down her forearm. 32 Case of Ms. R continued The receptionist became upset by this and reported it to the nursing staff who admonished Ms. R for her behavior. Feeling affronted and not supported by the clinic staff, Ms. R wrote a letter of complaint to the hospital administrator in her own blood. 33 Differential Diagnosis of PD Unlike other mental health disorders where clinicians rely on the patient's description of symptoms to assist in diagnosis, the clinical diagnosis of a Personality Disorder must often be derived by observation of the patient's behavior and style of interacting with others as well as the reports of others over time. Dysfunctional patterns are generally ego-syntonic ("there is nothing wrong with me"). Rule Outs for PD Diagnosis Dementia (HAD) or other CNS Disorder Psychotic Disorder (Paranoid, Schizoid, Schizotypal PD) Substance abuse (Antisocial PD) Mood disorder (Borderline, Narcissistic PD) Anxiety disorder (Avoidant, Obsessive-Compulsive PD) Metabolic disorder Malingering PTSD Autistic Spectrum Disorder (Schizoid, Schizotypal PD) HIV dementia subcortical, more associated with white matter, and similar to dementias associated with Huntington's Disease and Parkinson's dementia. Early symptoms: affect attention, motivation, and emotionality; can show early symptoms of depression, irritability, apathy and motor weakness/ataxia; more likely to see early personality changes than with cortical dementias like AD Late symptoms: global cognitive dysfunction (e.g., memory, judgement), mutism, organic hallucinations and Parkinson-like symptoms. HIV-Associated Dementia HIV-Associated Dementia continued An international meta-analysis of HAD among 35,000 participants in 32 countries reported: an overall prevalence of 42.9% 23.5% asymptomatic neurocognitive impairment 13.3% mild neurocognitive impairment 5.0% HAD Disruptive behaviors may be symptoms of HAD and may mimic symptoms of personality disorders or psychosis. Wang, Lui, Lu et al. (2020) Neurology 95 (10) 2610-2621 CNS Infections and HIV Maladaptive personality traits may be caused by underlying CNS infections. CNS infections common to AIDS are: HIV encephalopathy Lymphoma in brain Progressive multi-focal leukoencephalopathy Toxoplasmosis of brain Be on the look out . . . Frequent threats of suicidality, especially tied to interpersonal interactions Cutting or other forms of self-harm Repeated episodes of what appears like lying, especially accompanied by an apparent lack of concern when confronted with a lie Excessive compliments ("you are the best . . .," "you are the only . . ."), at times followed by complete devaluation when you have disappointed the individual Excessive Promiscuity Be on the look out . . . continued Apparent lack of remorse when having done something hurtful to someone else Extreme self-centeredness and lack of concern for the welfare of others Lack of personal connections that seem unrelated to understandable circumstances or inability to identify important people in one's life Consistent suspiciousness of other people's motives Strong emotional reactions on your part to your patient Approach to Patients with PD Effective communication Interdisciplinary integrated team approach Effective treatment plan Mental health management Listen carefully to identify the patient's goals Use body language that conveys support and respect Offer choices and options whenever possible to involve the patient shared decision making Establish clear, consistent and rational strategy about when to support and when to confront Need to avoid total responsibility as well as therapeutic nihilism Effective Communication Adopt team approach that focuses on clear communication among everyone involved in the patient's care - need for frequent staff conferencing Minimize patient's attempts at staff- splitting and projection (e.g. staff meetings to clarify treatment goals, reach consensus, set limits, etc.) Diffuse sense of responsibility among members of the treatment team as well as support for team members Interdisciplinary Team Effective Treatment Plan Shared decision making Setting limits when necessary, behavioral contracts Make all staff (including support staff) aware of any behavioral contracts help to avoid splitting Use a healthcare network to provide care primary and mental health care must be INTEGRATED!!!! Focus on long term goals, not immediate rewards Principles of Effective Therapies Stable and clear treatment framework primary clinician, with specific short and long-term goals and roles in team settings Therapist needs to be clear about what can and cannot be expected from them, especially regarding self-harm and other dangerous behaviors Support essential validating patient's distress, etc. but not necessarily validating perceptions of others; need also to convey therapeutic optimism and encouragement Principles of Effective Therapies continued Clinicians need to be active but nonreactive, contained and measured, as many patients extremely sensitive to signs of rejection Limit self-disclosure to certain patients Need to connect patients' feelings to events, including rejection, lost supports, other social stressors, in the here and now Monitoring and discussion of countertransference is key Cognitive Behavioral Therapies Time limited therapies some of which focus on distortions in information processing and maladaptive ways of thinking about oneself, the world and the future. Initially developed for depression but now used for many conditions including Personality Disorders. Education emphasized (e.g., pointing out dysfunctional distortions), homework often used, treatment very structured with an active therapist. Ability to recognize shifts in mood, identify negative thoughts, consider alternative behaviors. Dialectical Behavioral Therapy for BPD Major dynamic seen as a dysregulation of emotion (individual feeling mistreated & misunderstood) interacting with an invalidating environment Includes 1 hour of individual and 2 hours of manualized group therapy focusing on coaching patients to attain certain goals & teaching behavioral coping skills 6 hierarchical goals for change suicidal behaviors, therapy-interfering behaviors, behaviors interfering with quality of life, behavioral skill acquisition, post- traumatic stress behavior, & self-respect behaviors Individual therapists on call 24/7; use of consultation groups for treatment & clinician support; validation, empathy and alliance with patient all key elements Mentalization-Based Treatment Mentalization is the capacity to understand the mental activity that underlies social interactions leads to understanding and managing the many evolving thoughts, feelings, desires, and intentions that two individuals have in an interaction. Inability to mentalize leads to social-cognitive vulnerabilities (e.g., attachment insecurity). Treatment consists of individual and group therapy with therapist taking a curious rather than knowing stance. Much less training needed than with DBT. Interpersonal Therapy for BPD Developed for treatment of depression focuses on examining in detail and improving relationships with significant others. Manualized and time limited; treatment alliance key as is monitoring moods states to help stabilize social supports and important personal relationships; some aspects of treatment need to be modified. Borderline pathology seems intimately tied to problems with attachment, dependency and fear of abandonment, resulting in unstable emotions and relationships. Other Treatments for PDs Supportive therapy (General Psychiatric Management) Transference-focused Psychotherapy Group therapy Family therapy Keep in mind that for several PDs there is little evidence for the benefit of pharmacotherapies (Dependent, Avoidant, Obsessive-Compulsive, Schizoid), though comorbidity may warrant medications Pharmacotherapy More evidence for manualized psychotherapies for some Personality Disorders than for medication. Mood stabilizers for mood lability, anger, impulsivity e.g. Lithium, anticonvulsants e.g. Topiramate, Gabapentin. SSRIs for depressed mood, anxiety, impulsivity e.g. Fluoxetine, Sertraline, Paroxetine. Antipsychotics for distorted cognition/perception, mood lability, impulsivity Risperidone, Ziprasidone, Aripiprazole. Be cautious with BZD's: co-morbidity with SUDs Conclusions ASPD and BPD most challenging, especially when complicated by active substance abuse Cohesive treatment team is key as is supervision and consultation multimodal treatment approach Management of countertransference essential Focus on suicidal and other dangerous behaviors Need to consider higher levels of care when necessary HIV - HCV - PrEP - PEP Clinical Consultations For Providers in Upstate NY Call or E-mail for a consultation Monday Friday 8:00 am 4:30 pm* 518-262-6864 or [email protected] *If you have experienced an occupational exposure such as a needle stick, please call 518-262-4043. You will be given an opportunity on the telephone menu to speak to a physician 24 hours a day.