Case outcome: interim follow-up visits through 12 months

Patient #1 now reports gradual improvements in many of his symptoms with consistent sertraline (Zoloft) plus alprazolam (Xanax) use but had an altercation with his boss and another healthcare provider and called for help containing his anger and violence propensity

• – Psychotherapeutic interventions failed and he was offered low-dose, as-needed haloperidol (Haldol) 1–2 mg/d

  • This typical antipsychotic was chosen as the patient was at imminent risk of harming others and needed agitation control, not dissimilar to that required on some inpatient units where “as-needed” haloperidol is utilized with rapid effect

  • Interestingly, the CATIE trial had just come out as well, spurring the need to evaluate the use of typical versus atypical antipsychotics

  • At the time, the atypical agents were new, more expensive, and there was a push to really determine a cost–benefit analysis

  • This typical antipsychotic was taken for a few days with the patient finding it to be very helpful

• – The following weekend, patient calls at night with “lockjaw” and a broken tooth

• – He is prescribed the anticholinergic EPS antidote benztropine (Cogentin) 2 mg/d with resolution of his trismus-based EPS and is taken off the typical antipsychotic

  • In retrospect, the CATIE trial or a single study should not be evaluated and translationally used in a vacuum

Patient #2 also reports gradual improvements in many symptoms with consistent fluoxetine (Prozac), zolpidem-CR (Ambien-CR), and trazodone (Desyrel) use

• – However, he begins having difficulty with his teenage son and reports a gradual return of mood lability and affective dyscontrol symptoms

• – Chief complaint still is marked insomnia, and the trazodone (Desyrel) is increased to 200 mg at bedtime with good effectiveness

Question

Are you comfortable prescribing psychotropics for personality disorder symptoms?

Yes, they are clearly helpful in treating patients with pure personality disorder symptoms

Yes, they are clearly helpful in treating patients who have personality disorder symptoms underlying true affective disorder illness

Yes, there are no approved psychotropics here, but off-label use often may lower personality traits so that psychotherapy may proceed more efficiently

No, the evidence base is too weak to support this practice

No, personality disorders should be treated with an evidence-based psychotherapy such as DBT or DDP

• – DBT is an empirically supported, manualized treatment composed of both individual and group psychotherapy modalities

  • It is designed specifically for individuals who engage in self-destructive behaviors

  • It has also been found to be effective in treating eating disorders, SUD, and MDD in elderly patients

  • Considered a modification of CBT, DBT places equal emphasis on change-oriented and acceptance-based interventions

  • DBT skills groups are educational therapeutic classes aimed at reducing maladaptive behaviors by offering alternative ways to respond to stressful situations and intense emotions by teaching coping skills in mindfulness, interpersonal effectiveness, emotion regulation, and distress tolerance

• – DDP is a manual-based, PDP-based treatment developed for complex behavioral problems, including addiction, self-harm, eating disorder, and recurrent suicide attempts

  • In research studies, individuals with complex behavioral problems have demonstrated abnormalities in the way the brain processes negative emotions and interpersonal stresses

  • There is a relative deactivation of prefrontal brain regions and hyperactivation of other regions, including the amygdala and ventral striatum

  • These changes in brain functioning also account for the depression, anxiety, impulsivity, mood swings, and poor interpersonal functioning that so often accompany complex behavioral problems

  • DDP theoretically remediates and restores normal brain functioning by facilitating elaboration and integration of affect-laden interpersonal experiences and related attributions of self and other, as well as providing novel experiences in the patient–therapist relationship that promote self–other differentiation and a positive therapeutic alliance

  • Treatment involves weekly individual sessions for a 12-month period and follows sequential stages