Text adapted from: "The adult patient with a personality disorder," in Psychiatry in primary care by Michael Rosenbluth, Matthew Boyle & Lucille Schiffman (CAMH, 2019).
Optimal care requires coordinating treatment provided by multiple clinicians. Coordination includes clearly defining roles, determining which clinician is assuming primary or overall responsibility, clarifying what will occur in a crisis, and ensuring regular communication among clinicians and documentation of that communication.
Patients with personality disorders often see one clinician for psychotherapy while attending their primary care practitioner for medication. You must be aware of any treatment your patient is receiving elsewhere. This is important because some therapies may inadvertently promote regression in the patient and confuse clinicians. Certain therapies focus on uncovering early trauma and difficult emotional experiences. Sometimes this is necessary, but it can also occur before the patient is ready to do that kind of therapeutic work.
If your patient is seeing a clinician for psychotherapy and is getting much worse, you need to be aware of the situation and tactfully raise this concern with both patient and therapist. Doing so ensures the patient is getting appropriate psychotherapy and manages medical liability. If something happens in psychotherapy that results in a patient’s self-harm or suicide, you are likely to be included in any litigation that the family pursues.
The role of psychiatrists
It is always best if psychiatrists can be involved in the care of patients with personality disorders, either to manage the comorbid Axis I diagnosis or to facilitate psychotherapeutic involvement. However, access to a psychiatrist can be difficult. With an estimated 5 to 10 percent of the population having a personality disorder (Frances, 2005) and psychiatrists not being able to handle large caseloads because of the intensive nature of their work, primary care practitioners are familiar with the challenge of connecting patients with a psychiatrist.