Flexibility: Key to Managing Patients with Personality Disorders 

Providing dermatological treatment for patients who have personality disorders can be a complex endeavor. Dr. Mio Nakamura, a clinical assistant professor of dermatology at the University of Michigan in Ann Arbor, highlights this fact. With her vast clinical experience, she emphasizes the crucial need for flexibility and adaptability when working with these patients. “It’s essential to first recognize the personality disorder,” explains Dr. Nakamura, “then, understand the underlying conflicts and needs of the patient, and finally, adjust your approach accordingly.” This insight was shared by Dr. Nakamura at the annual meeting of the American Academy of Dermatology. 

Personality disorders are deeply ingrained patterns of maladaptive thinking and behavior that significantly deviate from societal norms. Affecting as much as 15% of the population, they can become incredibly challenging to treat, leading to frustration for healthcare providers. To offer effective care, Dr. Nakamura outlines strategies for dermatologists working with patients who present with three specific conditions: 

Borderline Personality Disorder (BPD): Navigating Emotional Instability and Impulsivity 

A hallmark of BPD is instability in relationships, an individual’s sense of self, and their emotional state. Patients are often driven by impulsivity, demonstrating self-injurious behaviors that include cutting, risky sexual conduct, or attempted suicide. “Intense feelings of emptiness, an overwhelming fear of abandonment, and emotional sensitivity dominate their experience,” states Dr. Nakamura. BPD patients tend to be emotionally needy and may exhibit outbursts of anger. 

Dr. Nakamura stresses that the dermatological complaint presented by a patient with BPD may often camouflage a much deeper psychological issue – essentially, a means of addressing their inner void. “They’re searching for ways to connect, and rejection can rapidly escalate into feelings of abandonment, leading to explosive anger and other strong negative emotions,” she elaborates. Dr. Nakumura urges caution against performing cosmetic procedures, tests, or treatments for those with BPD unless there is a clear clinical indication. “Unsuccessful or unfavorable results may exacerbate the patient’s dissatisfaction, fueling further demands and testing your professional judgment.” 

Instead, focus on exploring alternate treatment options to ensure the patient doesn't feel abandoned or rejected. “Demonstrating genuine care and empathy is crucial, along with regularly scheduled follow-ups.” 

Obsessive-Compulsive Personality Disorder (OCPD): Prioritizing Facts and Structure 

Individuals with OCPD exhibit an intense preoccupation with order, perfection, and control. According to Dr. Nakamura, "They become so excessively focused on details, rules, and organization that they often miss the bigger picture.” Additionally, OCPD patients may demonstrate an almost rigid adherence to morality and ethics. 

An underlying fear of losing control often drives patients with OCPD, potentially resulting in anxiety, depression, and even outbursts of anger. Dr. Nakamura recommends a structured approach when interacting with these patients during consultations: "Focus on providing facts and knowledge to alleviate any emotional distress. Information serves as a powerful tool for them, as it gives a sense of control over their condition.” A professional demeanor, coupled with detailed explanations and treatment plans, will foster a sense of security. "Offering clear, step-by-step written instructions and specific reasons behind prescribed treatments will resonate strongly with these patients," adds Dr. Nakamura. "Maintain a schedule of regular follow-up appointments to provide further reassurance." 

Narcissistic Personality Disorder (NPD): Understanding the Need for Validation 

The core characteristic of NPD is an inflated sense of self-importance. These individuals firmly believe in their uniqueness, superiority, and entitlement. They crave admiration, fantasize about incredible success and power, and often lack empathy. Dr. Nakamura emphasizes the underlying psychological insecurity: "Their outward personality often masks low self-esteem or deep insecurities. To truly connect, they require praise and an unwavering sense of power." 

A strategy Dr. Nakamura recommends is to engage with patients who have NPD in a more formal manner, similar to how you might interact with a professional colleague. “These patients respond positively to respect and measured concern, as opposed to excessive warmth." Involve them in their care by asking for input on treatment choices (within appropriate boundaries, of course). You might inquire about their preference between topical steroids from the same class, ointments or creams, and offer flexibility with follow-up schedules. Allowing them to make these decisions empowers them. 

However, Dr. Nakamura issues a strong caution: "Avoid outright rejection or dictating the course of treatment. Dismissiveness carries a significant risk of causing what’s known as ‘narcissistic injury’. The patient’s inflated ego is wounded and they may react with disproportionate anger and a desire for retribution.” 

Important Note: Dr. Nakamura openly discloses potential conflicts of interest. She holds positions as an investigator for pharmaceutical giants such as Amgen, argenx, Boehringer Ingelheim, Bristol-Meyers Squibb, Pfizer, and Regeneron. Furthermore, she serves on advisory boards for argenx, Boehringer Ingelheim, and Bristol-Myers Squibb. 

Beyond the Three: General Strategies for Success 

While Dr. Nakamura focused on BPD, OCPD, and NPD specifically, she acknowledges that a wide spectrum of personality disorders exists. Understanding some key principles will help dermatologists navigate their interactions with patients facing a variety of personality challenges: 

• Maintaining Professionalism and Boundaries: Setting clear, firm boundaries is essential. Clearly define your role as the care provider and reinforce the parameters of the doctor-patient relationship. While empathy is crucial, avoid getting drawn into the emotional complexities that patients with personality disorders may present. "It can be easy to lose your objectivity," Dr. Nakamura warns, "and your clinical judgment may be compromised." 
• Focus on the Physical: Address the core dermatological concerns that brought the patient to your care. Avoid engaging in extensive discussions that revolve heavily around their personal life or psychological struggles. By staying focused on the physical symptoms, you maintain professionalism and provide appropriate care. 
• Self-Care for Caregivers: Dealing with patients who have personality disorders can be incredibly draining on a mental and emotional level. "Don't underestimate how challenging these encounters can be," emphasizes Dr. Nakamura. Prioritize self-care practices such as de-stressing activities, maintaining a support system, or seeking professional guidance if needed. This protects your own well-being, ensuring you have the resilience to offer quality care even in complex situations. 

• When Referrals are Necessary: Know when to refer patients for specialized care. If a patient's personality disorder severely impacts their ability to engage with your treatment or significantly disrupts your practice, a referral to a mental health professional may be the best course of action. Dr. Nakamura reminds us that even when you refer a patient out, it's important to remain supportive and demonstrate care to avoid triggering feelings of rejection or abandonment. 

Additional Resources to Consider 

• The National Institute of Mental Health (NIMH): Offers a wealth of information on personality disorders, including detailed descriptions, diagnosis criteria, and options for treatment. You can access their website at [invalid URL removed] 
• The American Psychiatric Association (APA): Provides reliable resources and diagnostic tools specifically geared towards healthcare professionals. 
• Continuing Medical Education (CME): Seek out specific courses or workshops focused on effective communication strategies and management of patients with challenging personality disorders. These can significantly boost your confidence and competence when approaching these complex cases. 

Tailoring Your Approach: Recognizing Personality Disorder Clusters 

While general principles form a strong foundation, refining your approach becomes even more effective when you consider the broader clusters under which personality disorders are categorized. The DSM-5 (Diagnostic and Statistical Manual of Mental Disorders, 5th Edition) utilizes three primary clusters: 

• Cluster A: Odd or Eccentric Behaviors Disorders such as paranoid, schizoid, and schizotypal personality disorders fall within this category. Patients may present with social detachment, distrust, or unusual beliefs. Maintaining a neutral and non-confrontational demeanor is crucial. Avoid getting drawn into discussions about their beliefs or perceived 'realities'. Focus strictly on their dermatological concerns and set clear limits. 
• Cluster B: Dramatic, Emotional, or Erratic Behaviors This cluster encompasses disorders like antisocial, borderline, histrionic, and narcissistic personality disorders. As Dr. Nakamura discussed, emotional volatility, impulsivity, and a need for control or attention can be prominent. Empathy combined with clear boundaries becomes vital. Patients in this cluster may benefit most from frequent and shorter appointments to address their needs without overwhelming your resources. 
• Cluster C: Anxious or Fearful Behaviors Avoidant, dependent, and obsessive-compulsive personality disorders belong here. These patients may struggle with severe anxiety, a need for reassurance, or rigid perfectionism. Providing detailed information, structure, and offering options within your treatment plan can be particularly helpful with patients in this cluster. 

The Value of a Collaborative Team 

Successful management of patients with personality disorders often requires a team-based approach, stresses Dr. Nakamura. Collaborate with your colleagues, including nurses and front-office staff, to ensure consistency and clarity. "Brief your staff on effective communication strategies and appropriate boundaries," she suggests. 

Additionally, building relationships with mental health professionals in your area can be invaluable. They may provide you with guidance on handling specific situations, offer insights into a patient's background, or become an appropriate referral source if needed. 

The Importance of Documentation and Reflection 

With complex cases, meticulous documentation is essential. Record not only the patient's dermatological details but also note any behavioral observations, challenges encountered, and strategies that proved effective (or ineffective). “This documentation can protect you in the unfortunate event of complaints or issues that may arise," explains Dr. Nakamura. 

Furthermore, set aside time for reflection after challenging appointments. Analyze your interactions with patients, noting what worked well and what you could potentially improve for future encounters. This continuous self-assessment will sharpen your skills and help you confidently navigate the complexities of patient care. 

Patient-Centered Care: The Cornerstone of Success 

Despite the challenges, Dr. Nakamura urges dermatologists to remember that individuals with personality disorders are patients deserving of respectful, quality care. "While it may require extra effort, flexibility, and patience, the rewards of establishing these therapeutic relationships are immense," she explains. Building trust and rapport with your patients may lead to greater adherence to treatment plans, improved overall outcomes, and a deeper sense of professional satisfaction. 

The Reality of Practice Impact 

However, it's equally crucial to acknowledge the very real impacts on your practice. Consultations with patients who have personality disorders may be lengthier and emotionally demanding. Additionally, their complex needs may strain your resources and time. "It's important to be honest with yourself about the limitations of your practice and your personal capacity," Dr. Nakamura advises. Setting realistic expectations and developing strategies to manage appointment flow is essential to prevent burnout. 

Here are some practical tips to mitigate the impact on your practice: 

• Scheduling Strategy: Consider reserving specific time slots in your day for patients you know have complex needs. This gives you time to mentally prepare and helps prevent scheduling disruptions. 
• Team Support: Enlist the help of your staff to manage communication pre- and post-appointment. For example, reminder calls confirming the appointment's focus, duration, and expectations can reduce anxiety and miscommunication. 
• Debrief and Learn: Set aside short periods for reflection after such appointments. Discuss experiences with your team and identify what you can do differently in the future for greater efficiency and improved patient care. 

The Rewarding Pursuit: Making a Difference 

Managing dermatological conditions in patients with personality disorders is undeniably complex. Yet, Dr. Nakamura believes that the journey is as important as the destination. "Each encounter is an opportunity to hone your skills, increase your understanding of human psychology, and ultimately, make a profound difference in the lives of patients who may feel misunderstood or overlooked elsewhere," she notes. 

By following a patient-centered approach, employing the strategies shared, and embracing a spirit of continuous learning and adaptation, dermatologists can confidently provide effective care to all patients, regardless of the underlying challenges they might face. Remember, even the smallest gesture of empathy and respect can have a transformative impact on those battling the complexities of a personality disorder.