Management of difficult personality disorder patients

Ten per cent of the general adult population have a diagnosable personality disorder (Zimmerman & Coryell, 1990)and in 4% this is clinically severe (Tyrer, 1988). The clinical management of such patients may be difficult. However, much clinical difficulty is generated by interpersonal aspects deriving from the particular interaction of the patient and psychiatrist involved and the respec tive roles they play. It is important, therefore, to distinguish between the clinical problem proper and those aspects of the personal interaction of patient and psychiatrist which may unhelpfully (including via stigmatic labelling) contribute to the complexity of the case, further complicating the clinical management of it (Norton & Smith, 1994). This is because inter personal issues often become so prominent, in clinical transactions with personality disordered patients, that they make it impossible to achieve or maintain an ordinary clinical focus which could identify relevant and achievable goals of treatment. The psychiatrist can be side-tracked by such interpersonal aspects but recognising this may be problematic, since the distraction from a proper clinical focus may be subtle and is not necessarily negative in quality. There may be an inapprop riately positive interpersonal influence, at least initially (Yeomans, 1993).Whether the distraction is positive or negative, what is missing is an appropriate level of mutual respect and trust, so vital for carrying out the professional level clinical tasks. Too often the psychiatrist mistakenly takes its existence for granted. The aim of this paper is to identify some of the common pitfalls in the clinical management of personality disordered patients, indicating how they can be avoided or otherwise dealt with, so making treatment less arduous.