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Correctly Diagnosing Personality Disorders and Bipolar Disorder Comorbidities
James A. Jenkins, MD, staff psychiatrist, Emerson Hospital, Concord, Massachusetts, who recently gave a session titled "Narcissistic personality disorder: where we are and where we are going" at Psych Congress 2021 in San Antonio, Texas, discusses resources for clinicians to correctly diagnose comorbidities of personality disorders, such as bipolar disorder, and explores the impact of substance use disorders.
Comorbid bipolar disorder or major depressive disorder is high risk and affects personality disorder treatment personality disorder, said Dr Jenkins in the previous part 2. He also examined the common misconception that narcissistic personality disorder and BPD are major mood disorders with Psych Congress Network's Senior Digital Managing Editor Heather Flint.
In part 1, Dr Jenkins explains the differences between narcissistic personality disorders and BPD and how these 2 disorders often get misdiagnosed as bipolar disorder despite a lack of evidence to support the diagnosis.
Read the transcript:
Heather Flint: In terms of tips for clinicians or advice for clinicians, are there resources they can go to give them a better idea of how to correctly diagnose or at least find those comorbidities, maybe there is borderline personality or narcissistic personality disorder involved?
Dr James A Jenkins: One resource that I'm a huge proponent of is McLean Hospital up in Massachusetts. They have the borderline personality disorder training institute, and they have a website. They do trainings all the time in various different modalities of evidence-based psychotherapy, but they also have specialized conferences on some of the personality disorders.
I know that they're having a one-day conference coming up for obsessive-compulsive personality disorder, which is probably the most common personality disorder. Again, we don't really know much about it. They have trainings in what's called good psychiatric management, and it's an evidence-based treatment, mostly for borderline personality disorder.
Although they're starting to adapt it to narcissistic personality disorder, where you can learn how to manage and think about all of the different aspects of the personality disorder that we touched on today, about comorbidity, disclosing the diagnoses, structuring a treatment, setting goals in a treatment, managing emergencies or crises.
I always recommend that people take a look at that course. It's, I think, maybe seven hours long. It used to be offered free of charge because of a grant that was given by the family of a patient who benefited tremendously from treatment. Although, I don't know if that's still the case. That's one place.
There are a lot of good books that are out there. Some of the books that are out there that are good are a little bit old. In preparing for my talk for Psych Congress, I was referring back to Otto Kernberg's book, "Severe Personality Disorders." That might have been from 1986.
Flint: Oh, wow.
Dr Jenkins: It's interesting because the research seems to be catching up with what some of these people who did psychoanalysis or psychodynamic psychotherapy, how they were conceptualizing personality disorders. The research seems to be validating some of those things. Anything by Otto Kernberg would be good.
They're coming out with a new book, I think, specifically on the treatment of narcissistic personality disorder. Although, it's a little bit more intensive and probably complex and advanced for the average clinician and it's psychotherapy-based.
I think those are probably the biggest resources. I wish that they were easier to find. I wish that there are more of them. This is an area of psychiatry that's really been neglected.
Flint: Just to finish up with that idea of neglected, what advice would you have for other providers or clinicians when a patient comes in? Is there any symptom or statement that when they're learning and doing their intake, that it might ping in their mind as, "Let's deep dive into maybe a personality disorder"?
Dr Jenkins: I would say the number one thing, and I say this with some trepidation, is if someone comes in, and they say, "Nothing has ever worked for me before. I've been in treatment for 15 years. No meds work. Therapy is a scam. It doesn't work for me. What good is talking to someone going to do for me?"
If you have someone who's not responding to treatment, 3rd, 4th attempts at treatment, go back and reconsider the diagnosis. Set up an extra intake, if you have to, even if they're a patient that you're familiar with. Delve deep into the possibility that they might have a personality disorder.
This is, in some ways, anathema to we have all these exciting treatments that are coming out for treatment-resistant mood disorders. That makes me a little bit nervous because my worry is that this group of people are going to be funneled towards some invasive treatments.
Rather than first, stopping, reassessing, looking at the diagnosis, and considering whether there might be personality pathology at play.
Flint: That's interesting. I said final, but that's interesting that you brought that up. We do have a lot of research coming out, and a lot of excitement coming out, about, we said, the treatment-resistant ketamine therapies and the psychedelic therapies. That's what you were getting to.
Dr Jenkins: It is what I was getting to.
Flint: It's perfectly fine. No. It's what you were getting to. I think it's important that you make that known to stop, reassess, is this the right path for my patient? Because when nothing works, you go to something that says resistant. Right? Resistant treatment.
Dr Jenkins: Exactly.
Flint: I think that is another tip or advice for clinician. Not just going straight to something resistant, but maybe deep dive. Would that be your main goal, I'm sure, not against psychedelic therapy or these other treatments, but to take pause before starting?
Dr Jenkins: Take pause, exactly. These other treatments are great. It's the future of psychiatry. If you talk to someone who has a ketamine clinic or who is doing ketamine, they will let you know that a high percentage of the people that they're seeing are people who probably have a diagnosis of a personality disorder.
We do need to stop and pause and make sure that when we're saying this to someone who is treatment-resistant that we have the right diagnosis. If you don't have the right diagnosis, then they're not being treated appropriately. We know this now for bipolar disorder.
You treat someone for 10 years on average as a major depressive disorder and they're not getting better, so are they really treatment-resistant? You have the wrong diagnosis. In my mind, it's difficult to say that that's treatment-resistant.
First, you have to get the diagnosis right. Then, if you reformulate and come to the conclusion that it's bipolar disorder, start appropriate bipolar treatments. Then if they don't get better, then you can call them treatment-resistant. The same should be the case with the consideration of a personality disorder.
Flint: I appreciate you saying that because there is so much excitement around it right now. Clinicians are trying to jump in, and we've heard a lot that people are trying to jump in too quickly.
We've talked a lot about that at our network, about getting mentors, and taking pause, and reassessing. It's nice to try that at home yet again and introduce the fact that these orphan diagnoses exist in these different personality disorders. I want to say thank you so much for sitting with us...
Dr Jenkins: Welcome.
Interviewer: ...and for talking with us at Psych Congress and presenting this session that needs to be presented and getting this idea out there. Thank you.
Dr Jenkins: Thank you so much.
James A Jenkins, MD, spent his residency gaining expertise in a variety of psychotherapies and milieu treatments for people with complex psychiatric diagnoses and co-occurring personality disorder diagnoses. His advanced training includes certification and expert supervision in Dialectical Behavior Therapy, Mentalization-Based Therapy, and Good Psychiatric Management. Dr Jenkins is a former medical director of the McLean Hospital Cambridge Residence, a residential program for transitional age youths with emerging personality disorder diagnosis who are preparing to exit the mental health system. He was also a staff psychiatrist at the McLean Hospital Gunderson Residence, an intensive residential treatment program for adult women with complex personality disorder diagnoses and refractory psychiatric symptoms. Dr Jenkins is interested in the integration of medication management, milieu treatment, and evidence-based psychotherapies to provide the most comprehensive treatment for those whom prior treatments have failed. Additionally, he is interested in increasing accessibility of these treatments and their implementation in less resourced or traditional environments. Recently he joined the psychiatry department at MassGeneral Hospital and is working to help translate the principles of Dr John Gunderson's Good Psychiatric Management to the consultation-liason service and also in their psychiatric emergency room. Dr Jenkins is an active member of Alpha Omega Alpha and Gold Humanism Honor Society.
