Identification and Management

of Personality Disorders
and How They Can Affect
HIV Caregiving
James Satriano, Ph.D.
AIDS Education and Training Center
Columbia University Department of Psychiatry
Disclosures
“This program is supported by the Health Resources and
Services Administration (HRSA) of the U.S. Department of
Health and Human Services (HHS) as part of an award
totaling $3,845,677 with zero percent financed with
nongovernmental sources. The contents are those of the
author(s) and do not necessarily represent the official
views of, nor an endorsement, by HRSA, HHS or the U.S.
Government.”

2
Personality Disorders and HIV Care
Learning Objectives
 Understand the prevalence of Personality Disorders
among those in HIV care
 Describe the hallmarks of Personality Disorders in
HIV patients and best practices for treatment
 Appreciate how Personality Disorders can affect HIV
care (engagement, adherence, retention)
 Review approaches to working with clients with
Personality Disorders
 Understand conditions to rule out Personality
Disorders
Why is PD Identification Important in HIV Care?

 20 – 40% of individuals with HIV have a Personality Disorder

(and many others have traits associated with Personality
Disorders that may be impairing) versus 9-15% in the general
population.
 Risk factors for HIV associated Personality Disorders – adverse
childhood events (especially sexual traumas), impulsivity and
addictions – factors that could promote high risk behaviors.
 Management of HIV disease requires positive alliance with
treatment team (engagement/retention) and adherence to
treatment regimen – challenging tasks for many with
Personality Disorders.
Perkins, Davidson et al. (1993) A J of Psychiatry
Golding & Perkins (1996) Int Rev of Psychiatry
Personality
 “Personality traits are enduring patterns of perceiving,
relating to, and thinking about the environment and
oneself that are exhibited in a wide range of social and
personal contexts.” DSM-5
 Personality is the combination of behaviors, emotions,
motivations, and thought patterns that define an
individual.
 Personality traits have been the subject of much scientific
research in terms, among other things, of heritability,
childhood antecedents, stability over time, and
functional relevance to work, well-being, and physical
health.
Theories of Personality Formation
 Psychodynamic theories – symptoms reflect maladaptive
“compromises” outside of awareness (i.e., unconscious).
 Behavioral theories – focus on the interaction between the
individual and the environment, and what is observable and
measurable (versus internal psychic processes).
 Trait theories – personality make up of many traits – a
relatively stable characteristic that causes an individual to
behave in certain ways; e.g., five factor theory of personality.
 Humanist theories – focus on free will and individual
experience, emphasizing self-actualization (innate need for
human growth that motivates behavior); optimistic about
human nature.
Five Factor Model – Trait Theory
 Openness vs close-mindedness – curious, imaginative,
independent vs conventional, practical, conforming
 Conscientiousness vs undependable – organized,
hardworking, dependable vs impulsive, careless,
disorganized
 Extraversion vs introversion – sociable, adventure-
seeking, affectionate vs quiet, withdrawn, reserved
 Agreeableness vs disagreeableness – helpful, trusting,
empathic vs critical, suspicious, uncooperative
 Emotional stability vs neuroticism – calm, secure, self-
satisfied vs anxious, unhappy, self-pitying
Personality Disorders - DSM
 Categorical versus Dimensional Models
 Categorical approach used for other psychiatric
disorders – assessment of signs/symptoms (DSM
criteria); one has the disorder or one does not
 DSM-5 criteria versus “Alternative DSM 5 Model for
Personality Disorders” contained in the DSM
Appendix
 Conditions that exist on a continuum, such as
personality and personality traits might better be
assessed on a dimensional model
Categorical Approach - Problems
 Excessive diagnostic comorbidity among
Personality Disorders.
 Heterogeneity among individuals with the
same disorder.
 Inconsistent, unstable, arbitrary diagnostic
boundaries.
 Inadequate coverage (Personality Disorder
NOS the most frequent diagnosis).
DSM-5 Alternative Model for PDs
 Personality Disorders characterized by impairments
in personality functioning and pathological
personality traits which are often maladaptive variants
of non-pathological personality traits.
 Includes Antisocial, Avoidant, Borderline, Obsessive-
Compulsive, Narcissistic and Schizotypal PDs and a
Personality Disorder – Trait Specified.
 All Personality Disorders look at disturbances in self
(identity & self-direction) & interpersonal (empathy &
intimacy) functioning.
 25 specific traits in 5 domains – negative affectivity,
detachment, antagonism, disinhibition, psychoticism.
DSM-5 definition of PD
 An enduring pattern of inner experience and behavior
that deviates markedly from the expectations of the
individual’s culture manifested in at least two areas
(cognition, affect, interpersonal functioning, impulse
control).
 The pattern is inflexible and pervasive.
 The pattern leads to significant distress.
 Is stable and of long duration.
 Not better explained by another mental disorder or
attributable to substance abuse or a medical
condition.
DSM-5 definition of PD continued
 Enduring aspect – in theory Personality Disorders are
evident since adolescence or young adulthood and are
relatively chronic and stable throughout adulthood – most
other disorders generally more episodic
 Requirement of impairment or subjective distress – an
important point for almost all psychiatric disorders
 Ruling out another psychiatric disorder – particularly
important when there is a seeming change in personality
later in adulthood
Diagnosis of Personality Disorder
 Several semi-structured interviews available to ensure
a systematic assessment and increase reliability.
 Subjective assessments much more susceptible to bias
(e.g., gender or culturally based) as well as incomplete
assessment.
 Length of time for assessment can make semi-
structured interviews impractical but there are self-
report questionnaires that can be used as well.
 Patients with PDs tend to have poorer treatment
outcomes, greater recurrence of other psychiatric
disorders, and higher risk for suicidal behaviors.
PDs among People with HIV/AIDS
 The National Comorbidity Study (Kessler et al., 1996)
showed that substance use disorders are highly co-
morbid with other psychiatric disorders including
borderline personality disorder.
 Substance use disorders are very common among
people living with HIV/AIDS.
 Study of incarcerated men in NC with BPD –
symptoms associated with multiple partners, drug use
with sex partners, having sex while high, and
crack/cocaine and ecstasy use.
Borderline Personality Disorder Symptoms & HIV Risk Behaviors
among African-American Incarcerated Men, Scheidell, Lujuez, etc.
(2014).
PDs among People with SUDs
 40-50% of individuals with a SUD meet the criteria for ASPD
and about 90% of individuals with ASPD also have a co-
occurring SUD
Messina, N., Wish, E., & Nemes, S. (1999).
 Over 50% of individuals with a lifetime diagnosis of BPD also
had a SUD diagnosis in the previous 12 months
Grant, B.F., Chou, S.P., Goldstein, R.B., Stinson, F.S., Saha,
T.D., et al. (2008).
 60% of patients with a SUD had a Personality Disorder - BPD
more associated with current and ASPD with lifetime
disorders
Skodol, A.E., Oldham, J.M., Gallaher, P.E. (1999).
Personality Disorders among IDUs
 Injection drug users are more likely than the general
population to have Personality Disorders.
 Antisocial and Borderline Personality Disorders most
common
 22% of IDUs reported to have Antisocial Personality
Disorder.
 18% of IDUs reported to have Borderline Personality
Disorder.
Verhuel, R. et al. Substance use. In Oldham, J. Skodol, A., Bender, D.
The American Psychiatric Publishing Textbook of Personality Disorders. Washington
D.C. The American Psychiatric Publishing Inc.; 2005: 463-75.
HIV + Psych ER Visits
 58,000 consecutive ER visits
 2.0% known HIV +
 HIV + patients more likely to be:
 Male
 Homeless
 African American
 Living with dementia
 Substance abusing
 Suicidal
 Diagnosed with a borderline personality disorder

Murray Bennett, Joesch, Mazur & Roy-Byrne (2009)

Narcissistic Personality Features
 300 individuals with HIV/AIDS recruited from infectious
disease clinic – investigators looked at narcissistic
characteristics, substance use, and sexual risk behaviors.
 Majority of participants (85%) reported no unprotected
intercourse in previous 3 months with an HIV negative
partner or partner with unknown status.
 Narcissistic traits strongly predicted sexual activity
following substance use, more partners, more
unprotected sex acts, and low intentions to use condoms
in the future.
Transmission Risk Behaviors in a Subset of HIV-positive
Individuals: The Role of Narcissistic Personality Features,
Martin, Benotsch, Lance & Green (2012)
Personality Disorder Clusters
 Cluster A: Odd, Eccentric
 Cluster B: Dramatic, Emotional, Erratic
 Cluster C: Anxious, Fearful
Cluster A – Odd, Eccentric
 Paranoid PD – “pattern of pervasive distrust and
suspiciousness of others such that their motives are
interpreted as malevolent . . .” (Captain Queeg)
 Schizoid PD – “pervasive pattern of detachment from
social relationships and a restricted range of
expression of emotions in interpersonal settings . . .”
 Schizotypal PD – “pervasive pattern of social and
interpersonal deficits marked by acute discomfort
with, and reduced capacity for, close relationships as
well as by cognitive or perceptual distortions and
eccentricities of behavior . . .” (Travis Bickel)
Cluster C – Anxious, Fearful
 Avoidant PD – “pervasive pattern of social
inhibitions, feelings of inadequacy, and
hypersensitivity to negative evaluation . . .”
 Dependent PD – “pervasive and excessive need to be
taken care of that leads to submissive and clinging
behavior and fear of separation . . . “
 Obsessive-Compulsive PD – “a pervasive pattern of
preoccupation with orderliness, perfectionism, and
mental and interpersonal control, at the expense of
flexibility, openness, and efficiency . . .” (Melvin
Udall)
Cluster B – Dramatic, Emotional, Erratic
 Antisocial PD – “pervasive pattern of disregard for
and violation of the rights of others . . .” (Hannibal
Lecter).
 Borderline PD – “pervasive pattern of instability of
interpersonal relationships, self-image, and affects,
and marked impulsivity . . .” (Alex Forrest, Tommy
DeVito).
 Histrionic PD – “pervasive pattern of excessive
emotionality and attention seeking . . .” (Scarlett
O’Hara, Derek Zoolander).
 Narcissistic PD – “pervasive pattern of grandiosity (in
fantasy or behavior), need for admiration, and lack of
empathy . . .” (Walter White, Frank Underwood).
Antisocial Personality Disorder

 Failure to comply with social norms regarding lawful

behaviors
 Deceitfulness, as indicated by repeated lying for profit or
pleasure
 Impulsivity or failure to plan ahead
 Irritability and aggressiveness, as indicated by physical
fights/assaults
 Reckless disregard for the safety of self or others
 Consistent irresponsibility, as indicated by lack of consistent
work, paying debts, etc.
 Lack of remorse, as indicated by being indifferent or
rationalizing hurting, mistreating, stealing from others
Antisocial Personality Disorder continued
 Evidence of a conduct disorder before age 15 a criterion
 Because of the nature of the Disorder (deceit and
manipulation), collateral history especially important
 DSM criticized for focusing too much on behaviors rather
than character traits
 Concept of psychopathy focusing on lack of empathy,
inflated self-appraisal, superficial charm, etc.; often used in
correctional and forensic settings
Clinicians Reactions to ASPD
 Therapeutic nihilism
 Illusory alliance – clinician being manipulated
 Fear of assault/harm – can be warranted
 Denial – in response to real danger
 Helplessness/guilt – in response to lack of response
 Hatred and rage
Case of Mr. J
 Mr. J was a 19 year old African American man diagnosed
with HIV in September of 1996. Over the course of the
next year, Mr. J . had unprotected sex with many young
women in a small industrial town in a mostly rural
community not known for high rates of HIV. The
emergence of a cluster of new cases began an investigation.
Epidemiological interviewing of the first six cases led
public health officials to identify Mr. J as the source of the
cluster.
Case of Mr. J continued
Investigators identified more than three dozen young women who
admitted to having sex with Mr. J. Of this group, 16 of the women have
confirmed cases of HIV. The youngest of this group was 13 years old at
the time of diagnosis.
 Relentless and charming
 Menacing ; became physically abusive when threatened
 Sold crack and said he was a member of the Bloods; Hx incarceration
 Showered girls with gifts
 Never used condoms
 Claims to have had sex with over 300 women
Borderline Personality Disorder
 Frantic efforts to avoid real or imagined abandonment
 Unstable and intense interpersonal relationships
 Chronic feelings of emptiness
 Markedly and persistently unstable sense of self
 Impulsivity in 2 areas that are potentially self-damaging
– spending, sex, substance abuse, binge eating, etc.
 Recurrent suicidal behavior/threats or self-mutilating
behavior
Borderline Personality Disorder continued

 Affective instability due to a marked reactivity of mood

(intense episodic dysphoria, irritability or anxiety
usually lasting a few hours & no more than a few days)
 Inappropriate anger or difficulty controlling anger
 Transient stress-related paranoid ideation or severe
dissociative symptoms
 Frequent comorbidity – other Personality Disorders,
eating, substance use* and mood disorders, PTSD
 Natural course predicts eventual remission
Case of Ms. R
 Ms. R was a 29 year old Caucasian woman referred for HIV
care to a hospital-based outpatient clinic after testing
positive. She was assigned to be seen by Dr. B, an ID
physician on the team at the clinic. After routine intake
and a follow-up visit with Dr. B she stated that he was the
“best doctor I have ever seen.” The relationship between
Ms. R and Dr. B seemed to be working very well for the first
few months. She reported taking her medication as
prescribed and her labs showed a rise in CD4 cells and a
drop in viral load.
Case of Ms. R continued
 Encouraged by the good results, Dr. B decided to decrease
the frequency of Ms. R’s follow-up appointments. With the
onset of less frequent appointments, Ms R began making
many phone calls to Dr. B, complaining of odd symptoms
and medication side effects. She stated that she would
experience these side effects as soon as she put the pills in
her mouth. Also at this time Ms R began missing
scheduled appointments and showing up at the clinic at
non-scheduled times demanding to be seen.
Case of Ms. R continued
 Ms. R began to behave erratically in the clinic,
throwing a tantrum when told that Dr. B was running
behind and would be a half-hour late. The nursing
staff and support staff did not want to interact with
her because she seemed so volatile. During one
unscheduled visit, when the receptionist told her that
she could not be seen that day and to please schedule
an appointment, Ms. R threatened to hurt herself
and raised the sleeve on her blouse to show the
receptionist several dozen razor cuts up and down
her forearm.
Case of Ms. R continued
 The receptionist became upset by this and reported it to
the nursing staff who admonished Ms. R for her behavior.
Feeling affronted and not supported by the clinic staff, Ms.
R wrote a letter of complaint to the hospital administrator
in her own blood.
Differential Diagnosis of PD
 Unlike other mental health disorders where clinicians rely
on the patient’s description of symptoms to assist in
diagnosis, the clinical diagnosis of a Personality Disorder
must often be derived by observation of the patient’s
behavior and style of interacting with others as well as the
reports of others over time.
 Dysfunctional patterns are generally ego-syntonic (“there
is nothing wrong with me”).
Rule Outs for PD Diagnosis
 Dementia (HAD) or other CNS Disorder
 Psychotic Disorder (Paranoid, Schizoid, Schizotypal PD)
 Substance abuse (Antisocial PD)
 Mood disorder (Borderline, Narcissistic PD)
 Anxiety disorder (Avoidant, Obsessive-Compulsive PD)
 Metabolic disorder
 Malingering
 PTSD
 Autistic Spectrum Disorder (Schizoid, Schizotypal PD)
HIV-Associated Dementia
 HIV dementia subcortical, more associated with white
matter, and similar to dementias associated with
Huntington’s Disease and Parkinson’s dementia.
 Early symptoms: affect attention, motivation, and
emotionality; can show early symptoms of depression,
irritability, apathy and motor weakness/ataxia; more likely
to see early personality changes than with cortical
dementias like AD
 Late symptoms: global cognitive dysfunction (e.g., memory,
judgement), mutism, organic hallucinations and
Parkinson-like symptoms.
HIV-Associated Dementia continued
 An international meta-analysis of HAD among 35,000
participants in 32 countries reported:
 an overall prevalence of 42.9%
 23.5% asymptomatic neurocognitive impairment
 13.3% mild neurocognitive impairment
 5.0% HAD

 Disruptive behaviors may be symptoms of HAD and may

mimic symptoms of personality disorders or psychosis.

Wang, Lui, Lu et al. (2020) Neurology 95 (10) 2610-2621

CNS Infections and HIV
 Maladaptive personality traits may be caused by underlying
CNS infections.
 CNS infections common to AIDS are:
HIV encephalopathy
Lymphoma in brain
Progressive multi-focal leukoencephalopathy
Toxoplasmosis of brain
Be on the look out . . .
 Frequent threats of suicidality, especially tied to
interpersonal interactions
 Cutting or other forms of self-harm
 Repeated episodes of what appears like lying,
especially accompanied by an apparent lack of
concern when confronted with a lie
 Excessive compliments (“you are the best . . .,” “you
are the only . . .”), at times followed by complete
devaluation when you have disappointed the
individual
 Excessive Promiscuity
Be on the look out . . . continued
 Apparent lack of remorse when having done
something hurtful to someone else
 Extreme self-centeredness and lack of concern for the
welfare of others
 Lack of personal connections that seem unrelated to
understandable circumstances or inability to identify
important people in one’s life
 Consistent suspiciousness of other people’s motives
 Strong emotional reactions on your part to your
patient
Approach to Patients with PD
 Effective communication

 Interdisciplinary integrated team approach

 Effective treatment plan

 Mental health management

Effective Communication
 Listen carefully to identify the patient’s goals
 Use body language that conveys support and
respect
 Offer choices and options whenever possible to
involve the patient – shared decision making
 Establish clear, consistent and rational strategy
about when to support and when to confront
 Need to avoid total responsibility as well as
therapeutic nihilism
Interdisciplinary Team
 Adopt team approach that focuses on clear communication
among everyone involved in the patient’s care - need for
frequent staff conferencing
 Minimize patient’s attempts at staff- splitting and
projection (e.g. staff meetings to clarify treatment goals,
reach consensus, set limits, etc.)
 Diffuse sense of responsibility among members of the
treatment team as well as support for team members
Effective Treatment Plan
 Shared decision making
 Setting limits when necessary, behavioral contracts
 Make all staff (including support staff) aware of any
behavioral contracts – help to avoid splitting
 Use a healthcare network to provide care – primary and
mental health care must be INTEGRATED!!!!
 Focus on long term goals, not immediate rewards
Principles of Effective Therapies

 Stable and clear treatment framework – primary

clinician, with specific short and long-term goals and
roles in team settings
 Therapist needs to be clear about what can and
cannot be expected from them, especially regarding
self-harm and other dangerous behaviors
 Support essential – validating patient’s distress, etc.
but not necessarily validating perceptions of others;
need also to convey therapeutic optimism and
encouragement
Principles of Effective Therapies continued
 Clinicians need to be active but nonreactive, contained and
measured, as many patients extremely sensitive to signs of
rejection
 Limit self-disclosure to certain patients
 Need to connect patients’ feelings to events, including
rejection, lost supports, other social stressors, in the here
and now
 Monitoring and discussion of countertransference is key
Cognitive Behavioral Therapies

 Time limited therapies some of which focus on

distortions in information processing and
maladaptive ways of thinking about oneself, the world
and the future.
 Initially developed for depression but now used for
many conditions including Personality Disorders.
 Education emphasized (e.g., pointing out
dysfunctional distortions), homework often used,
treatment very structured with an active therapist.
 Ability to recognize shifts in mood, identify negative
thoughts, consider alternative behaviors.
Dialectical Behavioral Therapy for BPD
 Major dynamic seen as a dysregulation of emotion
(individual feeling mistreated & misunderstood)
interacting with an invalidating environment
 Includes 1 hour of individual and 2 hours of
manualized group therapy focusing on coaching
patients to attain certain goals & teaching behavioral
coping skills
 6 hierarchical goals for change – suicidal behaviors,
therapy-interfering behaviors, behaviors interfering
with quality of life, behavioral skill acquisition, post-
traumatic stress behavior, & self-respect behaviors
 Individual therapists on call 24/7; use of consultation
groups for treatment & clinician support; validation,
empathy and alliance with patient all key elements
Mentalization-Based Treatment
 Mentalization is the capacity to understand the
mental activity that underlies social interactions –
leads to understanding and managing the many
evolving thoughts, feelings, desires, and intentions
that two individuals have in an interaction.
 Inability to mentalize leads to social-cognitive
vulnerabilities (e.g., attachment insecurity).
 Treatment consists of individual and group therapy
with therapist taking a curious rather than knowing
stance.
 Much less training needed than with DBT.
Interpersonal Therapy for BPD

 Developed for treatment of depression focuses on

examining in detail and improving relationships with
significant others.
 Manualized and time limited; treatment alliance key
as is monitoring moods states to help stabilize social
supports and important personal relationships; some
aspects of treatment need to be modified.
 Borderline pathology seems intimately tied to
problems with attachment, dependency and fear of
abandonment, resulting in unstable emotions and
relationships.
Other Treatments for PDs
 Supportive therapy (General Psychiatric Management)
 Transference-focused Psychotherapy
 Group therapy
 Family therapy
 Keep in mind that for several PDs there is little evidence for
the benefit of pharmacotherapies (Dependent, Avoidant,
Obsessive-Compulsive, Schizoid), though comorbidity may
warrant medications
Pharmacotherapy
 More evidence for manualized psychotherapies for
some Personality Disorders than for medication.
 Mood stabilizers for mood lability, anger, impulsivity –
e.g. Lithium, anticonvulsants e.g. Topiramate,
Gabapentin.
 SSRIs for depressed mood, anxiety, impulsivity – e.g.
Fluoxetine, Sertraline, Paroxetine.
 Antipsychotics for distorted cognition/perception,
mood lability, impulsivity– Risperidone, Ziprasidone,
Aripiprazole.
 Be cautious with BZD’s: co-morbidity with SUDs
Conclusions
 ASPD and BPD most challenging, especially when
complicated by active substance abuse
 Cohesive treatment team is key as is supervision and
consultation – multimodal treatment approach
 Management of countertransference essential
 Focus on suicidal and other dangerous behaviors
 Need to consider higher levels of care when necessary
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