Personality disorders are among the most poorly understood conditions in psychiatry. Current “lore” includes numerous faulty assumptions and stigmatizing descriptions of patients with these conditions. In the emergency department (ED) setting, the use of the term “personality disorder” is usually reserved for those patients with behaviors that sabotage the physician’s efforts to help them. The appellation of “difficult” patient is rarely used for patients with a difficult to diagnose, treatment resistant, or medically complex disease. The term “difficult” usually describes a patient who provokes frustration in his or her treating clinicians. In the ED setting, these patients often have time and resource consuming interactions with the staff and often have a less than satisfactory outcome for the clinician, the patient, or both. These patients include but are not limited to: individuals with chronic pain, addiction, personality disorders, unexplained symptoms, or those who have poor interpersonal boundaries or acceptance of set limits. Despite multiple interventions, these patients will be dissatisfied or will display excessive emotion, and many of these patients will have either undiagnosed or well-established personality disorders. This chapter will review some useful strategies to manage personality disorders in the acute care setting.
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