Assessment and management of personality disorders.

Patients with personality disorders are common in primary care settings; caring for them can be difficult and frustrating. The characteristics of these patients' personalities tend to elicit strong feelings in physicians, lead to the development of problematic physician-patient relationships, and complicate the task of diagnosing and managing medical and psychiatric disorders. These chronic, inflexible styles of perceiving oneself and interacting with others vary widely in presentation. In the Diagnostic and Statistical Manual of Mental Disorders, 4th ed., these styles are categorized into three clusters based on their prominent characteristics: cluster A, the odd or eccentric (e.g., paranoid, schizoid, schizotypal); cluster B, the dramatic, emotional, or erratic (e.g., antisocial, borderline, histrionic, narcissistic); and cluster C, the anxious or fearful (e.g., avoidant, dependent, obsessive-compulsive). Knowledge of the core characteristics of these disorders allows physicians to recognize, diagnose, and treat affected patients. The goal of management is to develop a working relationship with patients to help them receive the best possible care despite their chronic difficulties in interacting with physicians and the health care system. Effective interpersonal management strategies exist for these patients. These strategies vary depending on the specific diagnosis, and include interventions such as the use of specific communication styles, the establishment of clear boundaries, limit setting on the patients' behavior and use of medical resources, and provision of reassurance when appropriate. Additionally, medications may be useful in treating specific symptoms in some patients.

Benefits and risks of psychiatric medications during pregnancy.

Traditionally, psychiatric medications were withheld during pregnancy because of fear of teratogenic and other effects. The emergence of evidence of the safety of most commonly used psychiatric medications, the availability of this information in the form of online databases, and the documentation of the adverse effects of untreated maternal mental illness have all increased the comfort of physicians and patients with respect to the use of psychiatric medications during pregnancy. The tricyclic antidepressants and fluoxetine (Prozac) appear to be free of teratogenic effects, and emerging data support similar safety profiles for the other selective serotonin reuptake inhibitors. The mood stabilizers appear to be teratogenic. With the exception of the known risk for depression to worsen in the postpartum period, there is little consistent evidence of the effects of pregnancy on the natural history of mental illness. Decisions regarding the use of psychiatric medications should be individualized, and the most important factor is usually the patient's level of functioning in the past when she was not taking medications.