"You are not doing enough for me" Personality Disorders in the Time of COVID-19

INTRODUCTION: Personality disorders persist into late life and pose complex care needs for patients who have difficulty navigating the health care system. As chronic maladaptive patterns of coping are part of the landscape of care for these patients, stressors related to COVID-19 including isolation, lonliness, boredom, access to care and transitions to telepsychiatry and remote medical care created unique challenges for these patients. While many patients adapted well to telephone and video visits, the lack of face to face contact, fears of infection and coping with the loss of family and friends created more needs and often demands for increase in services. Help seeking and help rejecting behaviors often increased over time. The goal of treatment of personality disorders in late life is not to cure the disorder but to decrease the frequency and intensity of symptoms. The COVID-19 global pandemic placed unique stressors on these vulnerable patients with limited coping skills. METHODS: Cases studies were identified from the patient population at Mount Sinai Beth Israel, an urban medical center serving a multicultural and socioeconomically diverse population. Mount Sinai Beth Israel has been serving the population of lower Manhattan since 1889 and provides full service behavioral health care. Patients were identified from those who presented to the outpatient geriatric psychiatry service. A personalized treatment planning approach was utilized during the time period of the COVID-19 pandemic. RESULTS: Ms. M is a 78 year old woman with many Borderline and Narcissistic traits was dissatisfied with every clinician who cared for her in the past. She wrote, called and came to the institution demanding different providers, new medications and updated care plans without following up on any. During the pandemic she held the view that recommendations to slow spread of COVID-19 were not applicable to her. She often cited her basic rights to refuse things such as wearing masks. She became hostile and called the provider from a pharmacy asking for an "exemption" to wearing a mask. A behavioral contract was developed to assist her in gaining control by chosing her own masks and thermal thermometer. She was able to return to in person visits and manage necessary community tasks using safety precautions. Ms. S is an 82 year old woman with a history of Paranoid personality disorder engaged with the clinic for decades; with periods of absences due to moving to different apartments over suspiciousness towards landlords and neighbors. She has been highly functional in isolative jobs but has difficulty relating to others as her suspicious thoughts become overwhelming. She has difficulty trusting health care professionals and is reluctant to seek care for medical problems. As the initial wave of COVID-19 emerged, her paranoid symptoms escalated acutely. She refused to have aides in her home, fearing that they were infected, although needed assistance with ADLs. She refused to come in to clinic appointments and disengaged from all services. She had no computer access, so phone sessions were initiated on a weekly bases to provide psychoeducation and supportive therapy. A modest increase in risperidone dose helped reduce her paranoia towards having home aides retun on a limited bases. She was able to engage in a telephone support group that included COVID-19 education and wellness help. Ms LL is an 84 year old woman with a lengthy history of Histrionic and Narcissistic traits who was followed for many years by a provider who retired in the month prior to COVID-19 quarantine restrictions. She entered treatment with a written list of demands for multiple controlled substances in 90 day quantities in order to "stock up" for the pandemic. She was initially quite hostile when her requests were not immediately met and called the clinic several times each day to reschedule future appointments, complain of being neglected and ask for medications. A treatment plan was developed that included alternating in-person appointments with brief telephone visits to adjst doses of trazodone and gabapentin, which were chosen in place of benzodiazepines. She remained in treatment although continued to call with complaints of "not getting enough care." CONCLUSIONS: The limited literature on the prevalence and longitudinal course of older adults with personality disorders makes treatment strategies difficult and challenging. These clinical vignettes illustrate how therapeutic strategies may be adjusted to meet the needs of older adults who are dissatisfied with care, utilize services at high rates but reject care repeatedly and often show limited benefits. Patients responded well to engagement but under the increased stress of COVID-19 quarantine conditions additional symptoms increasingly emerged. The ability of patients to adapt to required pandemic safety requirements was a challenge that was met wtih individualized treatment planning. FUNDING: Mount Sinai Beth Israel Deparment of Psychiatry