Mental Health and Personality Disorders

I taught for several years at a community-based residency program that was affiliated with a university. We hosted medical students from several local medical colleges, including subinternship students from our home medical school. The medical school was affiliated with an urban academic medical center, a 700-bed, fully integrated, and self-sufficient complex. The community hospital was no small critical access center; it was a 200-bed, 2,500-delivery local powerhouse in its own right. Students who rotated on our inpatient service always needed a few days to adjust to how intimate the care team was. Every nurse knew every resident and clinician in the hospital. There were no layers of residents, attendings, and fellows between the family medicine team and the consultants. There was no house staff lounge for the 12 family medicine residents; they just came in and out of the doctors’ lounge with the rest of us.

The team, consisting of two residents and a student, often spent time charting in that lounge because it was the best place to run into the specialists they needed to talk to. One day, I walked them to the lounge after rounds. As we badged ourselves in, I saw the senior resident nod to the student and say, “Hey, did you need to talk to psychiatry? He’s over there.”

The student had never worked at a hospital with just one psychiatrist to cover all of inpatient and outpatient referrals. Coming from an academic medical center, he was used to a large consult team and a busy, if waitlisted, clinic. The community-based hospital, 40 miles away, had far fewer resources. A fellow student had spent several weeks working on creating a list of community mental health resources and produced a remarkable document but reported feeling discouraged. It was hard to get calls returned, she said, and patients with Medicaid would have a lot of trouble finding clinicians.

Family physicians have always cared for patients with mental health conditions, but we are increasingly managing a broader scope of conditions and encountering an increased complexity of patients than ever before. Access to psychiatry services is decreasing; like primary care, psychiatry is a field experiencing shortages, especially in rural areas. This edition of FP Essentials addresses mental health conditions that family physicians are likely to encounter.

Section One covers attention-deficit/hyperactivity disorder in adults, a condition we see frequently. Section Two addresses posttraumatic stress disorder and offers recommendations for prevention and treatment. In Section Three, the authors discuss diagnosis and management of three common personality disorders. Although complex, these are encountered regularly in primary care. This edition concludes with a description of the evaluation of psychosis and associated symptoms in Section Four.

During my time at the community hospital and now at an academic medical center, having great specialist colleagues has been a rewarding part of my job. Likewise, in my work with FP Essentials, I’m grateful to the specialist peer reviewers and authors who contribute to this and other editions.

I hope you find this edition useful in your practice.

Kate Rowland, MD, MS, FAAFP, Associate Medical Editor
Vice Chair of Education and Associate Professor
Department of Family and Preventive Medicine
Rush University, Chicago, Illinois

Victoria Chisholm, DO, is a board-certified family medicine physician and behavioral health fellow at Cahaba Medical Care in Centreville, Alabama. Dr. Chisholm graduated residency in June of 2024. She has presented on multiple mental health topics, such as attention-deficit/hyperactivity disorder (ADHD) and borderline personality disorder. She has authored a manuscript on adverse childhood illnesses. Her areas of interest include ADHD, autism spectrum disorder, substance use disorders, and integration of mental health into primary care.

Boone G. Rountree, DO, MEd, is a board-certified general and child/adolescent psychiatrist who serves as chief psychiatrist for Cahaba Medical Care, program director for the Cahaba+University of Alabama (UAB) Rural Psychiatry Residency, and assistant professor in the Department of Psychiatry and Behavioral Neurobiology at the UAB. His interests include stress and trauma disorders, neurodevelopmental disorders, integrated psychiatry, psychotherapy, underrepresented communities, and medical education. He has presented at various meetings in the United States and Canada on topics including burnout, wellness, stress management, and meditation. He teaches developmental psychiatry modules at the UAB Heersink School of Medicine in Birmingham.

Disclosure: It is the policy of the AAFP that all individuals in a position to control CME content disclose any relationships with ineligible companies upon nomination/invitation of participation. Disclosure documents are reviewed for potential relevant financial relationships. If relevant financial relationships are identified, mitigation strategies are agreed to prior to confirmation of participation. Only those participants who had no relevant financial relationships or who agreed to an identified mitigation process prior to their participation were involved in this CME activity. All individuals in a position to control content for this activity have indicated they have no relevant financial relationships to disclose.

• Describe the features of attention-deficit/hyperactivity disorder in adults.
• Discuss the treatment of attention-deficit/hyperactivity disorder in adults.
• Identify patients at risk for posttraumatic stress disorder.
• Describe the types of trauma-based psychotherapy effective for posttraumatic stress disorder.
• Refer patients with personality disorders for appropriate psychotherapy.
• Avoid use of ineffective pharmacotherapy for patients with personality disorders.
• Identify patients with secondary causes of psychosis.
• Counsel patients on risk factors for psychosis, such as heavy cannabis use.