Personality Disorder

Personality

temperament (genetics) + character (environment)

Factors Contributing to Personality

genetics, past experiences, present experiences, view of future

Personality Traits

characteristic patterns of perceiving, interacting with and thinking about one's environment

Personality Disorder

enduring, inflexible and maladaptive manner of interacting with one's environment; code on axis II

Personality Disorder - Importance of Recognition

tailor treatment to patient's coping style; increased morbidity and mortality; increased rates of separation and divorce; affect course and prognosis of comorbid Axis I conditions; influence use of medications; reactions evoked in health care professionals

Cluster A

odd, eccentric; paranoid; schizoid; schizotypical

Cluster B

dramatic, erratic, emotional; histrionic, narcissistic, antisocial, borderline

Cluster C

anxious, fearful; dependant, avoidant, obsessive-compulsive

Schizotypal Personality Disorder

characterized by odd, eccentric behavior, perceptual distortions; 3-5%, may be more common in men; more common in biological relatives of schizophrenics

Schizotypal Personality Disorder - clinical features

magical thinking - clairvoyance, superstitious; peculiar appearance, speech; suspiciousness or paranoid ideation; Ideas of reference - not delusions of reference; illusions; poor interpersonal relationships --> few friends; eccentric speech; job instability; may decompensate under stress and become overtly psychotic for brief time; 30-50% have major depressive disorder

Schizotypal Personality Disorder - Course and Prognosis

may remain stable, work, get married (not common); premorbid personality for schizophrenia; 10% eventually commit suicide (related to the depression)

Schizotypal Personality Disorder - Treatment

psychotherapy - goal = social skills training; pharmacotherapy - antipsychotics, antidepressants; medical - respect need for privacy and distance

Schizoid Personality Disorder

Lifelong pattern of social withdrawal, discomfort, with human interaction, eccentricity, isolation; 7.5% of population; male > female, unknown etiology

Schizoid Personality Disorder - Clinical Features

appear apathetic and aloof, unsociable, seclusive; restricted affect; gravitate toward solitary jobs; solitary interests; no loss of capacity to recognize reality

Schizoid Personality Disorder - thoughts

Who cares what others think of me? I enjoy doing things alone more than with others.

Schizoid Personality Disorders - prognosis

onset early childhood; may not last entire life; may develop schizophrenia

Schizoid Personality Disorder - treatment

Psychotherapy - may become devoted patients if seek treatment, may reveal their fantasies, fears of dependance, group therapy may provide only social contact; Pharmacotherapy - antipsychotics, antidepressants, as needed; Medical - respect need for privacy, may be suspicious of authority figures (physicians)

Paranoid Personality Disorder

Long-standing suspiciosness and distrust of people leading to false interpretations of motivations and actions of others; .5 to 2.5%, male > female, higher incidence in: deaf, minorities, immigrants, relatives of schizophrenics, etiology is unknown

Paranoid Personality Disorder - clinical features

expect others to exploit or harm them; interpret other's actions as deliberately threatening; question, without justification, loyalty of friends, fidelity of spouse; hostile, irritable, angry; restricted affect - appearance unemotional; pesistent grudges (litigious); ideas of reference, illusions; 75% have another personality disorder (usually schizotypal p.d.)

Paranoid Personality Disorder - thoughts

Others can't be trusted. People try to annoy me.

Paranoid Personality Disorder - course and prognosis

may be lifelong, may be progrome of schizophrenia or paranoid delusional disorder, may diminish with time, lifelong problems living and working with others, difficulty with authority figures and intimate relationships.

Paranoid Personality Disorder - treatment

psychotherapy - difficult to engage, treatment of choice; pharmacotherapy - for agitation and anxiety, may need antipsychotics for delusional thoughts; medical - carefully explain procedures, medications and test results

Histrionic Personality Disorder

Dramatic, attention-seeking behavior in emotional people, 2-3% female > male

Histrionic Personality Disorder - Clinical Features

attention-seeking, seductive behavior; exaggerated thoughts and feelings; temper tantrums; constant need for praise and approval; excessive concern about physical attractiveness; superficial relationships; reality testing can become imparied under stress

Histrionic Personality Disorder - Typical Thoughts

To be happy, ohters must be paying attention to me. Feelings are more important than being rational.

Histrionic Personality Disorder - Course and Prognosis

show less symptoms as they age; may have problems with lay, promiscuity, substance abuse; somatization and conversion disorders common

Histrionic Personality Disorder - Treatment

Psychotherapy; pharmacotherapy - for depression and anxiety; medical - try to be respectful and professional in face of patient's potentially dramatic behavior

Narcissistic Personality Disorder

Heightened sense of self-importance, entitlement; epidemiology, <1%, 50-75% male, may be increased risk in children of those with narcissistic personality disorder

Narcissistic Personality Disorder - Clinical Features

special people who deserve special treatment; easily maddened with criticism; ambitious for fame and fortune; fragile relationships; lack of empathy; often exploit others; fragile self-esteem

Narcissistic Personality Disorder - Typical Thoughts

I'm a very special person. I'm superior to others so I'm entitled to special treatment. Others have no right to criticize me.

Narcissistic Personality Disorder - Course and Prognosis

chronic; major depressive disorder, psychosis and suicide in response to criticism, rejection; aging handled poorly

Narcissistic Personality Disorder - Treatment

psychotherapy - individual therapy (treatment of choice, difficult since must renounce narcissism); pharmacotherapy; medical - try to be nondefensive

Antisocial Personality Disorder

inability to conform to societal norms; epidemiology - 3% of men, 1% of women, poor urban areas, onset must be <15 yo, 50-75% of prisoners, 5x more common among first degree relatives

Antisocial Personality Disorder - clinical features

symptoms must begin in adolescence - lying, truancy, promiscuity, substance abuse; hostile, irritable, impulsive; lack of empathy, social responsibility, guilt; histories reveal lies, truancy, running away, substance abuse, legal trouble; manipulative, through charm and seduction; cannot be trusted; no impairment in reality testing

Antisocial Personality Disorder - typical thought

I must look out for myself. The strongest survive. It's okay to lie and cheat if you don't get caught. Who cares what others think?

Antisocial Personality Disorder - course and prognosis

chronic - sumptoms may go up or down with age; many have somatization disorders; depression, substance abuse; high risk for suicide

Antisocial Personality Disorder - treatment

psychotherapy - only agreeable if they are "cornered", self-help groups; pharmacotherapy - for anxiety, rage and depression; medical - try to avoid temptation to be punitive, but set limits, avoid overprescription of medications

Borderline Personality Disorder

Characterized by unstable inter-personal relationships, self-image, mood, behavior; epidemiology - 2-3%, 2 female:1 male, 5x more common among 1st degree relatives

Borderline Personality Disorder - clinical features

frequent crises; mood swings; state they don't have feelings; repeated self-destructive behavior; brief, intense, interpersonal relationships; brief psychotic episodes; intense fear of abandonment; always bored; splitting - all good/all bad; impulsive behavior - sex, spending, substance abuse, binge eating

Borderline Personality Disorder - thoughts

"I Hate You, Don't Leave Me" (Book); I feel dead and cutting helps me know I'm alive

Borderline Personality Disorder - etiology (multifactorial)

poor parenting styles - environmental instability; familial psychiatric disorders - often depression, alcoholism, borderline p.d.; Sexual abuse - women with borderline personality disorder are 3-10 times more likely to have been victims of incest

Borderline Personality Disorder - etiology (protective)

artistic talents, high school performance, above average intelligence

Borderline Personality Comorbidities - Axis I

PTSD, Substance Abuse, MDD

Borderline Personality Comorbidities - Axis II

Antisocial p.d., dependant p.d.

Borderline Personality Disorder - course and prognosis

symptoms most severe in 20's, more stable by 30's or 40's; impulsive and destructive behavior; up to 10% commit suicide

Borderline Personality Disorder - treatment

psychotherapy - behavior therapy for impulsivity, treat alcohol and drug abuse; pharmacotherapy - antidepressants, antipsychotics, anticonvulsants to stabilize mood and impulsivity; medical - difficulty trusting their physician, communicate openly with other staff to avoid splitting, psychiatric consult

Dependent Personality Disorder

characterized by: need to be taken care of, passivity, fears of being abandoned; epidemiology - female>male, 2.5%, may be more common in those who had physical disorders as children

Dependent Personality Disorder - clinical features

want others to make decisions for them; feel helpless when alone; avoid positions of leadership or authority; put needs of others ahead of their own; up to 80% also have another personality disorder (borderline, avoidant)

Dependent Personality Disorder - typical thought

I'm weak. I can't make decisions unless others help me or tell me what to do.

Dependent Personality Disorder - course and prognosis

impaired occupational functioning; prone to mental and physical abuse; at risk for depression if they lose person upon whom they are dependent

Dependent Personality Disorder - treatment

psychotherapy - gain independence, assertiveness training; pharmacotherapy - for anxiety, depression; medical - recognize need for reassurance but set limits, be consistent, be active in treatment planning

Avoidant Personality Disorder

fear of rejection leading to social withdrawal despite a desire to be socially involved; epidemiology - ~1%, may be more common in those who were timid as infants; etiology - genetic predisposition, temperamental predisposition to social avoidance and introversion

Avoidant Personality Disorder - clinical features

shy, timid; lack self-conficence; afraid to speak in public; do not form new relationships without guarantee of uncritical acceptance; choose occupations which do not involve much interpersonal contact

Avoidant Personality Disorder - typical thoughts

I'm socially inept and undesireable. If people get to know me, they'll reject me because they'll see the "real me"

Avoidant Personality Disorder - course and prognosis

protective environment --> function relatively well; depression and anxiety

Avoidant Personality Disorder - treatment

psychotherapy - encourage patient to take some risk; pharmacotherapy - for depression and anxiety, beta blockers for autonomic symptoms; medical - deal with patient in calm and reassuring manner, but expect them to participate in decision-making

Obsessive Compulsive Personality Disorder

preoccupation with orderliness, perfectionistism, different from OCD; epidemiology - 2 male: 1 female, first born child, more common in first degree biological relatives of those with disorder

Obsessive Compulsive Personality Disorder - clinical features

rigid, serious and formal; emotional constriction; no spontaneity; pefectionistic; few friends due to inflexibility; hoard money and items; stable marriages; lean toward highly structured occupations

Obsessive Compulsive Personality Disorder - typical thoughts

I have to depend on myself to make sure things get done right. There must be order to get a job done well. It's important to do everything perfectly.

Obsessive Compulsive Personality Disorder - course and prognosis

course not predicable; depression common

Obsessive Compulsive Personality Disorder - treatment

psychotherapy - group therapy can be useful; pharmacotherapy - treat depression and anxiety; medical - respect patient's need to be in control, do not withhold information from patient