Personality Disorders and OCD

Antisocial Personality Disorder

Pervasive socially irresponsible, exploitative, and guiltless behaviors that deviate sharply form the norms, values, and laws of society, often violating the rights of others.

• Hx of Conduct disorder: The adult continuation of childhood Conduct disorder.

Clinical manifestations:

• Often violate rights of others and break rules for personal benefit.

• impulsive, deceitful, and often break law w/o regard (may commit criminal acts)

• May come off as charming at first, they are frequently skilled at reading social cues.

Dx Criteria:

• Must be at least 18yrs and have hx by 15yrs of violating rights of others consistent w/ conduct d/o.

• 3 or more of following:

  • failure to conform to socail norms w/ disregard/violation of rights of others or unlawful acts.

  • lack of remorse,

  • aggressive or irritable, reckless for safety (drunk driving common), failure to maintain obligations (jobs, bills)

Management:

• CBT = first line for personality d/o.

• Establishing limits.

Avoidant Personality Disorder

Characterized by a pervasive pattern of inhibition d/t an intense fear of rejection, with a longing to relate to others, affecting their daily lives.

Epidemiology:

• 2% of general population, Closely related to social anxiety disorder.

Clinical Manifestations:

• 1.) Inferiority complex coupled w/ 2.) coexisting fear of rejection → manifests behaviorally as widespread avoidance of social interaction

• Unlike Schizoid in which pts. prefer to be alone → avoidant desire relationships but fear rejection.

Dx:

• pattern of social inhibition, feelings of inadequacy, and hypersensitivity to negative evaluation

  • Beginning by early adulthood and present in a variety of contexts.

  • fears of rejections, unwilling to get involved unless certain they will be liked.

  • Preoccupied w/ being criticized/rejected

  • Feelings of inadequacy

  • reluctant to take personal risk.

Schizoid Personality Disorder

Lifelong pattern of voluntary withdrawal, isolation, & anhedonic introversion

• Occurs more often in men, more severe in men'

• doesnt appear to have strong genetic relationship to Schizophrenia.

• “hermit-like” behavior.

Dx Criteria:

• A pervasive pattern of detachment from social relationships + restricted range of emotions. (indicated by 4/more of the following:

  • No desire/joy close relationships (including family)

  • almost always chooses solitary activities.

  • Little if any interest in sex

  • Takes pleasure in few things

  • Lacks close friends/confidants

  • Appears indifferent to praise/criticism

  • Shows emotional coldness.

• Does not occur exclusively during the course another psychotic disorder

management:

• Psychotherapy = first line (CBT)

Schizotypal Personality Disorder

Characterized by odd, eccentric, bizarre behavior, and peculiar thought process suggestive of schizophrenia w/o psychosis (no delusions or hallucinations).

• Usu early adulthood onset w/ manifestations beginning in childhood and adolescence.

• Small percentage may develop schizo and certain family traits of this d/o predominate in first-degree relatives w/ schizo.

Clinical Manifestations:

• 1.) Cognitive-perceptual

  • Odd beliefs/magical thinking (unrelated events are causally connected despite absence of any plausible link)

  • Unusual perceptual experiences and bodily illusions

  • Ideas of references (misinterpretation of incidents/events relating to oneself.)

• 2.) Oddness/Disorganized

  • Distorted cognition/reasoning (Hygiene, attire, social behaviors)

• 3.) Interpersonal:

  • Chronic social anxiety (pervasive discomfort w/ close relationships)

  • Social anhedonia.

Dx Criteria =/> 5 of the above.

Management:

• CBT

• Short term low-dose antipsychotics for psychotic episodes.

Paranoid Personality Disorder

Pervasive pattern of excessive distrust/suspiciousness of others, and often interpret their motives as malevolent.

• 1-4% of general population.

• Begins in early adulthood, MC in males.

• Higher incidence if family members of Schizophrenics.

Clinical Manifestations:

• Hallmark = Generalized distrust or suspiciousness.

  • Tend to bear grudges, easily slighted, and overly sensitive.

• Consistently project blame difficulties and problems onto others

• Externalizing their own emotions while paying keen attention to the emotions of others.

Dx Criteria

• >/= 4 of the 7 (basically if they are exhibiting the above clinical manifestations)

Management:

• CBT (often difficult tho cuz they lack trust)

• Group therapy should be avoided. → may misinterpret what others are saying.

Borderline Personality Disorder (BPD)

Characterized by instability of interpersonal relationships, self-image, and emotions.

• Hypersensitivity to rejections, as well as impulsivity, causing significant impairment or subjective distress.

Epidemiology:

• Pts have been shown to have higher rates of mood disorders and other psychiatric disorders.

Clinical Manifestations:

• Core Features:

  • Instability of relationships, Marked impulsivity

• Interpersonal Difficulties:

  • Chronic emptiness (fear of abandonment).

  • Relationships start with intense attachment and end over minor conflict.

  • Splitting: Black and white thinking.

• Affective dysregulation mood swings, excessive anger, and efforts to avoid abandonment.

• Behavior dysregulation: Impulsivity, Self-harm, substance abuse.

DX: >/= 5 out of 8

Management: Dialectical behavior therapy = first line

Histrionic Personality disorder

characterized by being overly emotional, dramatic, seductive (sexual provocativeness), and attention-seeking.

Clinical Manifestations:

• Hallmark → deliberate use of excessive, superficial emotionality and sexuality to draw attention, evade unpleasant responsibilities, and control/manipulate others.

• Appearance → large concern of appearance & attractiveness.

• Flirtatious behaviors, act out to gain the spotlight.

• Reward dependence

• Speak loudly/dramatically

• Liable emotions, childlike regressive behaviors (temper tantrums, tearful outbursts)

• Easily suggestable/persuaded by others around them.

Dx: >5 of the above

Management: Psychotherapy.

Narcissistic Personality

Grandiose, often excessive sense of self-importance, superiority, need for attention & admiration, & lack of empathy (may fluctuate between grandiose and vulnerable states)

• More common in men

Clinical Manifestations:

• Hallmarks → Grandiosity, notable lack of empathy, and lack of consideration for others. Also hypersensitive to evaluation.

• Grandiosity: exaggerated sense of self-importance/inflated self image.

• Excessive need for admiration: (constant need for center of attention), evaluation = highly sensitive too.

• Superficial/exploitative relationships: Will exploit/manipulate others for self gain.

• Lack of empathy

• Identity disturbance: sense of self that tis relatively stable, but highly superficial, extremely rigid, and often fragile.

  • Vulnerable to life transitions (mid-life crisis)

  • High value on youth and power → aging can be extremely difficult for them.

Dx: >/= 5 of the above

Management:

• Psychotherapy = initial TOC

  • Manualized psychotherapy, Transference focused.

• Cognitive-perceptual disturbances → atypical antipsychotics (Aripiprazole, Risperidone, Quetiapine)

• Impulsivity, recklessness, or behavioral dyscontrol: mood stabilizers (Lithium or Lamotrigine)

Dependent Personality Disorder

1.) Inability to assume responsibility, dependent or submissive, needy, & clinging behavior.

2.) Fear of being alone/abandoned

3.) Difficulty making day-to-day decisions.

Clinical Manifestations:

• Dependent behavior: relies on others to mee their emotional needs/ excessive need to be taken care of.

  • lack of self confidence, clingy, feels unable to care for self.

• Fear of separation: increasing appeasement/submissiveness when relationships are threatened.

• Difficulty making day-to-day decisions: (overdependence)

• Pessimistic outlook on life: expect the worst out of situations.

Dx: >5 of the following

Diff Dx:

• Borderline → reacts with rage/feelings of emptiness when relationships of threatened rather than submissiveness.

• Histrionic → both are dependent, but DPD is more stable and typically has longer lasting relations.

• Avoidant → more withdrawal from society d/t feelings of inadequacy predominating.

Managment:

• Psychotherapy = first line. (CBT, social skills, assertiveness skills)

• Pharm tx for comorbid anxiety/depression.

Obsessive-compulsive Personality Disorder.

perfectionism, inflexibility, and orderliness with intense focus on & preoccupation with order and details, w/o obsessions or compulsions

Clinical Manifestations:

• Ego syntonic behavior: don’t see anything wrong with their thoughts or behaviors or are aware their behavior causes issues.

• Often appear as serious, stiff, rigid, and formal.

• Often are successful professionally, but have poor interpersonal skills (impaired ability to function with others)

Dx Criteria: at least 4 of the following…

• Preoccupation w/ details, rules, lists…

• Perfectionism that interferes w/ task completion in timely fashion.

• Excessive devotion

• Overconscientious, scrupulous, inflexible w/ ethics, morality, values.

• Inability to discard worn-out/worthless objects

• Hesitant/reluctant to delegate tasks unless they submit to exact way of doing it.

• Adopts a miserly spending style toward self/others (money is to be hoarded for the future)

• Rigid, stubborn, restricted affect.

Diff Dx:

• OCD → have recurrent obsessions or compulsions. Also symptoms are ego-dystonic (aware they have the problem)

• Narcissistic personality disorder → both focus on assertiveness/achievement, but Narcissist are motivated by status rather than perfection.

Management:

• Psychotherapy → initial TOC (social training, CBT)

• SSRIs commonly used for comorbidities.

Obsessive-compulsive Disorder (OCD)

Characterized by 1.) obsessions (bothersome intrusive thoughts that cause discomfort) and/or 2.) compulsions (rituals, repetitive actions, or mental acts to relieve the discomfort) that are time consuming, distressing, and impairing.

Patho: theorized d/t abnormal communication between basal ganglia (caudate nucleus), orbitofrontal cortex, and anterior cingulate gyrus. Serotonin involved.

Clinical Manifestations:

• 4 Major Patterns:

  • 1.) Contamination (hand washing, avoidance)

  • 2.) Pathologic doubt or harm (forgetting to unplug iron/turn off stove.

    • compulsion = checking multiple times

  • 3.) Symmetric/Precision

    • Compulsion = being ordered, counting, rearranging, repeating.

  • 4.) Intrusive obsessive thoughts. (fear of aggression/harm), doubts, sexual or religious fears w/ or w/o compulsion.

DX Criteria:

• The presence of obsessions/compulsions or both

• Behaviors are time consuming (>1hr per day)

• Not due to other cause (drugs, medications)

• Not better explained by other mental d/o

Management:

• CBT = first line (exposure & response prevention)

• SSRI = first line medical tx (higher doses than depressive tx)

  • Pediatric → sertraline, Fluoxetine, Fluvoxamine approved.

Body Dysmorphic Disorder

Characterized by excessive preoccupation w/ at least 1 perceived flaw or defect in one’s physical appearance in which the individual believes they look abnormal, ugly, unattractive, or deformed that is not observable by others or appears slight to others in comparison.

• Ashamed, self-conscious → leading to functional impairment/significant distress.

• May commit repetitive acts/behaviors in response to this preoccupation.

Epidemiology: Average age of onset = 15yrs.

Dx Criteria:

• [A] preoccupation w/ non-existent/slight defect (at least 1 hr per day)

• [B] Concerns about appearance lead to repetitive behaviors (mirror checking, excessive grooming, skin picking) or mental acts (comparison)

• [C] Clinically sig. distress/psychosocial impairment

• [D] not better explained by an eating d/o.

Specifiers:

• Insight:

  • Fair-good = recog. that beliefs prob not true.

  • Poor = believes prob true

  • absent (delusional) = firmly believe they are true.

Managment

• SSRIs (Fluoxetine, Sertraline, or Escitalopram) or CBT

  • Add 2ng gen antipsychotic if not effective.

• TCA (Clomipramine) = alternative to SSRI