DSM 5 - Personality disorders

Paranoid Personality Disorder

DSM V Criteria:

A. A pervasive distrust and suspiciousness of others such that their motives are interpreted as malevolent,

beginning by early adulthood and present in a variety of contexts.

B. does not occur exclusively during the course of schizophrenia, a mood disorder with psychotic features,

or another psychotic disorder and is not due to the direct physiological effects of a general medical

condition

Paranoid Personality Disorder

Diagnostic Features

Indicated by four (or more) of the following:

1) Suspects, without sufficient basis, that others are exploiting, harming, or deceiving him or her.

2) Is preoccupied with unjustified doubts about the loyalty or trustworthiness of friends or associates.

3) Is reluctant to confide in others because of unwarranted fear that the information will be used

maliciously against him or her.

4) Reads hidden demeaning or threatening meanings into benign remarks or events.

5) Persistently bears grudges (i.e., is unforgiving of insults, injuries, or slights).

6) Perceives attacks on his or her character or reputation that are not apparent to others and is quick to

react angrily or to counterattack.

7) Has recurrent suspicions, without justification, regarding fidelity of spouse or sexual partner.

paranoid personality disorder

development and course:

​Paranoid personality disorder may be first apparent in childhood and

adolescence with solitariness, poor peer relationships, social anxiety, underachievement in school,

hypersensitivity, peculiar thoughts and language, and idiosyncratic fantasies. These children may appear to

be " odd" or " eccentric" and attract teasing. In clinical samples, this disorder appears to be more commonly

diagnosed in males.

Schizoid Personality Disorder

DSM5 Criteria

A. A pervasive pattern of detachment from social relationships and a restricted range of expression of

emotions in interpersonal settings, beginning by early adulthood and present in a variety of contexts.

B. Does not occur exclusively during the course of schizophrenia, a bipolar disorder or depressive disorder

with psychotic features, another psychotic disorder, or autism spectrum disorder and is not attributable to

the physiological effects of another medical condition.

Schizoid Personality Disorder

Diagnostic Features

Indicated by four (or more) of the following:

1) Neither desires nor enjoys intimacy, close relationships, including being part of a family.

2) Almost always chooses solitary activities, spending time by themselves.

3) Has little, if any, interest in having sexual experiences with another person.

4) Takes pleasure in few, if any, activities.

5) Lacks close friends or confidants other than first-degree relatives.

6) Appears indifferent to the praise or criticism of others.

7) Shows emotional coldness, detachment, or flattened affectivity.

Schizoid personality disorder

Development and Course:

​ may be first apparent in childhood and

adolescence with

solitariness, poor peer relationships, and underachievement in school, which mark these children or

adolescents as different and make them subject to teasing.

Schizotypal Personality Disorder

DSM 5 Criteria:

A. A pervasive pattern of social and interpersonal deficits marked by acute discomfort with,

and reduced capacity for, close relationships as well as by cognitive or perceptual distortions and

eccentricities of behavior, beginning by early adulthood and present in a variety of contexts.

B. Does not occur exclusively during the course of schizophrenia, a mood disorder with psychotic features,

another psychotic disorder, or a pervasive developmental disorder.

Schizotypal Personality Disorder

Diagnostic Features:

​Indicated by five (or more) of the following:

1) Ideas of reference (excluding delusions of reference).

2) Odd beliefs or magical thinking that influences behavior and is inconsistent with subcultural norms (e.g.,

superstitiousness, belief in clairvoyance, telepathy, or "sixth sense"; in children and as adolescents, bizarre

fantasies or preoccupations).

3) Unusual perceptual experiences, including bodily illusions.

4) Odd thinking and speech (e.g., vague, circumstantial, metaphorical, over elaborate, or stereotyped).

5) Suspiciousness or paranoid ideation.

6) Inappropriate or constricted affect.

7) Behavior or appearance that is odd, eccentric, or peculiar.

8) Lack of close friends or confidants other than first-degree relatives.

9) Excessive social anxiety that does not diminish with familiarity and tends to be associated with paranoid

fears rather than negative judgments about self.

​Schizotypal personality disorder

Development and Course:

has a relatively stable course, with only a small

proportion of individuals going on to develop schizophrenia or another psychotic disorder. Schizotypal

personality disorder may be first apparent in childhood and adolescence with solitariness, poor peer

relationships, social anxiety, underachievement in school, hypersensitivity, peculiar thoughts and language,

and bizarre fantasies. These children may appear "odd" or "eccentric" and attract teasing.

Antisocial Personality Disorder

DSM 5 Criteria:

A. A pervasive pattern of disregard for and violation of the rights of others, occurring since age 15 years

B. For this diagnosis to be given, the individual must be at least age 18 years.

C. There is evidence of conduct disorder with onset before age 15 years.

D. the occurrence of antisocial behavior is not exclusively during the course of schizophrenia or a manic

episode.

Antisocial Personality Disorder

Diagnostic Features:

indicated by three (or more) of the following:

1) Failure to conform to social norms with respect to lawful behaviors, as indicated by repeatedly

performing acts that are grounds for arrest.

2) Deceitfulness, as indicated by repeated lying, use of aliases, or conning others for personal profit or

pleasure.

3) Impulsivity or failure to plan ahead.

4) Irritability and aggressiveness, as indicated by repeated physical fights or assaults.

5) Reckless disregard for safety of self or others.

6) Consistent irresponsibility, as indicated by repeated failure to sustain consistent work behavior or honor

financial obligations.

7) Lack of remorse, as indicated by being indifferent to or rationalizing having hurt, mistreated, or stolen

from another.

Borderline Personality Disorder

DSM 5 Criteria:

A pervasive pattern of instability of interpersonal relationships, self-image, and affects, and

marked impulsivity, beginning by early adulthood and present in a variety of contexts.

Borderline Personality Disorder

Diagnostic Features: ​

indicated by five (or more) of the following:

1) Frantic efforts to avoid real or imagined abandonment.

2) A pattern of unstable and intense interpersonal relationships characterized by alternating between

extremes of idealization and devaluation.

3) Identity disturbance: markedly and persistently

4) Impulsivity in at least two areas that are potentially self-damaging (e.g., spending, sex, substance abuse,

reckless driving, binge eating).

5) Recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior.

6) Affective instability due to a marked reactivity of mood (e.g., intense episodic dysphoria, irritability, or

anxiety usually lasting a few hours and only rarely more than a few days). unstable self-image or sense of

self.

7) May be troubled by chronic feelings of emptiness.

8) Inappropriate, intense anger or difficulty controlling anger (e.g., frequent displays of temper, constant

anger, recurrent physical fights).

9) Transient, stress-related paranoid ideation or severe dissociative symptoms.

Histrionic Personality Disorder

DSM 5 Criteria:

A pervasive pattern of excessive emotionality and attention seeking, beginning by early

adulthood and present in a variety of contexts

Histrionic Personality Disorder

Diagnostic Features

​indicated by five (or more) of the following:

1) Is uncomfortable in situations in which he or she is not the center of attention.

2) Interaction with others is often characterized by inappropriate sexually seductive or provocative

behavior.

3) Displays rapidly shifting and shallow expression of emotions.

4) Consistently uses physical appearance to draw attention to self.

5) Has a style of speech that is excessively impressionistic and lacking in detail.

6) Shows self-dramatization, theatricality, and exaggerated expression of emotion.

7) Is suggestible (i.e., easily influenced by others or circumstances).

8) Considers relationships to be more intimate than they actually are. Ex. describing almost every

acquaintance as "my dear, dear friend"

Narcissistic Personality Disorder

DSM 5 Criteria:

A pervasive pattern of grandiosity (in fantasy or behavior), need for admiration, and lack of

empathy, beginning by early adulthood and present in a variety of contexts

Narcissistic Personality Disorder

Diagnostic Features: ​

indicated by five (or more) of the following:

1) Has a grandiose sense of self-importance (e.g., exaggerates achievements and talents, expects to be

recognized as superior without commensurate achievements).

2) Is preoccupied with fantasies of unlimited success, power, brilliance, beauty, or ideal love.

3) Believes that he or she is "special" and unique and can only be understood by, or should associate with,

other special or high-status people (or institutions).

4) Requires excessive admiration.

5) Has a sense of entitlement (i.e., unreasonable expectations of especially favorable treatment or

automatic compliance with his or her expectations).

6) Is interpersonally exploitative (i.e., takes advantage of others to achieve his or her own ends).

7) Lacks empathy: is unwilling to recognize or identify with the feelings and needs of others.

8) Is often envious of others or believes that others are envious of him or her.

9) Shows arrogant, haughty behaviors or attitudes

Avoidant Personality Disorder

DSM 5 Criteria:

​A pervasive pattern of social inhibition, feelings of inadequacy, and hypersensitivity to

negative evaluation, beginning by early adulthood and present in a variety of contexts

Avoidant Personality Disorder

Diagnostic Features: ​

Indicated by four (or more) of the following:

1) Avoids occupational activities that involve significant interpersonal contact because of fears of criticism,

disapproval, or rejection.

2) Is unwilling to get involved with people unless certain of being liked.

3) Shows restraint within intimate relationships because of the fear of being shamed or ridiculed.

4) Is preoccupied with being criticized or rejected in social situations.

5) Is inhibited in new interpersonal situations because of feelings of inadequacy.

6) Views self as socially inept, personally unappealing, or inferior to others.

7) Is unusually reluctant to take personal risks or to engage in any new activities because they may prove

embarrassing.

Dependent Personality Disorder

DSM 5 Criteria:

A pervasive and excessive need to be taken care of that leads to submissive and clinging

behavior and fears of separation, beginning by early adulthood and present in a variety of contexts.

Dependent Personality Disorder

Diagnostic Features: ​

as indicated by five (or more) of the following:

1) Has difficulty making everyday decisions without an excessive amount of advice and reassurance from

others.

2) Needs others to assume responsibility for most major areas of his or her life.

3) Has difficulty expressing disagreement with others because of fear of loss of support or approval. (Note:

Do not include realistic fears of retribution.)

4) Has difficulty initiating projects or doing things on his or her own (because of a lack of self-confidence in

judgment or abilities rather than a lack of motivation or energy).

5) Goes to excessive lengths to obtain nurturance and support from others, to the point of volunteering to

do things that are unpleasant.

6) Feels uncomfortable or helpless when alone because of exaggerated fears of being unable to care for

himself or herself.

7) Urgently seeks another relationship as a source of care and support when a close relationship ends.

8) Is unrealistically preoccupied with fears of being left to take care of himself or herself.

Obsessive-Compulsive Personality Disorder

DSM 5 Criteria:

OCPD (personality disorder) is different than OCD (anxiety disorder)

- A pervasive pattern of preoccupation with orderliness, perfectionism, and mental and interpersonal

control, at the expense of flexibility, openness, and efficiency, beginning by early adulthood and present in

a variety of contexts.

Obsessive Compulsive Personality Disorder

Diagnostic Features: ​

Indicated by four (or more) of the following:

1) Is preoccupied with details, rules, lists, order, organization, or schedules to the extent that the major

point of the activity is lost.

2) Shows perfectionism that interferes with task completion (e.g., is unable to complete a project because

his or her own overly strict standards are not met).

3) Is excessively devoted to work and productivity to the exclusion of leisure activities and friendships (not

accounted for by obvious economic necessity).

4) Is overconscientious, scrupulous, and inflexible about matters of morality, ethics, or values (not

accounted for by cultural or religious identification).

5) Is unable to discard worn-out or worthless objects even when they have no sentimental value.

6) Is reluctant to delegate tasks or to work with others unless they submit to exactly his or her way of doing

things. Ex. "pack rats"

7) Adopts a miserly spending style toward both self and others; money is viewed as something to be

hoarded for future catastrophes.

8) Shows rigidity and stubbornness.

Occupational Impact and TX:​ ​****​This is for all personality disorders****

Treatment: to establish a trusting and non-threatening relationship: formal,

honest and professional discussion.

Caution! Avoid being too friendly, too warm or too humorous, expect

accusations and belittling comments.

Avoid direct confrontation, motivational interviewing and problem

solving techniques very useful.

Cognitive-behavioral tx and Schema-based therapy

TX: psychodynamic,

DBT (dialectical behavior therapy​: a type of CBT that has shown

effectiveness.

What does "dialectical" mean?

The term "dialectical" means a synthesis or integration of opposites.

The primary dialectic within DBT is

between the seemingly opposite strategies of acceptance and change.

For example, DBT therapists accept

clients as they are while also acknowledging that they need to change in order to reach their goals. In

addition, all of the skills and strategies taught in DBT are balanced in terms of acceptance and change. For

example, the four skills modules include two sets of acceptance-oriented skills (mindfulness and distress

tolerance) and two sets of change-oriented skills (emotion regulation and interpersonal effectiveness).

How does DBT prioritize treatment targets?

DBT uses a hierarchy of

treatment targets to help the therapist determine the order in which problems should be addressed.

DBT treatment targets (in order of priority) are

Life-threatening behaviors

Therapy-interfering behaviors

Quality of life behaviors

Skills acquisition

What 4 sets of skills are taught in DBT?

Mindfulness: the practice of being fully aware and present in this one moment

Distress Tolerance: how to tolerate pain in difficult situations, not change it

Interpersonal Effectiveness: how to ask for what you want and say no while maintaining self-respect and

relationships with others

Emotion Regulation: how to change emotions that you want to change

Personality disorders are mental illnesses. The symptoms of the diagnosis can

affect:

Occupational performance (social participation, ADLs, IADLs, work and leisure).

Specifically

emotional regulation and coping.

social participation and Personality Disorders

due to limited interpersonal skills

often experience negative interactions and environments

in early life, which have impaired their ability to trust in adulthood.

Working with clients diagnosed with personality disorder to improve their communication and interaction skills

may

facilitate improved social participation in the community and with family and friends.

Emotional modulation and Personality disorders

because of abrupt and unpredictable emotions, clients my discontinue treatment

abruptly or prematurely, so the OT has to try to keep them engaged.

Younger clients are more impulsive

and have more irrational bx than older clients, this can yield clients that who engage in self-harming bx

(they act out this way to self-soothe and express uncomfortable emotions) as a coping strategy.

OTs can work with Individuals using DBT interventions to improve emotion modulation skills. Clients may be

manipulative and test professional boundaries.

Coping and Personality Disorders

limited skills in coping with daily life challenges, especially in interpersonal relationships.

They can potentially be involved in substance abuse

Situations that might mildly irritate the average individual can cause a great deal of emotional discomfort

and distress to these individuals.

They usually have low self- esteem and feel as they are

unable to function without help from others.

OT interventions for personality disorders focus on

mood stabilization,

appropriate feeling expression,

increased self-concept,

self-esteem,

insight, and

judgement,

and the development of appropriate interpersonal relationships,

effective coping strategies,

conflict resolution skills,

social skills, and

assertive communication skills.

4 strategies can be used to establish a therapeutic relationship

is key in working with people with personality disorders

-building and maintaining a collaborative relationship

- consistency in tx, predictable interventions

- validation, they need to know that their feelings are real

- building and maintaining motivation for change, the biggest challenge for OTs is to help the client identify

positive outcomes associated with changes in bx

Addressing Occupational Dysfunction:

Interpersonal skills, is the most common. OTs can engage the clients in life skills groups in which they can

develop new ways of adapting to problems.

DBT is commonly used to address maladaptive bxs.

Relaxation

activities to deal with anxiety, graded tasks to increase self-esteem.

OTs can examine tasks required for the client to have a job, or complete tasks, or provide supportive

employment interventions.

OTs can also address leisure by engaging the client in group games and activities that allow the client to

experience a sense of fun

Individuals with Cluster A PDs who experience cognitive, perceptual, or thought disorder may

benefit from a low dose

antipsychotic

● Individuals with Cluster B PDs who exhibit symptoms of mood lability, depression or interpersonal

sensitivity may be prescribed a

mood stabilizer or antidepressant.

● To treat the symptoms of Cluster C PDs (anxiety, obsessive thinking, inhibited behaviors) the individual may be prescribed

SSRIs or

antidepressants may be prescribed in addition to short-term use of Benzodiazepines