Final - New (Behave)

Personality Disorders

An enduring pattern of behavior and inner experiences that deviates significantly from the individual’s cultural standards

Features of Personality Disorder (General)

Inflexible and pervasive

Onset in adolescence or early adulthood

Stable over time

Leads to distress or impairment

Ego-syntonic

instincts or ideas that are acceptable to the self

Ego-dystonic

thoughts, impulses, and behaviors that are felt to be repugnant, distressing, unacceptable or inconsistent with one's self-concept.

What areas of mental status are affected by personality disorders

Cognition

Affectivity

Interpersonal function

Impulse control

What are some comorbidities of personality disorders

Anxiety

Mood Disorder

Substance Abuse Disorder

What is the mainstay of treatment for personality disorders

Psychotherapy

Dialectical Behavioral Therapy (DBT)

A psychotherapy tailored for BPD

What are the catergories of personalitiy disorder

Cluster A

Cluster B

Cluster C

What are Cluster A personality disorder

Paranoid

Schizoid

Schizotypal

What are the Cluster B personality disorders

Narcissitic

Bordeline

Antisocial

Histrionic

What are the Cluster C personality disorders

Obessive-Compulsive

Dependent

Aviodent

What is the common characteristic of Cluster A personality disorder

Presents with the negative symptoms of schizophrenia

Criteria for Paranoid Personality Disorder

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, as indicated by 4 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 other associates

3. Is reluctant to confide in others because of unwarranted fear that the information will be use maliciously against him or her

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

5. Persistently bears grudges (unforgiving of insults, injuries)

6. Perceives attacks on his or her own 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

B. Does not occur exclusively during the course of schizophrenia, a bipolar disorder or depressive disorder with psychotic features, or another psychotic disorder and is not attributable to the physiologic effects of another medical condition

Featuires of Paranoid Personality Disorder

Excessive suspiciousness and distrust of others

Often pathologically jealous and question the fidelity of their spouses or sexual partners

Affect: restricted and unemotional

Reluctant to confide in others for fear information they share will be used against them

Patients may have lifelong problems working and living with others

Occupational and marital problems are common

Hold grudges, blame others for shortcomings

Utilize projection as an unhealthy coping strategy

Risk for paranoid personality

Men > Women

Common in relatives of those with schizophrenia

Criteria for Schizoid Personality Disorder

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, as indicated by four (or more) of the following:

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

2. Almost always chooses solitary activities

3. Has little, if any interest in 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

B. Does not occur exclusively during the course of schizophrenia, a bipolar disorder or depressive disorder with psychotic features, or another psychotic disorder, or autism spectrum disorder and is not attributable to the physiologic effects of another medical condition

Featueres of Schizoid Personality

Lifelong pattern of social withdrawal and restricted range of emotional expression

Little need or longing for emotional ties

Seen by others as eccentric, isolated, lonely, cold, aloof

Few friends, little interest in sexual experiences with another person

Oblivious to social norms

Pursue and succeed at noncompetitive, lonely jobs

Invest enormous energy into nonhuman interests (Mathematics, Astronomy, dietary or health fads, philosophical movements)

Risk Factors for Schizoid Personality

Males > Females

Solitary jobs, may prefer night shift jobs

Criteria for Schizotypal Personality Disorder

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, as indicated by 5 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

3. Unusual perceptual experiences, including bodily illusions

4. Odd thinking or speech

5. Suspiciousness or paranoid ideation

6. Inappropriate or constricted affect

7. Behavior or appearance that is odd

8. Lack of close friends or confidants

9. Excessive social anxiety that does not diminish with familiarity and tends to be associated with paranoid fears rather than negative judgments about self

B. Does not occur exclusively during the course of schizophrenia, a bipolar disorder or depressive disorder with psychotic features, or another psychotic disorder, or autism spectrum disorder

Features of Schizotypal

Odd or strange with magical thinking, illusions but NOT PSYCHOTIC

May believe they have special powers of thought and insight

Speech may be peculiar but without derailment or incoherence

Superstitious and claim powers of clairvoyance

Ideas of reference

Isolated with few friends

May be involved in cults, strange religious practices, and astrology

May be the premorbid personality of patients with schizophrenia

What is the difference between schizoptypal and schizophrenia

Schizotypal retain some self awareness that their beliefs/speech/they are odd/eccentric

Schizotypal is not completely disconnected with reality

Many of the oddities of a schizotypal person are still within the frame work of a society driven norm

Risk Factors for Schizotypal Personality

Males> Females

biologic relatives of patients with schizophrenia

Criteria for Antisocial Personality

A. A pervasive pattern of disregard for and violation of the rights of other, occurring since age 15, as indicated by 3 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

B The individual is at least 18 years of age

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

D The occurrence of antisocial behavior is not exclusively during the course of schizophrenia or bipolar disorder

Features of Antisocal Personality

Pattern of disregard/violation of the rights of others

Patients can appear composed and credible but beneath the veneer lurks tension, hostility, irritability, rage

Impulsive

“Con man”: deceit and manipulation

Lack of remorse for actions

Do not conform to social norms

Lying, truancy, running away from home, thefts, fights, substance abuse, and illegal activities are typical experiences the patient reports as beginning in childhood

Promiscuity , abuse, and drunk driving

Risk Factors for antisocial personalityu

More common in poor urban areas

Men with alcohol use disorder (70%)

Prison population (75%)

Males> Females

Familial pattern-

Crtieria for Borderline Personality Disorder (BPD)

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

1. Frantic efforts to avoid real or imagined abandonment. (Note: Do not include suicidal or self-mutilating behavior covered in Criterion 5).

2. A pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation.

3. Identity disturbance: markedly and persistently unstable self-image or sense of self.

4. Impulsivity in at least two areas that are potentially self-damaging (e.g., spending, sex, substance abuse, reckless driving, binge eating). (Note: Do not include suicidal or self-mutilating behavior covered in Criterion 5.)

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).

7. 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.

Featurs of BPD

Patients always appear to be in a state of crisis

Mood swings are common- argumentative at one time then depressed the next

Self destructive behavior (self mutilating behavior)

Very impulsive

Instability in interpersonal relationships, self image, and affect

Cannot tolerate being alone, abandoned

Consider others as all good or all bad: splitting

High incidence of mood disorders

Risk Factors for BPD

Women> Men

more common with a first degree relative

criteria for Histrionic personality disorder

A. A pervasive pattern of excessive emotionality and attention seeking, beginning in early adulthood and present in a variety of contexts, as 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.

Features of Histronic Personality

Attention seeking

Exaggerate their thoughts and behaviors to make things sound more important than they really are

Seductive behavior is common- overly flirtatious, provocative clothing

Relationships are superficial

Risk Factors for Histronic Personality Disorder

Women > Men

Association with somatization disorder and alcohol use disorders

criteria for Narcissistic personality disorder

A. 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, as 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

Features of Narcissistic Personality Disorder

Grandiose sense of self importance

Lack empathy

Need for admiration

Require “the best of everything”

Self esteem is fragile and vulnerable to even minor criticism

Susceptible to bouts of depression and anger esp. when criticized

Interpersonal difficulties

Risk Factors of narcisstic perosnality

parents with narcissistic personality disorder

Often associated with anorexia nervosa and substance abuse (cocaine)

criteria for Avoidant personality disorder

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, as 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.

Features of Aviodant Personality Disorder

Hypersensitivity to rejection

Feelings of inadequacy

Timid/social inhibition

Want to be social but intense fear inhibits them

Express uncertainty, shows a lack of self confidence

Have few close friends or confidants

May have social phobia

criteria for Dependent personality disorder

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, 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 or support when a close relationship ends.

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

Features of Dependent Personality

Submissive and clinging behavior

Excessive need to be taken care of

Cannot make decisions without an excessive amount of advice and reassurance from others

Lack self confidence

Unsure of personal identity

Experience intense discomfort when alone for more than a brief period of time

Risk Factors of Dependent Personality

Women> Men

Children with chronic illness in childhood

criteria for Obsessive-Compulsive personality 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, as 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 over conscientious, 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.

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

Featurs of Obsessive-Compulsive personality Disorder

Preoccupied with rules, regulations, orderliness, neatness, details, and the achievement of perfection

Focus on control

Do not want others to see imperfections

Miserly

Poor time management

Self critical

Lack flexibility

Limited interpersonal skills

Indecisive and ruminate about making decisions

Risk Factors for Obessive Compulsive Personaility

Male >Female

Oldest child

More common if 1st degree relative with this

More common if harsh discipline in background

most commonly abused drug

Alcohol

most common illicit abused drug

Marijuana

Mesolimbic Pathway

Pathway’ involved in producing feelings of pleasure in response to naturally enjoyable stimuli, such as food, sex, and social interaction

Connects to other brain responsible for memory storage and behavior

Why do we repeat behaviors

perceived as pleasurable or rewarding

Parts of the Mesolimbic Pathway

Ventral tegmental area

Nucleus accumbens (aka ventral striatum)

Amygdala

Prefrontal cortex

Ventral tegmental area

Dopamine rich area

Nucleus accumbens (aka ventral striatum)

Target of VTA dopamine neurons

Mediates the rewarding effects of natural rewards and drugs of abuse

Amygdala

Memory consolidation for emotionally arousing events

Prefrontal cortex function

Emotional self-control

, focused problem-solving,

error detection,

performance monitoring,

adaptive response to changing conditions

Steps of Reward Pathway

Behavior

Stimulus

Neurotransmitter Release

Dopamine release from VTA

What neurotransmitters can trigger dopamine release from VTA

Endorphins

Anandamine

Dopamine

5-HT

GABA

NDMA

Acetylcholine

How do drugs of abuse effect the reward pathway

affect various neurotransmitters

artificial stimulants and act DIRECTLY on the VTA which causes a more intense release of dopamine than natural stimuli

This causes downregulation of dopamine, which leads to cravings and relapse

How does drugs of abuse cause complusive behavior

sends exaggerated signals to the prefrontal cortex

signal highjacks the prefrontal cortex into believing that, with drug use, an instinctual drive was just fulfilled and should be repeated

What causes depression symptoms from drugs of abuse

Changes in dopamine lead to increased stress hormones (cortisol, ACTH) which leads to depression symptoms

dual diagnosis

Patients with both substance use D/O and psychiatric illness diagnoses

Most common dual diagnosis

alcohol + another psychiatric diagnosis

Addiction

a treatable, chronic medical illness involving complex interactions among neural circuits, genetics, the environment, and an individual's life experiences.

Substance use disorder

a single diagnostic category that replaced two separate diagnoses of substance abuse and dependence

Opioid use disorder

2 of 11 clinical criteria are met within a 12-month period

How does alcohol affect the brain

Increases inhibitory NT like GABA

Decreases excitatory NT like glutamate

Causes release of endogenous opioids and increases levels of dopamine and serotonin

What is determine as “excess” for alcohol consumpation

More than 3 drinks

Most frequently used brain depressant

alcohol

Risk Factors for Alcohol Abuse

Cultural attitudes toward drinking/intoxication/\

availability of ETOH

close relatives’ w/ alcoholism

Children whose parent(s) were alcoholics were given up for adoption

Pre-existing schizophrenia or bipolar disorder

Impulsivity

Genetically low response rate to alcohol

males > females

Who are less likely to abuse ETOH

those with alcohol related skin flush (usually Asian population)

How is alcohol metabolized

ADH catalyzes conversion of alcohol into acetaldehyde.

ALDH clears acetaldehyde

Where is alcohol absorbed

Stomach

Duodenum

What effect does food have on alcohol absorption

Decreases

Where is alcohol excreted

Lungs

Urine

Sweat

Why do women often get more intoxicated then men

Women generally have less ADH therefore alcohol is not metabolized and inactivated

Alcohol flush syndrome

Deficiency of aldehyde dehydrogenase (ALDH-2)

Causes a build up of acetylaldehyde which leads to catecholamine release and triggers vasodilation and severe flushing

How does ETOH raise blood alcohol content

10-12g of ETOH (2 drinks) raises by 20 mg/dL

How does blood alcohol content decrease normally

15-20 mg/dL per hour

What is considered 1 drink

12 oz of beer

5 oz of wine

1.5 oz of hard liqiour

What are the levels of alcohol impairment

20-30 mg/dL (0.02-0.03%) → Slowed motor performance and decreased thinking

30-80 mg/dL (0.03-0.08%) → Increased motor or cognitive problems

80-200mg/dL (.08%-2%) → Increases in incoordination and judgment errors + Mood liability + Deterioration of cognition

200-300mg/dL (2%-3%) → Nystagmus, Marked Slurring of speech, and Blackouts

>300 mg/dL (>3%) → Impaired vitals + possible fatal

What is the most sensitive test for alcohol abuse

Carbohydrate-deficient transferrin (CDT)

When does CDT return to normal following cessation of alcohol

2-6 weeks

How does alcohol reflect in labs

AST elevation higher than ALT elevation

Elevated MCV (CBC)

Elevated Triglycerides

Alcohol abuse treatment

CBT x 6-12 months

Lifelong AA

Medication

• Naltrexone (Vivitrol/Revia) monthly IM

• Acamprosate (Campral) daily

• Disulfiram (Antabuse)

Naltrexone (Vivitrol/Revia)

Opioid antagonist

MOA of Naltrexone (Vivitrol/Revia)

Decreases activity of VTA

What alcohol abuse treatment medication can be used for substance use disorder

Naltrexone (Vivitrol/Revia)

Contraindication for Naltrexone (Vivitrol/Revia)

currently taking opioids

MOA of Acamprosate (Campral)

Decreases NMDA receptors

When can Acamprosate (Campral) be started

After 5 days of alcohol cessation

What medication for alcohol abuse helps to maintain abstinence

Acamprosate (Campral)

Contraindication for Acamprosate (Campral)

Renal Disease

MOA of Disulfiram (Antabuse)

Inhibits alcohol dehydrogenase

Induces vomiting and autonomic instability when alcohol ingested

Reaction can occur up to 14 days after last dose

SE of Disulfiram (Antabuse)

Depression,

psychotic symptoms,

peripheral neuropathy,

liver damage

Contraindications to Disulfiram (Antabuse)

Heart disease,

CVA,

HTN,

DM

When does alcohol withdrawal occur

abused alcohol on a daily basis for at least 3 months or they have consumed large quantities for at least 1 week

Presentation of Mild Alcohol Withdrawal

Within 24 hours of alcohol cessation

Tremulousness (shakes),

insomnia,

anxiety,

hyperreflexia,

diaphoresis,

mild autonomic hyperactivity,

GI upset

Presenation for moderate withdrawal

24-36 hours of alcohol cessation

Intense anxiety,

tremors,

insomnia,

excessive adrenergic symptoms

Tonic-Clonic Seizures

Delirium Tremens

Most severe version of alcohol withdrawal

Presentation of Delirium Tremens

occurs 72-96 hours after last drink

Confusion,

agitation,

severe diaphoresis,

hallucinations

Seizures

Death

The Clinical Institute Withdrawal of Alcohol Scale (CIWA-Ar)

Medication administration in symptom-triggered therapy

When is medication for alcohol withdrawal given

CIWA-Ar > 8

Treatment for Alcohol Withdrawal

Benzodiazepines

IVFs

Thiamine then glucose