Personality Disorders

Personality

Consistent emotional and behavioral response patterns of an individual toward their surroundings, stable and predictable

Disorder

A problem that interferes with day-to-day life

Personality disorder

An enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individual’s culture

Manifested in > 2 of the following:

-Cognition

-Affect

-Interpersonal functioning

-Impulse control

Personality Trait

Enduring patterns of perceiving, relating to, and thinking about oneself that are exhibited in a wide range of social and personal contexts.

-Flexible

Personality Disorder

When personality traits are inflexible and maladaptive and cause significant functional impairment or subjective distress

-Inflexible

genetic, child

Personality Disorder Development

-_______ predisposition → alcoholism + substance abuse increase likelihood

-Biological factors

-Nurture → reflection of what they experienced as a _______, such as child abuse or neglect

Cluster A

What cluster contains these personality disorders? 

-Paranoid, schizoid, schizotypal 

Cluster B

What cluster contains these personality disorders?

-Antisocial, borderline, histrionic, narcissistic

Cluster C

What cluster contains these personality disorders?

-Avoidant, dependent, obsessive-compulsive 

distrust, suspiciousness, malevolent, early, suspects, hidden, attacks, suspicions

Paranoid Personality Disorder

-Pervasive ______ and _____________ of others such that their motive are interpreted as ____________, beginning in _____ adulthood and present in a variety of contexts, as indicated by 4+ of the following:

• (1) _______, without sufficient basis, that others are exploiting, harming, or deceiving them

• (2) Preoccupied with unjustified doubts about the loyalty or trustworthiness of friends or associates

• (3) Reluctant to confide in others

• (4) Reads _______ demeaning or threatening meanings into benign remarks

• (5) Persistently bears grudges

• (6) Perceives _______ on their character or reputation

• (7) Recurrent __________, without justification, regarding fidelity of a spouse/sexual partner

-Does not occur exclusively during schizophrenia, BPD, depressive disorder with psychotic features, other psychosis, medical condition

Paranoid personality disorder

What is the leading diagnosis in this patient?

A 42 y/o man comes to the clinic for a routine physical exam but seems guarded and suspicious throughout the visit. He refuses to answer questions about his medical history, saying, “You’re just trying to get information to use against me”

He insists on reading every note the clinician writes and demands to know why certain questions are being asked. He reports that his coworkers are “plotting to get me fired” and that his neighbors “talk about him behind his back”.

When asked if he has close friends, he says he prefers to “keep to himself” because “you can’t trust anyone”. He denies hallucinations, delusions, or recent substance use. His thought process is logical, and he is A&O x 4.

detachment, relationships, emotions, desires, friends, coldness

Schizoid Personality Disorder

-Pervasive pattern of __________ from social ____________ and a restricted range of expressed _________ in interpersonal settings, in a variety of contexts, as indicated by 4+ of the following:

• (1) Neither ________ nor enjoys close relationships, including family 

• (2) Almost always chooses solitary activities 

• (3) Has little, if any, interest in sex

• (4) Takes pleasure in few activities 

• (5) Lacks close _________ or confidants other than 1st degree relatives 

• (6) Appears indifferent to praise or criticism

• (7) Emotional __________, detachment, or flattened affectivity 

-Does not occur exclusively during schizophrenia, bipolar, depressive disorder with psychotic features, other psychosis, autism, medical condition

Schizoid personality disorder

What is the leading diagnosis in this patient?

A 35 y/o man is brought to the clinic by his sister, who is concerned that he is “too isolated”. He lives alone, works as a night security guard, and spends most of his time reading science fiction or playing Fortnite.

He reports being content with his life and says he “doesn’t see the point” of having close friends or relationships. He denies sadness, anxiety, or hallucinations.

He has never dated, avoids social gatherings, and appears emotionally cold and detached during the interview. He answers questions briefly and shows no apparent desire for social interaction or praise.

social, discomfort, eccentricities, odd, unusual, anxiety

Schizotypal Personality Disorder

-Pervasive pattern of ______ and interpersonal deficits marked by acute ________ with, and reduced capacity for, close relationships as well as cognitive or perceptual distortions and _____________ of behavior, as indicated by 5+ of the following:

• (1) Ideas of reference

• (2) ___ beliefs or magical thinking

• (3) ________ perceptual experiences

• (4) Odd thinking and speech

• (5) Inappropriate or constricted affect

• (6) Suspiciousness or paranoid ideation

• (7) Behavior or appearance that is odd, eccentric, peculiar

• (8) Lack of close friends

• (9) Excessive social _______

-Does not occur during other conditions

Schizotypal Personality Disorder

What is the leading diagnosis in this patient? 

A 29 y/o man is brought to the clinic by his mother, who says he has become increasingly isolated. He lives alone and spends much of his time writing about “energy fields” and “cosmic vibrations”. 

He believes he can sense other people’s thoughts and sometimes wears a cape and jewelry made of crystals for “protection”. 

He reports few friends, saying most people “don’t understand his higher awareness”. During his interview, his speech is tangential, and he maintains odd eye contact. He denies hallucinations or delusions. 

disregard, violation, norms, aggressiveness, remorse, 18, conduct, bipolar

Antisocial Personality Disorder

-Pervasive pattern of _________ for and _________ of the rights of others, indicated by 3+ of the following:

• (1) Failure to conform to social ______

• (2) Deceitfulness

• (3) Impulsivity

• (4) Irritability and ___________

• (5) Reckless disregard for safety

• (6) Consistently irresponsible

• (7) Lack of _______

-The individual is at least __ years old

-Evidence of ______ disorder prior to age 15

-Does not exclusively occur along with schizophrenia or ______ disorder

-DDX → substance abuse disorder, schizophrenia, bipolar disorder, other personality disorders

Antisocial personality disorder

What is the leading diagnosis in this patient?

A 28 y/o man is brought to the ED by police after a bar fight. He appears unconcerned about the injuries he caused to another person and states, “He deserved it. People are weak if they can’t defend themselves.”

Review of records reveals a long history of arrests for theft, assault, and fraud. He was suspended from school multiple times for bullying and fighting. He also ran away from home at age 13. He admits to lying frequently and using others for money or favors, saying, “That’s just how you get ahead”

He denies remorse and laughs when told that his victim required hospitalization.

relationship, impulsivity, abandonment, intense, impulsive, suicidal, anger

Borderline Personality Disorder

-Pervasive pattern of instability of interpersonal ____________, self-image, and affects, and marked __________; indicated by 5+ of the following:

• (1) Frantic efforts to avoid real or imagined ______________

• (2) Pattern of unstable or _______ relationships

• (3) _________ behaviors 

• (4) Unstable self-image or sense of self

• (5) Recurrent _______ behavior, gestures, or threats 

• (6) Unstable mood

• (7) Chronic feelings of emptiness

• (8) Inappropriate, intense _____ or difficulty controlling anger

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

Borderline personality disorder

What is the leading diagnosis in this patient?

A 26 y/o woman presents to the ED after taking an overdose of Ibuprofen following an argument with her boyfriend. She says, “I can’t live without him, but I also hate him for what he did.”

Her medical record shows multiple prior visits for self-harm and impulsive behaviors, including binge drinking and reckless driving.

She describes her mood as “constantly up and down” and says she feels empty inside most of the time. She has intense relationships that start quickly but often end in anger or despair.

When the clinician informs her that she cannot be admitted immediately, she becomes angry and accuses the staff of not caring, but she tearfully apologizes and begs for help minutes later.

attention, seductive, appearance, emotion

Histrionic Personality Disorders

-Pervasive pattern of excessive emotionality and _________ seeking; indicated by 5+ of the following:

• (1) Needs to be the center of attention

• (2) Inappropriate sexually ________ or provocative behavior

• (3) Emotional lability

• (4) Consistently uses physical _________ to draw attention to self

• (5) Speech is impressionistic and lacking in detail

• (6) Shows self-dramatization, theatrically, and exaggerated expression of ________

• (7) Suggestible

• (8) Considers relationships to be more intimate than they actually are

Histrionic Personality Disorder

What is the leading diagnosis in this patient?

A 30 y/o woman comes to her new PCP for an annual physical. She is excessively friendly and animated, calling the PA “the best provider I’ve ever had” within minutes of meeting him. 

She is wearing bright, revealing clothing and frequently touches the clinician’s arm while talking. Her speech is dramatic and emotional, filled with vague descriptions like “I’ve just been through so much stress lately; you have no idea!”

When asked about her medical history, she cannot provide details and becomes tearful when the conversation shifts away from her. She says her boyfriend “doesn’t appreciate how much she sacrifices for him,” and later says she’s sure the PA “really understands her”. 

admiration, fantasies, special, arrogant

Narcissistic Personality Disorder

-Pervasive pattern of grandiosity, need for __________, lack of empathy; indicated by 5+ of the following:

• (1) Grandiose sense of self-importance

• (2) Preoccupied with _________ of unlimited success, power, brilliance, beauty, or ideal love

• (3) Believes that he is ______ and unique

• (4) Requires excessive admiration

• (5) Sense of entitlement

• (6) Interpersonally exploitative 

• (7) Lacks empathy

• (8) Is often envious of others

• (9) Shows ________, haughty behaviors or attitudes 

Narcissistic Personality Disorder

What is the leading diagnosis in this patient?

A 38 y/o man comes to clinic complaining that his coworkers “don’t appreciate his talents”. He says he’s the smartest person in the department and that is boss is “threatened by his brilliance”. 

He becomes irritated when the PA asks about his relationships, saying, “People are jealous of me, so I keep my distance.” He frequently name-drops and insists on being scheduled with the “most senior physician”.

When told his PE is normal, he scoffs and says, “I expected a more thorough evaluation. I’m not some average patient.”

He denies depression or anxiety, but admits to feeling angry and humiliated when others fail to recognize his talents.

inadequacy, negative, criticism, intimate, rejected, risks

Avoidant Personality Disorder

-Pervasive pattern of social inhibition, feelings of __________, and hypersensitivity to ________ evaluation; indicated by 4+ of the following:

• (1) Avoids activities that involve significant interpersonal contact because of fears of ________, disapproval, rejection

• (2) Unwilling to get involved with people unless certain of being liked

• (3) Shows restraint within _____ relationships because of the fear of being shamed or ridiculed

• (4) Preoccupied with being criticized or __________ in social situations

• (5) Inhibited in new interpersonal situations because of feelings of inadequacy

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

• (7) Unusually reluctant to take personal _____ or to engage in any new activities because they may prove embarrassing

Avoidant personality disorder

What is the most likely diagnosis in this patient?

A 28 y/o woman presents for evaluation of chronic loneliness. She says she wants to have friends and date, but avoids social gatherings because she’s terrified people will reject or judge her.

She describes herself as “socially awkward” and believes others view her as “boring and unattractive”. She turns down invitations even though she later regrets it.

At work, she avoids new projects unless she’s sure she won’t be criticized. She spends most weekends at home watching movies alone. When asked if she’d like to change, she says, “I wish I could, but I know people wouldn’t like me if they got to know me.”

She denies panic attacks, psychosis, or substance use. 

care, submissive, separation, responsibility, disagreement, alone, themselves

Dependent Personality Disorder

-Pervasive and excessive need to be taken ____ of that leads to _________ and clinging behavior and fears of __________; indicated by 5+ of the following:

• (1) Difficulty making everyday decisions without an excessive amount of advice and reassurance from others

• (2) Needs others to assume ____________ for most major areas of their life

• (3) Has difficulty expressing ______________ with others

• (4) Has difficulty initiating projects or doing things on their own

• (5) Goes to excessive lengths to obtain nurturance and support from others

• (6) Feels uncomfortable or helpless when ______

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

• (8) Unrealistically preoccupied with fears of being left to take care of _________

Dependent personality disorder

What is the leading diagnosis in this patient?

A 32 y/o woman comes to her PCP with worsening anxiety since her boyfriend broke up with her last month. She says she feels “completely lost without him” and has already started dating someone new because “I can’t stand being alone”.

She frequently seeks reassurance from others before making even minor decisions, such as what to wear or where to eat. She reports that she lets her partners make all major life choices and stays in relationships even when they are unhealthy because she’s afraid of being abandoned.

When asked about her future, she says, “I just want someone to take care of me.”

She denies psychosis, mania, or substance use.

perfectionism, flexibility, details, productivity, inflexible, discard, rigidity 

Obsessive-Compulsive Personality Disorder

-Pervasive pattern of preoccupation with orderliness, ___________, mental and interpersonal control, at the expense of __________, openness, and efficiency; indicated by 4+ of the following:

• (1) Preoccupied with _____, rules, lists, order, organization, or schedules

• (2) Shows perfectionism that interferes with task completion

• (3) Excessively devoted to work and ___________ to the exclusion of leisure and activities and friendships

• (4) Over conscientious, scrupulous, and ________ about matters of morality, ethics, or values

• (5) Unable to ______ worn-out or worthless objects even when they have no sentimental value

• (6) Reluctant to delegate tasks or to work with others unless they submit to their way of doing things

• (7) Frugal

• (8) Shows ______ and stubbornness 

Obsessive Compulsive Personality Disorder

What is the leading diagnosis in this patient?

A 40 y/o accountant presents to his PCP because his wife is frustrated with how controlling he is at home. He admits he gets “very upset” if household chores aren’t done exactly his way and often rewrites grocery lists until they’re “organized perfectly”.

He describes himself as a “perfectionist” who works long hours but rarely finishes projects on time because he’s constantly revising and double-checking his work. He refuses to delegate tasks to coworkers because “they’ll just mess it up”.

He has few close friends and often spends his weekends re-cleaning areas that are already clean. When asked about his emotions, he says, “I don’t like wasting time on feelings- there’s work to be done.”

He denies intrusive thoughts or repetitive behaviors that he finds distressing.

personality, delirium, endocrine

Personality Change Due to Another Medical Condition

-Persistent __________ disturbance

-Evidence of direct pathophysiological etiology of disturbance

-Not better explained by another mental disorder

-Does not exclusively occur during a long course of _______

-Causes clinically significant distress/impairment in social, occupational, or other important areas of functioning

-Personality change may be the first sign of serious neurologic, _______, or other medical illness

self-help, operant, DBT

Personality Disorders: Treatment

-Social → day hospitals, halfway houses, ____-_____ communities, “social pressures” to change the self-destructive behavior 

-Behavioral → ______ conditioning, aversive conditioning, extinction, and dialectical behavioral therapy (___) for borderline personality disorder

group, countertransference, antidepressants, antipsychotics, SSRI

Personality Disorders: Treatment

-____ and individual therapy, transference, or _____________

-Anxiety, depression, rejection sensitivity, aggression → _____________ (SSRI)

-Hostility, agitation, adjunctive therapy to antidepressants → ____________

-Anxiety → ____ + Benzodiazepines

-Hospitalization → if suicidal or homicidal