Chapter17

Persons with cluster A personality disorders often have symptoms of odd or eccentric thinking and behavior that stands out as being out of the norm for most people. There are three personality disorders under this category: paranoid personality disorder, schizotypal personality disorder, and schizoid personality disorder. PARANOID PERSONALITY DISORDER (301.0) Paranoid personality disorder or PPD involves an individual who has a pervasive lack of trust in others and a significantly cynical view of the world in general. These people are excessively sensitive to social, verbal, or physical attacks, having few people they actually like or love enough to trust. They are argumentative, secretive, excessively rational, unemotional, and aloof with those around them, often doing poorly with group projects or social activities. While they are often critical of others, they respond with hostility or defensiveness if they are criticized by others. 266 Brief psychotic reactions can happen to these individuals under stress or duress but it does not last. They do not respond to medications for psychosis and don’t have major deficits in reality testing, even at their worst. The content of their psychotic thinking isn’t bizarre and tends to be paranoid in nature. The disorder does not come out of having endured a traumatic experience so they do not have PTSD, in general. There are two major criteria in the DSM-V for PPD. The first is a global mistrust and suspicion of others which generally starts in adulthood. Four of the seven following sub-criteria must be met: A. Belief that they are being used, lied to, or harmed by others B. Doubts the loyalty or trustworthiness of others C. Lack of ability to confide in others D. Interprets benign remarks as threatening or hurtful E. Holds grudges F. Believes their character is being challenged by other and wants to retaliate G. Jealousy and suspicion of loved ones, believing them to be unfaithful The second criterion is that the symptoms are not part of a psychotic episode in any other mental illness. If the symptoms predate schizophrenia, the diagnosis of PPD is a premorbid one to schizophrenia. The features can be seen in childhood but the diagnosis is not made until adulthood. Interactions with others in childhood that end up in rejection may lead to lack of trust and subsequent lifelong suspicion of others. The prevalence of paranoid personality disorder is 2-4 percent, with a predominance of males. The DSM-V indicates that risk factors for the disorder include having a family history of schizophrenia or persecutory type delusional disorder. There are numerous comorbid personality disorders along with PPD, along with major depressive disorder, OCD, substance use disorders, and agoraphobia. Treatment is difficult with PPD as it is with all personality disorders because they do not see themselves as having a problem. Those who enter treatment will respond to cognitive 267 behavioral therapy, which challenges their maladaptive belief system. In the end, it is difficult to establish rapport with these individuals as they are mistrustful of others. Untreated individuals will have difficulty in workplace, educational, and social settings, often being unemployed or underemployed. They may wish to be intimate with others but know they cannot trust another that intimately. SCHIZOID PERSONALITY DISORDER (301.20) This is referred to as SPD and is another cluster A disorder. This occurs in less than 1 percent of the general population and involves individuals who stay away from close, personal relationships, choosing instead to remain away and detached from others in society. They engage in solitary activities and choose jobs that keep them away from frequent human-tohuman interaction. They see themselves as societal “bystanders” rather than being involved and active in society. This is not seen commonly, even in psychiatric populations. It is seen more commonly in males and among criminal offenders. No one knows the etiology of this disorder but it does seem to be related to schizophrenia (but not as severe in nature). It has a lot of similarities to the negative symptoms of schizophrenia, such as a lack of emotion, avoidance of others, and lack of motivation. It has some parallel features to other personality disorders, particularly narcissistic, avoidant, and antisocial personality disorders. The major feature is fear of the world with more comfort known by being isolated, secluded, and hidden from the rest of the world. They are extremely submissive and seek validation from within other than from other people. Their apathy often makes them more easily manipulated by others. Their isolation puts them at a higher risk of depression compared to people without the disorder. 268 In order for the diagnosis to be made, the individual must have four of the following symptoms: A. Extreme focus on introverted activities B. Does not want to be in close relationships or to be included C. Does not think of sexual experiences D. Anhedonia E. No close friends other than immediate family F. Apathetic to positive or negative feedback from others G. Emotional detachment and coldness, with flattened affect This tends to be more common among men and among individuals with relatives who have schizophrenia. Besides depression, they more frequently get diagnosed at some point in their lives with schizophrenia themselves. Risk factors include heritability, being raised where emotional needs are not met, and being hypersensitive and emotionally disconnected as teens. Many were mistreated as children or were abandoned in childhood. The anxiety these individuals have is related to having fear of close relationships; these people are indifferent to being secluded and do not display strong emotion when wrongly accused of something. They have a greater than average risk of having major depression, anxiety disorders, delusional disorders, and schizophrenia. They are aloof about the need to change and are defiant to therapeutic approaches, making them not really amenable to treatment. SCHIZOTYPAL PERSONALITY DISORDER (301.22) This personality disorder, called SPD, was covered extensively in Chapter 2 (under schizophrenic spectrum disorders) so it will briefly be touched on here. It is a cluster A disorder that involves individuals who often live in a fantasy world, showing little interest in social activity and leading solitary lives. They have little emotion, are apathetic, and have difficulty expressing themselves emotionally. They may have episodes of psychosis and depression. They tend to withdraw from the idea of relationships and have few intimate friends. It is commonly seen in families that have schizophrenia. 269 They may have many acquaintances but few close friends. They are secretive and do not share much with friends or family. Interpersonal problems are common. They may have paranoid characteristics and paranoid delusions. There are deficits in emotional expression and social skills. There is a high rate of suicide, with anxiety disorders, depression, borderline personality disorder, and narcissistic personality disorder. CLUSTER B PERSONALITY DISORDERS Cluster B personality disorders involve individuals who have overly-emotional, unpredictable, or dramatic thinking or behavior. They include borderline personality disorder, antisocial personality disorder, histrionic personality disorder, and narcissistic personality disorder. ANTISOCIAL PERSONALITY DISORDER (301.7) Antisocial personality disorder or APD was discussed in detail in Chapter 14 on Disruptive, Impulse Control, and Conduct Disorders. These individuals habitually and pervasively violate and disregard the considerations of others without any remorse. They are often habitual criminals but can be individuals who are simply amoral, who skirt the edges of the law in irresponsible ways and violate social norms and expectations. They make decisions purely on their own desires without considering the needs or negative effects of their actions on others. Patients with APD are not truly antisocial because they are not socially isolated nor are they loners. They are antisocial because they are against society and its rules, laws, and norms. They tend to be attractive, highly charismatic, and good at gaining others’ sympathies, often stating they are the victims of injustice when, in fact, they are perpetrators. They often have higher than normal intelligence and use their cunning against others through manipulation and exploitation. They may be empathetic of their victim’s suffering but derive pleasure from this. Those with some positive empathy are sometimes amenable to treatment. 270 BORDERLINE PERSONALITY DISORDER (301.83) This is a complex disorder that impacts the individual’s sense of self and their interpersonal relationships. They have an intense fear of abandonment, which is a major feature of their personality difficulties. It is almost always seen in women. They engage in many impulsive and unsafe behaviors in an attempt to avoid abandonment. There are frequent suicidal threats and attempts within this population. Self-injury is a coping strategy in patients with this problem. This is a pervasive pattern of instability of interpersonal relationships, affect, and self-image that begins in early adulthood and affects many areas of their life. They are fearful of abandonment and try to avoid becoming abandoned. There are frequent and intense changes in relationships in which the person exhibits strong love or hateful feelings toward their romantic partners. This extends to their doctors, relatives, and others in their lives. They have a distorted or weak sense of self as demonstrated by dramatic changes in goals, values, and interests. Healthy relationships might be destroyed and other self-destructive behavior happens. There may be reckless driving, binge eating, unhealthy spending, unsafe sex, and substance abuse. Self-injurious behavior is common. Disproportionate anger and temper tantrums can be seen as well as dissociative symptoms and paranoia. The prevalence is about 2 percent of the population but is much higher among psychiatric patients. There is a great deal of morbidity and mortality associated with borderline personality disorder, including an 8-10 percent suicide rate and many attempts at suicide and self-mutilation. Selfinjury is seen in up to 60 percent of teens with mental illness but this doesn’t always mean they have BPD. The treatment for the disorder is dialectical behavioral therapy or DBT, which involves a whole-systems approach. DBT teaches new coping skills from a position of understanding and empathy; it is considered the most effective therapy for treating this disorder. Group DBT will teach interpersonal skills. Because recurrent crises are typical of this disorder, having a therapist that can be reached is important. 271 HISTRIONIC PERSONALITY DISORDER (301.50) These are patients who display dramatic and attention-seeking behavior in order to gain the approval of others. They may be particularly flirtatious, seductive, or excessively emotional in order to gain the attention of those around them. The behavior is over-the-top with extreme self-centeredness and displays of temper that interfere with relationships. They are excessive in their attention to their appearance and display narcissistic qualities. They assume more familiarity with strangers and others than people without the disorder. It is more commonly seen in women and affects 1-3 percent of the US population. Symptoms of the disorder include having several of the following: A. Shallow, changeable emotions B. Excessive intimacy with others C. Hypersensitivity to criticism D. Manipulative behavior E. Sexual provocativeness F. Disproportionate emotional reactions G. Compulsive desire for attention H. Preoccupation with appearance I. Easily influenced and suggestible J. Compulsion to be the center of attention Factors that play into developing histrionic personality disorder include genetics and the inheritance of excitement-seeking and neurotic behavior. Parental influence also plays a role so that emotionally shallow parenting might be a factor. There are a lot of overlaps with this disorder and antisocial personality disorder with the suggestion that they might have similar etiologies. Childhood trauma plays a role in this disorder as it does in other personality disorders. 272 Comorbid personality disorders with HPD include borderline personality disorder, narcissistic personality disorder, and dependent personality disorder. Other comorbidities include major depressive disorder, somatic symptom disorder, and conversion disorder. These patients may also misuse substances or may develop anorexia nervosa. The onset of the disease is late teens to early twenties. The individual may seem charming and are able to function well in many social circles but will have more difficulty in their personal life and with romantic relationships. They often struggle to deal with failure and loss, frequently getting bored in ordinary situations and in relationships. They crave new experiences and excitement, leading to depression and risk-taking behavior. The patient often seeks treatment for things like depression and anxiety—not for the personality disorder itself. Still, they can be managed with cognitive behavioral therapy, support groups, and functional analytic psychotherapy. Medication is generally used for depression and anxiety symptoms, which can be coexisting with the personality disorder. NARCISSISTIC PERSONALITY DISORDER (301.81) This is a cluster B disorder that is not frequently diagnosed. These individuals seek psychiatric care for anxiety and depression—not for their personality disorder. It is a relatively recent diagnostic category that represents a subgroup of difficult-to-treat patients that do not easily respond to traditional psychotherapeutic treatment options. It is seen more commonly in males than females; it is seen more in clinical practice than it is seen in research circles. The major feature is grandiosity and the need for excessive admiration from others. There is a genuine lack of empathy for other individuals. It can negatively impact the patient’s interpersonal and work life, as well as their social life. They are condescending and denigrating, needing to be in control and frequently dismissing the needs and wishes of others. Internally, however, they feel a great sense of inadequacy and low self-esteem. They do not handle disapproval or rebuff of any kind. 273 According to the DSM-V, there must be five of these nine characteristics to make the diagnosis, which usually begins in early adulthood: A. Grandiose sense of self-importance B. Fixated on fantasies of infinite control, success, or idyllic love C. Belief that they are extraordinary and exceptional D. Desire for unwarranted admiration E. Having a sense of entitlement F. Interpersonally oppressive behavior G. No sense of empathy H. Resentment toward others and the belief that others resent them I. Egotistical and conceited behaviors or attitudes The prevalence is less than one percent in the general population with similar characteristics to the other cluster B personality disorders. Many will also have an Axis I disorder, such as substance use disorder, depression, or anxiety. About half of all patients seen will have major depression at the time of diagnosis. About 5-10 percent will have bipolar disorder and up to two-thirds of patients will have a substance use disorder. The treatment of NPD involves drug therapy and psychotherapy. Psychoanalytic psychotherapy tends to be the most effective; however, other types of therapy will help the disorder. Group therapy is not successful as these individuals do not have the skills for dealing with others in a group setting. There are no drugs for the treatment of NPD; however, many are treated with antidepressants, antipsychotics, and mood stabilizers to treat their comorbid disorders. Most will need long-term monitoring as they can have a chronic suicide risk because of their ongoing psychopathology. CLUSTER C PERSONALITY DISORDERS Patients with cluster C personality disorders have anxiety with fearful thinking or behavior. They include avoidant personality disorder, dependent personality disorder, and obsessive- 274 compulsive personality disorder. AVOIDANT PERSONALITY DISORDER (301.82) Avoidant personality disorder involves pervasive inadequacy and hypersensitivity to being negatively judged by others. There is extreme shyness that is the major feature of the disorder. This is present in many situations and affects the person’s social, occupational, and interpersonal life. They desire social connection but have so much personal inadequacy that they fear social rejection. They see themselves as being defective and unlikable so that others are likely to reject them. It may be a severe form of social anxiety disorder. In the general population, about 2 percent of people have this, with about 10-20 percent of psychiatric patients being affected by the disorder. It is included as a cluster C disorder because it involves anxiety, fearfulness, and internalization of distress. They tend to choose isolation because they don’t want to risk being negatively evaluated. There are seven criteria for the disorder and four of them must be met to make the diagnosis: A. Avoids occupational activities involving significant interpersonal contact because of fear of rejection or disapproval from others B. Unwilling to get involved with people unless they are guaranteed of acceptance C. Shows restraint within intimate relationships out of fears of shame or ridicule D. Preoccupied with fears of rejection in social situations E. Feels inferior to others, socially inept, or personally unappealing F. Feels inadequate in interpersonal situations G. Reluctant to take risks or to engage in new activities out of fear of being embarrassed The treatment of avoidant personality disorder involves individual psychotherapy, which helps them become less sensitive to rejection. They believe that rejection will be unbearable so they don’t seek treatment because they think the therapist will not like them. They are very sensitive to criticism in therapy and might see the therapist as being critical without basis. They do not 275 see the therapist’s genuine concern so they run the risk of terminating therapy prematurely. DEPENDENT PERSONALITY DISORDER (301.6) This is a diagnosis given to individuals who are excessively needy and dependent on others. The patient will have dependence on others early in life that is developmentally appropriate but will continue to have these feelings after they have grown to adulthood. The individual is usually able-bodied and not otherwise psychologically impaired so they have no particular reason to be dependent. There are eight features for the disorder that involves one specific criterion, which is an excessive need to be taken care of or to be submissive and clingy. Features of this criterion involve the following: • Difficulty making routine decisions without advice or input from others. • Needs others to assume responsibilities that they should be attending to. • Fear of disagreeing with others, risking disapproval. • Difficulty starting projects without support from others. • Need for nurturance and support from others. • Feels helpless and vulnerable when alone. • Seeks out a new relationship when one ends. • Preoccupation with being left alone and unable to care for themselves. This disorder can appear in adolescence or early adulthood with a lack of the normal autonomy that individuals have at this age. They rely on others to make decisions for them and do not step up to normal levels of responsibility. The prevalence is about 0.5 percent, seen more frequently in females than in males. The only known risk factor is being female, although having authoritarian parenting where decisions were made for them at a developmentally inappropriate age. There are no specific comorbidities except for substance use disorder, which is a comorbidity of all personality disorders. 276 Individuals with dependent personality disorder often tolerate situations from which others would usually withdraw, including verbal, sexual, and physical abuse. As such, they are at risk for spousal abuse as they are dependent on abusive spouses. Some will view them with pity, while others easily get frustrated with their lack of ability to make their own decisions. They tend to become involved in unhealthy relationship dynamics. There are enough overlapping features between DPD and other personality disorders, such as borderline personality disorder and histrionic personality disorder so these need to be ruled out. There are also cultural issues in which dependency in women is highly regarded. They may be seen as overly dependent in an American cultural setting. OBSESSIVE-COMPULSIVE PERSONALITY DISORDER (301.4) This is a cluster C disorder because it involves anxiety and fear. The patient with obsessivecompulsive personality disorder is perfectionistic and is preoccupied with orderliness. There is a need for control—both mentally and interpersonally. They need sameness and control that results in a loss of flexibility in daily living. There are lists, rules, schedules, and a need for control that is so severe that the original purpose of the task is easily forgotten. They can be overly obsessed with work and productivity to the point of complete exclusion of leisure activities and interpersonal relationships. One feature of this order is a need to hang onto their money, being reluctant to discard objects than no longer have any value. In this way, they are at risk for pathological hoarding. Patients with this disorder do not usually seek help unless there is significant distress or impairment in functioning. It is difficult to differentiate obsessive-compulsive personality disorder and OCD, except that people with OCD have true obsessions that aren’t really seen in the personality disorder. Patients with OCPD will often also receive the diagnosis of OCD, particularly if they have true obsessive thoughts and compulsive actions. If symptoms of both disorders are present, they are coded for separately under the DSM-V. Another comorbidity is hoarding disorder. 277 Sometimes drug use or CNS disorders cause these symptoms so these need to be ruled out. Certain anxiety disorders, such as hypochondriasis and anorexia nervosa can be linked to OCPD. This is perhaps the most prevalent personality disorder, affecting about 2-8 percent of the population. It may be underreported as people with OCPD do not seek treatment as long as they can manage their symptoms without help. The treatment of the disorder is difficult as many do not want to change these features of their personality. Treatment focuses on the use of CBT or other therapy in order to identify sources of stress and to learn interpersonal coping strategies. While anti-anxiety medications are helpful in OCD, it isn’t clear that it actually helps people with symptoms secondary to having the personality disorder.