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PATRICK J ENKING, PA-C, MSPHYSICIAN ASSISTANT PROGRAMUNIVERSITY OF NEW ENGLAND

Personality Disorders

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CONCEPT OF PERSONALITY AND PERSONALITY DISORDERS

Personality is the “style” of how one deals with the world

Personality traits Stylistic peculiarities of how one deals with world

especially in times of stress or external pressures. May change in adulthood as develop more coping skills

Personality Disorders – enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individual’s culture, is pervasive and inflexible, has an onset in adolescence or early adulthood, is stable over time and leads to distress or impairment.

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CHARACTERISTICS OFPERSONALITY DISORDERS

a long-term pattern of inner experience and behavior that is out of context from the expectations of ones own culture

These patterns exhibit themselves in the way that people see themselves, their impulse control, and their affective instability.

Becomes a problem if it interferes with normal daily functioning

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PERSONALITY DISORDERSETIOLOGY

Upbringing/parenting – within their own culture, ethnic and social background.

Personal and social development – sudden change in living situation

Genetics

Biological factors

If later in life: rule out medical causes or substances.

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CHARACTERISTICS OFPERSONALITY DISORDERS

Inflexible, maladaptive responses to stress Disability in working and loving Avoidance and fear of rejection Blurred boundaries between self and other Insensitivity to needs of others Demanding and fault finding Lack of accountability Evoke intense interpersonal conflict

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PREVALENCE AND CO-MORBIDITY

Prevalence: 10–15% in general population Up to 50% in psychiatric patients with co-

morbidity Often co-occur with depression & anxiety Often more than one diagnosis concurrently Substance abuse Somatization Eating disorders PTSD

That’s why it’s important to do a thorough evaluation of personality in the psych assessment

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BIOLOGICAL THEORIES OF PERSONALITY DISORDERS

Biological No single cause identified Genetics – play a role in Schizotypal, Schizoid

and paranoid personality disorders Neurobiological factors – Borderline PD related to

abnormality in Prefrontal, corticostriatal and limbic systems

Psychological Childhood abuse and trama Learned Cognitive

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DSM IV DIAGNOSTIC CRITERIA

A. An enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individual's culture. This pattern is manifested in two (or more) of the following areas:  (1) cognition (i.e., ways of perceiving and interpreting self, other people,

and events) (2) affectivity (i.e., the range, intensity, lability, and appropriateness of emotional response) (3) interpersonal functioning (4) impulse control 

B. The enduring pattern is inflexible and pervasive across a broad range of personal and social situations. 

C. The enduring pattern leads to clinically significant distress or impairment in social, occupational, or other important areas of functioning. 

D. The pattern is stable and of long duration and its onset can be traced back at least to adolescence or early adulthood. 

E. The enduring pattern is not better accounted for as a manifestation or consequence of another mental disorder. 

F. The enduring pattern is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition (e.g., head trauma).

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QUESTION: WHERE DO WE DOCUMENT PERSONALITY DISORDERS IN THE AXIS?

Axis II – Personality Disorders

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DSM CLUSTERS OF PERSONALITY DISORDERS

Cluster A: odd or eccentric Related to Schizophrenia Suspicious and quick to take offense

Cluster B: dramatic, emotional, erratic interpersonal interactions Manipulation is common Blaming others Attention seeking Moods are labile and often shallow

Cluster C: anxious or fearful Related to Axis I diagnosis of anxiety d/o Internalize blame for problems in life Often overcontrolled

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CLUSTER A: ODD OR ECCENTRIC

Paranoid - A chronic, suspicious distrust of others

Schizoid - Pattern of social detachment and decrease range of emotions

Schizotypal - Reduced capacity for close relationships, perceptual distortions and peculiar behavior

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PARANOID PERSONALITY DISORDER

The Caine Mutiny Steve X

Guarded/Suspicious Overly sensitive to

setbacks and rebuffs Self-important Easily

shamed/humiliated Close relationships Withdraws from others More common in males

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SCHIZOID PERSONALITY DISORDER Pattern of social

detachment decrease range of

emotions. Neither desires nor enjoys

human relationships. Fixated on personal

thought/fantasies. Demonstrates emotional

coldness, detachment, and flat affect.

Indifferent to praise or criticism.

Chooses solitary activities.

No desire to interact with others

NOT FEAR BASED

Dr Hahn

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SCHIZOTYPAL PERSONALITY DISORDER

Reduced capacity for close relationships.

perceptual distortions similar to schizophrenia

peculiar behavior and appearance

elaborate style of dressing, speaking, and interacting.

Magical thinking manifested.

Lacks close friends and think they may be harmful.

Excessive and unrelieved social anxiety.

Develop ideas of reference

Eccentric thinking FEAR Not Psychotic

Dr Hahn

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DIFFERENCES AND SIMILARITIES BETWEEN SCHIZOID AND

SCHIZOTYPAL PD There are many similarities between the Schizotypal and

Schizoid personalities. Most notable of the similarities is the inability to initiate or maintain

relationships (both friendly and romantic).

The difference between the two seems to be: Schizotypal avoid social interaction because of a deep-seated fear of

people. Schizoid individual simply feels no desire to form relationships,

because they quite literally see no point in sharing their time with others.

An important distinction is that people with Schizoid Personality don't typically experience the perceptual distortions, paranoia or illusions typical of Schizotypal Personality or the psychotic episodes of Schizophrenia.

Comparisons in film

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CLUSTER B: DRAMATIC, EMOTIONAL, ERRATIC Antisocial - Failure to conform to the norms of society, amoral behavior,

chronic irresponsibility and unreliability. Lack of regard for the law or rights of others. Must be over 18 y/o. M>W , Turbulant , fiery relationships, McDonalds Triad (bedwetting, animal cruelty, pyromania) in adolescents. CRIME.

Borderline - Unstable pattern of mood, emotions, relationships, and impulsivity. Issues of abandonment. Splitting behaviors. Recurrent suicide attempts. Feel empty and bored. Intense anger when ignored or mistreated. Self mutilating behaviors. May have brief psychotic episodes but short. Mood swings. Frequent suicide attempts (up to 10% complete it).

Histrionic - Excessive emotional and dramatic. Superficial and over reactive. Sexually provocative. Lack of remorse hurting others. Exaggerate and manipulative. Crave attention/excitement and approval of others. Women>Men. Cycle of rejection>histrionic behavior>rejection>histrionic….

Narcissistic - Grandiose sense of self importance. Attention Grabbing behaviors. Manipulation of others. Arrogant manner toward others. Expectation of special treatment. Envious of others with belief they are envious of him/her.

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ANTISOCIAL PERSONALITY DISORDER

*This diagnosis is not made before age 18.*Must not be made in the context of substance

use.*Before age 15, for 12 months or more the

person repeatedly violates rules, age appropriate societal norms or the rights of others. As shown by at least three of the following:

Agression toward people or animals Destruction of Property Lying or Theft Serious rule violation

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BORDERLINE PERSONALITY DISORDER

Attempts to prevent abandonment Unstable relationships Identity disturbance Self damaging impulsiveness Self mutilating behavior or suicidal thoughts or

threats Severe reactivity of mood leading to marked

instability Chronic feelings of emptiness Anger that is out of control or inappropriate and

intense Brief paranoid ideas or severe dissociative symptoms

related to stress My Story

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HISTRIONIC PERSONALITY DISORDER

Beginning in early adult life, emotional excess and attention-seeking behaviors are present in a variety of situations and shown by at least five of these:

Discomfort with situations in which the person is not the center of attention.

Relationships that are frequently fraught with inappropriately seductive or sexually provocative behavior

Expression of emotion that is shallow and rapidly shifting Frequent focusing of attention on self through use of

physical appearance Speech that is vague and lacks detail Overly dramatic expression of emotion Easy suggestibility (influenced by others) Belief that relationships are more intimate than they really

are

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NARCISSISTIC PERSONALITY DISORDER

Beginning in early adult life, grandiosity, lack of empathy, and need for admiration are present in a variety of situations and shown by at least five of these:

Grandiose sense of self importance Preoccupation with fantasies of beauty, brilliance, ideal love,

power or limitless success Belief that personal uniqueness renders the person fit only for

association with people or institutions of rarefied status Need for excessive admiration A sense of entitlement Exploitation of others to achieve personal goals Lack of empathy Frequent envy of others or belief that others envy the person Arrogance in attitude or behavior Dr Bowler

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CLUSTER C: ANXIOUS OR FEARFUL

Avoidant - Socially inhibited, wants contact with others but fearful of rejection or criticism. Easily wounded by criticism that they hesitate to become involved. Embarrassed easily. No close friends. Alone.

Obsessive/Compulsive (anankastic) - preoccupation with orderliness, perfectionism rules. Interferes with normal routines/rigid. Can be indecisive and preoccupied with detail. Have difficulty expressing affection. Jack.

Dependent - Difficulty taking responsibility for life. Need approval of others. Agree with others even when they don’t agree. Fear abandonment.

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ASSESSMENT AND DIAGNOSIS Common Risk

evaluations Ineffective coping skills Risk for other-directed

violence Risk for suicide Risk for self-mutilation Social isolation Disturbed thought

processes Hopelessness Chronic low self-

esteem

Other common complications Depression Substance use Accidents Self-harm and

suicide Unemployment Homelessness Crime/legal issues

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TREATMENTS FOR PERSONALITY DISORDERS

Some are outgrown with time i.e. Borderline Pers D/o

Crisis plan/support/monitoring

Psychodynamic psychotherapy

Cognitive-behavioral therapy

Dialectical behavior therapy (DBT)

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TREATMENT FOR PERSONALITY DISORDERS

Therapeutic community – positive interactions Ideals regarding self awareness,

interdependence, mutual respect, responsibility. Daily involvement for long time

Medications with low toxicity Antidepressants (SSRIs) Lithium carbonate Anticonvulsants Low-dose antipsychotics

Hospitalizations should be discouraged unless there is a danger to self or others

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SUMMARY OF PERSONALITY DISORDERS

Diagnosing PD should include: Verify the duration of the symptoms and that the

criteria are met May need to interview other informants Are these symptoms interfering with life in some

way? Sometimes requires a judgment call but try to be

as objective as possible. Rule out Axis I pathology

The General Criteria are very important as the basis for the diagnosis

Sometimes there are several criteria for different PD so it may appear more as a cluster

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DSM IV DIAGNOSTIC CRITERIA

A. An enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individual's culture. This pattern is manifested in two (or more) of the following areas:  (1) cognition (i.e., ways of perceiving and interpreting self, other people,

and events) (2) affectivity (i.e., the range, intensity, lability, and appropriateness of emotional response) (3) interpersonal functioning (4) impulse control 

B. The enduring pattern is inflexible and pervasive across a broad range of personal and social situations. 

C. The enduring pattern leads to clinically significant distress or impairment in social, occupational, or other important areas of functioning. 

D. The pattern is stable and of long duration and its onset can be traced back at least to adolescence or early adulthood. 

E. The enduring pattern is not better accounted for as a manifestation or consequence of another mental disorder. 

F. The enduring pattern is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition (e.g., head trauma).