Personality Disorders

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Personality Disorders

• Yana M. Van Arsdale, MD, PhD

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Personality Traits

• Relatively stable PATTERNS of -
  THINKING,
  - FEELING,
  - RELATING
• Demonstrated in a wide range of situations
• Consistently in the individuals adaptation to
  life

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Personality Disorder

• Traits become
  INFLEXIBLE
  MALADAPTIVE
• Serious problems
• in work
• interpersonal relationship

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Classification

• three clusters
• A Odd or Eccentric
• prone to Thought Disorders
• B Dramatic, Emotional, or Erratic
• prone to Affective Disorders
• C Anxious or Fearful
• prone to Anxiety Disorders
• Not Otherwise Specified (NOS)

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Cluster A

• Schizoid
• Schizotypal
• Paranoid
• 
  may be part of the
  schizophrenic spectrum

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Cluster B

• Borderline
• Histrionic
• Narcissistic
• Antisocial
  
• 
  The most difficult patients to
  deal with

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Cluster C

• Avoidant
• Dependent
• Obsessive-Compulsive
• 
  Inhibition in the assertion of
  socially acceptable impulses.
• Fearful reluctance to express anger or
  frustration.
• Internalization of blame. Anxiety.
  

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Not Otherwise Specified

• Passive-Aggressive
• Depressive
• Mixed

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General Characteristics

• Early onset childhood/adolescence
• Chronic
• Stress is poorly tolerated, and can result in
  brief psychotic episodes
• Inadequate coping skills
• Affects mood, cognition, behavior, interpersonal
  style, relating to others

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Epidemiology

• 5-10 - general population
• up to 60 - psychiatric inpatients

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Basic principles of Tx

• Establish a collaborative stance
• Relay that the patient is ultimately responsible
  for his/her care, and you are a consultant
• Appreciate that the irritating behavior is a
  defense against fear/insecurity

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Basic principles of Tx

• Set firm but compassionate limits
• Do not try to rescue the Pt
• Let the patient know the rules of treatment
• Be as consistent as possible
• Do not attempt to rationally debate with these
  patients when they are emotionally overwhelmed

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Basic principles of Tx

• Motivate them to make changes - confrontation
• Patients behavior can be irritating to
  caretakers - countertransference
• Treat Axis I illness first.
• Axis I or/and III illness can make traits appear
  to be disorder of Axis II

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Basic principles of Tx

• PDO is ego-syntonic maladaptation is not
  adequately recognized by the individual as a
  symptom that needs to be fixed
• Goal Ego-alienation
• If you wish to/not to, then you
• Ego-dystonic recognition of PDO is essential, gt
  effective approach than empathy and compassion

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Schizoid

• Long term pattern of social isolation
• Rarely seek treatment
• Goals
• decrease socially isolative behaviors
• increase socially outgoing behaviors
• Patient may seem detached or unappreciative

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Schizotypal

• Magical thinking, ideas of reference, recurrent
  illusions, odd behavior
• Anxiety in social situations
• Skills oriented psychotherapy
• Low dose neuroleptics
• Goals
• Help with reality testing
• Differentiating fantasy from fact

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Paranoid

• Suspiciousness, mistrust, hypervigilance,
  hypersensitivity to criticism/praise
• Extremely defensive
• Ascribe malicious intent to the actions of others
  and events
• Hard to develop working relationship in therapy
• A trusting relationship is essential for
  adherence to treatment.

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Paranoid

• Paranoid fears are heightened during any illness,
  including medical
• If the patient becomes hostile/difficult it is
  best to acknowledge that the pain and fear are
  real
• Cognitive and behavioral techniques
• Goals
• encourage to interface with the environment
• reevaluate paranoid ideas

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Borderline

• Stormy interpersonal relationship, behavioral
  dyscontrol, unstable affect
• Self-injuringgtsuicidal behavior
• Poor work Hx, multiple hospitalizations
• Abuse HxgtPTSD
• Comorbidity - depression, anxiety, substance
  abuse, eating DO
• Extremely defensive

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Borderline

• 1-2 general population
• 11 psychiatric outpatients
• 19 psychiatric inpatients
• 33 personality disorders in outpatient
• 63 personality disorders in inpatients
• Femalegtmale

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Pharmacotherapy, Borderline

• Treat Axis I disorder
• Low dose neuroleptics - Tx psychotic
  decompensations
• TCA are risky because of OD potential
• SSRI - preferable
• Benzodiazepines - avoided. SE
• behavioral disinhibition
• abuse potential
• Mood stabilizers

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Psychotherapy, Borderline

• Firm boundaries, stable framework
• Pay active attention to deviations from the frame
• Identify behavior in the therapy to diminish
  transference distortions
• Help to see that patient is communicating
  feelings through behavior
• Recognize projective identification
• Educate

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Psychotherapy, Borderline

• Pay attention to countertransference feelings
• Set limits on self-destructive behavior
• Contain and explore negative feelings from the
  patient without withdrawing or detachment
• Distinguish fantasy from reality
• Do not be drawn in by idealization or devaluation
  of others - splitting

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Antisocial

• Impulsivity, violence, irresponsibility
• Criminal behavior without remorse or empathy for
  others
• Hostility against authority
• Manipulative, charming, seductive
• Comorbidity - affective anxiety DO, substance
  abuse

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Antisocial

• Genetic component
• Conduct DO childhood/adolescence
• Decreased functioning of serotonergic
  adrenergic systems
• EEG abnormalities

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Antisocial

• 2-9.4 general population
• 3-37 psychiatric population
• 75 prison population
• Malegtfemale

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Antisocial, Tx

• Structured or secure/enforced environment
• Approach firm, no nonsense, not punitive that
  conveys streetwise awareness of the patients
  potential for manipulation
• Respect without aggravating the patients
  hostility
• Best to work with children to prevent progression
  to AS-PDO

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Antisocial, Tx

• SSRI - Tx agression
• Neuroleptics, Li, anticonvulsants, other mood
  stabilizers, beta-blockers, clonidine - Tx
  violent behavior explosive rage
• Patients rarely present voluntarily

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Narcissistic

• Grandiosity in fantasy and behavior, need for
  admiration, lack of empathy for others
• Unconscious feeling of inadequacy, insecurity
• Usually high functioning
• Available for treatment when they are depressed
• Devastated by illness because it shatters their
  feeling of invincibility
• Grandiosity contributes to denial of illness

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Narcissistic, Tx

• Respect for sense of self importance
• Not reinforcing pathological grandiosity
• Initial approach of support followed by gradual
  confrontation of vulnerabilities can help to
  recognize their illness and deal with it
• Support and confrontation minimize insecurity
• Results in less defensive obnoxious behavior

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Histrionic

• Attention seeking, dramatic, theatrical,
  provocative, seductive, excessively emotional,
  insecure
• Shallow and rapidly shifting emotional reactions
• Use physical appearance to draw attention

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Histrionic

• Feel uncomfortable if not the center of attention
• Highly suggestible
• Influenced by others
• 10-15 psychiatric population

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Histrionic, Tx

• Long term psychotherapy
• Set boundaries - seductiveness can lead to
  inappropriate sexual contact
• Tactful confrontation to gain a realistic
  understanding of situation and their illness, and
  deal with it

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Histrionic, Tx

• Treat medical illness - since self-esteem is
  centered on body image or physical prowess,
  medical illness can be devastating
• Treat Axis I illness
• Address Axis III illness

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Avoidant

• Timidity, hypersensitivity to criticism and
  rejection, social discomfort
• Shyness and insecurity
• Feel anxious, depressed angry for failing to
  develop social relationship
• Comorbidity strong genetic component with
  anxiety disorders
• 10 psychiatric population

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Avoidant, Tx

• Approach - consistency, empathy support
• Improved cooperation by respecting needs for
  privacy modesty
• Tx Axis I DO, especially social anxiety

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Avoidant, Tx

• Psychotherapy - good response
• CBT
• Group
• Assertiveness
• Social skills training
• SSRI and benzodiazepines - very effective

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Dependent

• Excessive need to be taken care of
• Submissive and clinging behavior
• Fear of separation
• Feel very uncomfortable when alone
• While depressed or medically ill can become more
  dependent

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Dependent

• The most prevalent PDO - psychiatric setting
• 2.5 - general population
• Particularly vulnerable to depression

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Dependent, Tx

• Psychotherapy - very good response to
• insight oriented
• CBT
• social skills training
• assertiveness training
• supportive

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Dependent, Tx

• Team approach
• Not to foster into dependency
• Explain clearly the realistic limits of
  availability
• Antidepressants - Axis I
• Address Axis III

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Obsessive-Compulsive

• Preoccupation with rules and schedules
• Excessive devotion to work and productivity
• Stinginess
• Emotional constriction intellectualization
• 5-10 psychiatric settings

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Obsessive-Compulsive, Tx

• Focus on feelings rather than thoughts
• CBT group psychotherapy - help to overcome
  difficulties with intimacy
• Educate about illness in scientific and detailed
  fashion to assume self-monitoring and control

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Depressive

• Persistently feel unhappy, joyless, cheerless,
  gloomy, dejected
• Depressive cognition
• CBT, group psychotherapy
• Antidepressants?

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Passive-Aggressive

• Negativistic attitudes passive resistence to
  demands for adequate performance
• Argumentative authority-disliking
• Complainers who feel misunderstood by others
• Group psychotherapy

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