PERSONALITY DISORDERS

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PERSONALITY DISORDERS

• WORLD LEADERS AND PERSONALITY DISORDERS
• Dr. B. Al-Saigh
• Psychiatry Rounds
• August 06

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RESOURCES

• Assessment and Management of Personality
  Disorders
• Randy Ward, M.D., Medical College of Wisconsin,
  Milwaukee, Wisconsin
• American Family Physician, October 2004
• Practice Guideline for the Treatment of Patients
  With Borderline Personality Disorder
• American Psychiatric Association
• Fasten Your Seat BeltsELIAS A. ZERHOUNI, Mayo
  Clinic Proceedings Commencement Address, May 2005

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RESOURCES

• Association for Academic Psychiatry
• Video Series
• http//www.hsc.wvu.edu/aap/
• From American Psychiatric Association.
  Personality disorders. In Diagnostic and
  statistical manual of mental disorders, 4th. ed.,
  text revision. Washington, D.C. American
  Psychiatric Association, 2000685-729

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ELIAS ZERHOUNI, MD, DIRECTOR, NIH

• We need to understand more about human behavior.
  What is it about humans that they do things they
  know they shouldnt do? What makes it possible
  for us to smoke, eat a poor diet, and not
  exercise, knowing full well that all this is
  harmful? Research on human behavior will need to
  be done during the next 10 to 15 years.
  Commencement Address
• Mayo Clinic School of Medicine
• May 2005

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DEFENITION OF PERSONALITY DISORDER (PD)

• Chronic pattern of inner experience and behavior
  that is inflexible and presents across a broad
  range of situations

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INTRODUCTION TO THE PERSONALITY DISORDERS

• - FROM Association for Academic Psychiatry
• Video Series
• http//www.hsc.wvu.edu/aap/

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VIDEO CLIP OF 10 PERSONALITY DISORDERS
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KEY PRINCIPLES

• PD are not diseases
• PD are dynamic systems
• Personality exists as a continuum
• Personality pathogenesis is not linear
• PD can be assessed but not definitively diagnosed
• Require strategically planned and combined modes
  of tactical intervention

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OVERVIEW

• Coded on DSM-IV axis II
• Personality disorders
• Personality traits
• Mental retardation
• Separate axis exists to ensure that appropriate
  attention is paid to these clinically significant
  disorders when a comprehensive psychiatric
  assessment is performed

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OVERVIEW

• Lifetime P in general population 10 to 13 .
• P in primary care outpatient settings 20 to 30
  
• Poorer treatment outcomes and health status /
  higher rates of health care use and costs in
  patients with co morbid personality disorders
• Many patients with whom physicians experience
  problematic relationships, and who have been
  referred to in the literature as patients who are
  "difficult" have personality disorders

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OVERVIEW

• Style of engagement may be inappropriate to the
  situation
• Distant
• Hostile
• Overly intimate
• Seductive
• Anxious

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OVERVIEW

• Interpersonal behavior of patient may elicit
  strong emotional reactions in physician
• Unrealistic expectations for the physician's
• Availability
• Time
• Ability to help the patient

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OVERVIEW

• Medical and psychiatric illnesses may present in
  an atypical fashion, and may not respond as
  expected to treatment
• Reactions to illness may exacerbate and intensify
  the patient's personality characteristics,
  further hampering his or her ability to obtain
  proper care
• The patient's insight into the presence of these
  disorders is usually limited or absent

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OVERVIEW

• Axis I psychiatric disorders can present with
  patterns of symptoms similar to those of a
  personality disorder
• These symptoms usually have an identifiable
  onset, and remit or improve with appropriate
  treatment
• Most efforts focus on maintaining and supporting
  the physician-patient relationship and
  establishing a working alliance
• Goal is to ensure that the patient is able to
  receive appropriate medical care despite the
  difficulty he or she may have in interacting with
  the physician and the health care system

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DDX OF PD SYMPTOMS OR CHANGE IN PERSONALITY

• Adjustment reaction
• Axis I psychiatric disorder
• Central nervous system disorder
• Medical disorder
• Medication use
• Substance abuse or dependence

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PD CLUSTERS

• A WEIRD
• B WILD
• C WORRIED

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CONTENT

• PART I
• Cluster A PD (Paranoid, Schizoid, Schizotypal)
• Cluster C PD (Avoidant, OC, Dependant)
• Narcissistic DP
• Histrionic
• Antisocial PD
• PART II
• Borderline PD

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PART I

• Cluster A PD (Paranoid, Schizoid, Schizotypal)
• Cluster C PD (Avoidant, OC, Dependant)
• Narcissistic DP
• Histrionic
• Antisocial PD

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CLUSTER A OVERVIEW

• Paranoid Schizoid - Schizotypal
• Often referred to as the "schizophrenic spectrum
  cluster"
• Do not respond appropriately to affective cues
  from the physician
• Are unable to form connections on a basic
  emotional level

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PARANOID PD

• Verbs used to describe
• Distrust
• Suspicion
• Heightened sense of fear / vulnerability
• Fear physician may harm / arguments / conflict

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PARANOID PD

• Physician should
• Adopt a professional stance
• Provide clear explanations
• Be empathetic to fears
• Avoid direct challenge to paranoid ideation

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PARANOID PD

• Mistrust of Friends
• Doubts the loyalty or trustworthiness of friends
  or associates
• Bearing Grudges
• Bears grudges seldom forgives others mistakes
• Feeling Victimized
• Feels exploited or victimized seldom expresses
  gratitude
• Healthy people trust their friends, are
  forgiving, and freely express praise and
  gratitude.

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PARANOID PD

• Historically, all of the worlds most murderous
  leaders exhibited Paranoid Personality Disorder
• Mistrust of Friends
• They promoted a culture of fear in which no one
  was trusted
• Bearing Grudges
• They promoted hatred of a common enemy to gain
  political power
• Feeling Victimized
• They convinced their followers that they were the
  victims of a global conspiracy of evil

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PARANOID PD

• Paranoia Cycles Out Of Control
• Feeling victimized by an imaginary villain
  leads to
• Wanting revenge against the imaginary villain
  which leads to
• A preemptive attack against the imaginary
  villain which leads to
• A defensive counter-attack from the injured party
  which leads to
• Feeling more victimized

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PARANOID PD

• Paranoia Has Killed Millions
• Leaders with Paranoid Personality Disorder
  eventually destroy millions of innocent
  civilians
• Mao Tse-Tung brought about the death of more than
  70 million people during peacetime
• Hitler brought about the Holocaust which killed 6
  million Jews and millions of other innocent
  minorities
• Stalin brought about the death of 20-60 million
  people as a direct result of his tyrannical rule

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SCHIZOID PD

• Verbs used to describe
• Emotional restriction
• Social detachment
• Anxiety because of forced contact with others
• Delay seeking care
• Appear unappreciative

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SCHIZOID PD

• Physician should
• Adopt a professional stance
• Provide clear explanations
• Avoid over involvement in personal
• and social issues

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SCHIZOTYPAL PD

• Verbs used to describe
• Odd beliefs and behavior
• Socially isolative
• Odd interpretations of illness
• Anxiety because of forced contact with others
• Delay seeking care

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SCHIZOTYPAL PD

• Physician should
• Adopt a professional stance
• Provide clear explanations
• Tolerate odd beliefs and behaviors
• Avoid over-involvement in personal and social
  issues

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CLUSTER A TARGET S/S

• Cognitive distortions
• Perceptual distortions
• Thought disorder
• Interpersonal mistrust and distance

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CLUSTER A TARGET S/S TX

• ATYPICAL ANTIPSYCHOTIC
• /- SSRI

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CLUSTER C OVERVIEW

• Avoidant OC - Dependant
• All patients exhibit anxiety in some form
• Caused by fears of evaluation by others,
  abandonment, or loss of order
• Uncomfortable ideas/sensations cause distress
  interfere with functioning within the
  physician-patient relationship
• Physician must use appropriate strategies to help
  allay this anxiety and establish an effective
  working relationship with these patients

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AVOIDANT PD

• Verbs used to describe
• Social inhibition due to fears of rejection or
• humiliation
• Heightened sense of inadequacy
• Low self-esteem
• Withholds information
• Avoids questioning or disagreeing with physician

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AVOIDANT PD

• Physician should
• Provide reassurance
• Validate concerns
• Encourage reporting of symptoms and concerns

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OBSESSIVE-COMPULSIVE

• Verbs used to describe
• Preoccupation with orderliness, perfection,
• control
• Fear of losing control of bodily functions
• and emotions
• Fear of relinquishing control
• Excessive questioning and attention to details
• Anger about disruption of routines

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OBSESSIVE-COMPULSIVE

• Physician should
• Complete thorough history and
• examinations
• Provide thorough explanations
• Do not overemphasize uncertainty
• Encourage patient participation in treatment

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DEPENDANT

• Verbs used to describe
• Excessive need to be taken care of
• Submissive/clinging behavior/fear of abandonment
• Helplessness
• Urgent demands for attention
• Prolongation of illness behavior to obtain
  attention and care

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DEPENDANT

• Physician should
• Provide reassurance
• Schedule regular check-ups
• Set realistic limits on availability
• Enlist others to support patient
• Avoid rejection of patient

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CLUSTER C TARGET S/S

• Anxiety
• Behavioral Inhibition
• Obsessional Thinking

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CLUSTER C TARGET S/S TX

• ANTI-DEPRESSANTS
• BZ FOR CONTROL OF SHORT-TERM S/S

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CLUSTER B OVERVIEW

• Narcissistic Histrionic Antisocial -
  Borderline
• Can be among the most challenging patients
  encountered in clinical settings
• Can be excessively demanding, manipulative,
  emotionally unstable, and interpersonally
  inappropriate
• May attempt to create relationships that cross
  professional boundaries
• Can place physicians in difficult or compromising
  positions

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CLUSTER B OVERVIEW

• Physicians often experience strong emotional
  reactions to these patients
• Physicians must be keenly aware of the issues of
  manipulative behavior, professional boundaries,
  limit setting, and monitoring their own emotional
  state

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NARCISSISTIC

• Verbs used to describe
• Grandiosity, Need for Admiration, Attitude
• of entitlement
• Lack of empathy
• Anxiety caused by doubts of personal adequacy
• Demanding / Denial of illness
• Alternating praise and devaluation of physician

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NARCISSISTIC

• Physicians should
• Validate concerns
• Give attentive and factual responses to
• questions
• Channel patient's skills into dealing with
  illness

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NARCISSISTIC

• Three behaviors form core of NPD
• Arrogance
• Is arrogant or proud feels superior to others
• Domineering Behavior
• Is domineering or dictatorial has a bossy way of
  ordering others around
• Greed
• Is selfishly greedy wants to possess much more
  than what he/she needs or deserves

Healthy people are humble,
democratic, and unselfish.
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NARCISSISTIC LEADERS

• Historically, many tyrants exhibited
  Narcissistic Personality Disorder
• Arrogance
• They were very arrogant and proud
• Domineering Behavior
• They were dictatorial and autocratic
• Greed
• They monopolized their nations power and wealth
• Usually exhibit both Paranoid and Narcissistic
  PD.

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HISTRIONIC

• Verbs used to describe
• Excessive attention-seeking behavior
• Emotionality Threatened sense of
• attractiveness and self-esteem
• Overly dramatic / Somatization
• Attention-seeking behavior
• Inability to focus on facts and details

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HISTRIONIC

• Physician should
• Avoid excessive familiarity
• Show professional concern for feelings
• Emphasize objective issues

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ANTISOCIAL

• Verbs used to describe
• Disregards rights of others
• Anger
• Entitlement masking fear
• Impulsive behavior
• Deceit, manipulative

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ANTISOCIAL

• Physicians should
• Carefully investigate concerns and motives
• Communicate in a clear and
• non-punitive manner
• Set clear limits

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ANTISOCIAL

• Three behaviors form the core of APD
• Intolerance
• Is judgmental or prejudiced doesnt respect the
  beliefs and practices of others
• Irresponsibility or Dishonesty
• Doesnt take responsibility for own actions is
  dishonest lies, cheats, or steals
• Manipulativeness
• Selfishly or unethically manipulates others for
  his/her own advantage

Healthy people are tolerant, responsible,
honest, and dont unethically exploit others
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ANTISOCIAL LEADERS

• Historically, the most ruthless world leaders had
  Antisocial Personality Disorder
• Intolerance
• Persecuted their minorities and permitted
  genocides
• Irresponsibility or Dishonesty
• They habitually lied to their citizens as their
  friends looted their nations wealth
• Manipulativeness
• They constantly manipulated others for their own
  unethical advantage

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CLUSTER B1 TARGET S/S

• Depression
• Interpersonal Sensitivity
• Impulsivity
• Aggression

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CLUSTER B1 TARGET S/S TX

• ANTI-DEPRESSANTS
• /- MOOD STABILIZER
• /- ATYPICAL ANTIPSYCHOTIC

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CLUSTER B2 TARGET S/S

• Mood lability
• Impulsivity
• Aggression
• FHx Bipolar Spectrum D/O

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CLUSTER B2 TARGET S/S TX

• MOOD STABILIZER
• /- ANTI-DEPRESSANT
• /- ATYPICAL ANTIPSYCHOTIC

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CLUSTER B3 TARGET S/S

• Paranoia
• Psychosis
• Hostility
• Overwhelming Anxiety

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CLUSTER B3 TARGET S/S TX

• ATYPICAL ANTI-PSYCHOTIC
• /- ANTI-DEPRESSANT
• /- MOOD STABILIZER

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PART II

• Borderline PD

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CORE CLINICAL FEATURES

• Pervasive pattern of
• Instability of interpersonal relationships
• Instability of affect
• Instability of self-image
• Marked impulsivity beginning in early
• childhood
• Severe and persistent enough to result in
  clinically significant impairment in social,
  occupational, or other important areas of
  functioning
• Severely impaired capacity for attachment
• Predictably maladaptive behavior in response to
  separation

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CORE CLINICAL FEAURES

• Very sensitive to abandonment
• Inappropriate rage
• Unfair accusations

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CORE CLINICAL FEAURES

• Self-mutilation or suicidal
• behaviors
• Relationships are unstable,
• intense, and stormy
• Views of others may suddenly and dramatically
  shift
• Alternating between extremes of idealization and
  devaluation, or seeing others as beneficent and
  nurturing and then as cruel, punitive, and
  rejecting

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CORE CLINICAL FEATURES

• Impulsive in
• Spending money irresponsibly
• Gambling
• Engaging in unsafe sexual behavior
• Abusing drugs or alcohol
• Driving recklessly
• Binge eating
• Self-mutilation (e.g., cutting or burning)
• Unstable self-image
• Chronic feelings of emptiness

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CORE CLINICAL FEATURES

• Inappropriate, intense anger
• Difficulty controlling anger during periods
• of extreme stress (e.g., perceived or actual
  abandonment)
• May experience transient paranoid ideation
• or severe dissociative symptoms
• (e.g., depersonalization)
• Recurrent suicidal behaviors, gestures, or
  threats
• Affective instability
• Marked mood reactivity (e.g., intense episodic
  dysphoria, irritability, or anxiety

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ASSOCIATED FEATURES

• Transient psychotic-like symptoms _at_
• times of stress
• Usually last for minutes or hours
• Generally of insufficient duration or
• severity to warrant an additional
• diagnosis
• Tendency to undermine themselves when a goal is
  about to be reached (e.g., severely regressing
  after a discussion of how well therapy is going).

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ASSOCIATED FEATURES

• Individuals with this disorder may feel
• more secure with transitional objects
• (e.g., a pet or inanimate object) rather than
• with interpersonal relationships
• Physical and sexual abuse, neglect,
• hostile conflict, and early parental loss or
  separation are more common in the childhood
  histories of those with borderline personality
  disorder than in those without the disorder

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COMORBID CONDITIONS

• Commonly co-occurring Axis I disorders
• Mood disorders
• Substance-related disorders
• Eating disorders (notably bulimia)
• PTSD
• Panic disorder
• ADHD
• Commonly co-occurring axis II disorders
• Antisocial
• Avoidant
• Histrionic
• Narcissistic
• Schizotypal

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COMORBID CONDITIONS

• BPD vs Bipolar D/O
• In BPD, the mood swings are often
• triggered by interpersonal stressors
• (e.g., rejection), and a particular mood
• is usually less sustained than in
• bipolar disorder
• BPD vs MDD
• Depressive features that appear particularly
  characteristic of borderline personality disorder
  are emptiness, self-condemnation, abandonment
  fears, self-destructiveness, and hopelessness

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COMORBID CONDITIONS

• BPD vs Dysthymic Disorder
• Chronic dysphoria is very
• common in individuals
• with borderline personality disorder
• Presence of the aforementioned
• affective features (e.g., mood
• swings triggered by interpersonal
• stressors) should prompt consideration of the
  diagnosis of BPD
• Other features of BPD (e.g., identity
  disturbance, chronic self-destructive behaviors,
  frantic efforts to avoid abandonment) are
  generally not characteristic of axis I mood
  disorders

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COMORBID CONDITIONS

• BPD vs PTSD
• Hx of trauma often characteristic of
• patients with BPD and does not
• necessarily warrant an additional
• diagnosis of PTSD
• PTSD should be diagnosed only when
• full criteria for the disorder are met
• PTSD is characterized by rapid-onset
• symptoms that occur, usually in adulthood,
• in reaction to exposure to a recognizable and
  extreme stressor in contrast, borderline
  personality disorder consists of the early-onset,
  enduring personality traits described earlier

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COMORBID CONDITIONS

• BPD vs DID
• DID is characterized by the
• presence of two or more distinct
• identities or personality states that
• alternate, manifesting different
• patterns of behavior

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EPIDEMIOLOGY

• Most common personality disorder in clinical
• settings
• Present in
• 10 of individuals seen in outpatient MHC
• 1520 of psychiatric inpatients
• 3060 of clinical populations with a
• personality disorder
• 2 of the general population

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EPIDEMIOLOGY

• Present in cultures around the world
• Approximately five times more
• common among first-degree
• biological relatives of
• those with the disorder than in the
• general population
• Greater familial risk for substance-related
  disorders, antisocial personality disorder, and
  mood disorders
• Diagnosed predominantly in women (gender ratio
  31)

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COMPLICATIONS

• Notable distress / Functional impairment
• Majority attempt suicide
• Completed suicide occurs in 10 of pts
• 50 times higher than in the general population.
• Risk highest when pts. are 20s as well
• as in presence of co-occurring
  MD/Substance-Related Disorders
• Difficulty with occupational, academic, or role
  functioning
• Recurrent job loss and interrupted education are
  common

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COMPLICATIONS

• Difficulties in relationships, as well
• as divorce
• Social cost for patients with BPD and their
• families is substantial
• May gradually attain functional roles
• 1015 years after admission to
• psychiatric facilities
• Still only about one-half will have stable,
• full-time employment or stable marriages
• Greater lifetime utilization of most major
  categories of medication and of most types of
  psychotherapy than do patients with Schizotypal,
  Avoidant, OC PD or patients with MDD

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BORDERLINE PD

• Physician should
• Avoid excessive familiarity
• Schedule regular visits
• Provide clear, nontechnical explanations
• Tolerate angry outbursts, but set limits
• Maintain awareness of personal feelings

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BAD WORLD LEADERS

• Historically, the worst world leaders had a
  combination of APD NPD PPD
• Their behavior exhibited
• Pathological mistrust
• Lack of forgiveness
• Feeling constantly the victim
• Arrogance / Greed
• Dictatorial behavior
• Intolerance / Dishonesty
• Manipulativeness

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PERSONALITY DISORDERSGEORGE W. BUSH