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PERSONALITY DISORDERS

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Title: PERSONALITY DISORDERS


1
PERSONALITY DISORDERS
  • WORLD LEADERS AND PERSONALITY DISORDERS
  • Dr. B. Al-Saigh
  • Psychiatry Rounds
  • August 06

2
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

3
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

4
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

5
DEFENITION OF PERSONALITY DISORDER (PD)
  • Chronic pattern of inner experience and behavior
    that is inflexible and presents across a broad
    range of situations

6
INTRODUCTION TO THE PERSONALITY DISORDERS
  • - FROM Association for Academic Psychiatry
  • Video Series
  • http//www.hsc.wvu.edu/aap/

7
VIDEO CLIP OF 10 PERSONALITY DISORDERS
8
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

9
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

10
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

11
OVERVIEW
  • Style of engagement may be inappropriate to the
    situation
  • Distant
  • Hostile
  • Overly intimate
  • Seductive
  • Anxious

12
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

13
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

14
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

15
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

16
PD CLUSTERS
  • A WEIRD
  • B WILD
  • C WORRIED

17
CONTENT
  • PART I
  • Cluster A PD (Paranoid, Schizoid, Schizotypal)
  • Cluster C PD (Avoidant, OC, Dependant)
  • Narcissistic DP
  • Histrionic
  • Antisocial PD
  • PART II
  • Borderline PD

18
PART I
  • Cluster A PD (Paranoid, Schizoid, Schizotypal)
  • Cluster C PD (Avoidant, OC, Dependant)
  • Narcissistic DP
  • Histrionic
  • Antisocial PD

19
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

20
PARANOID PD
  • Verbs used to describe
  • Distrust
  • Suspicion
  • Heightened sense of fear / vulnerability
  • Fear physician may harm / arguments / conflict

21
PARANOID PD
  • Physician should
  • Adopt a professional stance
  • Provide clear explanations
  • Be empathetic to fears
  • Avoid direct challenge to paranoid ideation

22
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.

23
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

24
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

25
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

26
SCHIZOID PD
  • Verbs used to describe
  • Emotional restriction
  • Social detachment
  • Anxiety because of forced contact with others
  • Delay seeking care
  • Appear unappreciative

27
SCHIZOID PD
  • Physician should
  • Adopt a professional stance
  • Provide clear explanations
  • Avoid over involvement in personal
  • and social issues

28
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

29
SCHIZOTYPAL PD
  • Physician should
  • Adopt a professional stance
  • Provide clear explanations
  • Tolerate odd beliefs and behaviors
  • Avoid over-involvement in personal and social
    issues

30
CLUSTER A TARGET S/S
  • Cognitive distortions
  • Perceptual distortions
  • Thought disorder
  • Interpersonal mistrust and distance

31
CLUSTER A TARGET S/S TX
  • ATYPICAL ANTIPSYCHOTIC
  • /- SSRI

32
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

33
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

34
AVOIDANT PD
  • Physician should
  • Provide reassurance
  • Validate concerns
  • Encourage reporting of symptoms and concerns

35
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

36
OBSESSIVE-COMPULSIVE
  • Physician should
  • Complete thorough history and
  • examinations
  • Provide thorough explanations
  • Do not overemphasize uncertainty
  • Encourage patient participation in treatment

37
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

38
DEPENDANT
  • Physician should
  • Provide reassurance
  • Schedule regular check-ups
  • Set realistic limits on availability
  • Enlist others to support patient
  • Avoid rejection of patient

39
CLUSTER C TARGET S/S
  • Anxiety
  • Behavioral Inhibition
  • Obsessional Thinking

40
CLUSTER C TARGET S/S TX
  • ANTI-DEPRESSANTS
  • BZ FOR CONTROL OF SHORT-TERM S/S

41
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

42
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

43
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

44
NARCISSISTIC
  • Physicians should
  • Validate concerns
  • Give attentive and factual responses to
  • questions
  • Channel patient's skills into dealing with
    illness

45
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.
46
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.

47
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

48
HISTRIONIC
  • Physician should
  • Avoid excessive familiarity
  • Show professional concern for feelings
  • Emphasize objective issues

49
ANTISOCIAL
  • Verbs used to describe
  • Disregards rights of others
  • Anger
  • Entitlement masking fear
  • Impulsive behavior
  • Deceit, manipulative

50
ANTISOCIAL
  • Physicians should
  • Carefully investigate concerns and motives
  • Communicate in a clear and
  • non-punitive manner
  • Set clear limits

51
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
52
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

53
CLUSTER B1 TARGET S/S
  • Depression
  • Interpersonal Sensitivity
  • Impulsivity
  • Aggression

54
CLUSTER B1 TARGET S/S TX
  • ANTI-DEPRESSANTS
  • /- MOOD STABILIZER
  • /- ATYPICAL ANTIPSYCHOTIC

55
CLUSTER B2 TARGET S/S
  • Mood lability
  • Impulsivity
  • Aggression
  • FHx Bipolar Spectrum D/O

56
CLUSTER B2 TARGET S/S TX
  • MOOD STABILIZER
  • /- ANTI-DEPRESSANT
  • /- ATYPICAL ANTIPSYCHOTIC

57
CLUSTER B3 TARGET S/S
  • Paranoia
  • Psychosis
  • Hostility
  • Overwhelming Anxiety

58
CLUSTER B3 TARGET S/S TX
  • ATYPICAL ANTI-PSYCHOTIC
  • /- ANTI-DEPRESSANT
  • /- MOOD STABILIZER

59
PART II
  • Borderline PD

60
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

61
CORE CLINICAL FEAURES
  • Very sensitive to abandonment
  • Inappropriate rage
  • Unfair accusations

62
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

63
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

64
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

65
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).

66
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

67
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

68
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

69
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

70
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

71
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

72
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

73
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)

74
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

75
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

76
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

77
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

78
PERSONALITY DISORDERSGEORGE W. BUSH
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