ICL 9.9: Personality Disorders

Question 1

what factors comprise someone’s personality?

Answer 1

personality = temperament (genetics) + character (environment)

personality is relatively stable and predictable, and characterizes the person’s responses in everyday living

factors contributing to personality:
1. genetics

2. past experiences
3. present experiences
4. view of future

Question 2

what are personality traits?

Answer 2

a characteristic patterns of perceiving, interacting with and thinking about one’s environment

everyone has personality traits, that’s normal!

Question 3

what is a personality disorder?

Answer 3

an enduring, inflexible and maladaptive manner of interacting with one’s environment

personality disorders often coexist with other disorders like depression and substance abuse

patient may meet criteria for > 1 personality d/o so don’t make dx based on one visit (illness-dependent) and take situation into account!!*** personality disorders must be enduring and you don’t know that from one visit

Question 4

why is it important to understand and recognize personality disorders?

Answer 4

1. help you tailor treatment to patient’s coping style
2. increased morbidity and mortality because o increased suicide, accidents, ED vists, injurious behaviors
3. increased rates of separation and divorce
4. affect course and prognosis of comorbid conditions
5. influence use of medications
6. reactions evoked in health care professionals; personality disorders can evoke strong feelings from healthcare professionals which may lead to nontherapeutic behaviors by staff or avoidance of patient which can result in failure to notice important sx

Question 5

in which demographics are personality disorders more common?

Answer 5

70-85% of criminals have personality d/o including murderers

60-70% of alcoholics have personality d/o

70-90% of drug abusers have personality d/o

Question 6

what are the 3 clusters of person disorders?

Answer 6

1. Cluster A = odd, eccentric

paranoid, schizoid, schizotypal

2. cluster B = dramatic, erratic, emotion

histrionic, narcissistic, antisocial, borderline

3. cluster C = anxious, fearful

dependent, avoidant, OCD

you can have more than one personality disorder! borderline and dependent traits are very common together

Question 7

which disorders are cluster A?

Answer 7

1. paranoid
2. schizoid
3. schizotypal personality disorder

Question 8

what is schizotypal personality disorder?

Answer 8

it’s characterized by odd, eccentric behavior, and perceptual distortions with social and interpersonal deficits resulting from discomfort with close relationships

pattern must begin in early childhood

Cluster A

Question 9

what is the clinical presentation of someone with schizotypal personality disorder?

Answer 9

1. magical thinking: clairvoyance, superstitious
2. peculiar appearance, speech
3. suspiciousness or paranoid ideation
4. ideas of reference; not delusions of reference – so you can reason with the patient and get them to realize the way they’re thinking isn’t right
5. poor interpersonal relationships = few friends
6. may decompensate under stress and become overtly psychotic for brief time

30-50% have Major Depressive Disorder

Question 10

what is the etiology of schizotypal personality disorder?

Answer 10

1. more common in biological relatives of schizophrenics
2. significantly less gray matter in temporal, frontal and parietal regions

deficits are linked to negative symptoms like social isolation, introversion, restricted emotions –> they won’t get your jokes or even fake laugh

Question 11

what is the course and prognosis of schizotypal personality disorder?

Answer 11

may be 1st apparent in childhood and adolescence with poor peer relationships, social anxiety, peculiar thoughts and language; may remain stable, work, get married

schizotypal personality disorder is premorbid personality for schizophrenia 10-20%

10% eventually commit suicide

Question 12

how do you treat schizotypal personality disorder?

Answer 12

most will not seek treatment and if do, it’s for related sx of depression, anxiety

1. psychotherapy

don’t be judgmental, goal is social skills training

2. pharmacotherapy

antipsychotics to treat ideas of reference and magical thinking and antidepressants for depression

3. medical

respect need for privacy due to fear of intimacy but demonstrate interest and concern for the patient

Question 13

which other conditions should be in your differential when you think someone has schizotypal personality disorder?

Answer 13

1. schizoid personality disorder

2. schizophrenia

Question 14

what is schizoid personality disorder?

Answer 14

lifelong pattern of social withdrawal, discomfort with human interaction, eccentricity, isolation beginning by early adulthood

“who cares what others think of me” or “I enjoy doing things alone more than with others”

Question 15

what are the clinical features of schizoid personality disorder?

Answer 15

1. appear apathetic and aloof, unsociable, seclusive –> difficult to make a connection with them, have few friends/confidantes
2. restricted affect
3. gravitate toward solitary jobs –> prefer night jobs, don’t want emotional ties with others, decreased experience of pleasure from sensory, bodily or interpersonal experiences
4. solitary interests; astronomy, computers, animals
5. no loss of capacity to recognize reality

Question 16

how do you treat schizoid personality disorder?

Answer 16

1. psychoterapy

may become devoted patients if they actually seek treatment and they may even reveal their fantasies, fears of dependence; group therapy may provide only social contact

2. pharmacotherapy

antipsychotics, antidepressants as needed

3. medical

respect their need for privacy due to fear of intimacy; they may be suspicious of authors figures

Question 17

which other conditions should be in your differential when you think someone has schizoid personality disorder?

Answer 17

1. schizphrenia
2. paranoid personality disorder
3. schizotypal personality disorder

Question 18

Miss G. is a 62-year-old woman recently diagnosed with cancer. Her doctors asked the psychiatrist to see Miss G. because she appeared depressed, was not eating, and refused to get out of her hospital bed, even to go to the bathroom. On exam, Miss G. said she had worked at a job which required little interaction with others. She said she had never married and did not have any friends. She did not appear bothered by this and said her dog was all the company she needed. She lived in her family’s home after her parents died. Her brother, who lived in another state, rarely heard from her. She reluctantly admitted to feeling depressed. Miss G. was started on Ritalin (a psychostimulant used to treat depression in medically ill patients in part because it works more quickly than antidepressants). The staff working with Miss G. were advised not to try to be too chummy with Miss G. because it made her uncomfortable. Miss G.’s depression responded well to the medication and staff reported improved interaction with her when they maintained a respectable distance.

Answer 18

schizoid personality disorder

Question 19

what is paranoid personality disorder?

Answer 19

long-standing suspiciousness and distrust of people leading to false interpretations of motivations and actions of others

“others can’t be trusted” and “people try to annoy me”

Question 20

what is the clinical presentation of someone with paranoid personality disorder?

Answer 20

1. expect others to exploit or harm them
2. interpret other’s actions as deliberately threatening
3. question, without justification, loyalty of friends, fidelity of spouse
4. hostile, irritable, angry
5. restricted affect - appear unemotional
6. persistent grudges (litigious)

associated with depression, suicide attempts

Question 21

what is the course and prognosis of paranoid personality disorder?

Answer 21

it may be prodrome of schizophrenia or delusional disorder; persecutory type:

normal vigilance –> paranoid personality disorder –> persecutory delusions –> paranoid schizophrenia

they’ll have lifelong problems living and working with others unless it’s a job that doesn’t require a lot of cooperation with others

difficulty with authority figures and intimate relationships

Question 22

how do you treat paranoid personality disorder?

Answer 22

1. psychotherapy

difficult to engage patients because of distrust but it’s the treatment of choice

2. pharmacotherapy

for agitation and anxiety; may need antipsychotics for delusional thoughts

3. medical = carefully explain procedures, medications and test results

Question 23

which other conditions should be in your differential when you think someone has paranoid personality disorder?

Answer 23

1. delusional disorder
2. paranoid schizophrenia
3. borderline personality disorder
4. schizoid

Question 24

what is histrionic personality disorder?

Answer 24

dramatic, attention-seeking behavior in emotional people

“to be happy, others must be paying attention to me”

“feelings are more important than being rational”

Question 25

what is the clinical presentation of someone with histrionic personality disorder?

Answer 25

1. attention-seeking, seductive behavior
2. constant need for praise and approval
3. exaggerated thoughts and feelings; use lots of superlatives in speech without specifics
4. excessive concern about physical attractiveness; continuous need for reassurance about their appearance
5. superficial relationships but they exaggerate level of intimacy of relationships (call new acquaintance a “dear friend”)
6. fundamentally insecure
7. increased risk for suicide gestures and threats to get attention

reality testing can become impaired under stress

may have comorbid MDD

Question 26

what is the course and prognosis of histrionic personality disorder?

Answer 26

they show less symptoms as they age

may have problems with law, promiscuity, and substance abuse due to thrill seeking

somatic symptoms and conversion disorders common

Question 27

how do you treat histrionic personality disorder?

Answer 27

1. psychotherapy

help them clarify their inner feelings of which they are often unaware

2. pharmacotherapy for depression and anxiety
3. medical: try to be respectful and professional in face of patient’s potentially dramatic behavior

Question 28

what is narcissistic personality disorder?

Answer 28

heighted sense of self-importance, and profound sense of entitlement

“I’m a very special person”

“I’m superior to others so I’m entitled to special treatment”

“others have no right to criticize me”

aka Barney Stinson!

Question 29

what are the clinical features of narcissistic personality disorder?

Answer 29

1. special people who deserve special treatment; inflated sense of self importance
2. easily maddened with criticism; snobbish, disdainful, patronizing
3. ambitious for fame and fortune; exaggerate their accomplishments, desire admiration, striking sense of entitlement
4. fragile relationships
5. lack of empathy

6, often exploit others

7. fragile self-esteem; sensitive to criticism and rejection, prone to substance abuse

Question 30

what is the course and prognosis of narcissistic personality disorder?

Answer 30

it’s chronic

aging is handled poorly since buety and youth are important

they often have MDD, psychosis and suicide in response to criticism or rejection

Question 31

how do you treat narcissistic personality disorder?

Answer 31

1. psychotherapy

this is the treatment of choice but it’s difficult since the patient will have to renounce their narcissism for effective treatment – they usually have negative therapeutic reactions and drop out early

2. pharmacotherapy

lithium for mood swings and antidepressants

3. medical: try to be non-defensive

Question 32

what is antisocial personality disorder?

Answer 32

inability to conform to societal norms

onset must be <15 years old

50-75% of prisoners

“I must look out for myself”, “the strongest survive”, “it’s okay to lie and cheat if you don’t get caught” and “who cares what others think”

ex. Walter White and Dexter

Question 33

what are the clinical features of antisocial personality disorder?

Answer 33

1. lying, truancy, promiscuity, substance abuse; symptoms must begin in adolescence
2. chronic disregard for rights of others; hostile, irritable, impulsive
3. lack empathy, social responsibility, guilt; unable to follow through on interpersonal commitments such as marriage and parenting
4. manipulative; ability to fool professionals

Question 34

what is the course and prognosis of antisocial personality disorder?

Answer 34

1. chronic; symptoms may decrease with increased age
2. many have somatic symptom disorder
3. depression, substance abuse
4. high risk for suicide

Question 35

how do you treat antisocial personality disorder?

Answer 35

1. psychotherapy

only agreeable if they are “cornered”, self-help groups have been the most successful

2. pharmacotherapy

for anxiety, rage and depression

3. medical: try to avoid temptation to be punitive, but set limits, avoid over prescription of medications

Question 36

what is borderline personality disorder?

Answer 36

characterized by unstable interpersonal relationships, self-image, mood, behavior

“i hate you, don’t leave me” or “I feel dead and cutting helps me know i’m alive”

ex. merideth grey

Question 37

how prevalent is borderline personality disorder?

Answer 37

2-3%

2 female : 1 male

Question 38

what are the clinical features of borderline personality disorder?

Answer 38

1. frequent crises
2. mood swings; but underlying affect usually chronic depression
3. repeated self-destructive behavior
4. brief, intense, interpersonal relationships
5. brief psychotic episodes when stressed, especially with perceived or real threat of abandonment
6. profound fear of abandonment, emptiness and boredom – can lead to promiscuous behavior, impulsivity, self-destructive behavior or suicide threats
7. feel chronically empty and bored
8. alternate between viewing others as either all good or all bad; can be the same person at different times
9. impulsive behavior: sex, spending, substance abuse, binge eating

Question 39

what is the etiology of borderline personality disorder?

Answer 39

it’s multifactorial

1. poor parenting styles; environmental instability
2. familial psychiatric disorders like depression, alcoholism, borderline personality disorder
3. sexual abuse; women with borderline personality disorder are 3-10 times more likely to have been victim of incest

Question 40

what is the course and prognosis of borderline personality disorder?

Answer 40

symptoms most severe in 20’s; 40-60% more stable by 30’s or 40’s and do not progress to develop schizophrenia

impulsive and destructive behavior which can result in significant morbidity and mortality

up to 10% commit suicide

Question 41

what is the treatment for borderline personality disorder?

Answer 41

1. psychotherapy
2. pharmacotherapy
3. medical

Question 42

how does psychotherapy help treat borderline personality disorder?

Answer 42

this is the treatment of choice!

1. behavior therapy for impulsivity
2. treat alcohol and drug abuse
3. deal with splitting and projective identification
4. must use reality-oriented approach

very difficult to get patients into therapy and they often don’t follow through; they’re quit impulsively when angry or feel abandoned

Question 43

how does pharmacotherapy help treat borderline personality disorder?

Answer 43

1. antidepressants like SSRIs decrease mood symptoms and impulsivity
2. antipsychotics for anger, hostility and psychotic symptoms
3. anticonvulsants to stabilize mood and impulsivity

Question 44

what considerations do you have to take as a physician when treating patients with borderline personality disorder?

Answer 44

they have difficulty trusting their MD

impulsiveness and self-destructive behavior hamper cooperation with medical recommendations

provide hope and a sense of stability

communicate openly with other staff to avoid splitting

psychiatric consult if necessary

Question 45

what is dependent personality disorder?

Answer 45

1. need to be taken care of
2. passivity
3. submission due to fears of being abandoned
4. pessimism

“I’m weak”, “I can’t make decisions unless others help me or tell me what to do”

Question 46

what are the clinical features of dependent personality disorder?

Answer 46

1. want others to make decisions for them as they lack self-confidence
2. feel helpless when alone
3. avoid positions of leadership or authority because they don’t want to make decisions
4. put needs of others ahead of their own due to dependency needs and fear or separation
5. may tolerate an abusive or chemically addicted spouse for long periods of time
6. typically begin new relationship quickly if an old relationship ends

Question 47

what is the course and prognosis of dependent personality disorder?

Answer 47

impaired occupational functioning due to difficulty functioning in an independent fashion

prone to mental and physical abuse due to their dependence on people and an inability to stand up for themselves

at risk for depression if they lose person upon whom they are dependent

Question 48

how do you treat dependent personality disorder?

Answer 48

1. psychotherapy

gain independence, assertiveness training (but don’t encourage them to leave their dependent relationship prematurely)

2. pharmacotherapy for anxiety and depression
3. medical

recognize need for reassurance but set limits, be consistent, provide structure, be very active in treatment planning

Question 49

what other conditions should be in your differential if you think someone has dependent personality disorder?

Answer 49

1. borderline personality disorder
2. histrionic personality disorder

dependent traits can be found in may psychiatric disorders

Question 50

what is avoidant personality disorder?

Answer 50

fear of rejection leading to social withdrawal despite a desire to be socially involved

“I’m socially inept and undesirable” or “if people get to know me they’ll reject me because they’ll see the real me”

ex. amy farrah fowler

Question 51

what are the clinical features of avoidant personality disorder?

Answer 51

1. shy, timid
2. lack self-confidence, views self as inferior and socially inept
3. afraid to speak in public
4. choose occupations which do not involve much interpersonal contact due to fears of criticism and rejection

can be difficult to distinguish from social phobia

Question 52

how do you treat avoidant personality disorder?

Answer 52

1. psychotherapy

encourage patient to take some risk and do assertiveness training

2. pharmacotherapy for depression and anxiety; B blockers for autonomic symptoms
3. medical: deal with patient in calm and reassuring manner, but expect them to participate in decision-making

Question 53

what other conditions should be in your differential if you think someone has avoidant personality disorder?

Answer 53

1. schizoid: dont’desire social interaction
2. borderline and histrionic: more demanding and irritable
3. dependent personality disorder: more fear of abandonment but may be very difficult to distinguish fear in situations in which one may be subject to the criticism

Question 54

what is obsessive compulsive personality disorder?

Answer 54

preoccupation with orderliness, perfectionism

this is different from OCD!!!! OCD has recurrent obsessions and compulsions and it’s not typically comorbid with this

“I have to depend on myself to make sure things get done right”

“there must be order to get a job done well”

“it’s important to do everything perfectly”

ex. Sheldon Cooper

Question 55

what are the clinical features of obsessive compulsive personality disorder?

Answer 55

1. rigid, serious and formal
2. emotional constriction; difficulty expressing emotions
3. no spontaneity; they plan everything
4. perfectionistic; overly concerned with details, orderliness; cannot delegate work because they think others won’t do it as well
5. lean toward highly structured occupations like mathematics and accounting

they devote themselves to work at the expense of social life

Question 56

how do you treat obsessive compulsive personality disorder?

Answer 56

1. psychotherapy; group therapy can be useful
   pts. seek treatment on their own because they know they are suffering
2. pharmacotherapy to treat depression and anxiety
3. medical: respect the patient’s need to be in control and don’t withhold information from the patient

Question 57

A 37-year-old white man has come to you with complaints of stomach pain. He really did not want to come to your office, but his wife insisted. He seems quite angry about being in your office, but really does not show much out-ward emotion. He tells you he does not trust health care professionals, or anyone else for that matter. He thinks his wife wanted him to leave the house so she could get together secretively with her friends.

diagnosis?

Answer 57

paranoid personality disorder

Question 58

A 23-year-old white female is making a return office visit for removal of sutures from her left wrist. She tells you she cut herself multiple times with a razor because she had been feeling badly last week. You also notice what appear to be cigarette burns on her hand. She tells you how nicely you treat her, and asks you to intervene on her behalf with the doctor, whom she tells you is so mean to her.

Answer 58

boderline personality disorder

Question 59

A 41-year-old married woman comes to your office for treatment of a possible broken finger. You also notice some bruises on her arms, and what appears to be a resolving black eye. When you suggest that her finger be splinted, she says she must ask her husband first, since he earns the money, makes all the decisions in the household, and may get upset if she spends too much money at your office.

Answer 59

dependent personality disorder

Question 60

which disorders are cluster B?

Answer 60

1. histrionic
2. narcissistic
3. antisocial
4. boderline

these are dramatic, erratic and emotional

Question 61

which disorders are cluster C?

Answer 61

1. dependent personality disorder
2. avoidant personality disorder
3. obsessive compulsive personality disorder

these are anxious and fearful people