Personality Disorders

Question 1

Define personality

Answer 1

• The characteristics of an individual that are enduring, pervasive, distinctive.
• Consists of a person’s typical thoughts, core beliefs, behavior, emotional traits,temperament, and interpersonal style that assist the individual to cope with, and adapt to internal/external demands and stressors.

Question 2

DSM-5 (Section 2)–General Criteria for Personality Disorder (PD)

Answer 2

• A. Enduring pattern of inner experience & behavior that deviates markedly from an _individual’s culture**_.
• B. Pattern lacks flexibility, and is pervasive, pernicious, and persistent (the 3 Ps).
• C. Pattern manifests in 2 or > areas of functioning:
  
  • 1. Cognition – how a person perceives and processes information about him/her, about others, and about events.
  • 2. Affectivity – range, intensity, lability and appropriateness of emotional response.
  • 3. Interpersonal functioning – how the person relates to others and maintains relationships.
  • 4. Impulse control‐ the degree to which a person does or does not control their impulses.
• D. The pattern causes clinically significant impairment for the individual in social, occupational or other important areas of functioning.
• E. Onset by adolescence or early adulthood; childhood manifestations possible.
  
  • If PD is diagnosed before the age of 18 years, features must be present for at least 1 yr.
• F. Pattern is not attributed to the physiological effects of a substance or to another medical condition.

Question 3

DSM-5: Personality Clusters and Diagnoses

Answer 3

• PDs are grouped into categories/clusters, based on descriptive similarities rather than a unifying theory of personality development.
• Descriptive approach-has limitations, may suggest a clearer delineation between the clusters than actually exists.
• 1. Cluster A – Odd / eccentric presentation.
     * Paranoid, Schizoid, Schizotypal.
     * a. Characterized by social withdrawal & deviant modes of social functioning.
• 2. Cluster B – Dramatic / emotional/erratic.
     * Anti‐Social, Borderline, Histrionic, Narcissistic.
     * a. Characterized by poor impulse control & excessive emotionality.
• 3. Cluster C ‐ Anxious / fearful
     * Avoidant, Dependent, Obsessive Compulsive.
     * a. Characterized by heightened sensitivity to social rejection, focus on conformity.
• 4. Personality change due to another medical disorder;
     * Other specified PD and unspecified PD;
     * e.g., Mixed PD; PDs not yet classified

Question 4

Development of PD-Biopsychosocial Model

Answer 4

• sexual abuse-55% of borderline PD report sexual abuse

Question 5

Prevalence of PDs

Answer 5

A. International samples: 6%

B. Community samples in U.S.: 15% (30 million)4

C. Psychiatric outpatient samples:

• 31.4% with a specific PD
• 45.5% with unspecified PD

Question 6

Psychiatric comorbidity

Answer 6

• increased comorbidity with other mental disorders
  
  • sub use disorders
  • depression, anxiety
  • schizophrenia
  • avoidant PD and social anxiety/social phobia
  • comorbidiy overlap within and betwen PDs
• comorbidity leads to impairment and poorer prognosis

Question 7

Medical Comorbidity

Answer 7

• chronic pain, sequelae of substance use disorders and impulsive/risky behaviors
• PD pts often present to PCP with physical complaints (rather than psych)
• PD complicates medical care/prolongs medical tx
• PD associated with greater medical comorbidity including:
  
  • pain conditions
  • obesity and associated problems
  • sequelae from substance use or risky behaviors
  • chronic fatigue
  • greater medical utilization (e.g., physician and emergency room visits, hospitalizations)
  • poor adjustment to illness
  • **compliance issues.

Question 8

General considerations

Answer 8

• variability in symptoms is common
  
  • some PDs improve over time (borderline)
  • some worsen with crises (schizotypal, obsessive compulsive PDs)
• Diagnosis of PD often takes time.
  • Rule in/out other psychiatric and medical conditions and treat them, before making a final diagnosis of a PD.
  • take a longitudinal approach to assessment and diagnosis
    
    • psychological/personal measure, interview, collateral info

Question 9

What are some possible indicators of a PD?

Answer 9

• 1. Pt has “always been that way”.
• 2. high degree of chaos in the pt’s life.
• 3. Pt present with atypical problems that don’t fit easily into other diagnoses.
• 4. The pt has poor insight into how his/her behavior impacts others, blames others for problems.
• 5. pt has poor compliance with medical care.
• 6. You have noticeable rxns to the patient’s behavior (countertransference).
     * Pts with PDs often evoke: frustration, anger, helplessness, depletion, rescue fantasies, anxiety, and inadequacy.
     * Countertransference rxns can complicate a physician’s interaction with a pt/impede care if not recognized.

Question 10

Cluster A-Paranoid PD

Answer 10

2.3%; >M

Question 11

Cluster A-Schizoid PD

Answer 11

• loners
• emotionally/social detached
• restricted range of emotional expression
• indifferent to praise or criticism
• Prevalence & Associated Features
  
  • a. 3.1%; > males.
  • b. Familial link: > prevalence in relatives of patients with schizophrenia or schizotypal PD.

Question 12

Cluster A-Schizotypal PD (3%)

Answer 12

• Eccentricities
  
  • a. Odd beliefs, magical thinking, superstitious.
  • b. Speech - metaphorical, over elaborate.
• loners, suspiciousness, marked social anxiety
• Prevalence & Associated Features
  
  • a. ~ 3%.
  • b. Familial link - greater prevalence in 1st degree relatives of patients with schizophrenia.
  • c. Abnormalities in the temporal cortex. (MRI studies)

Question 13

Cluster A Comorbidities

Answer 13

1. Depression and anxiety disorders.
2. Substance abuse disorders.
3. Schizophrenia (familial link)

Question 14

Cluster A Behavior Patterns

Answer 14

• paranoid PD expects to be exploited, betrayed
• schizoid/schizotypal

Question 15

Cluster A-Life Problems

Answer 15

• low:
  
  • stress tolerance
  • level of adherence
• interpersonal issues; leading to:
  
  • social isolation
  • occupational problems
  • idiosyncratic behaviors that conflict with social norms

Question 16

Cluster A-Management

Answer 16

• countertransference
• trust issues
• dont challenge pt’s cognitive distortions unless firm rapport established
• include family to increase compliance

Question 17

Cluster A-Differential Diagnosis

Answer 17

• mental disorder with psychotic sxs
  
  • scizophrenia, delusional DO, mood DO with psychotic features
  • distinguised by chronic psychotic symptoms and change form pre-morbid state
• neurodevelopmental disorder
  
  • autism spectrum (mild); communication disorders
• substnace use disorders
• personality change due to another medical condition

Question 18

Cluster B-Antisocial PD (2-4%; >males)

Answer 18

• disregard for the rights of others
• socially irresponsible
• impulsive, irritable, can be aggressive
• lack empathy and remorse
• can be glib and charming

Question 19

Cluster B-Borderline PD (1.6-5.9; >women)

Answer 19

• instability
• impulsivity
• cognition
• recurrent suicidal behavior (8-12%), self-injury

Question 20

Cluster B-histrionic PD (2-3%)

Answer 20

• 1. Dramatic!! with excessive emotionality.
• 2. Attention seeking.
• 3. Entertaining…“the life of the party”.
• 4. Poor frustration tolerance.
• may be provocative, seductive
• 5. Prevalence & Associated Features
     * a. 2 ‐ 3%.
     * b. More freq dx in women, underdx in men.

Question 21

Cluster B-narcisstic PD (6.2%; >M)

Answer 21

• 1. Pathological sense of self‐importance.
• 2. Sense of entitlement, “special”, best understood by other high status ppl
• 3. Lack empathy, arrogant.
• 4. Fragile self‐esteem.
     * fall short of internal ideal self
• 5. Prevalence & Associated Features
     * a. 6.2% (more common in men).

Question 22

Cluster B-Comorbidities

Answer 22

• 1. Depression, anxiety disorders occur frequently (e.g., PTSD in BPD).
• 2. Somatoform disorders, anorexia/eating disordered behaviors.
• 3. Substance abuse.
• 4. ADHD (antisocial PD).
• 5. Neurobiological correlates of antisocial and borderline PDs
     * dysregulation of serotonergic and DA systems (e.g., serotonergic activity reduced in impulsive aggression).
• 6. Reduced amygdala volume on fMRI in some studies of borderline PD patients.
• 7. Higher freq of brain injury/trauma.
• 8. Greater comorbidity within Cluster B.

Question 23

Cluster B-Behavior Patterns

Answer 23

• low self esteem; fear exploitation, loss of status, love or abandonment, tend to use the following defense mechanisms:
• a. controlling –manipulation of people/events to reduce inner tension.
• b. acting out – dealing with conflicts / stress through actions rather than talking, leading to
• impulsive behavior.
• c. splitting – compartmentalizing emotions, behavior, and people into all good / all bad categories
• d. self injury – use of physical pain to DECREASE emotional arousal or DECREASE emotional numbing.
• e. somatization – expressing emotional distress through physical symptoms.

Question 24

Cluster B-Life Problems

Answer 24

• 1. Impulsivity leads to interpersonal, economic, employment, legal issues, injury/death.
• 2. Substance use disorders.
• 3. Anti‐social and narcissistic patients fear dependence on others, difficulty asking/accepting help.
• 4. Illness or an injury threatens the patient’s sense of personal integrity in narcissistic PD.
• 5. Borderline patients exhibit chronic self defeating behaviors.

Question 25

Cluster B-Management

Answer 25

* 1. Countertransference rxns are usually strong for Cluster B pts, range includes: anger, sympathy, amusement, inadequacy. * 2. Work to **empathize** with the pt’s fears (which the pt will not express directly). * 3. Be consistent and set appropriate limits but don’t be punitive, and take precautions if there is a h/o violence. * 4. Verbalize your intention to help the patient and attempt to satisfy **_reasonable_** requests.

Question 26

Cluster B-Differential Diagnosis

Answer 26

* 1. substance use disorder and bipolar affective disorder * (e.g., stimulant abuse, or hypomanic/manic states may mimic the grandiosity of narcissistic PD & the affective instability of borderline PD) * other mood disorders. * 2. Rule out any head trauma / frontal lobe injury * associated with impulsivity,aggression, affective instability. * 3. Personality change due to another medical condition or other PD.

Question 27

Cluster C-Avoidant PD (2.4%)

Answer 27

* 1. Socially inhibited & feel inadequate. * 2. Hypersensitive to negative evaluation. * 3. Avoid interpersonal contact, avoid conflict. * 4. Low self esteem. * 5. Prevalence & Associated Features * a. 2.4%, M=W * may start in childhood and remit with age

Question 28

Cluster D-Dependent PD

Answer 28

* 1. Submissive behavior. * a. Go to great lengths to obtain nurturance & support. * urgently seeks new ships when close ship ends * 2. Want others to assume responsibility for major areas of his/her life. * 3. Feels unable to care for self; helpless * 4. Low self‐efficacy. * 5. Prevalence & Associated Features=0.5%. * great difficulty making decisions

Question 29

Cluster C-Obsessive-Compulsive PD

Answer 29

* 1. Perfectionism, inflexibility & high need for mental/interpersonal control. * 2. Preoccupied with rules, efficiency, details and procedures. * 3. Over conscientious, micromanagers. * rigidity and stubbornness * 4. Prevalence & Associated Features * a. 2.1%‐7.9%. * b. M 2X\> W

Question 30

Cluster C-Comorbidities

Answer 30

* 1. Anxiety disorders; social phobia, panic disorder w/agoraphobia. * 2. Depression. * 3. Substance use disorder.

Question 31

Cluster C-Behavior Patterns

Answer 31

* anxiety prone and rigid, tend to use the following defense mechanisms: * a. **inhibition** – of emotions and thoughts in order to avoid conflicts with others. * b. **avoidance** – of people and situations to reduce anxiety. * c. **somatization** – expressing emotional distress through physical symptoms. * d. **intellectualization** – isolation of feelings from thoughts.

Question 32

Cluster C-Life Problems

Answer 32

* interpersonal issues * OCPD pts are extreme perfectionists * great difficult making decisions and getting things done * problems at work/home

Question 33

Cluster C-Management

Answer 33

* 1. **Countertransference rxns** – may feel overprotective, frustrated or angry. * 2. Empathize with pt’s fears and cognitive style. * 3. **Foster autonomy and shared decision making** * **​**avoid telling pt what to do * Verbalize willingness to provide care * Avoid power struggles with OCPD, provide w/thoughtful explanations.

Question 34

Cluster C: Differential Diagnosis

Answer 34

* 1. Avoidant PD may overlap w/Social phobia. * distinguished from schizoid PD (pt lacks interest in social relations) * 2. OCPD ‐ distinguish from Obsessive Compulsive Disorder * OCD: obsessions, compulsions, rituals in thought or behavior; egodystonic * OCPD: egosyntonic * 3. Hoarding disorder. * 4. Personality change due to another medical condition or other PD.

Question 35

Personality change due to another medical condition

Answer 35

* evidence the PD is related to an identifiable med condition * temporal lobe epilepsy, head trauma, brain tumor, Huntington's, SLE with CNS involvement * Differential: delirium, substance use

Question 36

Other specified/unspecified PD

Answer 36

* other specified PD: mixed personality featurs * unspecified PD-PD but does not meet full criteria for any single diagnosis, or insufficiet info is available

Question 37

Tx of PD

Answer 37

* A. Approx 30% or \> of pts who receive psychiatric services have at least 1 PD. * B. Tx of a PD often takes longer than tx of other psychiatric conditions. * C. Tx of comorbidities = better outcomes. * D. Past pessimism about treatment now replaced with cautious optimism. * E. Dropout rates range 21% ‐ 31%.

Question 38

Psychotherapy Tx-CBT

Answer 38

* uses a range of techniques * cognitive restructuring, behavior modification, psychoeducation, coping skills training * 45 studies: generally support CBT as an effective tx modality for pts with PDs

Question 39

How/why are PDs maintained?

Answer 39

* maladaptive beliefs about self and others * contextual/environmental factors that reinforce problematic behavior (or undermine effective behavior) * coping skills deficit

Question 41

Dialectical behavioral therapy (DBT) for BPD and other PDs

Answer 41

* DBT places value on balancing acceptance and change, creation of a life worth living * (dialectical philosophy and Eastern spiritual traditions). * Standard OP DBT includes: * Individual DBT, group skills training, phone consultation for coaching. * coping skills training improves pt’s ability to respond effectively in difficult situations by: * teaching mindfulness, interpersonal effectiveness, emotion regulation and distress tolerance. * Efficacy of full DBT tx demonstrated in multiple RCTs: * decreased self-injury, anger, fewer ED visits and hospitalizations, decreased depression and impulsiveness, better social adjustment.

Question 42

Psychopharmacological Tx

Answer 42

* 1. **Antipsychotics** can be used to tx cognitive/perceptual organization problems related to dysfunction in DA system * (e.g., common in **Cluster A and B** disorders). * 2. Selective serotonin reuptake inhibitors (**SSRIs**) can be considered for tx of impulsive and aggressive behaviors related to dysfunction in serotonergic system * (e.g., common in **Cluster B** disorders). * Augmentation with a mood stabilizer or anticonvulsant if needed. * 3. **SSRIs** with careful augmentation can be considered for treatment of mood stability and dysphoria related to dysfunction in serotonergic, cholinergic, noradrenergic systems * (e.g., common in **Cluster B** disorders). * \*Augmentation with anxiolytics as needed, but must be closely and carefully regulated. * 4. **SSRI** for anxiety related to dysfunction in serotonergic and noradrenergic systems * (e.g., common in **Cluster C**), careful augmentation with long acting anxiolytic if needed.

Question 43

Meta-analysis of 21 placebo-controlled RCTs with BPD and schizotypal pts

Answer 43

* antipsychotics * moderate effect on cognitive-perceptual symptoms * moderate to large effect on anger * antidepressants * no effect on impulsive behavior, small but significant effect on anxiety * low effect on depressive symptoms * Mood stabilizers * very large effect on mpulsive-behavior and anger * large effect on anxiety * moderate effect on depression

Question 44

Take Home Points

Answer 44

* A. Most pts with PD seek behavioral health services at urging of family or employer because of interpersonal difficulties. * B. Goal: establish a good, working relationship with the pt * C. Work to develop an alliance based on trust, acceptance and confidence. * D. Strive for empathy and to understand the pt’s behavior. * While the pt’s behavior is maladaptive, his/her goal is to minimize internal distress & meet personal needs. * For the pt, the behavior usually feels like a survival mechanism. * E. **\*\*Don’t personalize the pt’s behavior.\*\*** * F. Refer pts for psychotherapy and consider evidence based medications for targeted symptom management.