What is a Personality Disorder

1
What is a Personality Disorder?

• Personality characteristics that are unchanging
  and occur in most settings
• Deviate from cultural norms
• Cause poor life functioning
• Long term traits feel natural to the pt
• Many pts display only when under stress

2
How is it different from Personality?

• The more general term, personality, is a
  consistent style of behavior
• It is uniquely recognizable in EACH individual

3
What Axis does a Personality Disorder fall under?

• Axis II

4
How does a personality disorder develop?

• Begins to take shape in childhood
• Become fixed by early 20s
• Some occur after organic insult to brain (trauma)
• Some have biologic and/or genetic component
• E.g., schizotypal and borderline personality
  disorders

5
What may facilitate diagnosis?

• Psychological Testing
• WAIS
• MMPI
• Bender-Gestalt
• Rorschach ink blot

6
What can a PD be confused with?

• An Axis I disorder. Why??? B/C
• Atypical and mixed types are common
• Some may grade into or be confused with Axis I dx
• Ex Paranoid PD may appear to be paranoid
  schizophrenia

7
How do PD pts deal with treatment?

• PD pts often resist treatment
• Change slowly
• Occasionally respond to some treatment
• Individual or group therapy
• Short-term use of antianxiety meds
• Low doses of major tranquilizers
• Some may require inpatient tx during periods of
  decompensation

8
Can children be dx with a PD?

• Yes -- Adolescents (under 18) and children may
  receive PD dx except for one.
• Which one can they not be diagnosed with?
• Antisocial PD

9
What are the guidelines for diagnosing a child
with a PD?

• The personality pattern must be stable and clear
• Must be incompatible with an Axis I childhood
  disorder

10
How many personality Disorders are there?

• Ten
• Divided into three clusters
• Name the clusters
• Odd eccentric
• Dramatic, emotional, and erratic
• Anxious, fearful

11
Name the three types of PD in the Odd Eccentric
Cluster

• Paranoid Personality Disorder
• Schizoid Personality Disorder
• Schizotypal Personality Disorder
• Mnemonic OPSS

12
What are characteristics of a pt with Paranoid PD?

• Aloof emotionally cold
• Unjustified suspiciousness
• Hostile hypersensitive to slights
• Jealous fears intimacy
• Grandiose, rigid, unforgiving, sarcastic,
  contentious, litigious
• Isolated and disliked
• Accept criticism poorly blame others

13
What disorders can Paranoid PD be associated with?

• Chronic CNS impairment
• Drug abuse (amphetamines)
• Depression
• OCD
• Precursor to schizophrenia

14
What is the tx of Paranoid PD?

• If psychotic decompensation occurs, major
  tranquilizers may be needed
• Otherwise, these pts rarely seek tx and therapy,
  including medication, is of little value

15
What are the characteristics of Schizoid PD?

• Seclusive
• Little desire/capacity to form interpersonal
  relations
• Derive little pleasure from social/sexual
  contexts
• Prefer and perform well at solitary activities
• Have limited emotions experience little pleasure
• Daydream excessively
• Humorless and detached
• Loners are not necessarily schizoid unless they
  have imparied functioning
• DO NOT have increased risk of developing
  schizophrenia!

16
How is Schizoid PD treated?

• Treatment is of little help.

17
What are characteristics of Schizotypal PD?

• They have features of schizoid pd
• Isolated, anhedonic, aloof
• In addition, these pts are peculiar.
• Relate strange intrapsychic experiences
• Have odd and magical beliefs strange speech
• Frequently anxious
• Difficult to get to know

18
What is the incidence of Schizotypal PD?

• 3 of population
• Commonly co-occurs with Major Depression
• Associated with increased incidence of
  schizophrenia in family members

19
What biological sx can occur with Schizotypal PD?

• Impaired eye tracking
• Increased CSF homovanillic acid
• What is the treatment for Schizotypal PD?
• Low dose antipsychotics may reduce flamboyant
  sxs

20
What are the 4 PDs of the Dramatic, Emotional,
and Erratic Cluster?

• Antisocial PD
• Borderline PD
• Histrionic PD
• Narcissistic PD

21
What are characteristics of Antisocial PD?

• Begins in childhood or early adolescence
• Aggressiveness fighting
• Poor peer relationships
• Irresponsibility, lying, theft, truancy
• Poor school performance
• Runaway, inappropriate sexual activity
• Drug and alcohol use

22
What are characteristics of Antisocial PD in
adults?

• Criminality assaultiveness
• Self-defeating impulsivity
• Hedonism
• Promiscuity
• Unreliability
• Crippling drug and alcohol abuse
• Fail at work and change jobs frequently
• Go AWOL dishonorable dc from service
• Are abusing parents and neglectful mates
• Cannot maintain intimate relationships

23
More characteristics of Antisocial PD

• Often spend time in jails and prisons
• Half or more of prisoners!
• Typically are anxious and depressed
• 5 commit suicide (impulsivity)
• Behavior peaks in adolescence
• Improves in 30s but rarely recover
• Males are more severely affected and more
  frequently than females
• Childhood can be marked with criminal parents,
  neglect, poverty, desertion, inconsistent
  discipline, and alcoholic and/or unemployed
  parents

24
What tests can help Dx Antisocial PD?

• No tests are diagnostic
• MMPI can help
• May be nonspecific EEG abnormalities
• Increased slow-wave activity

25
What must be r/o before Dx Antisocial PD?

• Primary drug and alcohol abuse
• Schizophrenia
• Pathological gambling, kleptomania, or pyromania

26
How do you treat Antisocial PD?

• Pts are very RESISTANT to treatment very
  manipulative
• Do not rely on info from pt check your own data
• Rarely seek help tx is often difficult and
  unsuccessful
• Best results follow closely supervised inpatient
  care (outpatient little value)

27
What are characteristics of Borderline PD?

• Socially adapted complex presentations
• Combinations of
• Anger, sarcasm, anxiety, intense and labile
  affect
• Brief disturbances in consciousness
• Chronic loneliness, boredom, emptiness
• Unstable and volatile interpersonal relations
• Identity confusion
• Impulsive behavior like self-cutting and
  self-mutilation
• Recurrent suicide attempts (death by suicide 8)
• Hypersensitivity to abandonment

28
What other diagnoses can occur with Borderline PD?

• Depression
• Brief Psychotic Disorder
• Other personality disorders
• Substance-related disorders
• Note There is sometimes a hx of childhood
  abuse

29
How do you treat Borderline PD?

• Psych testing useful
• R/O other organic states
• Mild delerium, epilepsy, acute drug use
• Long term, intermittent, supportive psychotherapy
  is often beneficial
• Low dose antipsychotics, antidepressants (SSRIs),
  or Lithium
• These pts may stabilize in 40s and 50s

30
What characterizes Histrionic PD pts?

• Initially seem charming and likable
• Later seen as emotionally unstable, egocentric,
  immature, and manipulative
• Excitement-seeking and shallow
• Demand attention exhibitionistic
• Limited ability to maintain stable interpersonal
  relationships with either sex

31
What disorders are associated with Histrionic PD?

• Depression
• Substance Abuse
• Conversion and Somatization Disorders
• How do you treat this?
• Lesser impaired pts may respond to psychotherapy

32
What are characteristics of Narcissistic PD?

• Often sx free and well functioning
• Chronically dissatisfied due to a constant need
  for admiration
• Have unrealistic self-expectations
• Impulsive and anxious
• Arrogant, envious, and lack empathy
• Ideas of being a special person
• Become quickly dissatisfied with others
• Maintain superficial, exploitative relationships
• May become depressed or rageful under stress and
  when others are not adequately admiring
• Mixtures with other PDs common

33
How do you treat Narcissistic PD?

• Long-term psychotherapy may help

34
What are the three disorders in the Anxious
Fearful Cluster?

• Avoidant PD
• Dependent PD
• Obsessive-Compulsive PD

35
What are characteristics of Avoidant PD?

• Shy, lonely, hypersensitive
• Low self-esteem
• Would rather avoid personal contact that face
  social disapproval, though desperate for personal
  involvement
• Assume others will be critical affects everyday
  life
• Troubled by anxiety and depression social phobia

36
How do you treat Avoidant PD?

• Group therapy may help

37
What are characteristics of Dependent PD?

• Excessively passive, unsure, pessimistic
• Isolated and hypersensitive to criticism
• Abnormally dependent on one or more persons
• Subtly controlling of others
• Anxiety and depression common (esp if
  relationship threatened)

38
What are characteristics of Obsessive-Compulsive
PD?

• Pts are frequently successful men
• Inhibited, stubborn, and perfectionistic
• Judgmental, overly conscientious
• Rigid and chronically anxious
• Avoid intimacy experience little pleasure from
  life
• Indecisive and demanding
• Perceived as cold and reserved

39
What disorders are Obsessive-Compulsive PD pts at
risk for developing?

• Depression
• Perhaps OCD
• How do you treat?
• Psychotherapy