Personality Disorders

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Personality Disorders

• W Klugh Kennedy, PharmD, BCPP, FASHP, FCCP
• Clinical Professor of Pharmacy Practice and
  Psychiatry
• Mercer University, Savannah Georgia
• kennedy_wk_at_mercer.edu

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Medications

• No medications specifically approved by the Food
  and Drug Administration (FDA) to treat
  personality disorders.
• Antidepressants. Antidepressants may be useful
  for have a depressed mood, anger, impulsivity,
  irritability or hopelessness, which may be
  associated with personality disorders.
• Mood stabilizers. May help even out mood swings
  or reduce irritability, impulsivity and
  aggression.
• Antipsychotic medications. may be helpful if
  symptoms include losing touch with reality
  (psychosis) or in some cases if you have anxiety
  or anger problems.
• Anti-anxiety medications. These may help if you
  have anxiety, agitation or insomnia. But in some
  cases, they can increase impulsive behavior, so
  they're avoided in some personality disorders.

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Personality Disorder

• Enduring pattern of inner experience and behavior
  that deviates markedly from expectations of
  individual's culture. Pattern is manifested in
  two (or more) of the following areas
• Cognition (i.e., ways of perceiving and
  interpreting self, others, and events)
• Affectivity (i.e. range, intensity, lability, and
  appropriateness of emotional response)
• Interpersonal functioning
• Impulse control
• Inflexible and pervasive across a broad range of
  personal and social situations
• Clinically significant distress or impairment in
  one or more area of functioning
• The pattern is stable and of long duration, and
  its onset can be traced back at least to
  adolescence or early adulthood
• Not better accounted for as a manifestation or
  consequence of another mental disorder
• Not due to the direct physiological effects of
  substance abuse or a general medical condition '
• Other Criteria
• If less than 18 years old, must have features for
  greater than or equal to one year
• Ego-syntonic in nature (i.e, belief that there is
  dysfunction with the outside world, but not
  within one's self)

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Personality Style

• enduring pattern of inner experience and behavior
  that deviates markedly from the expectations of
  the culture of the individual who exhibits it
• long-lasting rigid patterns of thought and
  behavior. inflexibility and pervasiveness of
  these patterns
• They do not cause significant problems and
  impairment of functioning for the persons who are
  afflicted with these disorders

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Clusters

• Cluster A, B, C
• Mad, Bad, Sad
• Weird, Wild, Worried

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Cluster A

• Schizoid
• Schizotypal
• Paranoid

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Paranoid Personality Disorder

• Diagnosis 4 or more
• Suspicion that others are deceiving him or her
• Preoccupation with doubts of loyalty of
  acquaintances
• Reluctance to confide in others
• Interpretation of benign remarks as threatening
  or demeaning
• Persistence of grudges
• Perception of attacks on his/her character
• Recurrence of suspicions regarding fidelity of
  spouse or lover

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Paranoid Personality Disorder

• Epidemiology
• Prevalence 0.5-2.5
• MengtWomen
• Higher incidence in family members of
  schizophrenics
• Course defined by personality DO
• Treatment

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Schizoid Personality Disorder

• Diagnosis 4 or more
• Neither enjoying nor desiring close relationships
• Choosing solitary activities
• Little interest in sexual activity
• Taking pleasure in few activities
• Few close friends
• Indifference to praise or critism
• Detached

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Schizoid Personality Disorder

• Epidemiology
• Prevalence 7
• MengtWomen
• No increased incidence of schizoid personality in
  families with hx of schizophrenia
• Course defined by personality DO
• Treatment

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Schizotypal Personality Disorder

• Diagnosis 5 or more
• Ideas of reference
• Magical thinking
• Unusual perceptual experiences
• Suspiciousness
• Inappropriate or restricted affect
• Odd or eccentric appearance or behavior
• Few close friends
• Odd thinking or speech
• Excessive social anxiety

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Schizotypal Personality Disorder

• Epidemiology
• Prevalence 3
• Course defined by personality DO
• Treatment

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Cluster B

• Antisocial
• Borderline
• Histrionic
• Narcissistic

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Antisocial Personality Disorder

• Diagnosis 3 or more
• Failure to conform to social norms
• Deceitful/manipulative
• Impulsive
• Irritable/aggressive
• Recklessness and disregard for safety of self or
  others
• Lack of remorse for actions
• Irresponsibility/failure to sustain work or honor
  financial obligations

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Antisocial Personality Disorder

• Epidemiology
• Prevalence 3 in men and 1 in women
• Higher incidence in poor urban areas
• Genetic component Five times increased risk
  among first-degree relatives
• Course defined by personality DO
• Treatment

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Borderline Personality Disorder

• Diagnosis 5 or more
• Desperate efforts to avoid real or imagined
  abandonment
• Unstable, intense interpersonal relationships
• Unstable self image
• Impulsive in at least 2 potentially harmful ways
  (spending, sexual activity, CD, etc.)
• Recurrent suicidal threats/attempts or self
  mutilation
• Unstable mood/affect
• General feeling of emptiness
• Difficulty controlling anger
• Transient, stress related paranoid ideation or
  dissociative sx

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Borderline Personality Disorder

• Epidemiology
• Course defined by personality DO
• Treatment

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Histrionic Personality Disorder

• Diagnosis 5 or more
• Uncomfortable when not the center of attention
• Inappropriately seductive
• Uses physical appearance to draw attn to self
• Uspech is impressionistic and lacking in detail
• Dramatic
• Easily influenced by others
• Perceives relationships as more intimate than
  they are

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Histrionic Personality Disorder

• Epidemiology
• Prevalence 2-3
• WomengtMen
• Course defined by personality DO
• Treatment

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Narcissistic Personality Disorder

• Diagnosis 5 or more
• Exaggerated sense of self-importance
• Preoccupied with fantasies of unlimed money,
  success, brillance
• Believes that he/she/ is special and can only
  associate with other high status people
• Needs excessive admiration
• Sense of entitlement
• Takes advantage of others for self-gain
• Lacks empathy
• Envious of others or believes others are envious
  of him/her
• Arrogant or haughty

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Narcissistic Personality Disorder

• Epidemiology
• Prevalence lt1
• Course defined by personality DO
• Treatment

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Cluster C

• Avoidant
• Dependent
• Obsessive-compulsive

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Avoidant Personality Disorder

• Diagnosis At least 4 of the following
• Avoids occupation that involves interpersonal
  contact due to fear of criticism
• Unwilling to interact unless certain of being
  liked
• Cautious of intrapersonal relationships
• Preoccupied with being criticized or rejected in
  social situations
• Inhibited in new social situations b/c he/she
  feels inadequate
• Believes he/she is socially inept
• Reluctant to engage in new activities for fear of
  embarrassment

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Avoidant Personality Disorder

• Epidemiology
• Prevalence 1-10
• Sex ratio unknown
• Course defined by personality DO
• Treatment

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Dependent Personality Disorder

• Diagnosis At least 5 of the following
• Difficulty making everyday decisions without
  reassurance from others
• Needs others to assume responsibilities for most
  areas of life
• Cannot express disagreement because of fear of
  loss of approval
• Difficulty initiating projects b/c of lack of
  self-confidence
• Goes to excessive lengths to obtain support from
  others
• Feels helpless when alone
• Urgently seeks another relationship when one ends
• Preoccupied with fears of being left to take care
  of self

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Dependent Personality Disorder

• Epidemiology
• Prevalence Approx. 1
• WomengtMen
• Course defined by personality DO
• Treatment

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Obsessive Compulsive Personality Disorder

• Diagnosis At least four of the following
• Preoccupation with details
• Perfectionism that is detrimental to completion
  of task
• Excessive devotion to work
• Excessive conscientiousness about morals
• Will not delegate tasks
• Unable to discard worthless objects
• Miserly
• Rigid and stubborn

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Obsessive Compulsive Personality Disorder

• Epidemiology
• Prevalence unknown
• MengtWomen
• Most often in eldest child
• Increased incidence in first degree relatives
• Course defined by personality DO
• Treatment

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Personality Disorder Gender Incidence (ratio) Prevalence Rates Prevalence Rates Prevalence Rates Prevalence Rates
Personality Disorder Gender Incidence (ratio) General Population Inpatient Psychiatric Setting Outpatient Psychiatric Setting Outpatient Psychiatric Setting
Paranoid Males gt females 0.5-2.5 10-30 2-10 2-10
Schizoid Males gt females Uncommon and undocumented Uncommon and undocumented Uncommon and undocumented     own
Schizotypal Males gt females 3 Unknown Unkn     own
Antisocial Males gt females 3 (males) 1 (females) 10-30 3 -30 3 -30
Narcissistic Malesgt females (21) lt1 Unknown 2-16 2-16
Histrionic Femalesgt males 2-3 10-15 10-15 10-15
Borderline Femalesgt males (31) 2 20 10 10
Avoidant Males females 0.5-1.0 Unknown 10 10
Dependent Femalesgt males Undocumented most frequently reported personality disorder in mental health clinics Undocumented most frequently reported personality disorder in mental health clinics Undocumented most frequently reported personality disorder in mental health clinics Undocumented most frequently reported personality disorder in mental health clinics
Obsessive- compulsive Malesgt females (21) 1 Unknown 3-10 3-10
Higher prevalence in substance abuse treatment
settings and prison/forensic settings (50-
60 prevalence rate in correctional settings)
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Pharmacologic Treatment (Evidence Based) No
medications are FDA-approved for the treatment of
personality disorders Medications may be
useful for the treatment of target symptoms
(i.e., depressed mood, impulsivity, and anxiety)
as an adjunct to psychotherapy Clusters A and
C no established pharmacological treatments
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c.
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• Cluster B Evidence-based Pharmacotherapy
• Antisocial Personality Disorder
• Anticonvulsant/mood stabilizers and target
  dosages used to treat symptoms of impulsivity
  and violent behavior (Refer to the Bipolar and
  the Neurology chapters for a more detailed
  description on the pharmacology of mood
  stabilizers and anticonvulsants.)
• a. Lithium carbonate 1200 mg/day (0.6 -1.5
  mEq/L)
• Phenytoin 300 mg/day
• Divalproex 750 mg/day
• Carbamazepine 450 mg/day
• Stimulants target symptoms of inattention,
  irritability, and impulsivity. Rarely used
  because of abuse potential. Methylphenidate
  dosages mimic those used for treatment of
  attention deficit hyperactivity disorder (ADHD)
• Selective Serotonin Reuptake Inhibitors (SSRis)
  target symptoms of hostility, impulsivity, and
  violent behavior
• Sertraline 150-200 mg/day b. Fluoxetine 60 - 80
  mg/day

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Borderline Personality Disorder Symptom clusters
responsive to medications Affective
dysregulation (e.g., mood lability, anger,
depressed mood, temper outbursts) Impulsive-behav
ioral dyscontrol (e.g., impulsive aggression,
self-damaging behavior) Cognitive-perceptual
symptoms (e.g., suspiciousness, referential
thinking, paranoid ideation)
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Evidence Based Treatment precautions Cluster
B Polypharmacy should be minimized Benzodiazep
ines are considered high risk treatments because
of suicidality, emotional dyscontrol, and abuse
potential Bupropion should not be used in a
patient with a co-occurring eating disorder,
because of increased seizure risk Tricyclic
antidepressants (TCAs) should be avoided in
patients with suicidality because of the risk of
lethality in overdose Antidepressants TCAs and
monoamine oxidase inhibitors (MAOis) have
inconsistent results and may cause a paradoxical
reaction in patients with BPD. Therefor SSRIs
if an antidepressant appears to be indicated
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Treatment Summary RCT evidence supports the use
of Interpersonal Therapy plus fluoxetine for the
treatment of depression and impulsive aggression
associated with borderline personality disorder.
Mixed results for TCAs and MAOs for the
treatment of depressive symptoms Antipsychotics
and mood stabilizers may be consider if SSRI is
ineffective Reserved for patients who display
temper outbursts, irritability, anger, or poor
impulse control Antipsychotic Pharmacologic
Treatment Summary Moderate evidence supports the
use of olanzapine or aripiprazole for the
treatment of depression, anger, and anxiety. Case
reports and open studies exist for the use of
clozapine and quetiapine in the treatment of BPD.
Ziprasidone has one failed study. RCT of
conventional antipsychotics have demonstrated
mixed results in the treatment of anger,
depression, and suicidality, with haloperidol
being studied the most. Mood Stabilizer
Pharmacologic Treatment Summary Mixed results
suggest not using lithium or carbamazepine for
target symptoms of BPD. Divalproex should be
considered for patients with co-occurring bipolar
disorder. Positive studies with topiramate and
lamotrigine indicate that they are effective for
specific BPD target symptoms of anger, anxiety,
aggression, and impulsivity.
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Less well studied Pharmacotherapy of Personality
Disorders Naltrexone 50-200 mg/day Case
reports and open trials suggest it may be helpful
for self-injurious behavior, flashbacks
associated with trauma, and dissociative
symptoms Clonidine 0.15 mg every morning 0.3 mg
at bedtime. A study in 2009 indicates that
clonidine may be advantageous for symptoms of
hyperarousal, subjective sleep latency, and
anxiety however a diagnosis of PTSD is likely
necessary. It is unlikely to be efficacious for
primary BPD symptoms, such as affective
dysregulation, impulsive-behavioral dyscontrol,
and cognitive-perceptual symptoms. Methylphenidat
e?
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