Transcript Personality Disorders

Personality Disorders
Norieta C. Balderrama, M.D.
Adult Psychiatry
Child and Adolescent Psychiatry
Forensic Psychiatry
Overview
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Diagnosis
Etiology
Clinical Course
Differential Diagnosis
Treatment
Specific personality Disorders
Overview
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Personality - composed of different personality
traits
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Personality traits - DSM - as enduring modes of
comprehending and relating to the environment
and oneself
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Personality disorder - - DSM - long term, stable
pattern of unusual and inflexible personality
traits that lead to functional impairment or
distress
Overview
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Axis II - described by DSM as
qualitatively different from other
psychiatric disorders
Placed on a separate diagnostic axis II
Diagnosis
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Diagnostic features - markedly deviant,
inflexible, maladaptive patterns of inner
perception and behavior
1. Patterns present since adolescence
or early adulthood.
2. Patterns not exclusively manifestation
of another mental disorder, substance
related nor due to GMC
Diagnosis
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3. Patterns occur in several of the
following areas :
A. cognition - the way they perceive self
and others
B. affect - quality of emotional
responsiveness
C. Interpersonal functioning
D. impulse control
Diagnostic Clues
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1. Presenting complaints - impaired
interpersonal relationships, chronic
unhappiness, low self esteem
2. History pattern of relationship
problems; adapting to environment
stress, failure to achieve social or
occupational goals
3. Mental status examination abnormalities
Diagnostic Clues
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MSE
Cluster A - peculiar thought process /
content / affect
Cluster B - mood and affect labile ,
dissociative symptoms, preoccupation
with rejection
Cluster C - anxiety and preoccupied with
criticism or rigidity
Physical examination
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Unremarkable
Evidence of violence - antisocial
Self destructive behavior - borderline
Laboratory Examination
Unremarkable , substance abuse with
antisocial and borderline personality
Types / Clusters
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2.
3.
Cluster A odd and eccentric
Paranoid personality disorder - distrust
and suspiciousness
Schizoid PD - detachment and
restricted emotionality
Schizotypal PD - discomfort with
relationships , thought distortion, and
eccentricity
Cluster B :
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dramatic , emotional, erratic
1. Antisocial PD- disregard and violation of
the basic rights of others
2. Borderline PD- social and emotional
instability
3. Histrionic PD- emotionality and attention
seeking behavior
4. Narcissistic PD- inflated self esteem ,
demands for admiration, lack for concern of
others
Cluster C
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1. Avoidant personality disorder - social
inhibition, feelings of inadequacy,
hypersensitive to criticism
2. Dependent personality disorder submissive and clinging behavior
associated with need to be taken cared
of
3. Obsessive compulsive personality
disorder - preoccupation with
orderliness, perfection and control
Other personality disorders
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Passive aggressive / depressive PD but some say there are an infinite
number of PD
Personality not otherwise specified
Distinguishing features
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1. Schizoid and avoidant - same
interpersonal behavior but different self
perceptions ( schizoid indifferent to
isolation but avoidant feel lonely )
2. Avoidant and dependent PD with
different interpersonal behavior avoidant isolate themselves, dependent
seek closeness )
Both with low self esteem
Etiology
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A. Theories - before the 20th century faulty parental stock or moral decay
Terms like manie sans delire
Moral insanity
Constitutional psychopathic inferiority
( like antisocial personality)
Freudian reshaped concepts
Central Tenets
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1. Adult personality - product of interaction
between inborn factors and childhood
experiences ; the way one learns to solve
problems
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2. Emotional problems of childhood - resolved
by defense mechanisms which are intra
psychic methods of decreasing anxiety ;
defense mechanisms underlie personality
traits
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Central tenets
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Faulty resolution of childhood emotional
conflicts leads to adult psychopathology and
emotional traumas during specific stages of
child development --> adult personality
disorders
Later - psychodynamic theories by Anna
Freud, Hartman - some personality traits are
not solely based on emotional conflicts but
may be realistic attempts at problem solving
or because intrinsically pleasurable
Psychodynamic theories
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1. Object relations - role of interpersonal
relationships , faulty sense of self
caused by pathologic childhood
interactions with caregivers creates
personality pathology
2. Temperament theory - goodness of fit
, temperament and adult personality ;
interaction of child’s temperament and
interpersonal environment
Psychodynamic theories
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Character armor - aberrant personality
traits are an individual’s armor against
the suffering generated by intra psychic
conflicts
Biologic Theories
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Genetic studies
1. Relationship of cluster A PD and
psychotic disorders
2. Relationship between Cluster B and
substance use, somatoform and mood
disorders
Relationship between Cluster C PD and
anxiety disorders
Clinical Course of Personality
Disorders
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A. personality traits - inflexible and
maladaptive during childhood , stability
increases with adolescence and
adulthood
B. Lifestyle - personality disorders
strongly influence and individual’s
choice of lifestyle - example with
occupation
C. PD limits flexibility and life choices
Symptoms
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Remittance - symptoms of borderline,
antisocial and avoidant PD often lessen
with time
Exacerbation - symptoms of paranoid
and schizoid PD exacerbates with age
Differential diagnoses
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1. Distinguishing personality disorder
from normal behavior
2. Distinguishing from Axis 1 disorders
3. Due to general medical condition
4. Post concussion
5. Co morbid conditions like mood,
anxiety, substance related disorders
Treatment
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Overview
- directed at improving the individual’s
adaptation and sense of well being by
making traits more flexible
- most are unaware and seek help due
to associated unhappiness, anxiety,
interpersonal problems
Psychodynamic and cognitive therapies
- treatments of choice for most PD.
Lengthy ; different techniques
Medications
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Antipsychotics - borderline, paranoid,
schizotypal
Antidepressant - borderline
Mood stabilizers - borderline ; antisocial
Anxiolytic - avoidant PD
Specific Personality disorders
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A. Paranoid personality disorders mistrustful, suspicious
Secretive, isolated
More common in males
Social separation imposed by culture or
economics
Prevalence 1 %
Schizophrenia and delusional disorder
more common
Paranoid personality disorder
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Associated features - socially isolated,
brief psychosis, persecutory delusions,
sensory impairment
Treatment - psychotherapy and
antipsychotic medications
Schizoid PD
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Emotionally distant, derive little joy from
living ; uninterested in interacting with
others ; indifferent to praise or criticisms
More common males
Prevalence unknown
Schizophrenia more common
Social drifting or dysphoria associated
feature
Schizoid PD
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Differential diagnosis - schizophrenia,
autistic, Asperger
Social isolation
Treatment : psychotherapy and
antidepressant
Schizotypal PD
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Isolated, uncomfortable interacting, peculiar
patterns of thinking, ideas of reference,
persecution, preoccupation with metaphysical,
magical thinking, occult or religious
phenomena , odd speech and affect
More in males
3% prevalence
Schizotypal and schizophrenia common
among relatives
Psychotherapy and antipsychotics
Antisocial PD
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Behave poorly, violate the law, lie,
irresponsible, aggressive, disregard for
safety of others, show lack of remorse,
may use manipulative means such as
charm, guilt, and induce others into
serving their ends
Male to female 3:1
Lower socio economic
3% male population
Antisocial PD
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Related illness - somatization,
substance related
Immersed in social strife
Criminal activity failed relationships,
abandoned responsibilities
Injuries or death because of violence
Treatment : psychotherapy , group or
milieu therapy ; limit setting ; mood
stabilizers
Borderline PD
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Unstable interpersonal relationships ,
emotions, and self image . Impulsive and
often destructive
Epidemiology 1:3 male to female
2% prevalence
Demanding, capricious in relationships, prone
to irresponsibility, emotionally labile
Suicide threats and attempts , self destructive
behavior
Fear of abandonment and chronic feelings of
identity confusion or emotional emptiness
Borderline PD
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Crises
Childhood abuse, like sexual abuse
Mood disorders, substance related
disorders ; eating disorders; eating
disorders, PTSD frequent co morbid
conditions
Treatment - psychotherapy and
pharmacotherapy
Histrionic personality disorder
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Extreme emotional lability , constantly
attract attention through dramatic
behavior or dress, inappropriately
seductive, emotionally shallow,
obsessed with physical appearance,
overdramatic, unduly influenced by
others
More females
2% of population
Histrionic PD
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Difficult interpersonal relationships,
social ostracism , somatization disorder,
conversion disorder, major depressive
disorder, and other personality disorders
Treatment - decrease behaviors used to
seek attention and improve
interpersonal relationships ; individual
psychotherapy
Narcissistic personality
disorder
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Overriding sense of entitlement and self
importance; lack of understanding and
feelings for others ; preoccupied with
own accomplishments, demand
attention from others, envy, dismiss or
exploit other individuals
3:2 male to female
Less than 1% prevalence
Narcissistic PD
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Hypersensitivity to real or imagined
slights from others , difficult
interpersonal relationships, extreme
ambitiousness, periods of anger and self
pity
Treatment ; psychotherapy reorganization of relationship with self
and others
Avoidant PD
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Shy away or avoid almost all occupational or
social relationships because of fears of
rejection that are based on feelings of
inadequacy
1:1 ratio
1% prevalence
Perceive self as substandard, preoccupied
with rejection , avoiding activities because of
fear of failure ; lonely and seek human contact
when acceptance is certain
Avoidant PD
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Associated - social phobia, panic
disorder , agoraphobia
Treatment - psychotherapy and
anxiolytic medications
Dependent personality
disorder
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Consumed by need to be taken cared of
Clinging behavior, allow others to
assume responsibility for important
decisions, avoids initiating activities
independently, worries unrealistically
about abandonment, feel inadequate
and helpless
1:1
Prevalence different - cultures
Dependent PD
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Avoid disagreements because of fear of
losing support
Lack confidence to make even
unimportant decisions independently
Constantly seek support from others,
dependency on family member, seeks
substitute when person is not available
Self doubt, excessive humility, mood
problems, adjustment problems, anxiety
Dependent PD
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Treatment - decrease inappropriate
dependency on others and to improve
self reliance and self esteem
Cognitive , behavioral and
psychodynamic therapies
Obsessive compulsive
personality disorder
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Preoccupied with details and lose a
sense of overall goals, strict,
perfectionist, over
conscientious, inflexible
obsessed with work and productivity
and are hesitant to delegate task to
others
2:1 male to female
1% of population
Obsessive compulsive PD
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Miserly and unable to give up useless
possessions
Should not be confused with OCD
Associated features, indecisiveness,
dysphoria, anger, social inhibition,
difficulty with interpersonal relationships
Treatment : decrease behavioral rigidity
And increase enjoyment of life
Antidepressants
Case
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A 25 year old female at the ER tells
them she has taken overdose of
fluoxetine. She ahs history of multiple
previous suicide gestures, which usually
follow the breakup of a stormy
relationship. She has history of
substance abuse , feels empty and fears
that she is going to be abandoned
What is the most likely diagnosis ?
Summary
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Personality disorders - at least 18 years of
age
Three clusters
Odd and eccentric
Dramatic, emotional and erratic
Anxious and fearful
Different modes of treatment
Associated feature and differential diagnoses
Thank you
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For your kind attention !
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Any questions ?