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Personality Disorders

Babatunde Idowu Ogundipe M.D. M.P.H. Comprehensive Clinical Services P.C. March 16 th 2012. Personality Disorders. What are Personality Disorders?. Common clinical syndromes that often go unrecognized.

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Personality Disorders

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  1. Babatunde Idowu Ogundipe M.D. M.P.H. Comprehensive Clinical Services P.C. March 16th 2012 Personality Disorders

  2. What are Personality Disorders? • Common clinical syndromes that often go unrecognized. • Characterized by deeply ingrained patterns of behavior that are inflexible & maladaptive interfering with the individuals long-term functioning. Abnormal functioning of the individual over time not limited to discrete periods of acute illness. • Such dysfunctional patients generate great deal of tension in clinical settings = difficult patients. • Such patients often neither suffer or wish to change, however, consequences of their behavior major concern for patients friends, family, coworkers, physicians, & communities (This is in contrast to patients with psychiatric & medical disorders who seek treatment due to personal distress). • Personality traits describe normal range behavior. They are adaptive, nonpathologic characteristics prominent in an individual’s unique adjustment to life. pharrah13.com

  3. What are Personality Disorders? • Often begin in childhood & continue through life. • DSM places personality disorders into Axis II disorders. • Personality is unique, complex, relatively stable, but difficult to describe with precision. Such a set of habits characterizing a person’s adjustment to life includes: • Major traits • Abilities • Attitudes • Interests • Drives • Moral values • Self-concept • Emotional responses • Behavioral patterns

  4. What are Personality Disorders? • Ordinary features of personality exaggerated forminterference with satisfying interpersonal relationships, inflexibility, impairment in social or occupational functioning, subjective distress. • Personality Disorders include: • Cluster A: “weird”: • Paranoid • Schizoid • Schizotypal • Cluster B: “wild”: • Borderline • Histrionic • Narcissistic • Antisocial marwan-abado.net

  5. What are Personality Disorders? • Cluster C “worried & wimpy”: • Obsessive –Compulsive • Avoidant • Dependent • Passive Aggressive

  6. Epidemiology Personality disorders http://pn.psychiatryonline.org/content/39/17/12.full

  7. Epidemiology Personality disorders • Cluster B:dramatic /emotional most frequently encountered in inpatient psychiatric units. They include: Borderline, histrionic, antisocial, & narcissistic personality disorder’s. • Except for antisocial personality disorder cluster B more common in women. • 15 % population with clinical features personality disorder. • 2.5% population meets criteria Antisocial Personality disorder (male > female). • Dependent & Histrionic personality disorders more common in females. • Overall prevalence personality disorders equal in men & women. • Etiology complex being shaped by many factors: • Heredity • Constitutional tendencies • Physical maturation & development • Cultural influences • Cultural conditioning • Critical environmental experiences

  8. Epidemiology Personality disorders • No single environmental or cultural phenomenondevelopment personality disorders. 50% variance in personality factors due to environment. • Other predisposing factors: • (1)First-degree biologic relatives with personality disorder. • (2)Lower socioeconomic level • (3)Urban dwelling • (4)Lack of childhood competence • (5)Low intellect • (6)Childhood emotional problems • (7)Mood disorder • (8)Abnormal underlying psychic structure

  9. Differential diagnosis Personality Disorders • Several psychiatric disorders may lower adaptive skills, judgement, occupational functioning, & social skillsappearance like personality disorder: • Residual schizophrenia • Mental retardation • Organic personality syndrome • Substance abuse • Depression • Manic episodes

  10. Borderline Personality disorder • Characterized by long-standing pattern of instability of mood, self-image, impulse control & interpersonal relationships(relatively minor events/disagreements interpreted as threatening a relationshipresponse with dramatic displays of anger/self harm). • Patients frequent Psychiatric emergency rooms presenting with wide range emergencies most commonly suicidal ideation. • Splitting=common defense mechanism used. Patient divides ambivalently regarded people into good people and bad people. i.e. therapist may be good while emergency room staff are bad. • Difficult to manage and manipulative in suicidal gestures, often made solely to gain attention or express anger. Risk that suicidal gesture may completed suicide. • Under stress borderline patients may have psychotic symptoms or major depression. bps-research-digest.blogspot.com

  11. Borderline Personality disorder diagnostic criteria • A pervasive pattern of instability of interpersonal relationships, self-image, & affects, & marked impulsivity beginning by early adulthood & present in a variety of contexts, as indicated by > 5 of the following: • (1)Frantic efforts to avoid real or imagined abandonment. Do not include suicidal or self-mutilating behavior (covered in criterion 5) • (2)A pattern of unstable & intense interpersonal relationships characterized by alternating between extremes of idealization & devaluation. • (3)Identity disturbance: markedly & persistently unstable self-image or sense of self. • (4)Impulsivity in at least two areas that are potentially self-damaging (i.e., spending, sex, substance abuse, reckless driving, binge eating). Do not include suicidal or self-mutilating behavior covered in criterion 5. • (5)Recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior. • (6)Affective instability due to a marked reactivity of mood(i.e.Intense episodic dysphoria, irritability, or anxiety usually lasting a few hours and only rarely more than a few days). • (7)Chronic feelings of emptiness. • (8)Inappropriate, intense anger or difficulty controlling anger (i.e., frequent displays of temper, constant anger, recurrent physical fights). • (9)Transient, stress-related paranoid ideation or severe dissociative symptoms.

  12. Management Personality disorders • Goals therapy: • (1) Reduce degree maladaptive behavior. • (2)Make patient aware impact personality disturbance has. • (3)Help patient control undesirable inhibitions, impulses, & preoccupations. • Physician should keep certain guidelines in mind to help better manage the patient: • (1)Important to solidify working relationship. Patient may subject clinician to wide range of attitudes: contempt, ridicule, provocation, pseudoconformity, dependence, & distortion. It will be useful to first establish such a positive relationship based on honesty, trust, understanding. It may be achieved by first acknowledging patients fears & insecurities before focusing on troublesome behavior.

  13. Management Personality disorders • (2)Important for physician to note that interpersonal dysfunction long-standing & likely to interfere with medical management. Even when patients troublesome behavior improves for some time often returns. • (3)Important to avoid harmful interventions. May be helpful to confine intervention to current problems, avoiding analytic probing & exploration unconscious material, distorted attitudes, & historical data. • (4)Important as physician to be consistent & accepting. Patients may require limit setting & attention to professional boundaries. Gentle confrontation mixed with empathy best approach. • (5) Personality disorders & clinical syndromes often coexist. Physicians should treat psychiatric syndromes i.e.panic disorders, major depressive episodes, psychosis, & substance abuse.

  14. Management Personality disorders • (6)Important to exercise acute crisis management. Some patients with personality disorders become self-destructive & must be protected from themselves, via hospitalization if necessary. • (7) As PCP caring for patient: • -see patient regularly • -provide longer sessions but with firm limits to duration. • -be tolerant when dealing with immature defenses, objectionable behavior, & lack of progress. • -inform patient that some info revealed to him may be transmitted to others when emergency protection needed. • (8)Physician needs to note how personality disorders interact with evaluation & diagnosis, treatment & management, & disease processes.

  15. Management Personality disorders • Drug Treatment: • Antipsychotics with efficacy in some borderline & schizotypal patients. • Borderline patients with behavioral dyscontrol may respond to (MAOI )tranylcypromine, anticonvulsant carbamazepine, & antipsychotic trifluoperazine. • Psychotherapy: • Useful in treatment many patients with personality disorder. • Group psychotherapy-focus on interpersonal relationships: • -Establishes working alliance • -identifies behavior patterns • -minimzes negative therapeutic reaction • -allows appropriate emotional distance • -facilitates better reality orientation

  16. Management Personality disorders • -improves social responses • -stimulates withdrawn patients • -allows identification with other group members + therapist. • Others that may be helpful in rehabilitation patients with personality disorder: • -Supportive psychotherapy + : • -social skills training • -assertiveness training • -impulse control training

  17. References • FIRST AID for the USMLE 3, Tao Le, VikasBhushan, Robert W. Grow, Veronique Tache. • Psychiatry History Taking. Third Edition. A Current Clinical Strategies medical book. Alex Kolevzon, Craig L.Katz. • Wikipedia. • Pocket Handbook of Primary Care Psychiatry. Harold I kaplan, M.D. Benjamin J. Sadock, M.D. • Fuller K, LeRoy J: Personality Disorders: An Overview for the Physician. Southern Medical Journal 1993; 86, 4: 430-437. • Oldham J: Psychodynamic Psychotherapy for Personality Disorders. American Journal of Psychiatry 2007; 164: 1465-1467. • Rizvi S, Linehan M: Dialectical Behavior Therapy For Personality Disorders. Focus: The Journal of Lifelong Learning In Psychiatry 2005; 3: 489-494. • Leichsenring F, Leibing E: The Effectiveness of Psychodynamic Therapy and Cognitive Behavior Therapy in the Treatment of Personality Disorders: A Meta-Analysis. American Journal of Psychiatry 2003; 160: 1223-1232. • Bender E:Personality Disorder Prevalence Surprises Researchers. Psychiatric News 2004; 39: 12 • Davison S:Principles of managing patients with personality disorder. Advances in psychiatric treatment journal of continuing professional development 2002; 8: 1-9

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