B2B: Personality Disorders

1. B2B: Personality Disorders Michelle Mathias, MA, MD, FRCPC April 3, 2013

2. Special thanks… … to Dr. Deanna Mercer

3. Objectives • General: • Differentiate between PD and other mental illness, recognizing the high prevalence of co-morbidities • Formulate appropriate management plan

4. Objectives • Specific: • List & interpret critical clinical findings, inc: • Sufficient clinical info (e.g. MSE) to dx type of PD • Risk factors associated with PDs (e.g. SI, substance) • Any co-existing psych conditions (e.g. mood d/o) • Construct an effective initial management plan, inc: • Proper management for pt needing immediate intervention (e.g. suicide risk, risk to others) • Judicious use of pharmacotherapy, with consideration of risk for abuse or overdose • Referral for multi-disciplinary and/or specialized care, if needed

5. 2-pass approach Criteria/overview By objective/detailed

6. B2B… PDs from the start …definitions & diagnostic criteria!

7. Definitions • Personality: • Individual’s characteristic pattern of response to his/her enviro • Includes: how one… • Thinks (cognitive) • Feels (affective) • Acts (behavioural) • Relates to others (interpersonal) • Etiology: transactional model • Temperament (bio) + Environmental (social) time

8. Definitions (cont’d) • Personality Disorders: • Clinically significant distress or impairment in functioning • Enduring pattern of inner experience and behaviour that deviates markedly from expectations of individual’s culture • Impacts: 2 or more • cognition, affectivity, interpersonal fxn & impulse control • Pattern: • Inflexible & pervasive across broad range of personal and social situations • Not better accounted for by other mental disorder, GMC or substance

9. Definitions (cont’d) • Personality Disorders: • Ego-syntonic: • Individual experiences sig distress, but doesn’t feel their thoughts, emotions or behaviors are source of their problem • Locus of control: external • E.g. OCPD VS • Ego-dystonic: • Individual sees their disorder as arising from their own thoughts, emotions or behaviours • Locus of control: internal • E.g. OCD

10. Definitions (cont’d) • Personality Disorder Clusters: 3-4-3 • Cluster A: ODD • Schizoid, Schizotypal, Paranoid • Cluster B: Dramatic • Borderline, Histrionic, Narcissistic, Antisocial • Cluster C: Anxious • Obsessive Compulsive, Dependent, Avoidant

11. Cluster A Paranoid, Schizoid, Schizotypal

12. Paranoid PD • Pervasive pattern of: • Distrust and suspiciousness of others • Motives of others are interpreted as malevolent … beginning by early adulthood and present in various settings • Practically: • Looks like delusional d/o (paranoid type), but • No full blown delusions • More pervasive suspiciousness

13. Schizoid PD • Pervasive pattern of: • Detachment from social relationships • Restricted range of expression of emotions in interpersonal settings … beginning by early adulthood and present in various settings • Practically: • Mostly solitary activities • Few friends other than first degree • Cold & detached • Little or no interest in relations; solitary lifestyle • Indifferent to praise or criticism

14. Schizotypal PD • Pervasive pattern of: • Social and interpersonal deficits • Acute discomfort with and reduced capacity for close relationships • Cognitive or perceptual distortions or eccentricities of behaviour … beginning by early adulthood and present in various settings • Practically: • Eccentric behaviours • Odd beliefs, unusual perceptions, suspiciousness, paranoia, odd speech • Discomfort in close relationships - paranoia • (not b/c of fear of judgment)

15. Flashback…

16. Flashback… Schizo ypal

17. Flashback… Devoid… Schizoid Schizo ypal

18. Cluster B Antisocial, Borderline, Histrionic, Narcissistic

19. Antisocial PD • Pervasive pattern of: • Disregard for and violation of rights of others … since age of 15 (must be at least 18yo) • Practically: • Repeated lawbreaking • Deceitfulness • Impulsivity • Irritability and aggressiveness • Disregard for safety of self or others • Consistent irresponsibility • Lack of remorse

20. Borderline PD

21. Borderline PD • Pervasive pattern of: • Instability of interpersonal relationships • Instability of self-image and affects • Marked impulsivity … beginning by early adulthood and present in various contexts • Practically: • Efforts to self-harm or end life • Unstable relationships • Mood lability

22. Histrionic PD • Pervasive pattern of: • Excessive emotionality • Attention seeking … beginning by early adulthood and present in various settings • Practically: • Theatrical • Intense but shallow emotions • Craves being centre of attention

23. Narcissistic PD • Pervasive pattern of: • Grandiosity (in fantasy or behaviour) • Need for admiration • Lack of empathy … beginning by early adulthood and present in various contexts

24. Cluster C Avoidant, Dependent, Obsessive Compulsive

25. Avoidant PD • Pervasive pattern of • Social inhibition • Feelings of inadequacy • Hypersensitivity to negative evaluation … beginning by early adult and present in various contexts • Practically: • Similar to social phobia, but more pervasive

26. Dependent PD • Pervasive and excessive need to be taken care of, leads to: • Submissive and clinging behaviour • Fears of separation … beginning by early adult and present in various contexts • Practically: • Dependent on relationships • Difficulty making everyday decisions without a lot of advice, reassurance from others • Unable to disagree with others because fears loss of support • Will do things that are unpleasant, degrading to maintain support

27. Obsessive Compulsive PD • Pervasive pattern of preoccupation with: • Orderliness • Perfectionism • Mental and interpersonal control … at the expense of flexibility, openness and efficiency … beginning by early adult and present in various contexts • Practically: • Controlling of others, inflexible • Excessively devoted to work • Reluctant to delegate tasks • Emotionally constricted

28. 2-pass approach Criteria/overview By objective/detailed

29. Objectives • Specific: • List & interpret critical clinical findings, inc: • Sufficient clinical info (e.g. MSE) to dx type of PD • Risk factors associated with PDs (e.g. SI, substance) • Any co-existing psych conditions (e.g. mood d/o) • Construct an effective initial management plan, inc: • Proper management for pt needing immediate intervention (e.g. suicide risk, risk to others) • Judicious use of pharmacotherapy, with consideration of risk for abuse or overdose • Referral for multi-disciplinary and/or specialized care, if needed

30. Objectives • Specific: • List & interpret critical clinical findings, inc: • Criteria (done) & MSE • Risk factors associated with PDs (e.g. SI, substance) • Any co-existing psych conditions (e.g. mood d/o) • Construct an effective initial management plan, inc: • Proper management for pt needing immediate intervention (e.g. suicide risk, risk to others) • Judicious use of pharmacotherapy, with consideration of risk for abuse or overdose • Referral for multi-disciplinary and/or specialized care, if needed

31. Objectives • Specific: • List & interpret critical clinical findings, inc: • MSE • Risk factors & prognosis • Any co-existing psych conditions (e.g. mood d/o) • Construct an effective initial management plan, inc: • Proper management for pt needing immediate intervention (e.g. suicide risk, risk to others) • Judicious use of pharmacotherapy, with consideration of risk for abuse or overdose • Referral for multi-disciplinary and/or specialized care, if needed

32. Objectives • Specific: • List & interpret critical clinical findings, inc: • MSE • Risk factors & prognosis • Comorbidities • Construct an effective initial management plan, inc: • Proper management for pt needing immediate intervention (e.g. suicide risk, risk to others) • Judicious use of pharmacotherapy, with consideration of risk for abuse or overdose • Referral for multi-disciplinary and/or specialized care, if needed

33. Objectives • Specific: • List & interpret critical clinical findings, inc: • MSE • Risk factors & prognosis • Comorbidities • Construct an effective initial management plan, inc: • Risk assessment & acute management (safety) • Judicious use of pharmacotherapy, with consideration of risk for abuse or overdose • Referral for multi-disciplinary and/or specialized care, if needed

34. Objectives • Specific: • List & interpret critical clinical findings, inc: • MSE • Risk factors & prognosis • Comorbidities • Construct an effective initial management plan, inc: • Risk assessment & acute management (safety) • Pharmacotherapy • Referral for multi-disciplinary and/or specialized care, if needed

35. Objectives • Specific: • List & interpret critical clinical findings, inc: • MSE • Risk factors & prognosis • Comorbidities • Construct an effective initial management plan, inc: • Risk assessment & acute management (safety) • Pharmacotherapy • Non-pharm treatment

36. Objectives • List & interpret critical clinical findings, inc: • MSE • Risk factors & prognosis • Comorbidities • Construct an effective initial management plan, inc: • Risk assessment & acute management (safety) • Pharmacotherapy • Non-pharm treatment

37. General Word on Tx approach

38. Cluster A Paranoid, Schizoid, Schizotypal

39. Paranoid PD(refresher… which one is this?) • MSE: • evasive, minimal answers, suspicious, paranoid thought content, serious, humourless affectively restricted, lack warmth • Risk factors & prognosis: • Relatives often have Schizophrenia • Lifelong problem working & living with others • Comorbidities: • Other cluster A PDs, mood disorder, substance use, agoraphobia, OCD

40. Paranoid PD(refresher… which one is this?) • Risk assessment & acute management (safety): • Suicide attempters in ER: 9% with PPD • Pharmacotherapy: • Antidepressants as indicated • Low dose antipsychotic for brief psychotic episodes (increased stress) • Non-pharm treatment: • Rarely seek help – insufficient trust to engage in process • CBT – address core beliefs • Group therapy – tend not to tolerate

41. Schizoid PD(refresher… which one is this?) • MSE: • Cold, constricted, aloof, difficulty gaining rapport, odd metaphors, ill at ease, difficulty tolerating eye contact • Risk factors & prognosis: • Parents – cold, neglectful, suggest relationships not worth pursuing • Introversion • Possible family link – schizophrenia • Childhood onset, likely stable course • Comorbidities: • other cluster A PDs, mood d/o, anxiety d/o

42. Schizoid PD(refresher… which one is this?) • Risk assessment & acute management (safety): • Low insight, low motivation… not usually self-directed for tx • Suicide attempters in ER: 4% • Pharmacotherapy: • Low-dose antipsychotic, antidepressants • Non-pharm treatment: • Psychoeducation • Therapeutic distance needed for pt to tolerate relationship • Social skills training

43. Schizotypal PD(refresher… which one is this?) • MSE: • Superstitious, difficulty identifying own feelings, odd mannerisms and interests, prone to minimal responses (use open-ended questions), peculiar speech, appear unusual • Risk factors & prognosis: • 10% commit suicide; pre-morbid personality of schizophrenia (or milder version of); 10-20% develop schizophrenia • 14% have schizophrenia in family • Comorbidities: • Other cluster A PDs, depression, possible Borderline PD traits (poor interpersonal relationships)

44. Schizotypal PD(refresher… which one is this?) • Risk assessment & acute management (safety): • SI assessment; intensity of delusion-like beliefs • Pharmacotherapy: • Treat comorbidities • Mild-mod improvement with low-dose antipsychotics • Non-pharm treatment: • Supportive psychotherapy • Social skills training • Encourage activity, but does not have to be social

45. Cluster B Antisocial, Borderline, Histrionic, Narcissistic

46. Antisocial PD(refresher… which one is this?) • MSE: • Try to impress MD, good verbal intelligence; possibly demanding • Appear composed & credible (underneath = tension, hostility… may need to push to discover) • Risk factors & prognosis: • Px better if connected to some group • Decrease impulsivity & criminal behaviour, but continue to be difficult people • ++ substance risk; ++ legal involvement • Comorbidities: • Substance use disorders; other cluster B PDs, impulse control disorders, ADHD

47. Antisocial PD(refresher… which one is this?) • Risk assessment & acute management (safety): • Harm to others!! Legal risk • Pharmacotherapy: • Mood stabilizers for impulsivity • Stimulants for ADHD • Tx comorbid depression, anxiety • Non-pharm treatment: • Firm limits • Rational Emotive Therapy (CBT alternative) • Psychoeducation • Probation officers

48. Borderline PD(refresher… which one is this?) • MSE: • Manipulation, splitting, inconsistencies, avoiding, deflecting, dramatic, poor problem solving, insight varies, poor judgment, thought process can vary and be significantly impaired in great distress • Risk factors & prognosis: • Abusive upbringing, substance use disorders • Can decrease over time, but less so than other PDs • Comorbidities: • Other cluster B PDs, somatization disorders • Mood disorders (BPD vs Bipolar), anxiety disorders (social anxiety) • Brief psychotic episodes • Substance use disorders

49. Borderline PD(refresher… which one is this?) • Risk assessment & acute management (safety): • SAFETY!!! Self-harm, suicide attempts, aggressive acts towards others • Hospitalization if needed… try to avoid • DBT support; ACT teams • Pharmacotherapy: • Avoid TCAs (lethal in OD); SSRIs; mood stabilizers • Antipsychotics for psychotic sx (derealization) • Non-pharm treatment: • DBT (modified CBT); individual + group • Psychoeducation… give them the diagnosis! • Psycho-analytic – NOT appropriate • Social skills training • Family & couples therapy

50. Histrionic PD(refresher… which one is this?) • MSE: • Dramatic, temper tantrums, superficial (nil when go deeper), dramatic appearance (often sexual, esp clothing), eye contact varies • Risk factors & prognosis: • As age, sx decrease • History of sexual abuse • Substance use • Comorbidities: • Other cluster B PDs, brief psychotic episodes, somatization, DID