Personality Disorders

1. Personality Disorders Yana M. Van Arsdale, MD, PhD

2. Personality Traits • Relatively stable PATTERNS of - THINKING, - FEELING, - RELATING • Demonstrated in a wide range of situations • Consistently in the individual’s adaptation to life

3. Personality Disorder • Traits become INFLEXIBLE MALADAPTIVE • Serious problems • in work • interpersonal relationship

4. Classification three clusters: • A: “Odd or Eccentric” – prone to ThoughtDisorders • B: “Dramatic, Emotional, or Erratic” – prone to AffectiveDisorders • C: “Anxious or Fearful” – prone to AnxietyDisorders • Not Otherwise Specified (NOS)

5. Cluster A • Schizoid • Schizotypal • Paranoid may be part of the schizophrenic spectrum

6. Cluster B • Borderline • Histrionic • Narcissistic • Antisocial The most difficult patients to deal with

7. Cluster C • Avoidant • Dependent • Obsessive-Compulsive Inhibition in the assertion of socially acceptable impulses. Fearful reluctance to express anger or frustration. Internalization of blame. Anxiety.

8. Not Otherwise Specified • Passive-Aggressive • Depressive • Mixed

9. General Characteristics • Early onset – childhood/adolescence • Chronic • Stress is poorly tolerated, and can result in brief psychotic episodes • Inadequate coping skills • Affects mood, cognition, behavior, interpersonal style, relating to others

10. Epidemiology • 5-10 % - general population • up to 60 % - psychiatric inpatients

11. Basic principles of Tx • Establish a collaborativestance • Relay that the patient is ultimately responsible for his/her care, and you are a consultant • Appreciate that the irritating behavior is a defense against fear/insecurity

12. Basic principles of Tx • Set firm but compassionate limits • Donottry torescuethe Pt • Let the patient know the rules of treatment • Be as consistent as possible • Do not attempt to rationally debate with these patients when they are emotionally overwhelmed

13. Basic principles of Tx • Motivate them to make changes - confrontation • Patients’ behavior can be irritating to caretakers - countertransference • Treat Axis Iillnessfirst. • Axis I or/and III illnesscan make traits appear to be disorder of Axis II

14. Basic principles of Tx • PDO is ego-syntonic: maladaptation is not adequately recognized by the individual as a symptom that needs to be “fixed” • Goal:Ego-alienation • “If you wish to…/not to…, then you…” • Ego-dystonicrecognitionof PDOis essential, > effective approachthan empathy and compassion

15. Schizoid • Long term pattern of social isolation • Rarely seek treatment • Goals: • decrease socially isolative behaviors • increase socially outgoing behaviors • Patient may seem detached or unappreciative

16. Schizotypal • Magical thinking, ideas of reference, recurrent illusions, odd behavior • Anxietyin social situations • Skills oriented psychotherapy • Low dose neuroleptics • Goals: • Help with reality testing • Differentiating fantasy from fact

17. Paranoid • Suspiciousness, mistrust, hypervigilance, hypersensitivity to criticism/praise • Extremely defensive • Ascribe malicious intent to the actions of others and events • Hard to develop working relationship in therapy • A trusting relationship is essential for adherence to treatment.

18. Paranoid • Paranoid fears are heightened during any illness, including medical • If the patient becomes hostile/difficult it is best to acknowledge that the pain and fear are real • Cognitive and behavioral techniques • Goals: • encourage to interface with the environment • reevaluate paranoid ideas

19. Borderline • Stormy interpersonal relationship, behavioral dyscontrol, unstable affect • Self-injuring>suicidal behavior • Poor work Hx, multiple hospitalizations • Abuse Hx>PTSD • Comorbidity - depression, anxiety, substance abuse, eating DO • Extremely defensive

20. Borderline • 1-2 % general population • 11 % psychiatric outpatients • 19 % psychiatric inpatients • 33 % personality disorders in outpatient • 63 % personality disorders in inpatients • Female>male

21. Pharmacotherapy, Borderline • Treat Axis I disorder • Low dose neuroleptics - Tx psychotic decompensations • TCA are risky because of OD potential • SSRI - preferable • Benzodiazepines - avoided. SE • behavioral disinhibition • abuse potential • Mood stabilizers

22. Psychotherapy, Borderline • Firm boundaries, stable framework • Pay active attention to deviations from the frame • Identify behavior in the therapy to diminish transference distortions • Help to see that patient is communicating feelings through behavior • Recognize projective identification • Educate

23. Psychotherapy, Borderline • Pay attention to countertransference feelings • Set limits on self-destructive behavior • Contain and explore negative feelings from the patient without withdrawing or detachment • Distinguish fantasy from reality • Do not be drawn in by idealization or devaluation of others - splitting

24. Antisocial • Impulsivity, violence, irresponsibility • Criminal behavior without remorse or empathy for others • Hostility against authority • Manipulative, charming, seductive • Comorbidity - affective & anxiety DO, substance abuse

25. Antisocial • Genetic component • Conduct DO –childhood/adolescence • Decreased functioning of serotonergic & adrenergic systems • EEG abnormalities

26. Antisocial • 2-9.4 % general population • 3-37 % psychiatric population • 75 % prison population • Male>female

27. Antisocial, Tx • Structured or secure/enforced environment • Approach: firm, no nonsense, not punitive that conveys streetwise awareness of the patient’s potential for manipulation • Respect without aggravating the patient’s hostility • Best to work with children to prevent progression to AS-PDO

28. Antisocial, Tx • SSRI - Tx agression • Neuroleptics, Li, anticonvulsants, other mood stabilizers, beta-blockers, clonidine - Tx violent behavior & explosive rage • Patients rarely present voluntarily

29. Narcissistic • Grandiosity in fantasy and behavior, need for admiration, lack of empathy for others • Unconscious feeling of inadequacy, insecurity • Usually high functioning • Available for treatment when they are depressed • Devastated by illness because it shatters their feeling of invincibility • Grandiosity contributes to denial of illness

30. Narcissistic, Tx • Respect for sense of self importance • Not reinforcing pathological grandiosity • Initial approach of support followed by gradual confrontation of vulnerabilities can help to recognize their illness and deal with it • Support and confrontation minimize insecurity • Results in less defensive obnoxious behavior

31. Histrionic • Attention seeking, dramatic, theatrical, provocative, seductive, excessively emotional, insecure • Shallow and rapidly shifting emotional reactions • Use physical appearance to draw attention

32. Histrionic • Feel uncomfortable if not the center of attention • Highly suggestible • Influenced by others • 10-15 % psychiatric population

33. Histrionic, Tx • Long term psychotherapy • Set boundaries - seductiveness can lead to inappropriate sexual contact • Tactful confrontationto gain a realistic understanding of situation and their illness, and deal with it

34. Histrionic, Tx • Treat medical illness - since self-esteem is centered on body image or physical prowess, medical illness can be devastating • Treat Axis I illness • Address Axis III illness

35. Avoidant • Timidity, hypersensitivity to criticism and rejection, social discomfort • Shyness and insecurity • Feel anxious, depressed & angry for failing to develop social relationship • Comorbidity & strong genetic component with anxiety disorders • 10 % psychiatric population

36. Avoidant, Tx • Approach - consistency, empathy & support • Improved cooperation by respecting needsforprivacy & modesty • Tx Axis I DO, especially social anxiety

37. Avoidant, Tx • Psychotherapy - good response • CBT • Group • Assertiveness • Social skills training • SSRI and benzodiazepines - very effective

38. Dependent • Excessive need to be taken care of • Submissive and clinging behavior • Fear of separation • Feel very uncomfortable when alone • While depressed or medically ill can become more dependent

39. Dependent • The most prevalent PDO - psychiatric setting • 2.5 % - general population • Particularly vulnerable to depression

40. Dependent, Tx • Psychotherapy - very good response to • insight oriented • CBT • social skills training • assertiveness training • supportive

41. Dependent, Tx • Team approach • Not to foster into dependency • Explain clearly the realistic limits of availability • Antidepressants - Axis I • Address AxisIII

42. Obsessive-Compulsive • Preoccupation with rules and schedules • Excessive devotion to work and productivity • Stinginess • Emotional constriction & intellectualization • 5-10 % psychiatric settings

43. Obsessive-Compulsive, Tx • Focus on feelings rather than thoughts • CBT&group psychotherapy - help to overcome difficultieswithintimacy • Educate about illness in scientific and detailed fashion to assume self-monitoring and control

44. Depressive • Persistently feel unhappy, joyless, cheerless, gloomy, dejected • Depressive cognition • CBT, group psychotherapy • Antidepressants?

45. Passive-Aggressive • Negativistic attitudes & passive resistence to demands for adequate performance • Argumentative & authority-disliking • Complainers who feel misunderstood by others • Group psychotherapy

47. Thanks for your attention