Personality Disorders Personality Disorders3xxx2

Personality Disorders Personality Disorders Sean M. Blitzstein, M.D. Learning Objectives o Be able to recognize each of the 10 Personality Disorders when presented with a case history o Be able to predict how these patients commonly present in a primary care setting o Be able to predict how these patients might commonly react to medical illnesses o Be able to name a specific technique that may be employed by a physician to successfully interact with a patient with each of the 10 Personality Disorders Personality o The totality of emotional and behavioral traits that characterize the person in day-to-day living under ordinary conditions. o Relatively stable and predictable. Personality Disorders o Deeply ingrained, inflexible, and maladaptive patterns of relating to and perceiving both the environment and themselves. o Influence cognition, affect, behavior and interpersonal style. o Cause subjective distress or significant functional impairment. o Symptoms are all plastic and ego-synchronic. o 5-10% of the population. o 60% of inpatient psychiatry patients. o 12-100% of psychiatric outpatients with mood disorders. o Having an understanding of personality disorders will improve the relationship, enhance compliance, and reduce their stress. o Axis II pathology affects the predisposition, presentation, course, and prognosis of Axis I pathology. o Genetic factors o Temperamental factors o Biological factors o Psychodynamic factors: Internal object relations and Defense mechanisms. Paranoid Personality Disorder o 0.5-2.5% of the population. o Men > Women. o Higher incidence in relatives of schizophrenics. o Higher among minorities, immigrants, and the deaf.

Paranoid Personality Disorder-Criteria o Suspects, without sufficient basis, that others are exploiting, harming, or deceiving him or her. o Is preoccupied with unjustified doubts about the loyalty or trustworthiness of friends or associates. o Is reluctant to confide in others because of unwarranted fear that the information will be used maliciously against him or her. o Reads hidden demeaning or threatening meanings into benign remarks or events. Paranoid Personality Disorder-Criteria o Persistently bears grudges, i.e., is unforgiving of insults, injuries, or slights. o Perceives attacks on his or her character or reputation that are not apparent to others and is quick to react angrily or to counterattack. o Has recurrent suspicions, without justification, regarding fidelity of spouse or sexual partner. o Does not occur exclusively during the course of a Psychotic Disorder and is not due to a general medical condition. Paranoid Personality Disorder-Interactions o Acknowledge mistakes. o Be open and honest. o Have a professional and not overly warm style. o Don confront. o Set limits. o Clearly explain procedures, medications and results. Schizoid Personality Disorder o 7.5% of the population. o A 2-to-1 male-to-female ratio. Schizorsoid Personality Disorder-Criteria o Neither desires nor enjoys close relationships, including being part of a family. o Almost always chooses solitary activities. o Has little, if any, interest in having sexual experiences with another person. o Takes pleasure in few, if any, activities. o Lacks close friends or confidants other than first-degree relatives. Schizoid Personality Disorder-Criteria o Appears indifferent to the praise and criticism of others. o Shows emotional coldness, detachment, or flattened affectivity. o Does not occur exclusively during the course of a Psychotic Disorder, or a Pervasive Developmental Disorder and is not due to a general medical condition.

Schizoid Personality Disorder-Interactions o Understand their need for isolation. o Minimize new contacts and intrusions. o Maintain a quiet, reassuring, and considerate interest in them. o Don insist on reciprocal responses. Schizotypal Personality Disorder o 3% of the population. o Sex ratio is unknown. o Greater association among biological relatives of schizophrenic patients. o The premorbid personality of the schizophrenic patient. Schizotypal Personality Disorder-Criteria o Ideas of reference (excluding delusions of reference). o Odd beliefs or magical thinking that influences behavior and is inconsistent with subcultural norms (e.g., superstitiousness, belief in clairvoyance, telepathy, or sixth sense?. o Unusual perceptual experiences, including bodily illusions. o Odd thinking and speech (e.g., vague, circumstantial, metaphorical, overelaborate, or stereotyped). o Suspiciousness or paranoid ideation. Schizotypal Personality Disorder-Criteria o Inappropriate or constricted affect. o Behavior or appearance that is odd, eccentric. or peculiar. o Lack of close friends or confidants other than first-degree relatives. o Excessive social anxiety that does not diminish with familiarity and tends to be associated with paranoid fears rather than negative judgments about self. o Does not occur exclusively during the course of a Psychotic Disorder or a Pervasive Developmental Disorder. Schizotypal Personality Disorder-Interactions o Similar to Schizoid PD. o Misperceptions of physical symptoms and treatment. o Do not ridicule or judge. o Respect their need for privacy. Antisocial Personality DisorderDisorder o 3% in men and 1% in women. o Most common in poor urban areas. o 75% in prison populations. o Familial pattern present.

Antisocial Personality Disorder-Criteria o Failure to conform to social norms with respect to lawful behaviors as indicated by repeatedly performing acts that are grounds for arrest. o Deceitfulness, as indicated by repeated lying, use of aliases, or conning others for personal profit or pleasure. o Impulsivity or failure to plan ahead. o Irritability and aggressiveness, as indicated by repeated physical fights or assaults. o Reckless disregard for safety of self or others. Antisocial Personality Disorder-Criteria o Consistent irresponsibility, as indicated by repeated failure to sustain consistent work behavior or honor financial obligations. o Lack of remorse, as indicated by being indifferent to or rationalizing having hurt, mistreated, or stolen from another. o The individual is at least age 18 years, and there is evidence of Conduct Disorder with onset before age 15 years. o The occurrence of antisocial behavior is not exclusively during the course of Schizophrenia or a Manic Episode. Antisocial Personality Disorder-Interactions o Set firm limits. o Try not to be manipulated. o Have high level of skepticism. o Be careful not to prescribe excessive and/or unnecessary medications. Borderline Personality Disorder o 1-2% of the population. o Twice as common in women as in men. o Increased prevalence of Major Depressive Disorder, Alcohol Abuse/Dependence, and Substance Abuse found in first-degree relatives. Borderline Personality Disorder-Criteria o Frantic efforts to avoid real or imagined abandonment. o A pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation. o Identity disturbance: markedly and persistently unstable self-image or sense of self. o Impulsivity in at least two areas that are potentially self-damaging (e.g., spending, sex, substance abuse, reckless driving, binge eating). o Chronic feelings of emptiness.

Borderline Personality Disorder-Criteria o Recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior. o Affective instability due to a marked reactivity of mood (e.g., intense episodic dysphoria, irritability, or anxiety usually lasting a few hours and only rarely more than a few days). o Inappropriate, intense anger or difficulty controlling anger (e.g., frequent displays of temper, constant anger, recurrent physical fights). o Transient, stress-related paranoid ideation or severe dissociative symptoms. Borderline Personality Disorder-Interactions o Be aware of and anticipate defenses. o Often regress. o Open and continuous communication with staff. o Stable and calm reaction. o Gently confront. o Set fair and consistent limits on acting out. Histrionic Personality Disorder o 2-3%. o Diagnosed more frequently in women than in men. o Associated with Somatization Disorder and Alcohol abuse/Dependence. Histrionic Personality Disorder-Criteria o Is uncomfortable in situations in which he or she is not the center of attention. o Interaction with others is often characterized by inappropriate sexually seductive or provocative behavior. o Displays rapidly shifting and shallow expression of emotions. o Consistently uses physical appearance to draw attention to self. Histrionic Personality Disorder-Criteria o Has a style of speech that is excessively impressionistic and lacking in detail. o Shows self-dramatization, theatricality, and exaggerated expression. o Is suggestible, i.e., easily influenced by others or circumstances. o Considers relationships to be more intimate that they actually are. Histrionic Personality Disorder-Interactions o Similar to Borderline PD. o Medical illnesses threaten their sense of attractiveness and self-image.

Narcissistic Personality Disorder o 2-16% in the clinical population. o 1% in the general population. o Number of cases increasing steadily. Narcissistic Personality Disorder-Criteria o Has a grandiose sense of self-importance (e.g., exaggerates achievements and talents, expects to be recognized as superior without commensurate achievements). o Is preoccupied with fantasies of unlimited success, power, brilliance, beauty, or ideal love. o Believes that he or she is special and unique and can only be understood by, or should associate with, other special or high-status people (or institutions). o Requires excessive admiration. Narcissistic Personality Disorder-Criteria o Has a sense of entitlement, i.e., unreasonable expectations of especially favorable treatment or automatic compliance with his or her expectations. o Is interpersonally exploitative, i.e., takes advantage of others to achieve his or her own ends. o Lacks empathy: is unwilling to recognize or identify with the feelings and needs of others. o Is often envious of others or believes that others are envious of him or her. o Shows arrogant, haughty behavior or attitudes. Narcissistic Personality Disorder-Interactions o Handle criticism poorly. o Become easily enraged. o Medical illnesses can be a blow to their self-esteem. o Reinforce that they are respected and appreciated. o Set limits on demanding behavior. Avoidant Personality Disorder o 1-10% of the population. o No information on sex ratio or familial pattern. o Infants with a timid temperament may be more likely to develop Avoidant PD.

Avoidant Personality Disorder-Criteria o Avoids occupational activities that involve significant interpersonal contact, because of fears of criticism, disapproval, or rejection. o Is unwilling to get involved with people unless certain of being liked. o Shows restraint within intimate relationships because of the fear of being shamed or ridiculed. Avoidant Personality Disorder-Criteria o Is preoccupied with being criticized or rejected in social situations. o Is inhibited in new interpersonal situations because of feelings of inadequacy. o Views self as socially inept, personally unappealing, or inferior to others. o Is unusually reluctant to take personal risks or to engage in any new activities because they may prove embarrassing. Avoidant Personality Disorder-Interactions o Have patience and understanding. o Medical illnesses may be embarrassing. o Minimize new and unfamiliar staff contacts. o Respond with a calm and reassuring demeanor. o Do not criticize them. Dependent Personality Disorder o Epidemiology is unknown. o More common in women than men. o Children with chronic physical illnesses may be more prone. Dependent Personality Disorder-Criteria o Has difficulty making everyday decisions without an excessive amount of advice and reassurance from others. o Needs others to assume responsibility for most major areas of his or her life. o Has difficulty expressing disagreement with others because of fear of loss of support or approval. o Has difficulty initiating projects or doing things on his or her own (because of a lack of selfconfidence in judgment or abilities rather than a lack of motivation or energy).

Dependent Personality Disorder-Criteria o Goes to excessive lengths to obtain nurturance and support from others, to the point of volunteering to do things that are unpleasant. o Feels uncomfortable or helpless when alone because of exaggerated fears of being unable to care for himself or herself. o Urgently seeks another relationship as a source of care and support when a close relationship ends. o Is unrealistically preoccupied with fears of being left to take care of himself or herself. Dependent Personality Disorder-Interactions o Respect their feelings of attachment. o Be careful when encouraging a patient to change the dynamics of an abusive relationship. o When medically ill they may become frustrated that they are not being helped. o Be active in the treatment planning. Obsessive-Compulsive Personality Disorder o Epidemiology unknown. o More common in men than in women. o Diagnosed more in oldest children. o Often a history of harsh discipline as a child. Obsessive-Compulsive PD-Criteria o Is preoccupied with details, rules, lists, order, organization, or schedules to the extent that the major point of the activity is lost. o Shows perfectionism that interferes with task completion (e.g., is unable to complete a project because his or her own overtly strict standards are not met). o Is excessively devoted to work and productivity to the exclusion of leisure activities and friendships. o Is over conscientious, scrupulous, and inflexible about matters of morality, ethics, or values. Obsessive-Compulsive PD-Criteria o Is unable to discard worn-out or worthless objects even when they have no sentimental value. o Is reluctant to delegate tasks or to work with others unless they submit to exactly his or her way of doing things. o Adopts a miserly spending style toward both self and others; money is viewed as something to be hoarded for future catastrophes. o Shows rigidity and stubbornness.

Obsessive-Compulsive PD-Interactions o Give precise and rational explanations. o Value efficiency and punctuality. o Medical illnesses create a disruption in the patient work, orderly lifestyle, and sense of control. o Acknowledge the importance of work, but point out how avoiding treatment may have harmful consequences. Obsessive-Compulsive PD-Interactions o Allow the patient to control his or her care as much as possible. o Provide them with information. o Avoid power struggles. o Understand their need for order and control. Personality Disorder Not Otherwise Specified o Passive-Aggressive Personality Disorder. o Depressive Personality Disorder. o Specific traits or behaviors (sadism or masochism). o Patient with features of more than one Personality Disorder.