Personality Disorders course 21-22/3/2012

1. Personality Disorders

2. Personality
Personality consists of enduring habitual
patterns of thinking, feeling, behaving,
relating and determine a person’s reaction to
the two worlds, namely the inner
psychological world and the outer
environment.

3. What, then, is a personality disorder ?

4. DSM-IV-TR defines personality disorders as
enduring subjective experiences and
behavior that-
–
deviate from cultural standards
–
are rigidly pervasive
–
have an onset in adolescence or early adulthood
–
are stable throughout time
–
lead to unhappiness and impairment

5. Classification
•Cluster A – Paranoid, Schizoid, Schizotypal
Weird
•Cluster B – Antisocial, Borderline, Histrionic,
Narcissistic
Wild
•Cluster
C – Avoidant, Dependent, Obsessive-
Compulsive
Wimpy

6. Prevalence - 10-18%
Outpatient - 30-50%
Inpatient > 50%
34% in alcohol abuse and anxiety disorders
48-65% among recurrent suicidal gestures
Etiology
Genetic
Biological factors
Environmental factors
Psychoanalytic theories

7. Psychoanalytic Factors
•Sigmund Freud – personality traits are
products of fixation at one psychosexual
stage of development
•Wilhelm Reich – personality arose from the
particular pattern of defense mechanisms
- character armor

8. Defense Mechanisms
The unconscious mental processes that the
ego uses to resolve conflicts
Flexible and adaptable
Inflexible and rigid in personality disorders
Ego-syntonic; a major reason why people
with these disorders are reluctant to alter
their behaviors

9. Defense Mechanisms
Primitive Neurotic Mature
Projection Introjection Humor
Denial Identification Suppression
Dissociation Displacement Asceticism
Splitting Rationalization Altruism
Idealization Repression Anticipation
Acting Out Undoing Sublimation

10. Cluster A Personality Disorders
WEIRD

11. 32 y/o male complaining of his girlfriend
being untrustworthy
Feels she is taking advantage of him
Does not like her talking to 'friends' on the
phone
Feels people at work don't like him
Lashed out at a stranger who was laughing
loudly during a funny movie

12. “Others are untrustworthy, and they try to take advantage
of me”

13. Paranoid Personality Disorder
SUSPECT (four of seven)
Spousal infidelity suspected
Unforgiving
Suspicious
Perceives attacks
Enemy or friend
Confiding in others feared
Threats perceived in benign events

14. Paranoid Personality Disorder
0.5-2.5% population, M > F, minorities,
immigrants, deaf
Course: Lifelong
Differential Disorder: Delusional d/o,
Schizophrenia, Schizoid PD, Avoidant PD
Treatment: Psychotherapy
Psychosis: Short term benzodiazepines and
antipsychotics

15. 38 y/o single lab tech having difficulty being
a 'team player.'
Resents having to train new assistants
Describes himself as a loner who feels
awkward when forced into spending time
with others.
Can spend long hours by himself playing
computer games.
Prefers being alone; not distressed by it.

16. “I prefer to be alone; my world is completely empty.”

17. Schizoid Personality Disorder
DISTANT (four of seven)
Detached (flat) affect
Indifferent to criticism or praise
Sexual experiences of little interest
Tasks performed solitarily
Absence of close friends
Neither desires nor enjoys close relations
Takes pleasure in few activites

18. Schizoid Personality Disorder
1-7.5% ;Males > Females 2:1
Higher incidence of psychotic disorder in relatives
Onset in early childhood and remains throughout life
Differential Diagnosis: Schizophrenia, Paranoid PD,
OCPD, Avoidant PD
Treatment: Supportive, Insight- oriented and
sometimes group therapy
No pharmacotherapy

19. 19 y/o college student presenting with long-
standing worry of 'losing height.'
Patient appeared disheveled and did not
make eye contact.
Frequently taps his nose to make a point.
Doctor unable to establish rapport.
Patient made some comments of a paranoid
nature with sexual content.

20. “I'd like to have friends but it's hard, because people find
me pretty strange.”

21. Schizotypal Personality Disorder
ME PECULIAR (five of ten)
Magical thinking or odd beliefs
Experiences unusual perceptions
Paranoid ideation
Eccentric behavior or appearance
Constricted (or inappropriate) affect
Unusual thinking and speech
Lacks close friends
Ideas of reference
Anxiety in social situations
Rule out psychotic disorder

22. Schizotypal Personality Disorder
3% , males> females, biological relatives of
schizophrenics
Prognosis is guarded
DD: Paranoid PD, Schizoid PD, Borderline PD,
Avoidant PD, Schizophrenia
Treatment: supportive therapy with social skills
training
Pharmacotherapy for brief periods of psychotic
decompensation

23. Cluster B Personality Disorders
WILD

24. 19 y/o male, comes in after encouragement
from mother
Appears intelligent, charming and funny
Admits to several arrests for robbery, claims
noble intentions
Story does not pan out
Extensive drug trafficking
Has been stealing from mother
No remorse

25. “I love to take advantage of people, and I never feel bad
about it.”

26. Antisocial Personality Disorder
CORRUPT (three of seven)
Conformity to law is lacking
Obligations ignored
Reckless disregard for safety of self or others
Remorse lacking
Underhanded
Planning insufficient (impulsive)
Temper

27. Antisocial Personality Disorder
Prevalence: 3% M; <1% F
5 times more common in first degree relatives
75% of poor urban prisons
Conduct disorder<15; comorbid ADHD, sub abuse
DD:Borderline PD, Narcissistic PD, Bipolar disorder,
Psychotic violence
Very difficult to treat.
Confined settings with external constraints
BT with a strong emphasis on legal sanctions
Pharmacotherapy for dangerous behavior

28. 45 y/o white female with a turbulent course in the
clinic
Has made suicide attempts in the clinic
Abnormally strong attachment to previous resident
Current resident feels disheartened, thinking they
can never match up to standards
Does not have children, therefore collects dolls
Requires weekly sessions to prevent destabilization

29. “I need people desperately, and fall apart completely when
they reject me.”

30. Borderline Personality Disorder
I DESPAIRR
Identity disturbance
Disordered, unstable affect
Emptiness- chronic feeling
Suicidal behavior, gestures, or threats
Paranoid ideation- transient, stress related
Abandonment- tries to avoid
Impulsivity
Rage, inappropriate, intense
Relationships- unstable, intense, extreme

31. Borderline Personality Disorder
Prevalence:2-3% of population; 2:1 F:M ratio
Increased prevalence of mood disorders in family
members; mothers of patients also have BPD
Diagnosed before 40 years, variable course
DD: paranoid PD, histrionic PD, bipolar disease
Treatment: Psychotherapy- exploratory, insight-
oriented, supportive, CBT, DBT
Medications for impulsivity, lability, psychosis, mood
symptoms
Be aware of Countertransference!

32. 31 year old WF discloses to her therapist that she
loved to party in college
Proud of the fact that she once slept with 12
different men at a party, including her 'best friend's
' boyfriend.
Responds strongly to positive comments about her
appearance.
Sometimes vague and shallow with emotions.
Easily influenced by TV, magazines and friends.

33. “I'm an emotional and sexually charming person, and I need
to be the center of attention!”

34. Histrionic Personality Disorder
PRAISE ME (five of eight)
Provocative behavior
•
Relationships (considered more intimate than they are)
•
Attention (likes to be center of)
•
Influenced easily
•
Style of speech (impressionistic)
•
Emotions (rapidly shifting, shallow)
•
Made up
•
Emotions exaggerated
•

35. Histrionic Personality Disorder
Prevalence: 2-3%, F>M
Course is variable; comorbid somatization,
dissociative, sexual and mood disorders.
DD: Borderline PD, narcissistic PD, dependent PD,
Somatization
Individual psychodynamic psychotherapy with
emotional clarification
Benzos for transient emotional outbursts and anti-
psychotics for dissociation and psychosis

36. 20 y/o male seen in clinic with 'impotence'
States that he agreed to have sex with a
platonic friend; extremely anxious about
inability to perform
Hates his job, 'they don't know what they're
doing'
Feels that his friends are petty, dating 'pretty
but stupid women'
Three years of therapy, never completes it

37. “I'm talented and special, and I get angry and depressed
when people don't recognize how great I am!”

38. Narcissistic Personality Disorder
SPEEECIAL (five of nine)
Special
•
Preoccupied with fantasies of success and power
•
Envious
•
Entitlement
•
Excessive admiration needed
•
Conceited
•
Interpersonal exploitation
•
Arrogant
•
Lacks empathy
•

39. Narcissistic Personality Disorder
Prevalence:1%; 2-15% of clinical population
Co-morbid mood disorders; severe mid-life crisis.
DD: Borderline PD, Histrionic PD, Anti-social PD
Treatment : Individual psychodynamic
psychotherapy
Insight-oriented psychotherapy
Pharmacotherapy for depression and mood swings

40. Cluster C Personality Disorders
WIMPY

41. 35 year old black male presents to unit after a
suicide attempt
Patient is in love with his neighbor of 10 years
Tells the psychiatrist that he would attempt suicide
again if she refused a date
Admits to being shy
Wants to be married and have children, and feels
sad that this may never happen
Often puts himself down during the interview

42. “I'm really afraid of what people will think of me, so I avoid
making new friends.”

43. Avoidant Personality Disorder
CRINGES (four of seven)
Certainty of being liked required
Rejection -preoccupied with
Intimate relationships avoided
New relationships avoided
Gets around interpersonal contact
Embarrassment prevents new activities
Self viewed as inept, inferior

44. Avoidant Personality Disorder
Prevalence:1-10%; temperament and disfiguring
physical illnesses are predisposing factors, M=F
Co-morbid mood d/o, anxiety d/o and social phobia
DD: Schizoid PD, Dependent PD, Social phobia
Course: Are able to function, marry and raise
families as long as the environment is safe
CBT
Anxiolytics, MAOIs and SSRIs for anxiety and
depression

45. 55 year old woman,married since she was
17, because she didn’t want to be alone
•
Husband takes care of all the finances, and
gives her a weekly allowance
Worries excessively about making mistakes
at her job and doesn’t want to be left alone
at work
Worried about teenage daughter who is in
college- 'doesn't care anymore'.

46. “ I'm passive and dependent on others, and I go far out of
my way to please those who are important to me.”

47. Dependent Personality Disorder
RELIANCE (five of eight)
Reassurance required
Expressing disagreement difficult
Life responsibilities assumed by others
Initiating projects difficult
Alone (feels helpless when alone)
Nurturance (goes to lengths to get support)
Companionship sought urgently
Exaggerated fears of being left to care for self

48. Dependent Personality Disorder
Prevalence - 2.5% , F>M ,increased incidence in
childhood separation anxiety
DD: Avoidant PD, Borderline PD, Agoraphobia
Course: co-morbid dysthymia, MDD, alcohol abuse;
victims of emotional and physical abuse
Treatment: Respond to individual psychotherapy,
group therapy with stress on cognitive techniques,
assertive training and social skills training
Pharmacotherapy: Benzos and SSRIs

49. 41 y/o grocery store manager who describes
herself as a 'micromanager' who likes to do things
'properly'
Has trouble with employees because she constantly
quadruple-checks everything they do
Despite her insistence on perfection, her store is
not doing well
Divorced, because 'I had too much to do, I couldn't
take care of him on top of it'
Never has time for fun

50. “I'm a perfectionist, I keep lists, drive myself hard, and I'm
very serious about life.”

51. Obsessive-Compulsive Personality
Disorder
LAW FIRMS (four of eight)
Loses point of activity
Ability to complete tasks compromised
Worthless objects (unable to discard)
Friendships excluded (preoccupied with work)
Inflexible
Reluctant to delegate
Miserly
Stubborn

52. Obsessive-Compulsive Personality
disorder
M>F, first degree relatives
DD: Obsessive-Compulsive disorder,
Narcissistic PD
Course: Variable, few intimate long term
relationships, may mellow with age.
Depression, ETOH/ somatoform disorders
Treatment: Patients often seek treatment on
their own
Group therapy , Benzos for anxiety

53. Personality Disorder NOS
Persistent personality dysfunction that does
not meet full criteria for a single PD, OR meets
criteria for Appendix -B of DSM-IV-TR
Passive aggressive PD
•
Passive resistance to authority figures and to
any request for adequate performance
Depressive PD
Pervasive pessimism, anhedonia, mirthlessness