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Author: Michael Jibson, M.D., Ph.D., 2009

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Personality
                         and
                 Personality Disorders


           M2 Psychiatry Sequence


Michael Jibson
Fall 2008
Personality Traits
•  Enduring patterns of perceiving,
  relating to, and thinking about the
  environment and oneself that are
  exhibited in a wide range of social and
  personal contexts. (DSM-IV)
    American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision.
    Washington, DC, American Psychiatric Association, 2000.
Personality Disorder
•  Only when personality traits are
  inflexible and maladaptive and cause
  significant functional impairment or
  subjective distress do they constitute
  Personality Disorders. (DSM-IV)
    American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision.
    Washington, DC, American Psychiatric Association, 2000.
Diagnostic Criteria for a Personality Disorder




     American Psychiatric Association: Diagnostic and Manual of Mental Disorders, 4th ed, Text Revision (DSM-IV-TR)
Dimensions of Personality

Hippocrates - Four humors 
• Blood - Emotional lability
• Black bile - Depression
• Yellow bile - Anger
• Phlegm - Slow, stolid, cold
Dimensions of Personality

Carl Jung - Psychological Types (1921)
• Introvert-Extravert
• Thinking-Feeling
• Sensing-Intuiting
• Judging-Perceiving
Dimensions of Personality

Assessment Instruments
• Self-report inventories 
  • Minnesota Multiphasic Personality Inventory
    (MMPI, 1937)
     • >500 True-false questions ( I believe I am being
       plotted against. I sometimes tease animals. )
     • Ten clinical scales (hypochondriasis, depression,...)
     • Three validity scales (detect faking good and
        faking bad )
     • Four special scales (ego strength, anxiety,...)
Dimensions of Personality

Assessment Instruments
• Self-report inventories 
  • Meyers-Briggs - Scores are plotted along Jung s
    four dimensions
Dimensions of Personality

Assessment Instruments
• Structured clinical interview for diagnosis
  (SCID) - Based on diagnostic criteria, not
  dimensions
• Clinical interview
Dimensions of Personality
Assessment Instruments
• Projective tests - Not diagnostic, but show
  patterns of thought, dynamics, defenses,
  disorders of thought, etc.
  • Rorschach (ink-blot)
  • Thematic Apperception Test (TAT) - (tell
    stories about evocative pictures)
  • Sentence-Completion Test (SCT) - ( I like...
     Sometimes I wish... )
  • Draw-A-Person (DAP)
Plate I of the Rorschach Test
                            




Rorschach, NowPublic
Etiology

Genetic and biologic factors
• Concordance rates of personality
  traits for monozygotic twins are
  higher than for dizygotic twins, even
  if they are raised apart
Etiology - Genetic and Biologic Factors
                                       

Larry Siever
•  Cognitive disorganization (includes
    interpersonal detachment ) - Cluster A
•  Impulsivity - Cluster B
   •  Decreased 5-HT and 5-HIAA (5-HT metabolite)
•  Affective instability - Cluster B
   •  Hyperresponsivity of noradrenergic system
•  Anxiety/Inhibition - Cluster C
   •  High autonomic arousal from infancy
Etiology - Genetic and Biologic Factors
                                      

Robert Cloninger
• Novelty seeking
• Harm avoidance
• Reward dependence
Etiology

Environmental factors
• Parenting and family style
• Psychosocial milieu
Etiology

Psychodynamic factors
• Internal drives and defenses
• Developmental tasks and stages
Cluster A Personality Disorders
                                  

• Odd or Eccentric
Cluster A Personality Disorders
                                  

Paranoid Personality Disorder
•  A pattern of distrust or
  suspiciousness such that 
others
  motives are interpreted as
  malevolent. (DSM-IV)
Cluster A Personality Disorders

Diagnostic Criteria for Paranoid Personality Disorder (DSM-IV)
A. A pervasive distrust and suspiciousness of others such that their motives are interpreted as
   malevolent, beginning by early adulthood and present in a variety of contexts, as indicated by our
   (or more) of the following:

 (1) suspects, without sufficient basis, that others are exploiting, harming, or deceiving him or her
 (2) is preoccupied with unjustified doubts about the loyalty or trustworthiness of friends or
     associates
 (3) is reluctant to confide in others because of unwarranted fear that the information will be used
     maliciously against him or her
 (4) reads hidden demeaning or threatening meanings into benign remarks or events
 (5) persistently bears grudges, i.e., is unforgiving of insults, injuries, or slights
 (6) perceives attacks on his or her character or reputation that are not apparent to others and is quick
     to react angrily or to counterattack
 (7) has recurrent suspicions, without justification, regarding fidelity of spouse or sexual partner

B.   Does not occur exclusively during the course of Schizophrenia, a Mood Disorder With Psychotic
     Features, or another Psychotic Disorder and is not due to the direct physiological effects of a
     general medical condition.
           DSM-IV-TR, pp. 694
Cluster A Personality Disorders
                                   

Paranoid Personality Disorder
•  Prevalence: 2% of population.
•  Sex ratio: F:M=3:1
•  Comorbidity: Brief reactive psychosis,
   delusional disorder, anxiety, substance abuse,
   depression, schizophrenia
•  Family: Delusional disorder, schizophrenia,
   Cluster A disorders
Cluster A Personality Disorders
                                  

Paranoid Personality Disorder
• Treatment
  • Psychotherapy - Treatment of choice, but
    patients have limited introspection
  • Medication - Anxiolytics are often
    useful; antipsychotics sometimes helpful
Cluster A Personality Disorders
                                  

Paranoid Personality Disorder
• Physician-patient interaction
  • A straightforward approach, without an
    expectation of personal warmth is most
    effective
  • Greater empathy may actually make the
    patient more anxious
Cluster A Personality Disorders
                                  

Schizoid Personality Disorder
•  A pattern of detachment from social
  relationships and a restricted range of
  emotional expression. (DSM-IV)
Cluster A Personality Disorders

Diagnostic Criteria for Schizoid Personality Disorder (DSM-IV)
A. A pervasive pattern of detachment from social relationships and a restricted range of expression of
   emotions in interpersonal settings, beginning by early adulthood and present in a variety of
   contexts, as indicated by four (or more) of the following:

  (1)   neither desires nor enjoys close relationships, including being part of a family
  (2)   almost always chooses solitary activities
  (3)   has little, if any, interest in having sexual experiences with another person
  (4)   takes pleasure in few, if any, activities
  (5)   lacks close friends or confidants other than first-degree relatives
  (6)   appears indifferent to the praise or criticism of others
  (7)   shows emotional coldness, detachment, or flattened affectivity

B. Does not occur exclusively during the course of Schizophrenia, a Mood Disorder With Psychotic
   Features, another Psychotic Disorder, or a Pervasive Development Disorder and is not due to the
   direct physiological effects of a general medical condition.


           DSM-IV-TR, pp. 697
Cluster A Personality Disorders
                                   

Schizoid Personality Disorder
•  Prevalence: 3% of population
•  Sex ratio: M>F
•  Comorbidity: Delusional disorder,
   schizophrenia
•  Family: Schizophrenia, Cluster A disorders, esp.
   schizotypal personality disorder
Cluster A Personality Disorders
                                  

Schizoid Personality Disorder
• Treatment
  • Psychotherapy - Treatment of choice;
    introspection is usually good
  • Medication - Low doses of antipsychotics or
    antidepressants are occasionally helpful
Cluster A Personality Disorders
                                  

Schizoid Personality Disorder
• Physician-patient interaction
  • A straightforward approach, without an
    expectation of personal warmth is preferred 
  • Greater empathy may actually make the
    patient more anxious
Cluster A Personality Disorders
                                  

Schizotypal Personality Disorder
•  A pattern of acute discomfort in close
  relationships, cognitive or perceptual
  distortions, and eccentricities of
  behavior. (DSM-IV)
Cluster A Personality Disorders

Diagnostic Criteria for Schizotypal Personality Disorder (DSM-IV)
A. A pervasive pattern of social and interpersonal deficits marked by acute discomfort with, and
   reduced capacity for, close relationships as well as by cognitive or perceptual distortions and
   eccentricities of behavior, beginning by early adulthood and present in a variety of contexts, as
   indicated by five (or more) of the following:

 (1) ideas of reference (excluding delusions of reference)
 (2) odd beliefs or magical thinking that influences behavior and is inconsistent with subcultural
     norms (e.g., superstitiousness, belief in clairvoyance, telepathy, or "sixth sense"; in children and
     adolescents, bizarre fantasies or preoccupations)
 (3) unusual perceptual experiences, including bodily illusions
 (4) odd thinking and speech (e.g., vague, circumstantial, metaphorical, overelaborate, or stereotyped)
 (5) suspiciousness or paranoid ideation
 (6) inappropriate or constricted affect
 (7) behavior or appearance that is odd, eccentric, or peculiar
 (8) lack of close friends or confidants other than first-degree relatives
 (9) excessive social anxiety that does not diminish with familiarity and tends to be associated with
     paranoid fears rather than negative judgments about self

          DSM-IV-TR, pp. 701
Cluster A Personality Disorders
                                   

Schizotypal Personality Disorder
•  Prevalence: 3% of population, but uncommon in
   clinical settings.
•  Sex ratio: M>F
•  Comorbidity: Depression, anxiety, brief reactive
   psychosis, delusional disorder, schizophrenia
•  Family: Schizophrenia, Cluster A disorders.
Cluster A Personality Disorders
                                  

Schizotypal Personality Disorder
• Treatment
  • Psychotherapy - Treatment of choice. Insight
    may be limited.
  • Medication - Antipsychotics may be useful
Cluster A Personality Disorders
                                  
Schizotypal Personality Disorder
• Physician-patient interaction
  • A straightforward approach, without an
    expectation of personal warmth is preferred 
  • Greater empathy may actually make the
    patient more anxious
  • Care must be taken not to ridicule odd or
    over-valued ideas
  • Avoid overt rejection - even a limited
    personal interaction may be very important to
    the patient, and its loss distressing
Cluster B Personality Disorders
                                  

• Dramatic, Emotional, or Erratic
Cluster B Personality Disorders
                                  

Antisocial Personality Disorder
•  A pattern of disregard for, and violation
  of, the rights of others. (DSM-IV)
Cluster B Personality Disorders
Diagnostic Criteria for Antisocial Personality Disorder (DSM-IV)
A. There is a pervasive pattern of disregard for and violation of the rights of others occurring since age
   15 years, as indicated by three (or more) of the following:

  (1) failure to conform to social norms with respect to lawful behaviors as indicated by repeatedly
      performing acts that are grounds for arrest
  (2) deceitfulness, as indicated by repeated lying, use of aliases, or conning others for personal profit
      or pleasure
  (3) impulsivity or failure to plan ahead
  (4) irritability and aggressiveness, as indicated by repeated physical fights or assaults
  (5) reckless disregard for safety of self or others
  (6) consistent irresponsibility, as indicated by repeated failure to sustain consistent work behavior or
      honor financial obligations
  (7) lack of remorse, as indicated by being indifferent to or rationalizing having hurt, mistreated, or
      stolen from another

B. The individual is at least age 18 years.

C. There is evidence of Conduct Disorder with onset before age 15 years.

D. The occurrence of antisocial behavior is not exclusively during the course of Schizophrenia or a
   Manic Episode.

          DSM-IV-TR, pp. 706
Cluster B Personality Disorders
                                   

Antisocial Personality Disorder
•  Prevalence: 3% of males and 1% of females
•  Sex ratio: M:F=3:1
•  Comorbidity: Substance abuse, attention deficit
   disorder, depression, anxiety 

•  Family: Somatization disorder, substance abuse,
   Cluster B disorders, esp. antisocial personality
   disorder
Cluster B Personality Disorders
                                   

Antisocial Personality Disorder
• Major clinical issues
  • Violence
  • Criminal behavior
  • Suicide
Cluster B Personality Disorders
                                  
Antisocial Personality Disorder
• Treatment – no psychiatric treatment
  addresses the core pathology
  • Psychotherapy - Not generally useful, although
    it may alleviate depression and anxiety,
    especially if the patient is immobilized (e.g., in
    jail)
  • Medication - May be useful for comorbid
    disorders; uncontrolled rage may be helped
    somewhat by antipsychotics or mood stabilizers
Cluster B Personality Disorders
                                   

Antisocial Personality Disorder
• Physician-patient interaction
  • Firm limits are essential
  • Substance abuse is a major problem
  • complicated by genuine distress and incessant
    manipulation
Cluster B Personality Disorders
                                   

Borderline Personality Disorder
•  A pattern of instability in interpersonal
  relationships, self-image, and affects, and
  marked impulsivity. (DSM-IV)
Cluster B Personality Disorders

Diagnostic Criteria for Borderline Personality Disorder (DSM-IV)
A pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked
impulsivity beginning by early adulthood and present in a variety of contexts, as indicated by five (or
more) of the following:

 (1) frantic efforts to avoid real or imagined abandonment
 (2) a pattern of unstable and intense interpersonal relationships characterized by alternating between
     extremes of idealization and devaluation
 (3) identity disturbance: markedly and persistently unstable self-image or sense of self
 (4) impulsivity in at least two areas that are potentially self-damaging (e.g., spending, sex, substance
     abuse, reckless driving, binge eating)
 (5) recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior
 (6) 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)
 (7) chronic feelings of emptiness
 (8) inappropriate, intense anger or difficulty controlling anger (e.g., frequent displays of temper,
     constant anger, recurrent physical fights)
 (9) transient, stress-related paranoid ideation or severe dissociative symptoms

          DSM-IV-TR, pp. 710
Cluster B Personality Disorders
                                   

Borderline Personality Disorder
•  Prevalence: 3% of females and 1% of males
•  Sex ratio: F:M=3:1
•  Comorbidity: Depression, substance abuse,
   eating disorders, brief reactive psychosis
•  Family: Mood disorders, substance abuse,
   Cluster B disorders, esp. antisocial personality
   disorder
Cluster B Personality Disorders
                                    
Borderline Personality Disorder
• Major clinical issues
  • Suicide and self-mutilation
  • Splitting - seeing the world as all good or all bad
  • Rage
  • Psychosis
  • Childhood trauma (especially sexual)
  • Dissociation
- depersonalization, derealization,
    amnestic episodes,
Cluster B Personality Disorders
                                  

Borderline Personality Disorder
• Treatment
  • Psychotherapy - Dialectical/behavioral
    therapy (DBT) is preferred. Individual, group,
    and cognitive/behavioral therapy (CBT) are
    difficult, but may be useful. 
  • Medication - Low-dose antipsychotics, mood
    stabilizers, and standard-dose antidepressants
    are moderately useful. Anxiolytics are
    beneficial in a minority of patients.
Cluster B Personality Disorders
                                   

Borderline Personality Disorder
• Physician-patient interaction
  • Idealization, devaluation, and splitting are
    common
  • Firm limits and high tolerance for regressive
    (childish) behavior are essential
  • Countertransference must be monitored
    carefully
Cluster B Personality Disorders
                                  

Histrionic Personality Disorder
•  A pattern of excessive emotionality and
  attention seeking. (DSM-IV)
Cluster B Personality Disorders
Diagnostic Criteria for Histrionic Personality Disorder (DSM-IV)
A pervasive pattern of excessive emotionality and attention seeking, beginning by early adulthood and
present in a variety of contexts, as indicated by five (or more) of the following:

 (1) is uncomfortable in situations in which he or she is not the center of attention
 (2) interaction with others is often characterized by inappropriate sexually seductive or provocative
     behavior
 (3) displays rapidly shifting and shallow expression of emotions
 (4) consistently uses physical appearance to draw attention to self
 (5) has a style of speech that is excessively impressionistic and lacking in detail
 (6) shows self-dramatization, theatricality, and exaggerated expression of emotion
 (7) is suggestible, i.e., easily influenced by others or circumstances
 (8) considers relationships to be more intimate than they actually are




          DSM-IV-TR, pp. 714
Cluster B Personality Disorders
                                   

Histrionic Personality Disorder
•  Prevalence: 2-3% of population
•  Sex ratio: F>M
•  Comorbidity: Somatization and conversion
   disorders, depression, anxiety
•  Family: Cluster B disorders
Cluster B Personality Disorders
                                  

Histrionic Personality Disorder
• Treatment
  • Psychotherapy - Dynamic therapy is the
    treatment of choice
  • Medication - Antidepressants and anxiolytics
    may help comorbid depression and anxiety
Cluster B Personality Disorders
                                   

Histrionic Personality Disorder
• Physician-patient interaction
  • Overly dependent or seductive behavior is
    common
  • A dramatic presentation may obscure the
    differences between major and minor physical
    problems
  • Rapid fluctuation between overwhelming
    anxiety about a medical problem and total
    indifference is common.
Cluster B Personality Disorders
                                  

Narcissistic Personality Disorder
•  A pattern of grandiosity, need for
  admiration, and lack of empathy. (DSM-IV)
Cluster B Personality Disorders

Diagnostic Criteria for Narcissistic Personality Disorder (DSM-IV)
A pervasive pattern of grandiosity (in fantasy or behavior), need for admiration, and lack of empathy,
beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the
following:

 (1) has a grandiose sense of self-importance (e.g., exaggerates achievements and talents, expects to be
     recognized as superior without commensurate achievements)
 (2) is preoccupied with fantasies of unlimited success, power, brilliance, beauty, or ideal love
 (3) 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)
 (4) requires excessive admiration
 (5) has a sense of entitlement, i.e., unreasonable expectations of especially favorable treatment or
     automatic compliance with his or her expectations
 (6) is interpersonally exploitative, i.e., takes advantage of others to achieve his or her own ends
 (7) lacks empathy: is unwilling to recognize or identify with the feelings and needs of others
 (8) is often envious of others or believes that others are envious of him or her
 (9) shows arrogant, haughty behaviors or attitudes


          DSM-IV-TR, pp. 717
Cluster B Personality Disorders
                                  

Narcissistic Personality Disorder
• Prevalence: <1% of population
• Sex ratio: 50-75% male
• Comorbidity: Mood disorders, anorexia,
  substance abuse
• Family: Cluster B disorders
Cluster B Personality Disorders
                                  

Narcissistic Personality Disorder
• Treatment
  • Psychotherapy - Psychotherapy is difficult, but
    is the treatment of choice. Interpersonal
    therapy (IPT) may be most effective.
  • Medication - Antidepressants or mood
    stabilizers may be helpful for comorbid mood
    disorders
Cluster B Personality Disorders
                                   

Narcissistic Personality Disorder
• Physician-patient interaction
  • Idealization gives way rapidly to
    contemptuous devaluation
  • Entitlement and condescension are common
  • Be aware that it is more often the physician
    than the patient who has these traits
Cluster B Personality Disorders
                                  

• Anxious or Fearful
Cluster C Personality Disorders
                                  

Avoidant Personality Disorder
•  A pattern of social inhibition,
  feelings of inadequacy, and
  hypersensitivity to negative
  evaluation. (DSM-IV)
Cluster C Personality Disorders

Diagnostic Criteria for Avoidant Personality Disorder (DSM-IV)
  A pervasive pattern of social inhibition, feelings of inadequacy, and hypersensitivity to negative
evaluation, beginning by early adulthood and present in a variety of contexts, as indicated by four (or
more) of the following:

 (1) avoids occupational activities that involve significant interpersonal contact, because of fears of
     criticism, disapproval, or rejection
 (2) is unwilling to get involved with people unless certain of being liked
 (3) shows restraint within intimate relationships because of the fear of being shamed or ridiculed
 (4) is preoccupied with being criticized or rejected in social situation
 (5) is inhibited in new interpersonal situations because of feelings of inadequacy
 (6) views self as socially inept, personally unappealing, or inferior to others
 (7) is unusually reluctant to take personal risks or to engage in any new activities because they may
     prove embarrassing



          DSM-IV-TR, pp. 721
Cluster C Personality Disorders
                                  

Avoidant Personality Disorder
• Prevalence: 0.5-1% of population
• Sex ratio: M=F
• Comorbidity: Social phobia, depression,
  anxiety
• Family: Cluster C disorders
Cluster C Personality Disorders
                                  

Avoidant Personality Disorder
• Treatment
  • Psychotherapy - Individual and group
    therapy, typically interpersonal (IPT), is the
    treatment of choice
  • Medication - Antidepressants and anxiolytics
    are often useful for accompanying depression
    and anxiety
Cluster C Personality Disorders
                                  

Avoidant Personality Disorder
• Physician-patient interaction
  • Unconditional respect and concern are very
    helpful
  • Avoid implications of rejection
  • Be aware that even a limited personal
    interaction may be very important, and its loss
    very distressing
Cluster C Personality Disorders
                                  

Dependent Personality Disorder
•  A pattern of submissive and clinging
  behavior related to an excessive need
  to be taken care of. (DSM-IV)
Cluster C Personality Disorders
Diagnostic Criteria for Dependent Personality Disorder (DSM-IV)
A pervasive and excessive need to be taken care of that leads to submissive and clinging behavior and
fears of separation, beginning by early adulthood and present in a variety of contexts, as indicated by
five (or more) of the following:

  (1) has difficulty making everyday decisions without an excessive amount of advice and
      reassurance from others
  (2) needs others to assume responsibility for most major areas of his or her life
  (3) has difficulty expressing disagreement with others because of fear of loss of support or approval
  (4) has difficulty initiating projects or doing things on his or her own (because of lack of self-
      confidence in judgment or abilities rather than a lack of motivation or energy
  (5) goes to excessive lengths to obtain nurturance and support from others, to the point of
      volunteering to do things that are unpleasant
  (6) feels uncomfortable or helpless when alone because of exaggerated fears of being unable to care
      for himself or herself
  (7) urgently seeks another relationship as a source of care and support when a close relationship
      ends
  (8) is unrealistically preoccupied with fears of being left to take care of himself or herself

          DSM-IV-TR, pp. 725
Cluster C Personality Disorders
                                  

Dependent Personality Disorder
• Prevalence: 2.5-27% of population
• Sex ratio: F>M
• Comorbidity: Mood and anxiety
  disorders, adjustment disorders
• Family: Cluster C disorders
Cluster C Personality Disorders
                                  

Dependent Personality Disorder
• Treatment
  • Psychotherapy - Dynamic, behavior, group,
    and family therapies are all used successfully
  • Medication - Anxiolytics are often helpful.
    Antidepressants may be used with comorbid
    depression.
Cluster C Personality Disorders
                                  

Dependent Personality Disorder
• Physician-patient interaction
  • Physicians should take an active role in
    treatment planning, with clear explanations
    and recommendations
  • Patients may need encouragement to make
    decisions about treatment plans
  • Family involvement is often helpful
Cluster C Personality Disorders
                                  

Obsessive Compulsive Personality 
Disorder
•  A pattern of preoccupation with
  orderliness, perfectionism, and
  control. (DSM-IV)
Cluster C Personality Disorders
Diagnostic Criteria for Obsessive Compulsive Personality Disorder
(DSM-IV)
A pervasive pattern of preoccupation with orderliness, perfectionism, and mental and interpersonal
control, at the expense of flexibility, openness, and efficiency beginning by early adulthood and present
in a variety of contexts, as indicated by four (or more) of the following:

  (1) is preoccupied with details, rules, list, order, organization, or schedules to the extent that the
      major point of the activity is lost
  (2) shows perfectionism that interferes with task completion (e.g., is unable to complete a project
      because his or her own overly strict standards are not met)
  (3) is excessively devoted to work and productivity to the exclusion of leisure activities and
      friendships (not accounted for by obvious economic necessity)
  (4) is overconscientious, scrupulous, and inflexible about matters of morality, ethic, or values (not
      accounted for by cultural or religious identification)
  (5) is unable to discard worn-out or worthless objects even when they have no sentimental value
  (6) is reluctant to delegate tasks or to work with others unless they submit to exactly his or her way
      of doing things
  (7) adopts a miserly spending style toward both self and others; money is viewed as something to be
      hoarded for future catastrophes
  (8) shows rigidity and stubbornness

          DSM-IV-TR, pp. 729
Cluster C Personality Disorders
                                   

Obsessive Compulsive Personality 
Disorder
•  Prevalence: 1% of population
•  Sex ratio: M:F=2:1
•  Comorbidity: Slight increase in mood and
   anxiety disorders
•  Family: Obsessive-compulsive personality
   disorder
Cluster C Personality Disorders
                                  

Obsessive Compulsive Personality 
Disorder
• Treatment
  • Psychotherapy - Psychoanalytic, behavioral,
    and group therapies are often useful
  • Medication - Serotonin-specific reuptake
    inhibitor (SSRI) antidepressants may be useful
Cluster C Personality Disorders
                                  

Obsessive Compulsive Personality 
Disorder
• Physician-patient interaction
  • Thorough explanations and specific, detailed
    information are valued
  • Uncertainty is rarely tolerated
  • Treatment options should be presented with
    clear risk-benefit analyses
Additional Source Information
                                    for more information see: http://open.umich.edu/wiki/CitationPolicy

Slide 4-6: American Psychiatric Association: Diagnostic and Manual of Mental Disorders, 4th ed, Text Revision (DSM-IV-TR), Washington, DC, American Psychiatric
   Association, 2000, p. 689
Slide 13: Rorschach, NowPublic, http://www.nowpublic.com/health/rorschach-plate-1-bat-butterfly-moth
Slide 21: DSM-IV-TR, pp. 694
Slide 26: DSM-IV-TR, pp. 697
Slide 31: DSM-IV-TR, pp. 701
Slide 37: DSM-IV-TR, pp. 706
Slide 43: DSM-IV-TR, pp. 710
Slide 49: DSM-IV-TR, pp. 714
Slide 54: DSM-IV-TR, pp. 717
Slide 60: DSM-IV-TR, pp. 721
Slide 65: DSM-IV-TR, pp. 725
Slide 70: DSM-IV-TR, pp. 729

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10.29.08(a): Personality and Personality Disorders

  • 1. Author: Michael Jibson, M.D., Ph.D., 2009 License: Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution–Share Alike 3.0 License: http://creativecommons.org/licenses/by-sa/3.0/ We have reviewed this material in accordance with U.S. Copyright Law and have tried to maximize your ability to use, share, and adapt it. The citation key on the following slide provides information about how you may share and adapt this material. Copyright holders of content included in this material should contact open.michigan@umich.edu with any questions, corrections, or clarification regarding the use of content. For more information about how to cite these materials visit http://open.umich.edu/education/about/terms-of-use. Any medical information in this material is intended to inform and educate and is not a tool for self-diagnosis or a replacement for medical evaluation, advice, diagnosis or treatment by a healthcare professional. Please speak to your physician if you have questions about your medical condition. Viewer discretion is advised: Some medical content is graphic and may not be suitable for all viewers.
  • 2. Citation Key for more information see: http://open.umich.edu/wiki/CitationPolicy Use + Share + Adapt { Content the copyright holder, author, or law permits you to use, share and adapt. } Public Domain – Government: Works that are produced by the U.S. Government. (17 USC § 105) Public Domain – Expired: Works that are no longer protected due to an expired copyright term. Public Domain – Self Dedicated: Works that a copyright holder has dedicated to the public domain. Creative Commons – Zero Waiver Creative Commons – Attribution License Creative Commons – Attribution Share Alike License Creative Commons – Attribution Noncommercial License Creative Commons – Attribution Noncommercial Share Alike License GNU – Free Documentation License Make Your Own Assessment { Content Open.Michigan believes can be used, shared, and adapted because it is ineligible for copyright. } Public Domain – Ineligible: Works that are ineligible for copyright protection in the U.S. (17 USC § 102(b)) *laws in your jurisdiction may differ { Content Open.Michigan has used under a Fair Use determination. } Fair Use: Use of works that is determined to be Fair consistent with the U.S. Copyright Act. (17 USC § 107) *laws in your jurisdiction may differ Our determination DOES NOT mean that all uses of this 3rd-party content are Fair Uses and we DO NOT guarantee that your use of the content is Fair. To use this content you should do your own independent analysis to determine whether or not your use will be Fair.
  • 3. Personality and Personality Disorders M2 Psychiatry Sequence Michael Jibson Fall 2008
  • 4. Personality Traits •  Enduring patterns of perceiving, relating to, and thinking about the environment and oneself that are exhibited in a wide range of social and personal contexts. (DSM-IV) American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision. Washington, DC, American Psychiatric Association, 2000.
  • 5. Personality Disorder •  Only when personality traits are inflexible and maladaptive and cause significant functional impairment or subjective distress do they constitute Personality Disorders. (DSM-IV) American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision. Washington, DC, American Psychiatric Association, 2000.
  • 6. Diagnostic Criteria for a Personality Disorder American Psychiatric Association: Diagnostic and Manual of Mental Disorders, 4th ed, Text Revision (DSM-IV-TR)
  • 7. Dimensions of Personality Hippocrates - Four humors • Blood - Emotional lability • Black bile - Depression • Yellow bile - Anger • Phlegm - Slow, stolid, cold
  • 8. Dimensions of Personality Carl Jung - Psychological Types (1921) • Introvert-Extravert • Thinking-Feeling • Sensing-Intuiting • Judging-Perceiving
  • 9. Dimensions of Personality Assessment Instruments • Self-report inventories • Minnesota Multiphasic Personality Inventory (MMPI, 1937) • >500 True-false questions ( I believe I am being plotted against. I sometimes tease animals. ) • Ten clinical scales (hypochondriasis, depression,...) • Three validity scales (detect faking good and faking bad ) • Four special scales (ego strength, anxiety,...)
  • 10. Dimensions of Personality Assessment Instruments • Self-report inventories • Meyers-Briggs - Scores are plotted along Jung s four dimensions
  • 11. Dimensions of Personality Assessment Instruments • Structured clinical interview for diagnosis (SCID) - Based on diagnostic criteria, not dimensions • Clinical interview
  • 12. Dimensions of Personality Assessment Instruments • Projective tests - Not diagnostic, but show patterns of thought, dynamics, defenses, disorders of thought, etc. • Rorschach (ink-blot) • Thematic Apperception Test (TAT) - (tell stories about evocative pictures) • Sentence-Completion Test (SCT) - ( I like... Sometimes I wish... ) • Draw-A-Person (DAP)
  • 13. Plate I of the Rorschach Test Rorschach, NowPublic
  • 14. Etiology Genetic and biologic factors • Concordance rates of personality traits for monozygotic twins are higher than for dizygotic twins, even if they are raised apart
  • 15. Etiology - Genetic and Biologic Factors Larry Siever •  Cognitive disorganization (includes interpersonal detachment ) - Cluster A •  Impulsivity - Cluster B •  Decreased 5-HT and 5-HIAA (5-HT metabolite) •  Affective instability - Cluster B •  Hyperresponsivity of noradrenergic system •  Anxiety/Inhibition - Cluster C •  High autonomic arousal from infancy
  • 16. Etiology - Genetic and Biologic Factors Robert Cloninger • Novelty seeking • Harm avoidance • Reward dependence
  • 17. Etiology Environmental factors • Parenting and family style • Psychosocial milieu
  • 18. Etiology Psychodynamic factors • Internal drives and defenses • Developmental tasks and stages
  • 19. Cluster A Personality Disorders • Odd or Eccentric
  • 20. Cluster A Personality Disorders Paranoid Personality Disorder •  A pattern of distrust or suspiciousness such that others motives are interpreted as malevolent. (DSM-IV)
  • 21. Cluster A Personality Disorders Diagnostic Criteria for Paranoid Personality Disorder (DSM-IV) A. A pervasive distrust and suspiciousness of others such that their motives are interpreted as malevolent, beginning by early adulthood and present in a variety of contexts, as indicated by our (or more) of the following: (1) suspects, without sufficient basis, that others are exploiting, harming, or deceiving him or her (2) is preoccupied with unjustified doubts about the loyalty or trustworthiness of friends or associates (3) is reluctant to confide in others because of unwarranted fear that the information will be used maliciously against him or her (4) reads hidden demeaning or threatening meanings into benign remarks or events (5) persistently bears grudges, i.e., is unforgiving of insults, injuries, or slights (6) perceives attacks on his or her character or reputation that are not apparent to others and is quick to react angrily or to counterattack (7) has recurrent suspicions, without justification, regarding fidelity of spouse or sexual partner B. Does not occur exclusively during the course of Schizophrenia, a Mood Disorder With Psychotic Features, or another Psychotic Disorder and is not due to the direct physiological effects of a general medical condition. DSM-IV-TR, pp. 694
  • 22. Cluster A Personality Disorders Paranoid Personality Disorder •  Prevalence: 2% of population. •  Sex ratio: F:M=3:1 •  Comorbidity: Brief reactive psychosis, delusional disorder, anxiety, substance abuse, depression, schizophrenia •  Family: Delusional disorder, schizophrenia, Cluster A disorders
  • 23. Cluster A Personality Disorders Paranoid Personality Disorder • Treatment • Psychotherapy - Treatment of choice, but patients have limited introspection • Medication - Anxiolytics are often useful; antipsychotics sometimes helpful
  • 24. Cluster A Personality Disorders Paranoid Personality Disorder • Physician-patient interaction • A straightforward approach, without an expectation of personal warmth is most effective • Greater empathy may actually make the patient more anxious
  • 25. Cluster A Personality Disorders Schizoid Personality Disorder •  A pattern of detachment from social relationships and a restricted range of emotional expression. (DSM-IV)
  • 26. Cluster A Personality Disorders Diagnostic Criteria for Schizoid Personality Disorder (DSM-IV) A. A pervasive pattern of detachment from social relationships and a restricted range of expression of emotions in interpersonal settings, beginning by early adulthood and present in a variety of contexts, as indicated by four (or more) of the following: (1) neither desires nor enjoys close relationships, including being part of a family (2) almost always chooses solitary activities (3) has little, if any, interest in having sexual experiences with another person (4) takes pleasure in few, if any, activities (5) lacks close friends or confidants other than first-degree relatives (6) appears indifferent to the praise or criticism of others (7) shows emotional coldness, detachment, or flattened affectivity B. Does not occur exclusively during the course of Schizophrenia, a Mood Disorder With Psychotic Features, another Psychotic Disorder, or a Pervasive Development Disorder and is not due to the direct physiological effects of a general medical condition. DSM-IV-TR, pp. 697
  • 27. Cluster A Personality Disorders Schizoid Personality Disorder •  Prevalence: 3% of population •  Sex ratio: M>F •  Comorbidity: Delusional disorder, schizophrenia •  Family: Schizophrenia, Cluster A disorders, esp. schizotypal personality disorder
  • 28. Cluster A Personality Disorders Schizoid Personality Disorder • Treatment • Psychotherapy - Treatment of choice; introspection is usually good • Medication - Low doses of antipsychotics or antidepressants are occasionally helpful
  • 29. Cluster A Personality Disorders Schizoid Personality Disorder • Physician-patient interaction • A straightforward approach, without an expectation of personal warmth is preferred • Greater empathy may actually make the patient more anxious
  • 30. Cluster A Personality Disorders Schizotypal Personality Disorder •  A pattern of acute discomfort in close relationships, cognitive or perceptual distortions, and eccentricities of behavior. (DSM-IV)
  • 31. Cluster A Personality Disorders Diagnostic Criteria for Schizotypal Personality Disorder (DSM-IV) A. A pervasive pattern of social and interpersonal deficits marked by acute discomfort with, and reduced capacity for, close relationships as well as by cognitive or perceptual distortions and eccentricities of behavior, beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following: (1) ideas of reference (excluding delusions of reference) (2) odd beliefs or magical thinking that influences behavior and is inconsistent with subcultural norms (e.g., superstitiousness, belief in clairvoyance, telepathy, or "sixth sense"; in children and adolescents, bizarre fantasies or preoccupations) (3) unusual perceptual experiences, including bodily illusions (4) odd thinking and speech (e.g., vague, circumstantial, metaphorical, overelaborate, or stereotyped) (5) suspiciousness or paranoid ideation (6) inappropriate or constricted affect (7) behavior or appearance that is odd, eccentric, or peculiar (8) lack of close friends or confidants other than first-degree relatives (9) excessive social anxiety that does not diminish with familiarity and tends to be associated with paranoid fears rather than negative judgments about self DSM-IV-TR, pp. 701
  • 32. Cluster A Personality Disorders Schizotypal Personality Disorder •  Prevalence: 3% of population, but uncommon in clinical settings. •  Sex ratio: M>F •  Comorbidity: Depression, anxiety, brief reactive psychosis, delusional disorder, schizophrenia •  Family: Schizophrenia, Cluster A disorders.
  • 33. Cluster A Personality Disorders Schizotypal Personality Disorder • Treatment • Psychotherapy - Treatment of choice. Insight may be limited. • Medication - Antipsychotics may be useful
  • 34. Cluster A Personality Disorders Schizotypal Personality Disorder • Physician-patient interaction • A straightforward approach, without an expectation of personal warmth is preferred • Greater empathy may actually make the patient more anxious • Care must be taken not to ridicule odd or over-valued ideas • Avoid overt rejection - even a limited personal interaction may be very important to the patient, and its loss distressing
  • 35. Cluster B Personality Disorders • Dramatic, Emotional, or Erratic
  • 36. Cluster B Personality Disorders Antisocial Personality Disorder •  A pattern of disregard for, and violation of, the rights of others. (DSM-IV)
  • 37. Cluster B Personality Disorders Diagnostic Criteria for Antisocial Personality Disorder (DSM-IV) A. There is a pervasive pattern of disregard for and violation of the rights of others occurring since age 15 years, as indicated by three (or more) of the following: (1) failure to conform to social norms with respect to lawful behaviors as indicated by repeatedly performing acts that are grounds for arrest (2) deceitfulness, as indicated by repeated lying, use of aliases, or conning others for personal profit or pleasure (3) impulsivity or failure to plan ahead (4) irritability and aggressiveness, as indicated by repeated physical fights or assaults (5) reckless disregard for safety of self or others (6) consistent irresponsibility, as indicated by repeated failure to sustain consistent work behavior or honor financial obligations (7) lack of remorse, as indicated by being indifferent to or rationalizing having hurt, mistreated, or stolen from another B. The individual is at least age 18 years. C. There is evidence of Conduct Disorder with onset before age 15 years. D. The occurrence of antisocial behavior is not exclusively during the course of Schizophrenia or a Manic Episode. DSM-IV-TR, pp. 706
  • 38. Cluster B Personality Disorders Antisocial Personality Disorder •  Prevalence: 3% of males and 1% of females •  Sex ratio: M:F=3:1 •  Comorbidity: Substance abuse, attention deficit disorder, depression, anxiety •  Family: Somatization disorder, substance abuse, Cluster B disorders, esp. antisocial personality disorder
  • 39. Cluster B Personality Disorders Antisocial Personality Disorder • Major clinical issues • Violence • Criminal behavior • Suicide
  • 40. Cluster B Personality Disorders Antisocial Personality Disorder • Treatment – no psychiatric treatment addresses the core pathology • Psychotherapy - Not generally useful, although it may alleviate depression and anxiety, especially if the patient is immobilized (e.g., in jail) • Medication - May be useful for comorbid disorders; uncontrolled rage may be helped somewhat by antipsychotics or mood stabilizers
  • 41. Cluster B Personality Disorders Antisocial Personality Disorder • Physician-patient interaction • Firm limits are essential • Substance abuse is a major problem • complicated by genuine distress and incessant manipulation
  • 42. Cluster B Personality Disorders Borderline Personality Disorder •  A pattern of instability in interpersonal relationships, self-image, and affects, and marked impulsivity. (DSM-IV)
  • 43. Cluster B Personality Disorders Diagnostic Criteria for Borderline Personality Disorder (DSM-IV) A pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following: (1) frantic efforts to avoid real or imagined abandonment (2) a pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation (3) identity disturbance: markedly and persistently unstable self-image or sense of self (4) impulsivity in at least two areas that are potentially self-damaging (e.g., spending, sex, substance abuse, reckless driving, binge eating) (5) recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior (6) 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) (7) chronic feelings of emptiness (8) inappropriate, intense anger or difficulty controlling anger (e.g., frequent displays of temper, constant anger, recurrent physical fights) (9) transient, stress-related paranoid ideation or severe dissociative symptoms DSM-IV-TR, pp. 710
  • 44. Cluster B Personality Disorders Borderline Personality Disorder •  Prevalence: 3% of females and 1% of males •  Sex ratio: F:M=3:1 •  Comorbidity: Depression, substance abuse, eating disorders, brief reactive psychosis •  Family: Mood disorders, substance abuse, Cluster B disorders, esp. antisocial personality disorder
  • 45. Cluster B Personality Disorders Borderline Personality Disorder • Major clinical issues • Suicide and self-mutilation • Splitting - seeing the world as all good or all bad • Rage • Psychosis • Childhood trauma (especially sexual) • Dissociation - depersonalization, derealization, amnestic episodes,
  • 46. Cluster B Personality Disorders Borderline Personality Disorder • Treatment • Psychotherapy - Dialectical/behavioral therapy (DBT) is preferred. Individual, group, and cognitive/behavioral therapy (CBT) are difficult, but may be useful. • Medication - Low-dose antipsychotics, mood stabilizers, and standard-dose antidepressants are moderately useful. Anxiolytics are beneficial in a minority of patients.
  • 47. Cluster B Personality Disorders Borderline Personality Disorder • Physician-patient interaction • Idealization, devaluation, and splitting are common • Firm limits and high tolerance for regressive (childish) behavior are essential • Countertransference must be monitored carefully
  • 48. Cluster B Personality Disorders Histrionic Personality Disorder •  A pattern of excessive emotionality and attention seeking. (DSM-IV)
  • 49. Cluster B Personality Disorders Diagnostic Criteria for Histrionic Personality Disorder (DSM-IV) A pervasive pattern of excessive emotionality and attention seeking, beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following: (1) is uncomfortable in situations in which he or she is not the center of attention (2) interaction with others is often characterized by inappropriate sexually seductive or provocative behavior (3) displays rapidly shifting and shallow expression of emotions (4) consistently uses physical appearance to draw attention to self (5) has a style of speech that is excessively impressionistic and lacking in detail (6) shows self-dramatization, theatricality, and exaggerated expression of emotion (7) is suggestible, i.e., easily influenced by others or circumstances (8) considers relationships to be more intimate than they actually are DSM-IV-TR, pp. 714
  • 50. Cluster B Personality Disorders Histrionic Personality Disorder •  Prevalence: 2-3% of population •  Sex ratio: F>M •  Comorbidity: Somatization and conversion disorders, depression, anxiety •  Family: Cluster B disorders
  • 51. Cluster B Personality Disorders Histrionic Personality Disorder • Treatment • Psychotherapy - Dynamic therapy is the treatment of choice • Medication - Antidepressants and anxiolytics may help comorbid depression and anxiety
  • 52. Cluster B Personality Disorders Histrionic Personality Disorder • Physician-patient interaction • Overly dependent or seductive behavior is common • A dramatic presentation may obscure the differences between major and minor physical problems • Rapid fluctuation between overwhelming anxiety about a medical problem and total indifference is common.
  • 53. Cluster B Personality Disorders Narcissistic Personality Disorder •  A pattern of grandiosity, need for admiration, and lack of empathy. (DSM-IV)
  • 54. Cluster B Personality Disorders Diagnostic Criteria for Narcissistic Personality Disorder (DSM-IV) A pervasive pattern of grandiosity (in fantasy or behavior), need for admiration, and lack of empathy, beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following: (1) has a grandiose sense of self-importance (e.g., exaggerates achievements and talents, expects to be recognized as superior without commensurate achievements) (2) is preoccupied with fantasies of unlimited success, power, brilliance, beauty, or ideal love (3) 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) (4) requires excessive admiration (5) has a sense of entitlement, i.e., unreasonable expectations of especially favorable treatment or automatic compliance with his or her expectations (6) is interpersonally exploitative, i.e., takes advantage of others to achieve his or her own ends (7) lacks empathy: is unwilling to recognize or identify with the feelings and needs of others (8) is often envious of others or believes that others are envious of him or her (9) shows arrogant, haughty behaviors or attitudes DSM-IV-TR, pp. 717
  • 55. Cluster B Personality Disorders Narcissistic Personality Disorder • Prevalence: <1% of population • Sex ratio: 50-75% male • Comorbidity: Mood disorders, anorexia, substance abuse • Family: Cluster B disorders
  • 56. Cluster B Personality Disorders Narcissistic Personality Disorder • Treatment • Psychotherapy - Psychotherapy is difficult, but is the treatment of choice. Interpersonal therapy (IPT) may be most effective. • Medication - Antidepressants or mood stabilizers may be helpful for comorbid mood disorders
  • 57. Cluster B Personality Disorders Narcissistic Personality Disorder • Physician-patient interaction • Idealization gives way rapidly to contemptuous devaluation • Entitlement and condescension are common • Be aware that it is more often the physician than the patient who has these traits
  • 58. Cluster B Personality Disorders • Anxious or Fearful
  • 59. Cluster C Personality Disorders Avoidant Personality Disorder •  A pattern of social inhibition, feelings of inadequacy, and hypersensitivity to negative evaluation. (DSM-IV)
  • 60. Cluster C Personality Disorders Diagnostic Criteria for Avoidant Personality Disorder (DSM-IV) A pervasive pattern of social inhibition, feelings of inadequacy, and hypersensitivity to negative evaluation, beginning by early adulthood and present in a variety of contexts, as indicated by four (or more) of the following: (1) avoids occupational activities that involve significant interpersonal contact, because of fears of criticism, disapproval, or rejection (2) is unwilling to get involved with people unless certain of being liked (3) shows restraint within intimate relationships because of the fear of being shamed or ridiculed (4) is preoccupied with being criticized or rejected in social situation (5) is inhibited in new interpersonal situations because of feelings of inadequacy (6) views self as socially inept, personally unappealing, or inferior to others (7) is unusually reluctant to take personal risks or to engage in any new activities because they may prove embarrassing DSM-IV-TR, pp. 721
  • 61. Cluster C Personality Disorders Avoidant Personality Disorder • Prevalence: 0.5-1% of population • Sex ratio: M=F • Comorbidity: Social phobia, depression, anxiety • Family: Cluster C disorders
  • 62. Cluster C Personality Disorders Avoidant Personality Disorder • Treatment • Psychotherapy - Individual and group therapy, typically interpersonal (IPT), is the treatment of choice • Medication - Antidepressants and anxiolytics are often useful for accompanying depression and anxiety
  • 63. Cluster C Personality Disorders Avoidant Personality Disorder • Physician-patient interaction • Unconditional respect and concern are very helpful • Avoid implications of rejection • Be aware that even a limited personal interaction may be very important, and its loss very distressing
  • 64. Cluster C Personality Disorders Dependent Personality Disorder •  A pattern of submissive and clinging behavior related to an excessive need to be taken care of. (DSM-IV)
  • 65. Cluster C Personality Disorders Diagnostic Criteria for Dependent Personality Disorder (DSM-IV) A pervasive and excessive need to be taken care of that leads to submissive and clinging behavior and fears of separation, beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following: (1) has difficulty making everyday decisions without an excessive amount of advice and reassurance from others (2) needs others to assume responsibility for most major areas of his or her life (3) has difficulty expressing disagreement with others because of fear of loss of support or approval (4) has difficulty initiating projects or doing things on his or her own (because of lack of self- confidence in judgment or abilities rather than a lack of motivation or energy (5) goes to excessive lengths to obtain nurturance and support from others, to the point of volunteering to do things that are unpleasant (6) feels uncomfortable or helpless when alone because of exaggerated fears of being unable to care for himself or herself (7) urgently seeks another relationship as a source of care and support when a close relationship ends (8) is unrealistically preoccupied with fears of being left to take care of himself or herself DSM-IV-TR, pp. 725
  • 66. Cluster C Personality Disorders Dependent Personality Disorder • Prevalence: 2.5-27% of population • Sex ratio: F>M • Comorbidity: Mood and anxiety disorders, adjustment disorders • Family: Cluster C disorders
  • 67. Cluster C Personality Disorders Dependent Personality Disorder • Treatment • Psychotherapy - Dynamic, behavior, group, and family therapies are all used successfully • Medication - Anxiolytics are often helpful. Antidepressants may be used with comorbid depression.
  • 68. Cluster C Personality Disorders Dependent Personality Disorder • Physician-patient interaction • Physicians should take an active role in treatment planning, with clear explanations and recommendations • Patients may need encouragement to make decisions about treatment plans • Family involvement is often helpful
  • 69. Cluster C Personality Disorders Obsessive Compulsive Personality Disorder •  A pattern of preoccupation with orderliness, perfectionism, and control. (DSM-IV)
  • 70. Cluster C Personality Disorders Diagnostic Criteria for Obsessive Compulsive Personality Disorder (DSM-IV) A pervasive pattern of preoccupation with orderliness, perfectionism, and mental and interpersonal control, at the expense of flexibility, openness, and efficiency beginning by early adulthood and present in a variety of contexts, as indicated by four (or more) of the following: (1) is preoccupied with details, rules, list, order, organization, or schedules to the extent that the major point of the activity is lost (2) shows perfectionism that interferes with task completion (e.g., is unable to complete a project because his or her own overly strict standards are not met) (3) is excessively devoted to work and productivity to the exclusion of leisure activities and friendships (not accounted for by obvious economic necessity) (4) is overconscientious, scrupulous, and inflexible about matters of morality, ethic, or values (not accounted for by cultural or religious identification) (5) is unable to discard worn-out or worthless objects even when they have no sentimental value (6) is reluctant to delegate tasks or to work with others unless they submit to exactly his or her way of doing things (7) adopts a miserly spending style toward both self and others; money is viewed as something to be hoarded for future catastrophes (8) shows rigidity and stubbornness DSM-IV-TR, pp. 729
  • 71. Cluster C Personality Disorders Obsessive Compulsive Personality Disorder •  Prevalence: 1% of population •  Sex ratio: M:F=2:1 •  Comorbidity: Slight increase in mood and anxiety disorders •  Family: Obsessive-compulsive personality disorder
  • 72. Cluster C Personality Disorders Obsessive Compulsive Personality Disorder • Treatment • Psychotherapy - Psychoanalytic, behavioral, and group therapies are often useful • Medication - Serotonin-specific reuptake inhibitor (SSRI) antidepressants may be useful
  • 73. Cluster C Personality Disorders Obsessive Compulsive Personality Disorder • Physician-patient interaction • Thorough explanations and specific, detailed information are valued • Uncertainty is rarely tolerated • Treatment options should be presented with clear risk-benefit analyses
  • 74. Additional Source Information for more information see: http://open.umich.edu/wiki/CitationPolicy Slide 4-6: American Psychiatric Association: Diagnostic and Manual of Mental Disorders, 4th ed, Text Revision (DSM-IV-TR), Washington, DC, American Psychiatric Association, 2000, p. 689 Slide 13: Rorschach, NowPublic, http://www.nowpublic.com/health/rorschach-plate-1-bat-butterfly-moth Slide 21: DSM-IV-TR, pp. 694 Slide 26: DSM-IV-TR, pp. 697 Slide 31: DSM-IV-TR, pp. 701 Slide 37: DSM-IV-TR, pp. 706 Slide 43: DSM-IV-TR, pp. 710 Slide 49: DSM-IV-TR, pp. 714 Slide 54: DSM-IV-TR, pp. 717 Slide 60: DSM-IV-TR, pp. 721 Slide 65: DSM-IV-TR, pp. 725 Slide 70: DSM-IV-TR, pp. 729