Download Thursday, February 15, 2001

Tuesday, March 27, 2001
Psychiatry, Phillip Short MD
11am
Sam/Ting
PERSONALITY DISORDERS
AXIS II
NOTICIO: Get yourself a handout. Dr Short followed the order of the handout, but used his own list-style notes -- which he read verbatim. He added
little explanation or description of the various disorders, but instead showed several movie clips to illustrate several of the disorders. He did mention
that he will only write a couple of exam questions and that they will be very straightforward. Know the handout.
 Personality Traits Vs Personality Disorder – The way you look at the world, interact with the world, etc. Everyone has a personality, and
personality traits. Dr. Short refers to his daughter as a bit paranoid…she doesn’t see the world as a very safe place, but she doesn’t have
delusions or illusions. A personality disorder can be distinguished from traits when the traits deviate enough from the culture that there is
actually some dysfunction.
PERSONALITY DISORDER:
 WHO the person is (identity), not WHAT the person has (e.g. a person may HAVE schizophrenia, but he/she is an obsessive/compulsive
type of person…the latter is the personality d/o).
 Limited self-awareness
 Ego-syntonic: It supports who you are, not in consternation to it (okey-dokey)
 Pervasive, early onset and enduring
 Functional impairment or subjective distress
 Not state dependent
 The last two can be found in any psychiatric diagnosis….If you are paranoid because you are on a “speed run,” it does not mean that
you have a paranoid personality disorder.
 Brief Summary of Personality Disorder Features (Handout, pg. 2)
 Three clusters of personality disorders based on DSM IV classification (Dr Short read the entire table found on pg 2 of the handout,
therefore I will not reproduce it):
1) CLUSTER A (Odd, eccentric): Schizotypal, Schizoid, Paranoid
2) CLUSTER B (Dramatic, emotional, erratic): Histrionic, Narcissistic, Antisocial, Borderline
3) CLUSTER C (Anxious, fearful): Avoidant, Dependent, Obsessive-compulsive
- Cluster A personality d/o (schizotypal, etc) is found along the spectrum of thought disorders (delusional d/o or schizophrenia), but does not
meet the full criteria.
- It should be recognized that although the personality d/o’s are described as distinct entities, there is a great deal of crossover between them.
- Cluster B personality d/o has a long list of therapies – alluding to the fact that nothing works very well. These people can be more disruptive
than the cluster A group.
- Cluster C is the healthier group for the most part.
 Parking Lot of the Personality Disordered (Handout, pg. 9) – look at the funny picture
CLUSTER A PERSONALITY DISORDERS
1.
Paranoid personality d/o
- Pervasive, persistent and inappropriate mistrust of others
- Suspiciousness of others, questioning fidelity, loyalty & reluctant to confide
- They find hidden meaning in everything & hold grudges
- Probably premorbid paranoid schizophrenia or delusional d/o paranoid type w/o reaching full psychotic criteria
TREATMENT:
- Some antipsychotics in pts with psychotic decompensation may be helpful
- These people usually don’t want help or see themselves as having a problem
 MOVIE CLIP #1 The Caine Mutiny (1954)…court scene vaguely illustrating a paranoid personality d/o
2.
Schizoid personality d/o
- Refer to The Fisher King (1991) for some good characters w/ schizoid personality d/o
- Profound defect in ability to relate to others in any meaningful way (many homeless “street people” are this)
- Socially isolated – they don’t want relationships
- Chronic anhedonia
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3.
Decreased range of emotional expression – aloof, detached, cold & flattened affect
Probably premorbid to schizophrenia with enough stress
Rarely seek treatment, except for depression
Schizotypal personality d/o
- Even more like schizophrenia….again, refer to The Fisher King for some representative characters. Also, Kramer from Seinfeld
might fit this personality d/o, or anyone from the Addams Family (?)
- Pervasive symptoms of cognitive and perceptional distortions, usually with paranoia.
- Eccentric behavior is a hallmark feature
- Socially inept and anxious with a decreased desire for relationships
- Instead of delusions and hallucinations, these people have illusions, ideas of reference, telepathy, and clairvoyance
CLUSTER B PERSONALITY DISORDERS
1. Antisocial personality d/o
- Common in the prison system (both inmates and staff)
- Age criteria: Person must be older than age 18y, and the characteristics must be present since the age of 15y
- Long standing pattern of socially irresponsible behavior with a disregard for the rights of others
- Unlawful acts are repeated
- Lack of interest or concern for feelings of others
- Lack of remorse
- Impulsive, not future oriented
- Substance abuse and aggression
- Poor work & debt history
- In order to differentiate antisocial personality d/o from narcissistic personality d/o (both having a marked lack of empathy or
concern for others): antisocial personality d/o shows more impulsiveness and reckless behavior with materialistic gain driving
their exploitation and irrespect of others, while narcissist’s irrespect for others is derived more from a sense of superiority rather
than materialistic gain.
- Some good antisocial characters from the movies: Jeff Bridges’ character in The Fisher King, Bill Murray’s in Groundhog Day
(1993), Robert Duvall’s in Apocalypse Now (1979), and Mark Wahlberg’s in Fear (1996)
TREATMENT:
- Best in confined settings, like military or prison
- Decreasing the individual’s episodes of acting out may reveal more depressive and introspective concerns
- Confrontation by peer groups
2. Borderline personality d/o (see Handout, pg 10 for pseudo-Calvin Klein advertisement)
- Borderline personality d/o is the most widely studied personality d/o
- Defect of object constancy (?)
- Common in 2-3% of the population, and is present in every culture
- Most prevalent Axis II diagnosis (both inpatient and outpatient settings): 12-15%
- Impaired capacity for attachment, with maladaptive behavioral patterns related to any form of separation or threat thereof.
- Pervasive patterns of instability in relationships, self-image, affect
- Markedly impulsive in a variety of contexts, sometimes self-damaging (e.g. self mutilation, sexual promiscuity, substance
abuse, binge eating)
- Recurrent suicidal behavior – both gestures and threats
- Self mutilation may be an attempt to harm one’s self, but it also may be a relief of stress (pt typically relates that ‘it felt good to
cut myself’)
- Reactive mood
- May have stress related paranoia and dissociative-type symptoms
- These people are very difficult and demanding. They engage your care taking role, but become enraged at your failure to
nurture them (which inevitably happens).
TREATMENT
- Individual and group psychotherapy works fairly well
- Counter transference is a central issue with these people (although this meaning is outdated). It is said that your family and
office staff will know that you are treating a borderline personality before you will. In this context, counter transference refers to
inappropriate feelings, thoughts, or actions by the doctor to the patient.
- Medication: neuroleptics and mood stabilizers work well (also for chronic PTSD).
 MOVIE CLIP #2 Fatal Attraction (1987) – Scene showing Glenn Close going just a bit nutty when Michael Douglas attempts to leave
her apartment after a bout in the sac. She cuts her wrists so that he will not leave. It worked.
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3. Histrionic personality d/o
- Over concern with attention and appearance
- Excessive emotionality which may be labile and shallow
- They may be sexually seductive and provocative, but their goal is ATTENTION not sex
- Self dramatic and suggestible
- Uninhibited and lively
- Compared to narcissists, histrionics are more likely to play the clown, the fool , or the dependent for attention. This is because
narcissists only engage in attention seeking behaviors that will enhance their image.
 MOVIE CLIP #3 Streetcar Named Desire (1951) – Scene displaying Vivien Leigh’s histrionic, overly dramatic character.
4. Narcissistic personality d/o
- Grandiose self esteem, arrogance
- Vulnerable to intense reaction when self-image is damaged
- Overreaction to criticism or sleights, or they may ignore them altogether
- Need for admiration
- Lack of empathy
- Entitlement: unreasonable expectation of especially favorable treatment, or automatic compliance with one’s expectations. Dr
Short gave an example of his narcissistic daughter’s mother who, in the days before call waiting would go through the operator
declaring an emergency if the person’s line she was calling was busy. She simply expected everything to go her way.
- Interpersonal exploitation with elevation of self-image as the goal.
 MOVIE CLIP #4 Casablanca (1942) – Humphrey Bogart’s character is narcissistic, with a lack of empathy for others.
CLUSTER C PERSONALITY DISORDERS
1. Avoidant personality d/o
- Social inhibition, excessive & pervasive anxiety and discomfort in social situations and intimate relationships.
- Contrary to the schizoid personality d/o’s, these people WANT relationships, but avoid them due to fear of criticism, ridicule.
- Low self esteem, feelings of inadequacy, inferiority, ineptitude, self conscious, shy, awkward
- Occupational activities are more isolated (e.g. computer industry)
- Few risks unless certain of being liked
- Social phobia is a more specific anxiety d/o involving a fear of social performance in a person who is otherwise functional. For
example, Mickey Mantle had social phobia and an intense fear of public speaking, such that he had to down several martinis
before a press conference.
- Sandra Bullock in The Net (1995) is a good example of an avoidant personality d/o. She does everything through the computer,
and engages in very little human contact. Jim Carrey before putting the mask on in The Mask (1994) and Clark Kent in
Superman (1978) are also good examples.
TREATMENT
- These people are difficult to engage in therapy. They require a gentle, supportive, accepting, and less confrontational approach
compared to the Cluster B d/o’s.
- Attempt to increase their assertiveness and social skills, employing cognitive behavioral therapy to improve the negative selfimage.
- Medication: anxiolytics in small dosages in appropriate settings with good education can be useful. Dr Short is one of the few
who do not believe benzos are the 8th deadly sin. He thinks they are very useful if used correctly.
2. Dependent personality d/o
- Bill Murray in What About Bob? (1991) is a perfect example…and by the way, Richard Dreyfuss plays a good narcissist as his
psychiatrist.
- Excessive need to be cared for by others
- Submissive & clinging behaviors
- Excessive fear of separation or aloneness
- Overly rely on others for decision making, responsibility
- Low self esteem
- Constantly seeking support and reassurance of others
- Difficulty being alone – they usually replace one ended dysfunctional relationship for another one.
- In group settings, they often switch their identity to whomever they perceive as the strongest.
- Both borderline personality d/o and dependent personality d/o have difficulty with separation, but the dependent is much more
likely to be appeasing, pleading and pitiful, while the borderline will quickly become enraged and self destructive or destructive to
whoever is leaving.
TREATMENT
- Depression and anxiety with a threatened or actual loss of a dependent relationship may bring these people in for treatment.
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The focus is to build self-esteem, social skills, assertiveness, and to reduce the fear of independence.
The therapeutic relationship may be quite difficult, and there may be some counter-transference.
3. Obsessive-compulsive personality d/o
- We all have some of these characteristics and traits.
- Jack Lemon in The Odd Couple (1968) is a classic obsessive-compulsive personality d/o. However, do not confuse this with
Jack Nicholson in As Good as it Gets (1997), who has obsessive-compulsive disorder – he has intrusive thoughts and rituals that
he has to do in order to avoid something bad happening to him. Those people with obsessive-compulsive personality d/o just
think the world would be a better place if everyone were super-organized and tidy.
- Preoccupation with orderliness, details, rules, lists, and perfectionism….to the point that it may actually interfere with completion
of tasks (this is when it becomes a personality disorder).
- At the expense of flexibility, openness, and efficiency
- Control, both personal and interpersonal is central
- Devotion to work and productivity so much that leisure activities may be difficult
- Interpersonal relationships are also difficult…these people are overly conscientious, inflexible, and stubborn.
- They have difficulty discarding things (Throw away your old anatomy notes, already)
- Difficulty delegating tasks – “I would gladly relinquish responsibility if I could find someone as capable as me”
- Easily offer criticism
- Overly watchful of money
- Difficulty expressing warmth or emotion
- Excessively intellectual
THERAPY
- Working with these pts in therapy is what Dr Short calls Obi Wan Kanobi therapy…”just trust your feelings, Luke. Your feelings
are what matter, not what you THINK.”
- They are often extremely boring patients to work with.
 Check the back of the handout for some signal symptoms related to personality functioning:
SELF MUTILATION -------------------------------- BORDERLINE PERSONALITY D/O
EXTREME PERFECTIONISM ------------------- OBSESSIVE-COMPULSIVE PERSONALITY D/O
LAW BREAKING ------------------------------------ ANTISOCIAL PERSONALITY D/O
The rest of the symptoms can be associated with various personality disorders, and should be assessed in the context of the patient:
PROBLEMATIC ANGER & PHYSICALLY DESTRUCTIVE BEHAVIOR
LOW SELF ESTEEM
INTENSE ANXIETY
POOR EMPATHIC ABILITY
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