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WORLD LEADERS AND PERSONALITY DISORDERS Dr. B. Al-Saigh PERSONALITY DISORDERS Psychiatry Rounds August ‘06 RESOURCES : Assessment and Management of Personality Disorders Randy Ward, M.D., Medical College of Wisconsin, Milwaukee, Wisconsin American Family Physician, October 2004 Practice Guideline for the Treatment of Patients With Borderline Personality Disorder American Psychiatric Association Fasten Your Seat Belts ELIAS A. ZERHOUNI, Mayo Clinic Proceedings Commencement Address, May 2005 DR. B. Al-Saigh Regina General Hospital 2 RESOURCES : Association for Academic Psychiatry Video Series http://www.hsc.wvu.edu/aap/ From American Psychiatric Association. Personality disorders. In: Diagnostic and statistical manual of mental disorders, 4th. ed., text revision. Washington, D.C.: American Psychiatric Association, 2000:685-729 DR. B. Al-Saigh Regina General Hospital 3 ELIAS ZERHOUNI, MD, DIRECTOR, NIH : “We need to understand more about human behavior. What is it about humans that they do things they know they shouldn’t do? What makes it possible for us to smoke, eat a poor diet, and not exercise, knowing full well that all this is harmful? Research on human behavior will need to be done during the next 10 to 15 years.” Commencement Address Mayo Clinic School of Medicine May 2005 DR. B. Al-Saigh Regina General Hospital 4 DEFENITION OF PERSONALITY DISORDER (PD) : Chronic pattern of inner experience and behavior that is inflexible and presents across a broad range of situations DR. B. Al-Saigh Regina General Hospital 5 INTRODUCTION TO THE PERSONALITY DISORDERS - FROM Association for Academic Psychiatry Video Series http://www.hsc.wvu.edu/aap/ DR. B. Al-Saigh Regina General Hospital 6 VIDEO CLIP OF 10 PERSONALITY DISORDERS DR. B. Al-Saigh Regina General Hospital 7 KEY PRINCIPLES : PD are not diseases PD are dynamic systems Personality exists as a continuum Personality pathogenesis is not linear PD can be assessed but not definitively diagnosed Require strategically planned and combined modes of tactical intervention DR. B. Al-Saigh Regina General Hospital 8 OVERVIEW : Coded on DSM-IV axis II – Personality disorders Personality traits Mental retardation Separate axis exists to ensure that appropriate attention is paid to these clinically significant disorders when a comprehensive psychiatric assessment is performed DR. B. Al-Saigh Regina General Hospital 9 OVERVIEW : Lifetime P in general population : 10 to 13 %. P in primary care outpatient settings : 20 to 30 % Poorer treatment outcomes and health status / higher rates of health care use and costs in patients with co morbid personality disorders Many patients with whom physicians experience problematic relationships, and who have been referred to in the literature as patients who are "difficult" have personality disorders DR. B. Al-Saigh Regina General Hospital 10 OVERVIEW : Style of engagement may be inappropriate to the situation Distant Hostile Overly intimate Seductive Anxious DR. B. Al-Saigh Regina General Hospital 11 OVERVIEW : Interpersonal behavior of patient may elicit strong emotional reactions in physician Unrealistic expectations for the physician's: Availability Time Ability to help the patient DR. B. Al-Saigh Regina General Hospital 12 OVERVIEW : Medical and psychiatric illnesses may present in an atypical fashion, and may not respond as expected to treatment Reactions to illness may exacerbate and intensify the patient's personality characteristics, further hampering his or her ability to obtain proper care The patient's insight into the presence of these disorders is usually limited or absent DR. B. Al-Saigh Regina General Hospital 13 OVERVIEW : Axis I psychiatric disorders can present with patterns of symptoms similar to those of a personality disorder These symptoms usually have an identifiable onset, and remit or improve with appropriate treatment Most efforts focus on maintaining and supporting the physicianpatient relationship and establishing a working alliance Goal is to ensure that the patient is able to receive appropriate medical care despite the difficulty he or she may have in interacting with the physician and the health care system DR. B. Al-Saigh Regina General Hospital 14 DDX OF PD SYMPTOMS OR CHANGE IN PERSONALITY : Adjustment reaction Axis I psychiatric disorder Central nervous system disorder Medical disorder Medication use Substance abuse or dependence DR. B. Al-Saigh Regina General Hospital 15 PD CLUSTERS : A – “WEIRD” B – “WILD” C – “WORRIED” DR. B. Al-Saigh Regina General Hospital 16 CONTENT : PART I Cluster A PD (Paranoid, Schizoid, Schizotypal) Cluster C PD (Avoidant, OC, Dependant) Narcissistic DP Histrionic Antisocial PD PART II Borderline PD DR. B. Al-Saigh Regina General Hospital 17 PART I : Cluster A PD (Paranoid, Schizoid, Schizotypal) Cluster C PD (Avoidant, OC, Dependant) Narcissistic DP Histrionic Antisocial PD DR. B. Al-Saigh Regina General Hospital 18 CLUSTER A : OVERVIEW Paranoid – Schizoid - Schizotypal Often referred to as the "schizophrenic spectrum cluster" Do not respond appropriately to affective cues from the physician Are unable to form connections on a basic emotional level DR. B. Al-Saigh Regina General Hospital 19 PARANOID PD : Verbs used to describe … Distrust Suspicion Heightened sense of fear / vulnerability Fear physician may harm / arguments / conflict DR. B. Al-Saigh Regina General Hospital 20 PARANOID PD : Physician should … Adopt a professional stance Provide clear explanations Be empathetic to fears Avoid direct challenge to paranoid ideation DR. B. Al-Saigh Regina General Hospital 21 PARANOID PD : Mistrust of Friends Doubts the loyalty or trustworthiness of friends or associates Bearing Grudges Bears grudges; seldom forgives others’ mistakes Feeling Victimized Feels exploited or victimized; seldom expresses gratitude Healthy people trust their friends, are forgiving, and freely express praise and gratitude. DR. B. Al-Saigh Regina General Hospital 22 PARANOID PD : Historically, all of the world’s most murderous leaders exhibited Paranoid Personality Disorder Mistrust of Friends Bearing Grudges They promoted a culture of fear in which no one was trusted They promoted hatred of a common “enemy” to gain political power Feeling Victimized They convinced their followers that they were the “victims” of a global conspiracy of evil DR. B. Al-Saigh Regina General Hospital 23 PARANOID PD : Paranoia Cycles Out Of Control Feeling victimized by an imaginary “villain” leads to … Wanting revenge against the imaginary “villain” which leads to … A preemptive attack against the imaginary “villain” which leads to … A defensive counter-attack from the injured party which leads to … Feeling more victimized DR. B. Al-Saigh Regina General Hospital 24 PARANOID PD : Paranoia Has Killed Millions Leaders with Paranoid Personality Disorder eventually destroy millions of innocent civilians: Mao Tse-Tung brought about the death of more than 70 million people – during peacetime Hitler brought about the Holocaust which killed 6 million Jews and millions of other innocent minorities Stalin brought about the death of 20-60 million people as a direct result of his tyrannical rule DR. B. Al-Saigh Regina General Hospital 25 SCHIZOID PD : Verbs used to describe … Emotional restriction Social detachment Anxiety because of forced contact with others Delay seeking care Appear unappreciative DR. B. Al-Saigh Regina General Hospital 26 SCHIZOID PD : Physician should … Adopt a professional stance Provide clear explanations Avoid over involvement in personal and social issues DR. B. Al-Saigh Regina General Hospital 27 SCHIZOTYPAL PD : Verbs used to describe … Odd beliefs and behavior Socially isolative Odd interpretations of illness Anxiety because of forced contact with others Delay seeking care DR. B. Al-Saigh Regina General Hospital 28 SCHIZOTYPAL PD : Physician should … Adopt a professional stance Provide clear explanations Tolerate odd beliefs and behaviors Avoid over-involvement in personal and social issues DR. B. Al-Saigh Regina General Hospital 29 CLUSTER A TARGET S/S : Cognitive distortions Perceptual distortions Thought disorder Interpersonal mistrust and distance DR. B. Al-Saigh Regina General Hospital 30 CLUSTER A TARGET S/S TX : ATYPICAL ANTIPSYCHOTIC +/- SSRI DR. B. Al-Saigh Regina General Hospital 31 CLUSTER C : OVERVIEW Avoidant – OC - Dependant All patients exhibit anxiety in some form Caused by fears of evaluation by others, abandonment, or loss of order Uncomfortable ideas/sensations cause distress & interfere with functioning within the physician-patient relationship Physician must use appropriate strategies to help allay this anxiety and establish an effective working relationship with these patients DR. B. Al-Saigh Regina General Hospital 32 AVOIDANT PD : Verbs used to describe … Social inhibition due to fears of rejection or humiliation Heightened sense of inadequacy Low self-esteem Withholds information Avoids questioning or disagreeing with physician DR. B. Al-Saigh Regina General Hospital 33 AVOIDANT PD : Physician should … Provide reassurance Validate concerns Encourage reporting of symptoms and concerns DR. B. Al-Saigh Regina General Hospital 34 OBSESSIVE-COMPULSIVE : Verbs used to describe … Preoccupation with orderliness, perfection, control Fear of losing control of bodily functions and emotions Fear of relinquishing control Excessive questioning and attention to details Anger about disruption of routines DR. B. Al-Saigh Regina General Hospital 35 OBSESSIVE-COMPULSIVE : Physician should … Complete thorough history and examinations Provide thorough explanations Do not overemphasize uncertainty Encourage patient participation in treatment DR. B. Al-Saigh Regina General Hospital 36 DEPENDANT : Verbs used to describe … Excessive need to be taken care of Submissive/clinging behavior/fear of abandonment Helplessness Urgent demands for attention Prolongation of illness behavior to obtain attention and care DR. B. Al-Saigh Regina General Hospital 37 DEPENDANT : Physician should … Provide reassurance Schedule regular check-ups Set realistic limits on availability Enlist others to support patient Avoid rejection of patient DR. B. Al-Saigh Regina General Hospital 38 CLUSTER C TARGET S/S : Anxiety Behavioral Inhibition Obsessional Thinking DR. B. Al-Saigh Regina General Hospital 39 CLUSTER C TARGET S/S TX : ANTI-DEPRESSANTS BZ FOR CONTROL OF SHORT-TERM S/S DR. B. Al-Saigh Regina General Hospital 40 CLUSTER B : OVERVIEW Narcissistic – Histrionic – Antisocial - Borderline Can be among the most challenging patients encountered in clinical settings Can be excessively demanding, manipulative, emotionally unstable, and interpersonally inappropriate May attempt to create relationships that cross professional boundaries Can place physicians in difficult or compromising positions DR. B. Al-Saigh Regina General Hospital 41 CLUSTER B : OVERVIEW Physicians often experience strong emotional reactions to these patients Physicians must be keenly aware of the issues of manipulative behavior, professional boundaries, limit setting, and monitoring their own emotional state DR. B. Al-Saigh Regina General Hospital 42 NARCISSISTIC : Verbs used to describe … Grandiosity, Need for Admiration, Attitude of entitlement Lack of empathy Anxiety caused by doubts of personal adequacy Demanding / Denial of illness Alternating praise and devaluation of physician DR. B. Al-Saigh Regina General Hospital 43 NARCISSISTIC : Physicians should … Validate concerns Give attentive and factual responses to questions Channel patient's skills into dealing with illness DR. B. Al-Saigh Regina General Hospital 44 NARCISSISTIC : Healthy people are humble, democratic, and unselfish. Three behaviors form core of NPD: Arrogance Is arrogant or proud; feels superior to others Domineering Behavior Is domineering or dictatorial; has a bossy way of ordering others around Greed Is selfishly greedy; wants to possess much more than what he/she needs or deserves DR. B. Al-Saigh Regina General Hospital 45 NARCISSISTIC LEADERS : Historically, many tyrants exhibited Narcissistic Personality Disorder: Arrogance Domineering Behavior They were dictatorial and autocratic Greed They were very arrogant and proud They monopolized their nation’s power and wealth Usually exhibit both Paranoid and Narcissistic PD. DR. B. Al-Saigh Regina General Hospital 46 HISTRIONIC : Verbs used to describe … Excessive attention-seeking behavior Emotionality Threatened sense of attractiveness and self-esteem Overly dramatic / Somatization Attention-seeking behavior Inability to focus on facts and details DR. B. Al-Saigh Regina General Hospital 47 HISTRIONIC : Physician should … Avoid excessive familiarity Show professional concern for feelings Emphasize objective issues DR. B. Al-Saigh Regina General Hospital 48 ANTISOCIAL : Verbs used to describe … Disregards rights of others Anger Entitlement masking fear Impulsive behavior Deceit, manipulative DR. B. Al-Saigh Regina General Hospital 49 ANTISOCIAL : Physicians should … Carefully investigate concerns and motives Communicate in a clear and non-punitive manner Set clear limits DR. B. Al-Saigh Regina General Hospital 50 ANTISOCIAL : Healthy people are tolerant, responsible, honest, and don’t unethically exploit others Three behaviors form the core of APD: Intolerance Is judgmental or prejudiced; doesn’t respect the beliefs and practices of others Irresponsibility or Dishonesty Doesn’t take responsibility for own actions; is dishonest; lies, cheats, or steals Manipulativeness Selfishly or unethically manipulates others for his/her own advantage DR. B. Al-Saigh Regina General Hospital 51 ANTISOCIAL LEADERS : Historically, the most ruthless world leaders had Antisocial Personality Disorder: Intolerance Persecuted their minorities and permitted genocides Irresponsibility or Dishonesty They habitually lied to their citizens as their friends looted their nation’s wealth Manipulativeness They constantly manipulated others for their own unethical advantage DR. B. Al-Saigh Regina General Hospital 52 CLUSTER B1 TARGET S/S : Depression Interpersonal Sensitivity Impulsivity Aggression DR. B. Al-Saigh Regina General Hospital 53 CLUSTER B1 TARGET S/S TX : ANTI-DEPRESSANTS +/- MOOD STABILIZER +/- ATYPICAL ANTIPSYCHOTIC DR. B. Al-Saigh Regina General Hospital 54 CLUSTER B2 TARGET S/S : Mood lability Impulsivity Aggression FHx Bipolar Spectrum D/O DR. B. Al-Saigh Regina General Hospital 55 CLUSTER B2 TARGET S/S TX : MOOD STABILIZER +/- ANTI-DEPRESSANT +/- ATYPICAL ANTIPSYCHOTIC DR. B. Al-Saigh Regina General Hospital 56 CLUSTER B3 TARGET S/S : Paranoia Psychosis Hostility Overwhelming Anxiety DR. B. Al-Saigh Regina General Hospital 57 CLUSTER B3 TARGET S/S TX : ATYPICAL ANTI-PSYCHOTIC +/- ANTI-DEPRESSANT +/- MOOD STABILIZER DR. B. Al-Saigh Regina General Hospital 58 PART II : Borderline PD DR. B. Al-Saigh Regina General Hospital 59 CORE CLINICAL FEATURES : Pervasive pattern of : Instability of interpersonal relationships Instability of affect Instability of self-image Marked impulsivity beginning in early childhood Severe and persistent enough to result in clinically significant impairment in social, occupational, or other important areas of functioning Severely impaired capacity for attachment Predictably maladaptive behavior in response to separation DR. B. Al-Saigh Regina General Hospital 60 CORE CLINICAL FEAURES : Very sensitive to abandonment Inappropriate rage Unfair accusations DR. B. Al-Saigh Regina General Hospital 61 CORE CLINICAL FEAURES : Self-mutilation or suicidal behaviors Relationships are unstable, intense, and stormy Views of others may suddenly and dramatically shift Alternating between extremes of idealization and devaluation, or seeing others as beneficent and nurturing and then as cruel, punitive, and rejecting DR. B. Al-Saigh Regina General Hospital 62 CORE CLINICAL FEATURES : Impulsive in : Spending money irresponsibly Gambling Engaging in unsafe sexual behavior Abusing drugs or alcohol Driving recklessly Binge eating Self-mutilation (e.g., cutting or burning) Unstable self-image Chronic feelings of emptiness DR. B. Al-Saigh Regina General Hospital 63 CORE CLINICAL FEATURES : Inappropriate, intense anger Difficulty controlling anger during periods of extreme stress (e.g., perceived or actual abandonment) May experience transient paranoid ideation or severe dissociative symptoms (e.g., depersonalization) Recurrent suicidal behaviors, gestures, or threats Affective instability Marked mood reactivity (e.g., intense episodic dysphoria, irritability, or anxiety DR. B. Al-Saigh Regina General Hospital 64 ASSOCIATED FEATURES : Transient psychotic-like symptoms @ times of stress Usually last for minutes or hours Generally of insufficient duration or severity to warrant an additional diagnosis Tendency to undermine themselves when a goal is about to be reached (e.g., severely regressing after a discussion of how well therapy is going). DR. B. Al-Saigh Regina General Hospital 65 ASSOCIATED FEATURES : Individuals with this disorder may feel more secure with transitional objects (e.g., a pet or inanimate object) rather than with interpersonal relationships Physical and sexual abuse, neglect, hostile conflict, and early parental loss or separation are more common in the childhood histories of those with borderline personality disorder than in those without the disorder DR. B. Al-Saigh Regina General Hospital 66 COMORBID CONDITIONS : Commonly co-occurring Axis I disorders : Mood disorders Substance-related disorders Eating disorders (notably bulimia) PTSD Panic disorder ADHD Commonly co-occurring axis II disorders : Antisocial Avoidant Histrionic Narcissistic Schizotypal DR. B. Al-Saigh Regina General Hospital 67 COMORBID CONDITIONS : BPD vs Bipolar D/O : In BPD, the mood swings are often triggered by interpersonal stressors (e.g., rejection), and a particular mood is usually less sustained than in bipolar disorder BPD vs MDD : Depressive features that appear particularly characteristic of borderline personality disorder are emptiness, self-condemnation, abandonment fears, self-destructiveness, and hopelessness DR. B. Al-Saigh Regina General Hospital 68 COMORBID CONDITIONS : BPD vs Dysthymic Disorder : Chronic dysphoria is very common in individuals with borderline personality disorder Presence of the aforementioned affective features (e.g., mood swings triggered by interpersonal stressors) should prompt consideration of the diagnosis of BPD Other features of BPD (e.g., identity disturbance, chronic selfdestructive behaviors, frantic efforts to avoid abandonment) are generally not characteristic of axis I mood disorders DR. B. Al-Saigh Regina General Hospital 69 COMORBID CONDITIONS : BPD vs PTSD : Hx of trauma often characteristic of patients with BPD and does not necessarily warrant an additional diagnosis of PTSD PTSD should be diagnosed only when full criteria for the disorder are met PTSD is characterized by rapid-onset symptoms that occur, usually in adulthood, in reaction to exposure to a recognizable and extreme stressor; in contrast, borderline personality disorder consists of the early-onset, enduring personality traits described earlier DR. B. Al-Saigh Regina General Hospital 70 COMORBID CONDITIONS : BPD vs DID : DID is characterized by the presence of two or more distinct identities or personality states that alternate, manifesting different patterns of behavior DR. B. Al-Saigh Regina General Hospital 71 EPIDEMIOLOGY : Most common personality disorder in clinical settings Present in : 10% of individuals seen in outpatient MHC 15%–20% of psychiatric inpatients 30%–60% of clinical populations with a personality disorder 2% of the general population DR. B. Al-Saigh Regina General Hospital 72 EPIDEMIOLOGY : Present in cultures around the world Approximately five times more common among first-degree biological relatives of those with the disorder than in the general population Greater familial risk for substance-related disorders, antisocial personality disorder, and mood disorders Diagnosed predominantly in women (gender ratio 3:1) DR. B. Al-Saigh Regina General Hospital 73 COMPLICATIONS : Notable distress / Functional impairment Majority attempt suicide Completed suicide occurs in 10% of pts 50 times higher than in the general population. Risk highest when pts. are 20s as well as in presence of co-occurring MD/Substance-Related Disorders Difficulty with occupational, academic, or role functioning Recurrent job loss and interrupted education are common DR. B. Al-Saigh Regina General Hospital 74 COMPLICATIONS : Difficulties in relationships, as well as divorce Social cost for patients with BPD and their families is substantial • May gradually attain functional roles 10–15 years after admission to psychiatric facilities Still only about one-half will have stable, full-time employment or stable marriages Greater lifetime utilization of most major categories of medication and of most types of psychotherapy than do patients with Schizotypal, Avoidant, OC PD or patients with MDD DR. B. Al-Saigh Regina General Hospital 75 BORDERLINE PD : Physician should … Avoid excessive familiarity Schedule regular visits Provide clear, nontechnical explanations Tolerate angry outbursts, but set limits Maintain awareness of personal feelings DR. B. Al-Saigh Regina General Hospital 76 BAD WORLD LEADERS : Historically, the worst world leaders had a combination of APD + NPD + PPD Their behavior exhibited: Pathological mistrust Lack of forgiveness Feeling constantly the “victim” Arrogance / Greed Dictatorial behavior Intolerance / Dishonesty Manipulativeness DR. B. Al-Saigh Regina General Hospital 77 PERSONALITY DISORDERS GEORGE W. BUSH : DR. B. Al-Saigh Regina General Hospital 78