Download - Psychiatry Lectures

Personality Disorders
Derek S. Mongold MD
Assistant Professor WVU
2012
Objectives.
• Learn how to differentiate between the three
major categories of personality disorders.
• Identify specific personality disorders within each
category.
•
Learn specific treatments for each personality
disorder.
Overview.
• Definition.
• Cluster A disorders.
• Cluster B disorders.
• Cluster C disorders.
1
Definition .
• An enduring pattern of inner experience and
behavior that deviates markedly from the
expectations of the individual’s culture in at least 2
of the following areas.
• Cognition (i.e., ways of perceiving and interpreting self,
others, and events).
• Affectivity (range, intensity, labiality, and
appropriateness of emotional response).
• Interpersonal functioning.
• Impulse control.
1
Definition .
• The pattern is enduring, inflexible, and pervasive
across a broad range of situations.
• Leads to clinically significant distress or impairment
in social, occupational, or other important areas of
functioning.
• Stable, of long duration, and its onset can be traced
back at least to adolescence or early adulthood.
• Not substance induced or due to another mental,
physical, or medical disorder.
The Clusters.
• Cluster A.
• Cluster B.
• Cluster C.
Cluster A Disorders.
• Paranoid.
• Schizoid.
• Schizotypal.
Cluster B Disorders.
• Antisocial.
• Borderline.
• Histrionic.
• Narcissistic.
Cluster C Disorders.
• Avoidant.
• Dependent.
• Obsessive-compulsive.
Mnemonic.
• Weird.
• Wild.
• Worried.
Cluster A.
1
Paranoid .
•
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
4 or more of the following:
•
•
•
•
•
•
•
Suspects, without sufficient basis, that others are exploiting, harming, or deceiving them.
Is preoccupied with unjustified doubts about the loyalty or trustworthiness of friends or associates.
Is reluctant to confide in others because of unwarranted fear that the information will be used
maliciously against them.
Reads hidden demeaning or threatening meanings into benign remarks or events.
Persistently bears grudges (i.e., is unforgiving of insults, injuries, or slights).
Perceives attacks on his or her character or reputation that are not apparent to others and is quick to
react angrily or to counterattack.
Has recurrent suspicions, without justification, regarding fidelity of spouse or sexual partner.
•
Does not due to something else.
•
If criteria are met prior to Schizophrenia add “premorbid”.
1
Schizoid .
•
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 4 or more of the following:
•
•
•
•
•
•
•
Neither desires nor enjoys close relationships, including being part of a family.
Almost always chooses solitary activities.
Has little, if any, interest in having sexual experiences with another person.
Takes pleasure in few, if any, activities.
Lacks close friends or confidants other than first-degree relatives.
Appears indifferent to the praise or criticism of others.
Shows emotional coldness, detachment, or flattened affectivity.
•
Not due to something else.
•
If criteria are met prior to Schizophrenia add “premorbid”.
1
Schizotypal .
•
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 5 or more of the following.
•
Ideas of reference (excluding delusions of reference).
•
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).
•
Unusual perceptual experiences, including bodily illusions.
•
Odd thinking and speech (e.g., vague, circumstantial, metaphorical, overelaborate, or stereotyped).
•
Suspiciousness or paranoid ideation.
•
Inappropriate or constricted affect.
•
Behavior or appearance that is odd, eccentric, or peculiar.
•
Lack of close friends or confidants other than first-degree relatives.
•
Excessive social anxiety that does not diminish with familiarity and tends to be associated with paranoid fears rather than
negative judgments about self.
•
Not due to something else.
•
If criteria are met prior to Schizophrenia add “premorbid”.
Cluster B.
1
Antisocial .
•
There is a pervasive pattern of disregard for and violation of the rights of others occurring
since age 15 years, as indicated by 3 or more of the following:
•
•
•
•
•
•
•
Failure to conform to social norms with respect to lawful behaviors as indicated by repeatedly
performing acts that are grounds for arrest.
Deceitfulness, as indicated by repeated lying, use of aliases, or conning others for personal profit or
pleasure.
Impulsivity or failure to plan ahead.
Irritability and aggressiveness, as indicated by repeated physical fights or assaults.
Reckless disregard for safety of self or others.
Consistent irresponsibility, as indicated by repeated failure to sustain consistent work behavior or
honor financial obligations.
Lack of remorse, as indicated by being indifferent to or rationalizing having hurt, mistreated, or stolen
from another.
•
At least 18 years old.
•
Evidence of Conduct Disorder with onset before age 15.
•
Does not happen exclusively during a course of Schizophrenia or Manic Episode.
Borderline Personality
Disorder1.
•
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.
• Frantic efforts to avoid real or imagined abandonment.
• A pattern of unstable and intense interpersonal relationships characterized by
alternating between extremes of idealization and devaluation.
• Identity disturbance: markedly and persistently unstable self image or sense of self.
• Impulsivity in at least two areas that are potentially self damaging (e.g., spending, sex,
substance abuse, reckless driving, binge eating). Not suicidal or self-mutilating
behavior.
• Recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior.
• 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).
• Chronic feelings of emptiness.
• Inappropriate, intense anger or difficulty controlling anger (e.g., frequent displays of
temper, constant anger, recurrent physical fights).
• Transient, stress-related paranoid ideation or severe dissociative symptoms.
Histrionic Personality
Disorder1.
•
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:
• Is uncomfortable in situations in which he or she is not the center of
attention.
• Interaction with others is often characterized by inappropriate sexually
seductive or provocative behavior.
• Displays rapidly shifting and shallow expression of emotions.
• Consistently uses physical appearance to draw attention to self.
• Has a style of speech that is excessively impressionistic and lacking in
detail.
• Shows self-dramatization, theatricality, and exaggerated expressions of
emotion.
• Is suggestible, I.e., easily influenced by others or circumstances.
• Considers relationships to be more intimate than they actually are.
Narcissistic Personality
Disorder1.
•
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 5 (or more) of the following:
• Has a grandiose sense of self-importance (e.g., exaggerates achievements and talents,
expects to be recognized as superior without commensurate achievements).
• Is preoccupied with fantasies of unlimited success, power, brilliance, beauty, or ideal
love).
• 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).
• Requires excessive admiration.
• Has a sense of entitlement, i.e., unreasonable expectations of especially favorable
treatment or automatic compliance with his or her expectations.
• Is interpersonally exploitative, i.e., takes advantage of others to achieve his or her own
ends.
• Lacks empathy: Is unwilling to recognize or identify with the feelings and needs of
others.
• Is often envious of others or believes that others are envious of him or her.
• Shows arrogant, haughty behaviors or attitudes.
Cluster C.
Avoidant Personality
Disorder1.
•
A pervasive pattern of social inhibition, feelings or inadequacy, and
hypersensitivity to negative evaluation, beginning by early adulthood
and present in a variety of contexts, as indicated by 4 (or more) of the
following:
• Avoids occupational activities that involve significant interpersonal contact,
because of fears of criticism, disapproval, or rejection.
• Is unwilling to get involved with people unless certain of being liked.
• Shows restraint within intimate relationships because of the fear of being shamed
or ridiculed.
• Is preoccupied with being criticized or rejected in social situations.
• Is inhibited in new interpersonal situations because of feelings of inadequacy
• Views self as socially inept, personally unappealing, or inferior to others.
• Is unusually reluctant to take personal risks to to engage in any new activities
because they may prove embarrassing.
Dependent Personality
Disorder1.
•
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 5 (or more) of the following:
• Has difficulty making everyday decisions without an excessive amount of advice and
reassurance from others.
• Needs others to assume responsibility for most major areas of his or her life.
• Has difficulty expressing disagreement with others because of unrealistic fears of loss
of support or approval.
• Has difficulty initiating projects or doing things on his or her own (because of a lack of
self-confidence in judgment or abilities rather than a lack of motivation or energy).
• Goes to excessive lengths to obtain nurturance and support from others, to the point of
volunteering to do things that are unpleasant.
• Feels uncomfortable or helpless when alone because of exaggerated fears of being
unable to care for himself or herself.
• Urgently seeks another relationship as a source of care and support when a close
relationship ends.
• Is unrealistically preoccupied with fears of being left to take care of himself or herself.
Obsessive-Compulsive
Personality Disorder1.
•
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 4 (or more) of the following:
•
•
•
•
•
•
•
•
Is preoccupied with details, rules, lists, order, organization, or schedules to the extent that the major
point of the activity is lost.
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).
Is excessively devoted to work and productivity to the exclusion of leisure activities and friendships
(not accounted for by obvious economic necessity).
Is overconscientious, scrupulous, and inflexible about matters of morality, ethics, or values (not
accounted for by cultural or religious identification).
Is unable to discard worn-out or worthless objects even when they have no sentimental value.
Is reluctant to delegate tasks or to work with others unless they submit to exactly his or her way of
doing things.
Adopts a miserly spending style toward both self and others; money is viewed as something to be
hoarded for future catastrophes.
Shows rigidity and stubbornness.
Personality Disorder NOS1.
• Meets the general diagnostic criteria for a
Personality Disorder, but does not meet criteria for
any specific Personality Disorder.
Cluster A.
Paranoid Personality
Disorder.
Paranoid Personality
Disorder2.
• Overview.
• Long-standing suspiciousness and mistrust of persons
in general.
• Often hostile, irritable, and angry.
• Often develop into:
•
•
•
•
Bigots.
Injustice collectors.
Pathologically jealous spouses.
Litigious cranks.
Paranoid Personality
Disorder1.
•
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 4 or more of the following:
•
•
•
•
•
•
•
Suspects, without sufficient basis, that others are exploiting, harming, or deceiving them.
Is preoccupied with unjustified doubts about the loyalty or trustworthiness of friends or
associates.
Is reluctant to confide in others because of unwarranted fear that the information will be used
maliciously against them.
Reads hidden demeaning or threatening meanings into benign remarks or events.
Persistently bears grudges (i.e., is unforgiving of insults, injuries, or slights).
Perceives attacks on his or her character or reputation that are not apparent to others and is
quick to react angrily or to counterattack.
Has recurrent suspicions, without justification, regarding fidelity of spouse or sexual partner.
•
Does not due to something else.
•
If criteria are met prior to Schizophrenia add “premorbid”.
Paranoid Personality
Disorder2.
• Epidemiology.
• 0.5-2.5% of the general population.
• Relatives of patients with schizophrenia show a higher
incidence of paranoid personality disorder than
controls.
• More common in men than women.
• Thought to be higher among minority groups,
immigrants, and persons who are deaf.
Paranoid Personality
Disorder2.
• Interview.
•
•
•
•
•
•
Formal in manner.
Act baffled about having to seek psychiatric help.
Humorless and serious.
Scan the environment.
Have muscular tension.
Are unable to relax.
Paranoid Personality
Disorder2.
• Interview.
• Thought content shows:
• Projection.
• Prejudice.
• Occasional ideas of reference.
Paranoid Personality
Disorder2.
• Clinical features.
• Long-standing suspiciousness and mistrust of others.
• Interpret actions of others as deliberately demeaning,
malevolent, threatening, exploiting, or deceiving and
expect to be harmed by them.
• Express disdain for those they see as weak, sickly,
impaired, or defective and are impressed with, and pay
close attention to, power and rank.
• They are often hostile, irritable, angry and show
pathological jealousy, but can often pull themselves
together and appear undistressed during an interview.
Paranoid Personality
Disorder2.
• Differential Diagnosis.
• Unlike in delusional disorder, there are no fixed
delusions.
• Unlike in Schizophrenia, there are no hallucinations or
formal thought disorder.
• Unlike borderline personality disorder, patents are not
in overly close relationships.
• No extensive history of antisocial behavior.
• Patients with schizoid personality disorder are also
withdrawn, but do not have paranoid ideation.
Paranoid Personality
Disorder2.
• Course and Prognosis.
• No adequate, systematic long-term studies exist.
• In general, patients have lifelong problems working and
living with others and occupational and marital
problems are common.
• Some patients go on to develop Schizophrenia.
Paranoid Personality
Disorder2.
• Treatment.
• Psychotherapy.
• Treatment of choice.
• Therapists need to be straightforward and professional (not
overly warm) with honesty and an apology preferable to a
defensive explanation for the mistakes patients will often
point out.
• Since patients may behave threateningly and with
delusional accusations, limit setting and dealing with
accusations must be done realistically (but gently).
Paranoid Personality
Disorder2.
• Treatment.
• Psychotherapy.
• Therapists should never offer to take control unless they
are willing and able to do so since patients are profoundly
frightened when they feel those that are helping them are
weak.
• Patients do not do well in group psychotherapy.
• Many cannot tolerate the intrusiveness of behavior therapy
(but it is often used for social skills training).
Paranoid Personality
Disorder2.
• Treatment.
• Pharmacotherapy.
• Benzodiazepines may help with anxiety.
• Antipsychotics may be needed in small dosages for brief
periods of time.
• Some evidence that pimozide (Orap) may be helpful.
Schizoid Personality
Disorder.
Schizoid Personality
Disorder2.
• Overview.
• Lifelong pattern of social withdrawal.
• Discomfort with human interaction, introverted, bland
and constricted affect.
• Seen by others as:
• Eccentric.
• Isolated.
• Lonely.
Schizoid Personality
Disorder1.
•
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 4 or more of the following:
•
•
•
•
•
•
•
Neither desires nor enjoys close relationships, including being part of a family.
Almost always chooses solitary activities.
Has little, if any, interest in having sexual experiences with another person.
Takes pleasure in few, if any, activities.
Lacks close friends or confidants other than first-degree relatives.
Appears indifferent to the praise or criticism of others.
Shows emotional coldness, detachment, or flattened affectivity.
•
Not due to something else.
•
If criteria are met prior to Schizophrenia add “premorbid”.
Schizoid Personality
Disorder2.
• Epidemiology.
• Prevalence is unknown but may affect 7.5% of the
population.
• Sex ratio is unknown but may be 2:1, Male:Female.
Schizoid Personality
Disorder2.
• Interview.
Patients appear ill at ease.
Rarely tolerate eye contact.
Seem eager for the interview to end.
Affect may be constricted, aloof, or inappropriately
serious, but fear may be recognized underneath.
• Difficult to be lighthearted and their humor may seen
adolescent and off the mark.
•
•
•
•
Schizoid Personality
Disorder2.
• Interview.
• Give short answers, avoid spontaneous conversation
and may occasionally use unusual figures of speech
such as odd metaphors.
• May be fascinated with inanimate objects or
metaphysical constructs.
• May think they have a sense of intimacy with personas
they do not know well.
• Sensorium is intact, memory functions well, and
proverb interpretations are abstract.
Schizoid Personality
Disorder2.
• Clinical Features.
• Seem cold, aloof, quiet, distant, seclusive, unsociable.
• Have solitary, lonely jobs that involve little or no
contact with others (often night shifts).
• Show no involvement with everyday events and
concerns of others.
• Last to be aware of fashion changes.
Schizoid Personality
Disorder2.
• Clinical Features.
• Sexual lives are postponed and may only exist in
fantasy.
• Have a normal capacity to recognize reality, have a
lifelong inability to express anger directly and respond
to threats with fantasized omnipotence or resignation.
Schizoid Personality
Disorder2.
• Differential Diagnosis.
• No positive psychotic symptoms as there is in
schizophrenia, delusional disorder, and affective
disorders with psychotic features.
• Patients with paranoid personality disorder show more
social engagement, aggressive verbal behavior, and a
greater tendency to project their feelings onto others.
Schizoid Personality
Disorder2.
• Differential Diagnosis.
• Patients with obsessive-compulsive and avoidant
personality disorders experience loneliness as dysphoric
and possess a richer history of past object relations.
• Closely resembles Schizotypal personality disorder, but
with less positive schizophrenia like symptoms.
Schizoid Personality
Disorder2.
• Course and Prognosis.
• Occurs in early childhood.
• Long lasting but not necessarily lifelong.
• The proportion of patients who develop schizophrenia
is unknown.
Schizoid Personality
Disorder2.
• Treatment.
• Psychotherapy.
• Treated similarly to paranoid personality disorder.
• Since they tend toward introspection, they may become
devoted, but distant patients.
• After trust develops, fantasies, imaginary friends, fears of
unbearable dependence, even merging with the therapist
may be revealed.
Schizoid Personality
Disorder2.
• Treatment.
• Psychotherapy.
• In group therapy, patients may be silent for long periods
and should be protected against aggressive group members,
but eventually become involved.
• Other group members become important to the patient and
may provide the only social contact they receive.
Schizoid Personality
Disorder2.
• Treatment.
• Pharmacotherapy.
• Small doses of antipsychotics, antidepressants, and
psychostimulants have benefitted some patients.
• Serotonergic agents may make patients less sensitive to
rejection.
• Benzodiazepines may help diminish interpersonal anxiety.
Schizotypal Personality
Disorder.
Schizotypal Personality
Disorder2.
• Overview.
• Strikingly odd or strange, even to laypersons.
• Characterized by:
•
•
•
•
•
Magical thinking.
Peculiar notions.
Ideas of reference.
Illusions.
Derealization.
Schizotypal Personality
Disorder1.
•
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 5 or more of the following.
•
Ideas of reference (excluding delusions of reference).
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).
Unusual perceptual experiences, including bodily illusions.
•
Odd thinking and speech (e.g., vague, circumstantial, metaphorical, overelaborate, or stereotyped).
•
•
Suspiciousness or paranoid ideation.
Inappropriate or constricted affect.
•
•
•
Behavior or appearance that is odd, eccentric, or peculiar.
Lack of close friends or confidants other than first-degree relatives.
Excessive social anxiety that does not diminish with familiarity and tends to be associated with paranoid fears
rather than negative judgments about self.
•
•
•
Not due to something else.
•
If criteria are met prior to Schizophrenia add “premorbid”.
Schizotypal Personality
Disorder2.
• Epidemiology.
• 3% of the population.
• Sex ratio is unknown.
• Associated with biological relatives that have
schizophrenia.
• Monozygotic:dizygotic twin ratio is 33:4.
Schizotypal Personality
Disorder2.
• Interview.
• History taking may be difficult because of the patients’
unusual way of communicating.
• Diagnosis is made based on peculiarities of thinking,
behavior, and appearance.
Schizotypal Personality
Disorder2.
• Clinical features.
• Disturbed thinking and communication, but no frank
thought disorder.
• May not know their own feelings but are exquisitely
sensitive to others (especially negative) feelings.
• Superstitious, and think they have special powers such
as clairvoyance.
• May have vivid imaginary relationships and child-like
fears and fantasies.
Schizotypal Personality
Disorder2.
• Clinical features.
• May have perceptual illusions and, brief, psychosis
when stressed.
• Have few friends because they are so strange.
• May show features of borderline personality disorder.
• Severe cases show anhedonia and severe depression.
Schizotypal Personality
Disorder2.
• Differential diagnosis.
• Distinguished from schizoid and avoidant personality
disorders by the oddities in their behavior, thinking,
perception, and communication (and family history of
schizophrenia).
• Unlike schizophrenia, they have brief, if any, periods of
psychosis.
• Patients with paranoid personality disorder are
suspicious, but lack the odd behavior of patients with
schizotypal personality disorder.
Schizotypal Personality
Disorder2.
• Course and Prognosis.
• 10% of patients eventually commit suicide.
• Since it is considered the premorbid personality of
Schizophrenia, many patients develop that disease.
• Some patients maintain a stable schizotypal personality
throughout their lives and may marry and work despite
their oddities.
Schizotypal Personality
Disorder2.
• Treatment.
• Psychotherapy.
• Same as treatment of schizoid personality disorders, but
clinicians must be more sensitive.
• Many patients are involved in cults, strange religious
practices, and the occult.
• Therefore clinicians must be nonjudgmental and not ridicule
these activities.
Schizotypal Personality
Disorder2.
• Treatment.
• Pharmacotherapy.
• Antipsychotics may help with ideas of reference, illusions,
and other symptoms.
• Antidepressants are useful there there is a depressive
component.
Antisocial Personality
Disorder.
Antisocial Personality
Disorder2.
• Overview.
• Inability to conform to the social norms that ordinarily
govern many aspects of a person’s adolescent and adult
behavior
• Is called dissocial personality disorder in ICD-10.
Antisocial Personality
Disorder1.
•
There is a pervasive pattern of disregard for and violation of the rights of others occurring
since age 15 years, as indicated by 3 or more of the following:
•
•
•
•
•
•
•
Failure to conform to social norms with respect to lawful behaviors as indicated by repeatedly
performing acts that are grounds for arrest.
Deceitfulness, as indicated by repeated lying, use of aliases, or conning others for personal profit or
pleasure.
Impulsivity or failure to plan ahead.
Irritability and aggressiveness, as indicated by repeated physical fights or assaults.
Reckless disregard for safety of self or others.
Consistent irresponsibility, as indicated by repeated failure to sustain consistent work behavior or
honor financial obligations.
Lack of remorse, as indicated by being indifferent to or rationalizing having hurt, mistreated, or stolen
from another.
•
At least 18 years old.
•
Evidence of Conduct Disorder with onset before age 15.
•
Does not happen exclusively during a course of Schizophrenia or Manic Episode.
Antisocial Personality
Disorder2.
• Epidemiology.
•
•
•
•
3% in men. 1% in women.
Most common in poor urban areas.
Boys come from larger families than girls.
Onset is before age 15.
Antisocial Personality
Disorder2.
• Epidemiology.
• Girls usually have symptoms before puberty, and boys
even earlier.
• Prevalence may be 75% in prisons.
• 5 X more common among first-degree relatives of men
with the disorder than among controls.
Antisocial Personality
Disorder2.
• Interview.
• Even experienced clinicians may be fooled.
• Patient’s appear composed and credible, but
underneath the veneer is tension, hostility, irritability,
and rage.
• A “stress interview”, in which patients are vigorously
confronted with inconsistencies may be necessary to
reveal the pathology.
Antisocial Personality
Disorder2.
• Clinical features.
• Seem normal, harming and ingratiating, especially to
opposite-sex clinicians (but same-sex clinicians may
think they are manipulative and demanding).
• Histories often include lying, truancy, running away
from home, thefts, fights, substance abuse, and other
illegal activities that begin in childhood.
• Later engage in promiscuity, spousal abuse, child abuse,
and drunk driving.
Antisocial Personality
Disorder2.
• Clinical features.
• Extremely manipulative “con men”.
• Have a striking lack of remorse or conscience.
• No anxiety, depression, delusions, or other irrational
thinking.
• May threaten suicide and have somatic preoccupations.
Antisocial Personality
Disorder2.
• Differential diagnosis.
• Distinguished from illegal behavior because it involves
many areas of a person’s life.
• Difficult to differentiate from substance abuse and both
diagnoses should be given unless the illegal behavior is
clearly secondary to substance use.
Antisocial Personality
Disorder2.
• Differential diagnosis.
• Clinicians must adjust for socioeconomic status,
cultural background, and sex.
• The diagnosis should not be given if the criminal
behavior is secondary to mental retardation,
schizophrenia, or mania.
Antisocial Personality
Disorder2.
• Course and Prognosis.
• Usually lifelong.
• Some reports show that symptoms decrease as a person
grows older.
• Height of antisocial behavior is in late adolescence.
• Many patients have Somatization Disorder and
multiple physical complaints.
Antisocial Personality
Disorder2.
• Treatment.
• A diagnostic workup should include a thorough
neurological examination since patients often show
abnormal EEG results and soft neurological signs
suggesting minimal brain damage in childhood.
Antisocial Personality
Disorder2.
• Treatment.
• Psychotherapy.
• If patients are “immobilized” (placed in hospitals), they
become amenable to psychotherapy.
• Since patients do better when among peers, self-help
groups have been very helpful.
• Firm limits are essential.
• Self-destructive behavior and fear of intimacy salient
clinical challenges.
• Therapists face the challenge of separating control from
punishment and of separating help and confrontation from
social isolation and retribution.
Antisocial Personality
Disorder2.
• Treatment.
• Pharmacotherapy.
• Must be used judiciously since patients are often substance
abusers.
• Psychostimulants may help if ADHD is present.
• Antiepileptics may help control impulsive behavior,
especially if abnormal waveforms are noted on EEG.
• B-Adrenergic receptor antagonists may help reduce
aggression.
Borderline Personality
Disorder.
Borderline Personality
Disorder2.
• Overview.
• Patients stand at the borderline between neurosis and
psychosis.
• Extraordinarily unstable affect, mood, behavior, object
relations, and self-image.
• Chronic feelings of emptiness.
• Short-lived psychotic episodes
• Impulsive acts.
• Demand extraordinary relationships.
• May mutilate themselves and make manipulative suicide
attempts.
Borderline Personality
Disorder2.
• Other names:
•
•
•
•
•
Ambulatory Schizophrenia.
As-if personality.
Pseudoneurotic schizophrenia.
Psychotic character disorder.
ICD-10: Emotionally unstable personality disorder.
Borderline Personality
Disorder1.
•
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.
• Frantic efforts to avoid real or imagined abandonment.
• A pattern of unstable and intense interpersonal relationships characterized by
alternating between extremes of idealization and devaluation.
• Identity disturbance: markedly and persistently unstable self image or sense of self.
• Impulsivity in at least two areas that are potentially self damaging (e.g., spending, sex,
substance abuse, reckless driving, binge eating). Not suicidal or self-mutilating
behavior.
• Recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior.
• 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).
• Chronic feelings of emptiness.
• Inappropriate, intense anger or difficulty controlling anger (e.g., frequent displays of
temper, constant anger, recurrent physical fights).
• Transient, stress-related paranoid ideation or severe dissociative symptoms.
Borderline Personality
Disorder2.
• Epidemiology.
• 1-2% of the population.
• Female:male 2:1.
• An increased prevalence of major depressive disorder,
alcohol use disorders, and substance abuse is found in
first-degree relatives of persons with borderline
personality disorder.
Borderline Personality
Disorder2.
• Clinical features.
• Almost always appear to be in a state of crisis.
• Mood swings are common.
• Can have short-lived psychotic episodes that are almost
always circumscribed, fleeting, or doubtful.
• Behavior is highly unpredictable with repetitive selfdestructive acts such as self-mutilations.
• Relationships are tumultuous with dependency, but
enormous anger toward intimate friends.
Borderline Personality
Disorder2.
• Clinical features.
• Cannot tolerate being alone and will accept a stranger
as a friend or behave promiscuously so they don’t have
to be alone.
• Show splitting (identifying people as all good or all
bad).
• They often complain of depression, chronic feelings of
emptiness, boredom, and a lack of a consistent sense of
identity.
Borderline Personality
Disorder2.
• Clinical features.
• Use the immature defense mechanism of projective
identification in which intolerable aspects of the self
are projected into another, the other person is induced
to play the projected role, and the two persons act in
unison.
• Show ordinary reasoning abilities on structured tests
(IQ testing), but show deviant processes on
unstructured projective tests (Rorschach test).
Borderline Personality
Disorder2.
• Differential diagnosis.
• Distinguished from schizophrenia by a lack of
prolonged psychotic episodes, thought disorder, and
other classic schizophrenic signs.
Borderline Personality
Disorder2.
• Course and Prognosis.
• Patients change little over time.
• The diagnosis is usually made before 40, when patients
are attempting to make occupational, marital, and
other choices found in the normal stages of the life
cycle.
• There is no progression toward schizophrenia.
• There is a high incidence of major depressive episodes.
Borderline Personality
Disorder2.
• Treatment.
• Psychotherapy.
• Patients do well in the hospital setting where they:
• Receive intensive psychotherapy.
• Are given limits on behaviors.
• Ideally patients stay until they show marked improvement (up
to 1 year).
• Patients can then be discharged to special support systems such
as day hospitals, night hospitals, and halfway houses.
Borderline Personality
Disorder2.
• Treatment.
• Psychotherapy.
• Common features of psychotherapy for BPD.
1.
2.
3.
4.
5.
6.
7.
8.
9.
Therapy is not expected to be brief.
A strong helping relationship develops between patient and therapist.
Clear roles and responsibilities of patient and therapist are established.
Therapist is active and directive, not a passive listener.
Patient and therapist mutually develop a hierarchy of priorities.
Therapist conveys empathic validation plus the need for patient to control
his/her behavior.
Flexibility is needed as new circumstances, including stresses, develop.
Limit setting, preferably mutually agreed upon, is used.
Concomitant individual and group approaches are used.
Borderline Personality
Disorder2.
• Treatment.
• Psychotherapy.
• Difficult for patient and therapist alike.
• Patients regress easily, act out their impulses, and show
labile or fixed negative or positive transferences, which are
difficult to analyze.
• Projective identification may cause countertransference
problems (especially when the therapists are unaware that
the patients are trying to coerce them to act out a particular
behavior).
Borderline Personality
Disorder2.
• Treatment.
• Psychotherapy.
• Splitting causes patients to alternately love and hate the
therapist.
• A reality-oriented approach is more effective than in-depth
interpretations of the unconscious.
Borderline Personality
Disorder2.
• Treatment.
• Psychotherapy
• Behavior therapy: Helps control patients’ impulses and
angry outbursts and to reduce their sensitivity to criticism
and rejection.
• Social Skills Training: Helps enable patients to see how
their actions affect others and improve their interpersonal
behavior (especially when videotape playback is used).
Borderline Personality
Disorder2.
• Treatment.
• Psychotherapy
• DBT: Treatment of choice for Borderline Personality
Disorder.
Borderline Personality
Disorder2.
• DBT.
• Developed by Marsha Linehan, Ph.D.
• Originally developed for BPD patients with chronically
self-injurious patients with parasuicidal behavior.
• Eclectic and draws on:
• Therapy techniques such as supportive, cognitive, and
behavioral therapy.
• Eastern philosophy such as Zen.
Borderline Personality
Disorder2.
• DBT.
• Patients are seen weekly with two main goals in mind:
• Decrease self-destructive behavior.
• Improve interpersonal skills.
Borderline Personality
Disorder2.
• DBT.
• These goals are accomplished by providing 5 essential
Functions:
• Enhance and expand skillful behavioral patterns.
• Improve motivation to change by reducing reinforcement of
maladaptive behavior, including dysfunctional cognition and
emotion.
• Ensure new behavioral patterns generalize from therapy to the
home environment.
• Structure the environment so that effective behaviors are
reinforced.
• Enhance motivation and capabilities of the therapists so that
effective treatment is rendered.
Borderline Personality
Disorder2.
• DBT.
• The five essential functions are accomplished by
providing 4 modes of treatment.
•
•
•
•
Group skills training.
Individual therapy.
Phone Consultations.
Consultation team.
Borderline Personality
Disorder2.
• DBT.
• Group Skills training.
• A didactic approach is used to teach behavioral,
emotional, cognitive, and interpersonal skills geared at
control of emotional dysregulation and inpulsive behavior.
• Individual Therapy.
• Weekly 50-60 minute sessions are used to reskills learned
during group training and life events of the previous week.
Patients also keep diary cards which are analyzed in the
session.
Borderline Personality
Disorder2.
• DBT.
• Telephone consultation.
• Therapists are available 24 hours per day for brief (~10
min) phone calls. Patients are encouraged to call if they
feel themselves heading toward a crisis.
• Consultation team.
• Therapists meet weekly to provide support for each other,
maintain motivation in their work, and compare
techniques.
Borderline Personality
Disorder2.
• DBT.
• Results of studies show:
•
•
•
•
•
Low dropout rate.
Decrease in parasuicidal behaviors.
Decrease in self reported angry affect.
Improved social adjustment.
Improved work performance.
Borderline Personality
Disorder2.
• Treatment.
• Pharmacotherapy.
• Antipsychotics: Control anger, hostility, and brief psychotic
episodes.
• Antidepressants: improve depressed mood.
• SSRI’s: have been helpful in some cases.
• MAOI’s: Have successfully modulated impulsive behavior in
some patients.
• Benzodiazepines: (especially Xanax), help anxiety and
depression, but some patients show disinhibition.
• Anticonvulsants: May improve global functioning for some
patients.
Histrionic Personality
Disorder.
Histrionic Personality
Disorder2.
• Overview.
• Patients are excitable and emotional.
• They behave in colorful, dramatic, extroverted,
flamboyant fashion.
• However, they have an inability to maintain deep,
long-lasting attachments.
Histrionic Personality
Disorder1.
•
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:
• Is uncomfortable in situations in which he or she is not the center of
attention.
• Interaction with others is often characterized by inappropriate sexually
seductive or provocative behavior.
• Displays rapidly shifting and shallow expression of emotions.
• Consistently uses physical appearance to draw attention to self.
• Has a style of speech that is excessively impressionistic and lacking in
detail.
• Shows self-dramatization, theatricality, and exaggerated expressions of
emotion.
• Is suggestible, I.e., easily influenced by others or circumstances.
• Considers relationships to be more intimate than they actually are.
Histrionic Personality
Disorder2.
• Interview.
• Cooperative and eager to give a detailed history.
• Gestures and dramatic punctuation in their conversations are
common.
• Make frequent slips of the tongue.
• Language is colorful.
• Affective display is common.
• However, when pressed to acknowledge certain feelings, they
may respond with surprise, indignation, or denial.
• Although MSE is grossly normal, they seem to forget affectladen material.
Histrionic Personality
Disorder2.
• Clinical features.
• Patients show a high degree of attention-seeking.
• Exaggerate their thoughts and feelings.
• Make everything sound more important than it
really is.
• Display temper tantrums, tears, and accusations
when they are not the center of attention or
receiving praise or approval.
• Have an endless need for reassurance.
Histrionic Personality
Disorder2.
• Clinical features.
• Seductive behavior is common in both sexes.
• Sexual fantasies are common, but patients are
inconsistent about verbalizing these fantasies and
may be coy or flirtatious rather than sexually
aggressive.
• May have psychosexual dysfunction with
anorgasmia in women and impotence in men.
Histrionic Personality
Disorder2.
• Clinical features.
• May act on their sexual impulses to reassure
themselves that they are attractive.
• Relationships tend to be superficial and they can be
vain, self-absorbed, and fickle.
• Their strong dependence needs make they overly
trusting and gullible.
Histrionic Personality
Disorder2.
• Differential Diagnosis.
• May be difficult to distinguish from borderline
personality disorder. However, in borderline
personality disorder, the following are more likely:
• Suicide attempts.
• Identity diffusion.
• Brief psychotic episodes.
Histrionic Personality
Disorder2.
• Differential Diagnosis.
• Somatization disorder may occur in conjunction
with histrionic personality disorder.
• Patients with brief psychotic disorder and
dissociative disorders may warrant a coexisting
diagnosis of histrionic personality disorder.
Histrionic Personality
Disorder2.
• Course and Prognosis.
• With age, patients show fewer symptoms.
• Patients are sensation seekers and may:
• Get into trouble with the law.
• Abuse substances.
• Be promiscuous.
Histrionic Personality
Disorder2.
• Treatment.
• Psychotherapy.
• Since patients are unaware of their own real
feelings, clarification of inner feelings is an
important therapeutic process.
• Psychoanalytically oriented psychotherapy is
probably the treatment of choice.
Histrionic Personality
Disorder2.
• Treatment.
• Pharmacotherapy.
• No standard medications are recommended but
symptoms may be targeted in a rational manner
(e.g. antidepressants for depression).
Narcissistic Personality
Disorder.
Narcissistic Personality
Disorder2.
• Overview.
• Patients have a heightened sense of self-importance and
grandiose feelings of uniqueness.
Narcissistic Personality
Disorder1.
•
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 5 (or more) of the following:
• Has a grandiose sense of self-importance (e.g., exaggerates achievements and talents,
expects to be recognized as superior without commensurate achievements).
• Is preoccupied with fantasies of unlimited success, power, brilliance, beauty, or ideal
love).
• 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).
• Requires excessive admiration.
• Has a sense of entitlement, i.e., unreasonable expectations of especially favorable
treatment or automatic compliance with his or her expectations.
• Is interpersonally exploitative, i.e., takes advantage of others to achieve his or her own
ends.
• Lacks empathy: Is unwilling to recognize or identify with the feelings and needs of
others.
• Is often envious of others or believes that others are envious of him or her.
• Shows arrogant, haughty behaviors or attitudes.
Narcissistic Personality
Disorder2.
• Epidemiology.
• <1% in the general population.
• 2-16% in the clinical population.
• Since these patients impart an unrealistic sense of
omnipotence, grandiosity, beauty, and talent to their
children, their offspring may have a higher than usual
risk for developing the disorder themselves.
• The number of cases reported is increasing steadily.
Narcissistic Personality
Disorder2.
• Clinical features.
Grandiose sense of self-importance.
Self entitled.
Expect special treatment.
Handle criticism poorly.
When someone dares to criticize them they either
become enraged or may appear completely indifferent
to criticism.
• Want their own way and are frequently ambitious to
achieve fame and fortune.
•
•
•
•
•
Narcissistic Personality
Disorder2.
• Clinical features.
• Relationships are fragile.
• Can make others furious by their refusal to obey
conventional rules of behavior.
• Interpersonal exploitiveness is commonplace.
• Cannot show empathy and feign sympathy only to
achieve their own selfish ends.
Narcissistic Personality
Disorder2.
• Clinical features.
• However, they have a fragile self-esteem.
• Are susceptible to depression.
• The stresses they are least able to handle are also the
ones they teen to cause and include:
•
•
•
•
Interpersonal difficulties.
Occupational problems.
Rejection.
Loss.
Narcissistic Personality
Disorder2.
• Differential Diagnosis.
• Borderline, histrionic, and antisocial personality
disorders often accompany narcissistic personality
disorder and are hard to tease out.
• Compared with borderlines, narcissists have less anxiety,
tend to lead less chaotic lives, and are less likely to attempt
suicide.
• Compared with antisocials, narcissists have less impulsive
behavior, alcohol or substance abuse, and less trouble with
the law.
• However, histrionics show exhibitionism and interpersonal
manipulativeness that resembles narcissists.
Narcissistic Personality
Disorder2.
• Course and Prognosis.
• Chronic and difficult to treat.
• Patients must constantly deal with blows to their
narcissism.
• Aging is handled poorly since patients value beauty,
strength, and youthfulness.
• May be more vulnerable to a midlife crisis.
Narcissistic Personality
Disorder2.
• Treatment.
• Psychotherapy.
• Treatment is difficult since patients must renounce their
narcissism to make progress.
• Psychoanalytic approaches and group therapy are
advocated, but much more research is needed.
Narcissistic Personality
Disorder2.
• Treatment.
• Pharmacotherapy.
• Lithium has been used when mood swings are present.
• Antidepressants may be helpful since patients tolerate
rejection so poorly.
Avoidant Personality
Disorder.
Avoidant Personality
Disorder2.
• Overview.
Extreme sensitivity to rejection.
Socially withdrawn life.
Appear shy, but have a great desire for companionship.
Need unusually strong guarantees of uncritical
acceptance.
• Described as having an inferiority complex.
•
•
•
•
Avoidant Personality
Disorder1.
•
A pervasive pattern of social inhibition, feelings or inadequacy, and
hypersensitivity to negative evaluation, beginning by early adulthood
and present in a variety of contexts, as indicated by 4 (or more) of the
following:
• Avoids occupational activities that involve significant interpersonal contact,
because of fears of criticism, disapproval, or rejection.
• Is unwilling to get involved with people unless certain of being liked.
• Shows restraint within intimate relationships because of the fear of being shamed
or ridiculed.
• Is preoccupied with being criticized or rejected in social situations.
• Is inhibited in new interpersonal situations because of feelings of inadequacy
• Views self as socially inept, personally unappealing, or inferior to others.
• Is unusually reluctant to take personal risks to to engage in any new activities
because they may prove embarrassing.
Avoidant Personality
Disorder2.
• Epidemiology.
• 1-10% of the general population.
• No data is available on sex ratio or familial pattern.
• Infants with a timid temperament may be more
susceptible to the disorder.
Avoidant Personality
Disorder2.
• Interview.
• Patients have anxiety about talking with the
interviewer.
• Their nervous and tense manner appears to wax and
wane with how much they think the interviewer likes
them.
• Vulnerable to the interviewer’s comments and
suggestions.
• May regard a clarification or interpretation as a
criticism.
Avoidant Personality
Disorder2.
• Clinical Features.
•
•
•
•
Show hypersensitivity to rejection by others.
Appear timid, shy, and eager to please.
Afraid to speak up in public or make requests of others.
When talking to someone they:
• Express uncertainty
• Show a lack of self confidence.
• May speak in a self-effacing manner.
Avoidant Personality
Disorder2.
• Clinical Features.
• Desire companionship, but have no close friends.
• Justify their avoidance of relationships with their fear
of rejection.
• Misinterpret others comments as derogatory or
ridiculing.
• If any of their requests are refused, they withdraw and
feel hurt.
• Rarely attain much personal advancement or exercise
much authority.
Avoidant Personality
Disorder2.
• Course and prognosis.
• Able to function in a protected environment.
• Some marry and have children.
• May live their lives surrounded only by family
members.
• Have a high likelihood of social phobia.
Avoidant Personality
Disorder2.
• Treatment.
• Psychotherapy.
• Treatment depends on solidifying an alliance with patients.
• Therapist must convey an accepting attitude toward the
patient’s fears, especially of rejection.
• Therapist may eventually encourage patient to take more
social risks.
• However, failure can reinforce the patients’ low self-esteem.
• Troup therapy may help patients understand how their
sensitivity to rejection affects them and others.
• Assertiveness training may help with poor self-esteem.
Avoidant Personality
Disorder2.
• Treatment.
• Pharmacotherapy.
• B-blockers may help with autonomic hyperactivity.
• Serotonergic agents may help with rejection sensitivity.
• Theoretically, dopaminergic drugs might encourage
novelty-seeking behavior.
Dependent Personality
Disorder.
Dependent Personality
Disorder2.
• Overview.
• Patients subordinate their own needs to those of others.
• Get others to assume responsibility for major areas of
their lives.
• Lack self-confidence.
• May experience intense discomfort when alone for
more than a brief period.
• Has been called passive-dependent personality.
Dependent Personality
Disorder2.
• Freud described “oral-dependent personality”
characterized by:
•
•
•
•
•
•
•
Dependence.
Pessimism.
Fear of sexuality.
Self-doubt.
Passivity.
Suggestibility.
Lack of perseverance.
Dependent Personality
Disorder1.
•
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 5 (or more) of the following:
• Has difficulty making everyday decisions without an excessive amount of advice and
reassurance from others.
• Needs others to assume responsibility for most major areas of his or her life.
• Has difficulty expressing disagreement with others because of unrealistic fears of loss
of support or approval.
• Has difficulty initiating projects or doing things on his or her own (because of a lack of
self-confidence in judgment or abilities rather than a lack of motivation or energy).
• Goes to excessive lengths to obtain nurturance and support from others, to the point of
volunteering to do things that are unpleasant.
• Feels uncomfortable or helpless when alone because of exaggerated fears of being
unable to care for himself or herself.
• Urgently seeks another relationship as a source of care and support when a close
relationship ends.
• Is unrealistically preoccupied with fears of being left to take care of himself or herself.
Dependent Personality
Disorder2.
• Interview.
•
•
•
•
Try to cooperate.
Compliant.
Welcome specific questions.
Look for guidance.
Dependent Personality
Disorder2.
• Clinical features.
• Pervasive pattern of dependent and submissive
behavior.
• Cannot make decisions without an excessive amount of
advice and reassurance from others.
• Avoid positions of responsibility and become anxious
if asked to assume leadership roles.
• Can easily perform tasks for someone else, but can not
do the same tasks on their own.
Dependent Personality
Disorder2.
• Clinical features.
• Prefer to be submissive and will often tolerate an
abusive, unfaithful, or alcoholic spouse.
• These patients often experience:
•
•
•
•
•
Pessimism.
Self-doubt.
Passivity.
Fear of expressing sexual feelings.
Fear of expressing aggressive feelings.
Dependent Personality
Disorder2.
• Differential Diagnosis.
• Very difficult since dependent traits are found in many
psychiatric disorders.
• Unlike histrionic and borderline personalities, patients
usually have a long-term relationship with ONE
person, rather than a series of people.
• Dependents are not overtly manipulative.
• Dependence can occur in agoraphobia, but these
patients have a higher level of anxiety and panic.
Dependent Personality
Disorder2.
• Course and Prognosis.
Little is known about long-term outcome.
Occupational functioning tends to be impaired.
Social relationships are limited.
Patients may suffer physical or mental abuse.
Major depressive disorder can develop if patients loose
the person they depend on.
• However, with treatment, prognosis is favorable.
•
•
•
•
•
Dependent Personality
Disorder2.
• Treatment.
• Psychotherapy.
• Treatment is often successful.
• Therapists mush show great respect for the patients feelings
of attachment, even if they are pathological.
• One pitfall of treatment is when therapists ask patients to
change the dynamics of a pathological relationship. At
that point, patients may feel torn between complying with
the therapist and losing a pathological external
relationship.
Dependent Personality
Disorder2.
• Treatment.
• Psychotherapy.
• Insight-oriented therapies help patients understand the
antecedents of their behaviors.
• Other helpful therapies include:
• Behavioral therapy.
• Assertiveness training.
• Family therapy.
• Group therapy.
Dependent Personality
Disorder2.
• Treatment.
• Pharmacotherapy.
• Some evidence that imipramine (Tofranil) helps patients
with panic attacks or high levels of separation anxiety.
• SSRI’s and Benzodiazepines may also help anxiety.
• Some patients depression and withdrawal symptoms
respond to psychostimulants.
Obsessive-Compulsive
Personality Disorder.
Obsessive-Compulsive
Personality Disorder2.
• Overview.
• Pervasive pattern of perfectionism and inflexibility.
• Patients show:
•
•
•
•
•
Emotional constriction.
Orderliness.
Perseverance.
Stubbornness.
Indecisiveness.
• ICD-10:
• Anancastic personality disorder.
Obsessive-Compulsive
Personality Disorder1.
•
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 4 (or more) of the following:
•
•
•
•
•
•
•
•
Is preoccupied with details, rules, lists, order, organization, or schedules to the extent that the major
point of the activity is lost.
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).
Is excessively devoted to work and productivity to the exclusion of leisure activities and friendships
(not accounted for by obvious economic necessity).
Is overconscientious, scrupulous, and inflexible about matters of morality, ethics, or values (not
accounted for by cultural or religious identification).
Is unable to discard worn-out or worthless objects even when they have no sentimental value.
Is reluctant to delegate tasks or to work with others unless they submit to exactly his or her way of
doing things.
Adopts a miserly spending style toward both self and others; money is viewed as something to be
hoarded for future catastrophes.
Shows rigidity and stubbornness.
Obsessive-Compulsive
Personality Disorder2.
• Epidemiology.
•
•
•
•
•
•
Prevalence is unknown.
More common in men than women.
Diagnoses is most often in the eldest child.
More common in first-degree relatives.
Patients often have backgrounds of harsh discipline.
Freud thought it was associated with difficulties in the anal
stage (2 year olds) , but various studies have failed to validate
this.
Obsessive-Compulsive
Personality Disorder2.
• Interview.
•
•
•
•
•
•
Patients are stiff, formal, and rigid.
Mood is serious.
Lack spontaneity.
May be anxious about not being in control.
Answers are unusually detailed.
Affect is constricted, but not blunted or flat.
Obsessive-Compulsive
Personality Disorder2.
• Interview.
• Defense mechanisms include:
•
•
•
•
•
Rationalization.
Isolation.
Intellectualization.
Reaction formation.
Undoing.
Obsessive-Compulsive
Personality Disorder2.
• Clinical features.
• Preoccupied with:
•
•
•
•
•
•
Rules.
Regulations.
Orderliness.
Neatness.
Details.
Achievement of perfection.
Obsessive-Compulsive
Personality Disorder2.
• Clinical features.
• Insist that rules be followed rigidly an cannot tolerate
infractions.
• Lack flexibility.
• Capable of prolonged work if it is routinized and does
not require changes.
Obsessive-Compulsive
Personality Disorder2.
• Clinical features.
• Have limited interpersonal skills and few friends.
•
•
•
•
Alienate people.
Are unable to compromise.
Insist others submit to their needs.
Eager to please those more powerful than them and carry
out their wishes in an authoritarian manner.
Obsessive-Compulsive
Personality Disorder2.
• Clinical features.
•
•
•
•
•
Formal and serious.
Lack a sense of humor.
Indecisive and ruminate about making decisions.
Anything that can upset their “stability” causes anxiety.
Usually keep their anxiety “bound up” in their rituals.
Obsessive-Compulsive
Personality Disorder2.
• Differential diagnosis.
• Unlike OCPD, which is pervasive throughout a
patient’s life, OCD involves specific obsessions and
compulsions.
• An axis I diagnosis of OCD can also be comorbid.
• A diagnosis of personality disorder should only be
given if the symptoms cause significant impairments in
their occupational or social effectiveness.
• Delusional disorder is sometimes comorbid and should
also be diagnosed.
Obsessive-Compulsive
Personality Disorder2.
• Course and prognosis.
• Variable and unpredictable.
• Patients may develop obsessions or compulsions.
• Adolescents often go either of two ways:
1.
2.
Evolve into warm, open, and loving adults.
Develop Schizophrenia or (decades later) MDD.
Obsessive-Compulsive
Personality Disorder2.
• Course and prognosis.
• Patients may flourish in positions demanding
methodical, deductive, or detailed work.
• Are vulnerable to unexpected changes.
• Personal lives may remain barren.
• Depressive disorders are common (especially late onset
ones).
Obsessive-Compulsive
Personality Disorder2.
• Treatment.
• Psychotherapy.
• Patients are often aware of their problems and seek
treatment.
• Patients value free association and no-directive therapy
highly.
• Treatment is often long and complex.
• Countertransference problems are common.
Obsessive-Compulsive
Personality Disorder2.
• Treatment.
• Psychotherapy.
• Group and behavior therapy occasionally offer certain
advantages.
• Maladaptive interactions or explanations can be easily
interrupted.
• Preventing completion of habitual behavior raises the patients
anxiety and leaves them susceptible to learning new coping
strategies.
• Direct rewards for change can be given in group therapy.
Obsessive-Compulsive
Personality Disorder2.
• Treatment.
• Pharmacotherapy.
• Klonopin has reduced symptoms in severe OCD, but it is
unknown if it is helpful in OCPD.
• Antidepressants [specifically clomipramine (Anafranil),
fluoxetine, and nefazodone (Serzone)] have benefitted
some people.
References.
• 1. (2000). Diagnostic and statistical manual of mental
disorders, dsm-iv-tr.. (IV ed.). Washington, DC.:
Amer Psychiatric Pub Inc.
• 2. Sadock, B. J., H. I. Kaplan, and V. A. Sadock.
Kaplan & sadock\'s synopsis of psychiatry, behavioral
sciences/clinical psychiatry. 10. Lippincott Williams &
Wilkins, 2007. Print.