Download MSIV personality disorders v 2012_Dr D Mercer

Personality Disorders
Deanna Mercer MD FRCPC
MSIV March 21 2012
[email protected]
Objectives
• Describe personality disorders: criteria,
clusters and core symptoms
• Axis I and Axis II comorbidity
• Understanding self injurious behaviour
• Borderline Personality Disorder: diagnosis
and treatment
• Antisocial Personality Disorder: diagnosis
and basic treatment
5296 Describe the general diagnostic criteria for a PD.
5297 State the classification of PD in three clusters.
5298 Describe the main enduring pattern of each PD type.
5299 Explain the clinical relevance of comorbity of Axis I and
Axis II disorders.
5300 Describe the mental disorders associated with
self‐injurious behaviors (SIB)
5301 List the biological, demographic, economic, social and
developmental factors associated with SIB.
5302 Describe the pertinent factors in the recognition of the
potential of SIB.
5303 List criteria for borderline personality disorder (BPD).
5304 Describe common psychiatric comorbidities asociated with
BPD.
5305 Describe a treatment approach to BPD including use of
hospitalization, outpatient care, pharmacological
treatment and psychotherapy
Good References
• Disordered Personalities
• Field Guide to Disordered Personalities
Dave Robinson MD Rapid Psychler Press
Personality Disorders
Introduction
Criteria, clusters and core
symptoms
Personality
What is it?
How do you
get one?
Personality: Definition
• An individual’s characteristic pattern
of response to his/her environment.
• Includes: how one thinks, feels, acts
and relates to others.
Personality: Etiology
Temperament X Environment
Time
Disorder
• Leads to clinically significant distress or
impairment in functioning
DSM IV general criteria for personality
disorder
• Enduring pattern of inner experience and
behavior that deviates markedly from the
expectations of the individual’s culture
• cognition, affectivity, interpersonal
functioning and impulse control
• Pattern is inflexible and pervasive
• Leads to clinically significant distress or
impairment in functioning
• Not better accounted for by other mental
disorder
PD’s are Ego Syntonic
• Ego Syntonic: Individual experiences significant
distress, but does not feel that their thoughts,
emotions or behaviours are the source of their
distress
• external locus of control
• Ego Dystonic: Individual sees their disorder as
arising from their own thoughts, emotions or
behaviours
• internal locus of control
Epidemiology
 DSM “informed speculation”
–Any PD 9%
–Most PD’s 1-2 %
–No sex differences in any PD
• In clinical populations 50 -80%
• Torgersen 2001 Norway,
• Lezenweger 2007 National Comorbidity Survey Replication
Prognosis
• All tend to improve over time (years)
• Cluster B the most
• Schizotypal, Borderline and Avoidant have
the greatest functional impairment
• Narcissistic, Histrionic, Obsessive
Compulsive personality disorders have the
least functional impairment
Why make a diagnosis of
Personality Disorder?
Why make a PD diagnosis ?
• Axis I with PD
• More impaired, more chronicity
• Overall poorer response to treatment
requiring more intensive and prolonged
care
• Certain PD’s (BPD, ASPD, Schizotypal
PD) have specific treatments or are
contraindications for certain treatments
Personality Disorders: Clusters
• Cluster A: odd
Schizoid, schizotypal, paranoid
• Cluster B: dramatic
Borderline, histrionic, narcissistic, antisocial
• Cluster C: anxious
Obsessive compulsive, dependent, avoidant
Cluster A Personality Disorders
Schizoid PD
Schizotypal PD
Paranoid PD
Pictures of famous People with
Schizoid Personality Disorder
Schizoid Personality Disorder
• “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 settings..”
• “DR”
• Detached from relationships
• Restricted range of emotional expression
Schizotypal Personality Disorder
Schizotypal PD
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
settings
“ACE”
•
Acute discomfort in close relationships:

•
Cognitive and perceptual distortions:

•
paranoia rather than fear of judgment
odd beliefs, unusual perceptions, suspiciousness,paranoia,
odd speech
Eccentric Behaviours
Paranoid Personality Disorder
Paranoid PD
•
“A pervasive distrust and suspiciousness of
others such that their motives are
interpreted as malevolent, beginning by
early adulthood and present in a variety of
settings…”
•
•
•
•
“DSMM”
Distrusts others,
Suspiciousness
others Motives are interpreted as
Malevolent
How to Remember Cluster A
• Schizoid: looks like negative symptoms of
scz
• Schizotypal: looks like positive symptoms
of scz (but not full blown psychosis)
• Paranoid PD: looks like delusional
disorder, paranoid type ( but no full blown
delusions and more pervasive
suspiciousness)
All cluster A have:
• Increased risk of brief psychotic episodes
• Genetic link to schizophrenia:
– Schizotypal>schizoid>ppd
• Few relationships
– Schizoid: if any close relationship it is with 1˚
family
– Schizotypal: lacks close friends except 1˚ family
– Paranoid: few friends with similar beliefs
• Risk of developing scz
– Schizotypal: 10-20%
Cluster B
Histrionic PD
Antisocial PD
Narcissistic PD
Borderline PD
Histrionic
Personality
Disorder
Histrionic PD
• “A pervasive pattern of excessive
emotionality and attention seeking,
beginning by early adulthood and present
in a variety of contexts…”
• “theatrical”
• Intense but shallow emotions
• Craves being the centre of attention
Antisocial
Personality
Disorder
Antisocial PD
• “Pervasive pattern of disregard for and violation of
the rights of others occurring since age 15 years /
must be at least age 18 years”
•
•
•
•
•
•
•
Repeated lawbreaking
Deceitfulness
Impulsivity
Irritability and aggressiveness
Reckless disregard for safety of self or others
Consistent irresponsibility
Lack of remorse
ASPD epidemiology
• DSMIV tr 1% females 3% males
• New community based studies 1% M=F
ASPD prognosis
• Highest risk of ASPD: early onset conduct
(before age 10) and ADHD
• 75% of conduct disorder resolves by adulthood
• Prognosis better if has some connection to a
group
• ASPD > Sociopathy ( Tony Soprano) >
Psychopath (Ken Lay)
• Decrease impulsivity and criminal behavior, but
continue to be difficult people (poor spouses,
parents, employees)
Treatment
 Rarely seek help for distress caused by their actions
 Most common reasons for psychiatric contact:
detox, seeking meds with a street value, notes for
missing work, assessments to avoid criminal
responsibility, military service, work that they see as
undesirable
 Psychotherapy usually contraindicated, particularly
psychopathy
 Stay respectful, but avoid emotional investment in
patient
◦ Confront denial and minimization
◦ Restrict focus to possible outcomes of antisocial behaviour
◦ Help to find healthier alternatives to acting out
Psychopathy
http://www.youtube.com/watch?v=s5h
EiANG4Uk
Narcissistic Personality Disorder
Narcissistic PD
“ A pervasive pattern of grandiosity (in
fantasy or behaviour) need for admiration,
and lack of empathy, beginning by early
adulthood and present in a variety of
contexts”
• “AGE”
– need for Admiration,
– Grandiosity (fantasy or behaviour)
– lack of Empathy for others
Borderline
Personality
Disorder
Borderline PD
“ 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…”
Cluster C” anxious”
Obsessive Compulsive
Avoidant
Dependent
Obsessive Compulsive
Personality Disorder
OCPD
http://www.youtube.com/watch?v=
T-GKovedEy4&feature=related
OCPD
• “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..”
• “OCP”
• Orderliness
• Perfectionism
• Control : mental and interpersonal
• *Most do not have OCD (only 30%)
• Adolescents with strong OCPD traits can grow out
of the diagnosis
Avoidant Personality Disorder
Avoidant PD
“A pervasive pattern of social
inhibition, feelings of inadequacy,
and hypersensitivity to negative
evaluation, beginning by early
adulthood and present in a variety
of contexts”
• similar to social phobia, but more
pervasive
Dependent PD
•
A pervasive and excessive need to be taken
care of that leads to submissive and clinging
behaviour and fears of separation, beginning
by early adulthood and present in a variety of
contexts..”
•
•
•
•
“Dependent on relationships”
Difficulty making everyday decisions without a lot of advice,
reassurance from others
unable to disagree with others because fears loss of support,
will do things that are unpleasant, degrading to maintain
support
If person’s fear of retribution realistic (abusive spouse) do not
make diagnosis
Borderline
Personality
Disorder
BPD DSMIV
• A pervasive pattern of instability of interpersonal
relationships, self-image and affects, and
marked impulsivity
• Affective: emotional lability, problems with anger
• Relationships: chaotic, idealizing/devaluing,
fears of abandonment “I hate you, don’t leave
me”
• Behaviours: suicide and self harm, impulsive
(sex, A&D, binge eating, driving fast,
promiscuity)
• Cognitive: emptiness, unstable sense of self, mild
psychotic symptoms under stress, dissociation
Self Harm / SIB
• Behaviours that inflict harm to one’s body without the
obvious intention of committing suicide
• 1-4 % general population
• chronic/severe SH 1%
• Teens 5- 13 %, college age 17- 35%
• Age of onset: 14 - 24
• majority (75%) <10 times
• Increasing in teens
• Increased risk of suicide behaviours
• F=M
• abrading/scratching> cutting, banging> biting, burning
Risk Factors
• Social: Low SES, adverse events during
childhood (abuse and trauma)
• Biological: ↓ serotonin, impulsivity
• Psychiatric Disorders (90%) : Personality
disorders (BPD -75%), depression, pervasive
developmental delay, dissociative identity
disorder, eating disorders,
• Alcohol and substance abuse are common
SIB
• Situational Risk factors: recent negative
life events
• Reasons:
– relief from intense painful emotions
– self punishment
– to get significant others to respond
Assessing for SIB
• Suspect in teens and young adults who are
presenting with psychological distress
• Important to recognize that SIB is usually an
attempt to reduce emotional distress
• Best way to solve the problem is to look for a
solution to the event that caused the emotional
distress
SIB: intervention
• Start by validating that the prompting
problem and the distress are real and that
it makes sense to want to reduce
emotional pain
• Highlight that while SH does reduce
emotional pain in the short term, it is not a
great way to solve the problem that got the
distress going in the long run
• Invite the person to look at other methods
of problem solving
Objective # 5305
Describe a treatment approach to
BPD including use of
hospitalization, outpatient care,
pharmacological
treatment and psychotherapy
Bio-Social Theory
EMOTION DYSREGULATION
Emotionally
Vulnerable
individual
Invalidating
Environment
Linehan 1993
BPD: prognosis
• With primarily OPD treatment 75% of
patients with BPD no longer meet criteria
after 6 years
• 75% have history of suicide and self harm
attempts. 5 - 10% die by suicide
• Worst prognostic factor: concurrent
substance dependence
• Best prognostic factor: GAF at time of
diagnosis
BPD: Comorbidity
• Mood disorders : depression 50%,
dysthymia 70%. At time of admission 90%
MDE
• Bipolar I,II: 18%
• Eating Disorders(An, BN, obesity) : 50%
• Anxiety Disorders: 90%
• Substance Use Disorders: 60%
• Narcissistic PD, antisocial PD: 50%
Treatment of BPD
• Mainstay of treatment is outpatient care
and psychotherapy
– BPD patients are exquisitely sensitive to what
happens in their environment – treatment has
to help them find ways to :
1.Solve problems causing painful emotions
2.Feel better
3.Tolerate both the situation and how they feel
about it without making the situation worse
BPD treatment: Psychotherapy
• All empirically based psychotherapies (DBT,
MBT, TFP, Schema focused)
– Focus of treatment is to establish connection between
actions and feelings
– Therapists manage, pay careful attention to
countertransference.
– Therapist has ongoing discussion with colleagues or
easy access to consultation
– Here and now focus
BPD: Hospitalization
• Admission indicated:
– After a serious suicide attempt
– Psychosis/severe disorganization
• May be indicated
– loss of significant social support
– Worsening depression, substance abuse
• Caution when
– Hospital has not been helpful or has made
person worse
Links 2010
BPD: Meds
• Adjunct to psychotherapy, limit expectations
(yours and your patient’s!)
• Concurrent MDE: SSRI’s, Effexor
• Affective lability: mood stabilizers – Lamotrigine,
Aripiprazole
• Insomnia, agitation, brief psychotic symptoms –
low dose quetiapine, olanzapine
• Avoid: benzodiazepines, meds that are
dangerous in overdose (lithium, tricyclics)