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Personality Disorders Norieta C. Balderrama, M.D. Adult Psychiatry Child and Adolescent Psychiatry Forensic Psychiatry Overview Diagnosis Etiology Clinical Course Differential Diagnosis Treatment Specific personality Disorders Overview Personality - composed of different personality traits Personality traits - DSM - as enduring modes of comprehending and relating to the environment and oneself Personality disorder - - DSM - long term, stable pattern of unusual and inflexible personality traits that lead to functional impairment or distress Overview Axis II - described by DSM as qualitatively different from other psychiatric disorders Placed on a separate diagnostic axis II Diagnosis Diagnostic features - markedly deviant, inflexible, maladaptive patterns of inner perception and behavior 1. Patterns present since adolescence or early adulthood. 2. Patterns not exclusively manifestation of another mental disorder, substance related nor due to GMC Diagnosis 3. Patterns occur in several of the following areas : A. cognition - the way they perceive self and others B. affect - quality of emotional responsiveness C. Interpersonal functioning D. impulse control Diagnostic Clues 1. Presenting complaints - impaired interpersonal relationships, chronic unhappiness, low self esteem 2. History pattern of relationship problems; adapting to environment stress, failure to achieve social or occupational goals 3. Mental status examination abnormalities Diagnostic Clues MSE Cluster A - peculiar thought process / content / affect Cluster B - mood and affect labile , dissociative symptoms, preoccupation with rejection Cluster C - anxiety and preoccupied with criticism or rigidity Physical examination Unremarkable Evidence of violence - antisocial Self destructive behavior - borderline Laboratory Examination Unremarkable , substance abuse with antisocial and borderline personality Types / Clusters 1. 2. 3. Cluster A odd and eccentric Paranoid personality disorder - distrust and suspiciousness Schizoid PD - detachment and restricted emotionality Schizotypal PD - discomfort with relationships , thought distortion, and eccentricity Cluster B : dramatic , emotional, erratic 1. Antisocial PD- disregard and violation of the basic rights of others 2. Borderline PD- social and emotional instability 3. Histrionic PD- emotionality and attention seeking behavior 4. Narcissistic PD- inflated self esteem , demands for admiration, lack for concern of others Cluster C 1. Avoidant personality disorder - social inhibition, feelings of inadequacy, hypersensitive to criticism 2. Dependent personality disorder submissive and clinging behavior associated with need to be taken cared of 3. Obsessive compulsive personality disorder - preoccupation with orderliness, perfection and control Other personality disorders Passive aggressive / depressive PD but some say there are an infinite number of PD Personality not otherwise specified Distinguishing features 1. Schizoid and avoidant - same interpersonal behavior but different self perceptions ( schizoid indifferent to isolation but avoidant feel lonely ) 2. Avoidant and dependent PD with different interpersonal behavior avoidant isolate themselves, dependent seek closeness ) Both with low self esteem Etiology A. Theories - before the 20th century faulty parental stock or moral decay Terms like manie sans delire Moral insanity Constitutional psychopathic inferiority ( like antisocial personality) Freudian reshaped concepts Central Tenets 1. Adult personality - product of interaction between inborn factors and childhood experiences ; the way one learns to solve problems 2. Emotional problems of childhood - resolved by defense mechanisms which are intra psychic methods of decreasing anxiety ; defense mechanisms underlie personality traits Central tenets Faulty resolution of childhood emotional conflicts leads to adult psychopathology and emotional traumas during specific stages of child development --> adult personality disorders Later - psychodynamic theories by Anna Freud, Hartman - some personality traits are not solely based on emotional conflicts but may be realistic attempts at problem solving or because intrinsically pleasurable Psychodynamic theories 1. Object relations - role of interpersonal relationships , faulty sense of self caused by pathologic childhood interactions with caregivers creates personality pathology 2. Temperament theory - goodness of fit , temperament and adult personality ; interaction of child’s temperament and interpersonal environment Psychodynamic theories Character armor - aberrant personality traits are an individual’s armor against the suffering generated by intra psychic conflicts Biologic Theories Genetic studies 1. Relationship of cluster A PD and psychotic disorders 2. Relationship between Cluster B and substance use, somatoform and mood disorders Relationship between Cluster C PD and anxiety disorders Clinical Course of Personality Disorders A. personality traits - inflexible and maladaptive during childhood , stability increases with adolescence and adulthood B. Lifestyle - personality disorders strongly influence and individual’s choice of lifestyle - example with occupation C. PD limits flexibility and life choices Symptoms Remittance - symptoms of borderline, antisocial and avoidant PD often lessen with time Exacerbation - symptoms of paranoid and schizoid PD exacerbates with age Differential diagnoses 1. Distinguishing personality disorder from normal behavior 2. Distinguishing from Axis 1 disorders 3. Due to general medical condition 4. Post concussion 5. Co morbid conditions like mood, anxiety, substance related disorders Treatment Overview - directed at improving the individual’s adaptation and sense of well being by making traits more flexible - most are unaware and seek help due to associated unhappiness, anxiety, interpersonal problems Psychodynamic and cognitive therapies - treatments of choice for most PD. Lengthy ; different techniques Medications Antipsychotics - borderline, paranoid, schizotypal Antidepressant - borderline Mood stabilizers - borderline ; antisocial Anxiolytic - avoidant PD Specific Personality disorders A. Paranoid personality disorders mistrustful, suspicious Secretive, isolated More common in males Social separation imposed by culture or economics Prevalence 1 % Schizophrenia and delusional disorder more common Paranoid personality disorder Associated features - socially isolated, brief psychosis, persecutory delusions, sensory impairment Treatment - psychotherapy and antipsychotic medications Schizoid PD Emotionally distant, derive little joy from living ; uninterested in interacting with others ; indifferent to praise or criticisms More common males Prevalence unknown Schizophrenia more common Social drifting or dysphoria associated feature Schizoid PD Differential diagnosis - schizophrenia, autistic, Asperger Social isolation Treatment : psychotherapy and antidepressant Schizotypal PD Isolated, uncomfortable interacting, peculiar patterns of thinking, ideas of reference, persecution, preoccupation with metaphysical, magical thinking, occult or religious phenomena , odd speech and affect More in males 3% prevalence Schizotypal and schizophrenia common among relatives Psychotherapy and antipsychotics Antisocial PD Behave poorly, violate the law, lie, irresponsible, aggressive, disregard for safety of others, show lack of remorse, may use manipulative means such as charm, guilt, and induce others into serving their ends Male to female 3:1 Lower socio economic 3% male population Antisocial PD Related illness - somatization, substance related Immersed in social strife Criminal activity failed relationships, abandoned responsibilities Injuries or death because of violence Treatment : psychotherapy , group or milieu therapy ; limit setting ; mood stabilizers Borderline PD Unstable interpersonal relationships , emotions, and self image . Impulsive and often destructive Epidemiology 1:3 male to female 2% prevalence Demanding, capricious in relationships, prone to irresponsibility, emotionally labile Suicide threats and attempts , self destructive behavior Fear of abandonment and chronic feelings of identity confusion or emotional emptiness Borderline PD Crises Childhood abuse, like sexual abuse Mood disorders, substance related disorders ; eating disorders; eating disorders, PTSD frequent co morbid conditions Treatment - psychotherapy and pharmacotherapy Histrionic personality disorder Extreme emotional lability , constantly attract attention through dramatic behavior or dress, inappropriately seductive, emotionally shallow, obsessed with physical appearance, overdramatic, unduly influenced by others More females 2% of population Histrionic PD Difficult interpersonal relationships, social ostracism , somatization disorder, conversion disorder, major depressive disorder, and other personality disorders Treatment - decrease behaviors used to seek attention and improve interpersonal relationships ; individual psychotherapy Narcissistic personality disorder Overriding sense of entitlement and self importance; lack of understanding and feelings for others ; preoccupied with own accomplishments, demand attention from others, envy, dismiss or exploit other individuals 3:2 male to female Less than 1% prevalence Narcissistic PD Hypersensitivity to real or imagined slights from others , difficult interpersonal relationships, extreme ambitiousness, periods of anger and self pity Treatment ; psychotherapy reorganization of relationship with self and others Avoidant PD Shy away or avoid almost all occupational or social relationships because of fears of rejection that are based on feelings of inadequacy 1:1 ratio 1% prevalence Perceive self as substandard, preoccupied with rejection , avoiding activities because of fear of failure ; lonely and seek human contact when acceptance is certain Avoidant PD Associated - social phobia, panic disorder , agoraphobia Treatment - psychotherapy and anxiolytic medications Dependent personality disorder Consumed by need to be taken cared of Clinging behavior, allow others to assume responsibility for important decisions, avoids initiating activities independently, worries unrealistically about abandonment, feel inadequate and helpless 1:1 Prevalence different - cultures Dependent PD Avoid disagreements because of fear of losing support Lack confidence to make even unimportant decisions independently Constantly seek support from others, dependency on family member, seeks substitute when person is not available Self doubt, excessive humility, mood problems, adjustment problems, anxiety Dependent PD Treatment - decrease inappropriate dependency on others and to improve self reliance and self esteem Cognitive , behavioral and psychodynamic therapies Obsessive compulsive personality disorder Preoccupied with details and lose a sense of overall goals, strict, perfectionist, over conscientious, inflexible obsessed with work and productivity and are hesitant to delegate task to others 2:1 male to female 1% of population Obsessive compulsive PD Miserly and unable to give up useless possessions Should not be confused with OCD Associated features, indecisiveness, dysphoria, anger, social inhibition, difficulty with interpersonal relationships Treatment : decrease behavioral rigidity And increase enjoyment of life Antidepressants Case A 25 year old female at the ER tells them she has taken overdose of fluoxetine. She ahs history of multiple previous suicide gestures, which usually follow the breakup of a stormy relationship. She has history of substance abuse , feels empty and fears that she is going to be abandoned What is the most likely diagnosis ? Summary Personality disorders - at least 18 years of age Three clusters Odd and eccentric Dramatic, emotional and erratic Anxious and fearful Different modes of treatment Associated feature and differential diagnoses Thank you For your kind attention ! Any questions ?