Personality Disorders

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harm avoidance contiuum of Temperment

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timidity to risk taking

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novelty seeking risk continuum

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passivity to intrusiveness

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Reward dependence continuum

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indifference to indulgence

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persistence continuum

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apathy to fanacticism

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What is the component of personality that is most subject to genetic predispositions and to the influence of biologic factors in the environment

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temperment

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DSM Personality DX criteria?

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A. An enduring pattern of feeling, thinking, and behaving that deviates markedly from the expectations of the person's culture. This pattern is manifested in at least two of the following areas:
1. Cognition (ways of perceiving and interpreting self, other people and events)
2. Affect (the range, intensity, volatility, and appropriateness of their emotional responses)
3. Interpersonal relationships
4. Impulse control
B. This pattern of feeling, thinking, and behaving is inflexible and is exhibited across a broad range of personal and social situations
C. The pattern of feeling, thinking, and behaving leads to distress in the individual and others and to impairments in interpersonal, social, school, and/or occupation functioning
D. The pattern of feeling, thinking, and behaving is enduring, and its onset can usually be traced back to childhood, adolescence, or early adulthood
E. The dysfunctional pattern of feeling, thinking, and behaving is not caused by another type of psychiatric disorder or a consequence of a medical condition such as brain injury

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What axis is personality disorders on?

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Axis II

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Personality cluster A

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Odd/eccentric,
• Paranoid Personality
• Schizoid Personality
• Schizotypal Personality

oTend to be detached and distrustful
oInvolve use of fantasy and projection
oAssociated with tendency toward psychotic thinking
oCognitive disorganization when stressed

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Cluster B

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Dramatic/erratic

• Borderline Personality
• Antisocial Personality
• Narcissistic Personality
• Histrionic Personality
oIndividuals tend to be emotionally unstable, impulsive and intense.
oUse dissociation, denial, splitting, and acting out
oDisorders are common

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Cluster C

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Anxious/fearful

• Dependent Personality
• Avoidant Personality
• Obsessive-compulsive personality
Use isolation, passive aggression, and hypochondriasis

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Why do • Paranoid Personality Disorder and Schizotypal Personality Disorder feel threatened and persecuted for no substantiated reason

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so self-absorbed that they distort reality
o They are often conflicted about their own angry and sexual feelings, that they unconsciously project onto others

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the first-line treatments for most people with personality disorders is

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• Insight-oriented and cognitive-behavioral

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T/F: Anxiety and mood disorders commonly coexist with personality disorders so medication may be a component of treatment

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•Anxiety and mood disorders commonly coexist with personality disorders so medication may be a component of treatment

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o Impulsive traits associated with

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increased levels of testosterone, 17- estradiol, and estrone

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Low levels of platelet monoamine oxidase may be associated with what

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sociability or with schizotypal personality disorder

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Abnormal saccadic eye movements associated with:

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•Low self-esteem
•Introversion
•Social withdrawal
•SCHIZOTYPAL PERSONALITY DISORDER

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Low levels of 5 HIAA associated with

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with suicide attempts, impulsiveness, and aggressions

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Raising serotonin levels pharmacologically may be associated with

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diminished sensitivity to rejection and increased assertiveness, self-esteem, and stress tolerance

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Cluster A paranoid personality disorder requires 4 of what featues

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1. Suspects without sufficient basis, that others are exploiting, harming, or deceiving him/her
2. Is preoccupied with unjustified doubts about the loyalty or trustworthiness of friends or associates
3. Is reluctant to confide in others because of unwarranted fear that the information will be used maliciously against him or her
4. Suspicious about partner's fidelity
5. Responds by counterattacking
6. Perceives attacks on his or her character and is quick to react angrily
7. Persistently bears grudges
8. Reads hidden demeaning or threatening meanings into benign remarks or events

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paranoid personality disorder defense mechanisms

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projection, denial, and rationalization

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What does Delusional disorder, persecutory type have compared to paranoid personality dx

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the patient has systematized, encapsulated non-bizarre delusions:


Delusional Disorder, Persecutory type evidences circumscribed area of paranoia
• Paranoid personalities are hypervigilent, suspicious, and self-referential but fall short of having delusions.
• Their behavior is not encapsulated- it is pervasive throughout most if not all of their interactions with others

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Systematized?

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scheme of actions and concerns that appear logical “only if” the initial premise of persecution is taken as correct

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what does Encapsulation mean

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indicates the activities of the person outside the delusion are not obviously unusual

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Schizoid personality disorder

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Diagnosis requires four or more of the following:
1.Neither desires nor enjoys close relationships
2.Almost always chooses solitary activities
3.Has little, if any, desire for a sexual experience with another person
4.Takes pleasure in few, if any, activities
5.Lacks close friends or confidants other than first-degree relatives
6.Appears indifferent to the praise or criticism of others
7.Shows emotional coldness, detachment, or flattened affect

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DDX schizoid personality disorder

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Paranoid Personality Disorder- the patient is involved with others

Schizotypal Personality Disorder- the patient exhibits oddities and eccentricities of manners

Avoidant Personality Disorder- the patient is isolated but WANTS to be involved with others

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Schizotypal Personality Disorder

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• Diagnosis requires five or more of the following:
1.Ideas of reference
2.Odd beliefs or magical thinking
3.Unusual perceptual experiences
4.Odd thinking and speech
5.Suspiciousness or paranoid ideation
6.Inappropriate or constricted affect
7.Behavior or appearance is odd, eccentric or peculiar
8.Lack of close friends or confidantes other than first degree relatives
9.Excessive social anxiety that does not diminish with familiarity

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Features of schizotypal personality disorder

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•Abnormal saccadic eye movements with poor eye tracking
•Diminished brain mass, especially in the temporal lobe
•Psychodynamics: magical thinking, splitting, isolation of affect

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What usually brings schizotypal disorder in for help?

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acute stressor or the encouragement of a family membe

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What type of psychosis may schizotypal patients exhibit?

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periods of psychosis that last from minutes to hours. These episodes are referred to as micropsychotic episodes.

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Schizoid DDX?

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oParanoid Personality Disorder- the patient is suspicious and guarded
oSchizoid Personality Disorder- the patient has no particular eccentricities
oBorderline Personality Disorder- the patient shows emotional instability, intensity and impulsiveness
oSchizophrenia- the patient is out of touch with reality; has true thought disorder

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Cluster B Anti social personality disorder SX

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• Diagnosis requires three or more of the following:
1. Failure to conform to social norms with respect to lawful behaviors
2. Deceitfulness
3. Impulsivity or failure to plan ahead
4. Irritable or aggressive
5. Reckless disregard for safety of self and others
6. Consistently irresponsible
7. Has no remorse for behavior or its consequences
8. Must be 18 years of age (If not, use Conduct Disorder)

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psychotic features of antisocial personality dx

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• “Mask of Sanity”
• May appear trustworthy but commonly manipulative, cunning, and calculating

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Borderline personality disorder

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• Diagnosis requires five or more of the following:
1. Frantic efforts to avoid real or imagined abandonment
2. Unstable and intense interpersonal relationships (alternating between idealization and devaluation – all-or-none type of mindset).
3. Identity disturbance
4. Impulsivity in at least 2 areas that are potentially self-damaging
5. Recurrent suicidal behavior, gestures, threats or self-mutilating behavior
6. Affect instability (unstable mood)
7. Chronic feelings of emptiness
8. Inappropriate intense anger or difficulty controlling anger
9. Transient, stress related paranoia or dissociation

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Borderline personality disorder DDX

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oPsychotic Disorder- persisting impaired reality testing
oMood Disorder- sometimes difficult to delineate. Usually see sustained depressive periods
oPersonality change 2° to general medical condition- test results would indicate
oSchizotypal Personality Disorder- affective features much less severe
oAntisocial Personality Disorder- defects in conscience and attachment ability more severe
oHistrionic Personality Disorder- suicide and self-mutilation are less common. Patient’s interpersonal relationships more stable
oNarcissistic Personality Disorder - more stable identity formation
oDependent Personality Disorder- attachments are stable
oParanoid Personality Disorder- suspiciousness more extreme and enduring

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Histrionic personality disorder

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• 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
1. Patient is uncomfortable when he or she is not the center of attention
2. Sexually seductive or provocative
3. Rapidly shifting and shallow expression of emotions.
4. Self dramatization, theatricality, exaggerated expression of emotion
5. Speech is excessively impressionistic and lacking in detail
6. Consistently uses physical appearance to draw attention to oneself
7. Suggestible
8. Considers relationships to be more intimate than they actually are

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Histrionic personality disorder DX

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oBorderline Personality Disorder- more overt despair, suicidal, and self-mutilating features
oSomatization Disorder- physical complaints predominate
oConversion Disorder- Physical symptoms most prominent
oDependent Personality Disorder- Emotional flamboyance lacking

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Describe narcissitic disoder

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• Pattern of grandiosity, heightened sense of self importance, preoccupation with fantasies of ultimate success and self image, and disturbance in interpersonal relationships

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Narcissistic disorder DX

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• Diagnosis requires five or more of the following:
1. Grandiose sense of self importance
2. Preoccupied with fantasies of unlimited success, power, brilliance, beauty or ideal love
3. Believes that he or she is special and can only be understood by other high ranking or special people
4. Requires excessive admiration
5. Sense of entitlement
6. Interpersonally exploitative
7. Lacks empathy
8. Often envious of others or believes that others are envious of him/her
9. Shows arrogant, haughty behavior or attitudes

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narcissistic disorder DDX

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oAntisocial Personality Disorder- patient overtly disregards the law and rights of others
oParanoid schizophrenia- patient has clear delusions
oBorderline Personality Disorder- patient shows greater emotionality and greater instability
oHistrionic Personality disorder- patient more emotional

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OCD DX

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• Diagnosis requires four or more of the following:
1. Preoccupied with details, rules, lists, order, organization, etc
2. Perfectionism that interferes with task completion
3. Excessively devoted to work with the exclusion of leisure activities and friendships
4. Over-conscientious, scrupulous and inflexible about matters of morality, ethics, or values
5. Unable to discard worn-out or worthless objects even when they have no sentimental value
6. Reluctant to delegate tasks to others unless they submit to doing things exactly his or her way
7. Hoards money (miserly spending)
8. Rigid and stubborn

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Difference between OCD and personality disorder

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• Patient with personality disorder does NOT have true obsessions or compulsions

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Avoidant personality disorder DX

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• Diagnosis requires four or more of the following:
1. Avoids occupational activities that involve significant interpersonal contact, because of fears of criticism, disapproval or rejection
2. Unwilling to become involved with others unless certain of being liked
3. Shows restraint with intimate relationships because of fear of shame or ridicule
4. Preoccupied with being criticized or rejected in social situations
5. Inhibited in new interpersonal situation because of feelings of inadequacy
6. Views self as
• Socially inept
• Personally unappealing
• Inferior to others
7. Reluctant to take personal risks or to engage in any new activity for fear of embarrassment

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Avoidant personality disorder DDx

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o Schizoid Personality Disorder- no overt desire for involvement with others
o Social Phobia- specific social situations rather than personal relationships are avoided
o Dependent personality disorder- patient does not avoid attachments and has greater fear of being abandoned. Disorders may co-exist
o Borderline and Histrionic Personality Disorders- patient demanding, irritable, and unpredictable

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Dependent personality disorder

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• Diagnosis requires five or more of the following:
1. Difficulty making everyday decisions without an excessive amount of advice or reassurance from others
2. Needs others to assume responsibility for major areas of his or her life
3. Difficulty expressing disagreement because of fear of loss of support or approval
4. Difficulty initiating new projects
5. Goes to excessive lengths to obtain nurturance or support (volunteers to do things that are unpleasant)
6. Feels uncomfortable when alone
7. Urgently seeks another relationship when one relationship ends
8. Unrealistically preoccupied with fears of being left alone

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Depressive personality disorder

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• Patients have depressive traits throughout lives- pessimism, self-doubt, and chronic unhappiness.
• Introverted, passive, and strong sense of duty

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Depressive personality disorder DDX

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oDysthymic disorder- fluctuations in mood greater than in depressive personality disorder
oAvoidant personality disorder- patient tends to be more anxious than depressed