05 Personality Disorders

Front 1

What is meant by personality?

Back 1

Personality

A person's set of stable, predictable emotional and behavioral traits

Front 2

What is meant by personality disorder?

Back 2

Personality Disorder

Long-term, stable pattern of maladaptive and inflexible personality traits that leads to impairment or distress

Front 3

What is the prevalence of personality disorders?

Back 3

10-20% of the general population

30-50% in psychiatric patients

Front 4

What is the typical age of onset of personality disorders?

Back 4

DSM-IV definition requires an onset no later than early adulthood.

However, some individual's personality disorders may not come to clinical attention until later in life.

Front 5

DSM-IV Criteria for Personality Disorders

Back 5

1) Pattern of behavior/inner experience that deviates from the person's culture and is manifested in 2 or more of the following ways:
--Cognition
--Affect
--Personal Relations
--Impulse Control

2) Pattern:
--Is pervasive and inflexible in a broad range of situations
--Is stable and has an onset no later than adolescence or early adulthood
--Is not accounted for by another mental/medical illness or by use of a substance

Front 6

What are some ways in which the assessment of patients with personality disorders is unique?

Back 6

1) It is often necessary to conduct more than one interview with patients and to space these over time, since a personality disorder is defined as a stable, inflexible way of interacting with others
2) Assessment can also be complicated by the fact that the characteristics defining a personality disorder may not be considered problematic by the individual (ie, the traits are often egosyntonic)
3) Be sure to rule out Axis I Disorders first

Front 7

What are some clues to the diagnosis of personality disorder?

Back 7

1) Impaired interpersonal relations
2) Externalization of blame, that is, "It's not my fault"
3) Failure to learn from past mistakes
4) Physician countertransference: conscious or unconscious emotional response of the therapist to the individual, including feelings of irritation, frustration, anger or being manipulated

Front 8

What are the 3 clusters of personality disorders?

Back 8

"3 W's"
1) Cluster A ("Weird")
--Paranoid, Schizoid, Schizotypal
--Eccentric, peculiar or withdrawn
--Familial association with psychotic disorders
2) Cluster B ("Wild")
--Antisocial, Borderline, Histrionic, Narcissistic
--Emotional, dramatic or erratic
--Familial association with mood disorders
3) Cluster C ("Worried")
--Avoidant, Dependent, Obsessive-Compulsive
--Anxious or fearful
--Familial association with anxiety disorders

Front 9

What "Axis" are personality disorders grouped under in the DSM?

Back 9

Axis II

Front 10

How are personality disorders generally treated?

Back 10

Personality Disorders can be difficult to treat, as few patients are aware that they need help and these disorders tend to be chronic.

Group and individual psychotherapy are the mainstays of treatment. Pharmacologic treatment is used mostly for comorbid conditions (eg, depression and anxiety)

Front 11

What other psychiatric diseases are more commonly seen among relatives of individuals with Paranoid Personality Disorder (PPD)?

Back 11

1--Schizophrenia

2--Delusional Disorder

Front 12

DSM-IV Criteria for Paranoid Personality Disorder (PPD)

Back 12

General distrust of others, beginning by early adulthood and present in a variety of contexts. At least 4 of the following must also be present:
--Suspicion (without evidence) that others are exploiting or deceiving him or her
--Preoccupation with doubts of loyalty or trustworthiness of acquaintances
--Reluctance to confide in others
--Interpretation of benign remarks as threatening or demeaning
--Persistence of grudges
--Perception of attacks on his or her character that are not apparent to others; quick to counterattack
--Recurrence of suspicions regarding fidelity of spouse or lover

Front 13

Differential Diagnosis of Paranoid Personality Disorder (PPD)

Back 13

1--Psychotic Disorders with Persecutory Delusions (especially paranoid schizophrenia)
2--Delusional Disorder
3--Personality Changes due to General Medical Conditions
4--Substance-Induced Personality Changes
5--Other Personality Disorders

Front 14

What is the difference between paranoid schizophrenia and PPD?

Back 14

People with PPD do not have fixed delusions and are not frankly psychotic, although they may have transient psychosis under stressful situations

Front 15

What is the typical course of PPD?

Back 15

PPD tends to have a chronic course

Symptoms may intensify later in life with social/sensory isolation

Some patients may eventually be diagnosed with schizophrenia or delusional disorder

Front 16

How is PPD treated?

Back 16

Psychotherapy is the mainstay of treatment

Antipsychotic or antianxiety medications can be useful for transient psychosis

Front 17

What is the prevalence of Schizoid Personality Disorder?

Back 17

7%

Front 18

DSM-IV Criteria for Schizoid Personality Disorder (PD)

Back 18

A pattern of voluntary social withdrawal and restricted range of emotional expression, beginning by early adulthood and present in a variety of contexts. 4 or more of the following must also be present:
--Neither enjoying nor desiring close relationships (including family)
--Generally choosing solitary activities
--Little (if any) interest in sexual activity with another person
--Taking pleasure in few activities (if any)
--Few close friends or confidants (if any)
--Indifference to praise or criticism
--Emotional coldness, detachment or flattened affect

Front 19

Differential Diagnosis of Schizoid Personality Disorder (PD)

Back 19

1. Residual Symptoms in Schizophrenia
2. Autistic Disorder
3. Asperger Disorder
4. Other Personality Disorders

Front 20

Treatment for Schizoid Personality Disorder

Back 20

--Psychotherapy is the treatment of choice

--Short-term antipsychotic or antidepressant medications can be used for transient psychosis or comorbid depression

Front 21

What psychiatric diseases are more commonly seen among relatives of individuals with schizotypal PD?

Back 21

Schizotypal PD and Schizophrenia

Front 22

DSM-IV Criteria:

Schizotypal Personality Disorder

Back 22

A pattern of social deficits marked by eccentric behavior, cognitive or perceptual distortions and discomfort with close relationships, beginning by early adulthood and present in a variety of contexts.
Five or more of the following:
--Ideas of reference (excluding delusions of reference)
--Odd beliefs or magical thinking, inconsistent with cultural norms
--Unusual perceptual experiences (such as bodily illusions)
--Suspiciousness
--Inappropriate or restricted affect
--Odd or eccentric appearance or behavior
--Few close friends or confidants
--Odd thinking or speech (eg, vague, stereotyped)
--Excessive social anxiety

Front 23

What is the differential diagnosis of Schizotypal Personality Disorder?

Back 23

--Psychotic Symptoms in Schizophrenia
--Autistic Disorder
--Asperger Disorder
--Other Personality Disorders

Front 24

What is a good way to distinguish between schizotypal and schizoid PD?

Back 24

For Schizoid PD, think of "Batman": withdrawn, no desire to interact with other people

For Schizotypal PD, think of "The Joker": outwardly strange behavior, odd beliefs

Front 25

What is the difference between schizotypal PD and schizophrenia?

Back 25

Patients with schizotypal PD are not frankly psychotic, although they can be transiently

Front 26

What is the treatment for schizotypal PD?

Back 26

Psychotherapy is the treatment of choice

Short-term antipsychotic medication can be used for transient psychosis

Front 27

What is the prevalence of antisocial PD?

Back 27

3% in men

1% in women

Front 28

What population and areas contain a higher incidence of antisocial PD?

Back 28

More common in lower socioeconomic areas and prisons

Front 29

What is the risk of antisocial PD in relatives of those afflicted with this disorder?

Back 29

Five times increased risk among first-degree relatives

Front 30

What other psychiatric diseases are more commonly seen among relatives of individuals with antisocial PD?

Back 30

Somatization Disorder

Substance-Related Disorders

Front 31

What family characteristics have been associated with the development of antisocial behavior?

Back 31

--Physical abuse
--Family discord
--Parental history of alcoholism

Front 32

DSM-IV Criteria:

Antisocial Personality Disorder (ASPD)

Back 32

Pattern of disregard for others and violation of the rights of others since age of 15. Patients must be at least 18 years old for this diagnosis. History of behavior as a child/adolescent must be consistent with conduct disorder
Three or more of the following:
--Failure to conform to social norms by committing unlawful acts
--Deceitfulness/repeated lying/manipulating others for personal gain
--Impulsivity/failure to plan ahead
--Irritability and aggressiveness/repeated fights or assaults
--Recklessness and disregard for safety of self or others
--Irresponsibility/failure to sustain work or honor financial obligations
--Lack of remorse for actions

Front 33

Differential Diagnosis:

Antisocial Personality Disorder (ASPD)

Back 33

1--Intermittent Explosive Disorder
2--Substance-related Disorders
3--Manic Episodes in Bipolar Disorder or Schizoaffective Disorder
4--Other Personality Disorders

Front 34

How does one distinguish antisocial PD from intermittent explosive disorder?

Back 34

Individuals with intermittent explosive disorder exhibit discrete episodes of loss of control. They show little or no signs of general impulsiveness or aggressiveness between these episodes. Also, they tend to be remorseful and worried about the consequences of their actions.

Front 35

What is the difference between antisocial behavior associated with antisocial PD versus that seen with substance-related disorders?

Back 35

Antisocial behavior associated with substance-related disorders occurs only in the context of disinhibition from substance intoxication or emotional lability from substance withdrawal. The behavior is not present during periods of sobriety. Patients with antisocial PD will display antisocial behaviors whether they are intoxicated or not.

Front 36

In addition to the symptoms mentioned in the DSM criteria, what trait might an antisocial person display in a clinical interview?

Back 36

Antisocial persons are know to be charming individuals. This attribute makes them good at manipulating others.

Front 37

What is the typical course of Antisocial PD?

Back 37

Onset of symptoms during childhood.
Early adulthood is often complicated by drug abuse, poor academic and occupational performance and criminal behavior.
Symptoms may improve as patient ages.

Front 38

How is Antisocial PD treated?

Back 38

Goals of treatment are to decrease impulsivity and increase the individual's conformity with societal values.
--Group and individual psychotherapies are the treatment of choice
--"Limit-setting" (ie, refusal of acquaintances to tolerate abuse) for antisocial behaviors is often necessary
--Pharmacotherapy can be used for symptoms of anxiety or depression

Front 39

What is the prevalence of Borderline Personality Disorder (BPD)?

Back 39

1-2%

Front 40

Are there any gender disparities in the incidence of BPD?

Back 40

Yes.

Women are twice as likely to have borderline PD

Front 41

What psychiatric comorbidities are often seen in patients with BPD?

Back 41

--Mood Disorders (especially depression)
--Substance-related Disorders
--Eating Disorders
--Post-Traumatic Stress Disorder (PTSD)

Front 42

What psychiatric diseases are more commonly seen among relatives of individuals with BPD?

Back 42

--Borderline Personality Disorder (BPD)
--Substance-Related Disorders
--Mood Disorders

Front 43

What percentage of patients with BPD commit suicide?

Back 43

10-15%

Front 44

DSM-IV Criteria:

Borderline Personality Disorder

Back 44

Pervasive pattern of impulsivity and unstable relationships, affects self-image and behaviors, present by early adulthood and in a variety of contexts.
At least 5 of the following:
--Desperate efforts to avoid real or imagined abandonment
--Unstable, intense interpersonal relationships
--Unstable self-image
--Impulsivity in at least 2 potentially harmful ways (eg, spending, sexual activity, substance abuse)
--Recurrent suicidal threats or attempts or self-mutilation
--Unstable mood/affect
--General feeling of emptiness
--Difficulty controlling anger
--Transient, stress-related paranoid ideation or dissociative symptoms

Front 45

Differential Diagnosis:

Borderline Personality Disorder

Back 45

--Mood Disorders (especially Bipolar Disorder and Cyclothymia)
--Other Personality Disorders
--Adolescent Angst

Front 46

What is often seen in the social history of patients with BPD?

Back 46

Higher rates of childhood sexual, emotional and physical abuse

Front 47

What are some defense mechanisms used by people with BPD?

Back 47

--Splitting
--Denial
--Projection
--Projective Identification
--Acting Out
--Idealization

Front 48

The tendency to view people or events as either all good or all bad

Back 48

Splitting

A classic example is for a borderline patient to view one of his/her doctors as perfect and the others as bad, which can cause conflict amongst the treatment team

Front 49

Performing an action to express emotional conflicts (often unconsciously)

Back 49

Acting Out

Examples are throwing a temper tantrum or behaving promiscuously

Front 50

What are "micro-psychotic" episodes?

Back 50

Transient episodes in which patients may appear psychotic because of the intensity of their distress and resultant distortions.

This is commonly seen in patients with BPD

Front 51

What is the typical course of BPD?

Back 51

Usually chronic

Some improvement in symptoms is seen with age

Front 52

Treatment:

Borderline Personality Disorder

Back 52

Goals of treatment are to improve emotional stability, sense of identity, and interpersonal relationships, and to decrease self-destructive behavior
--Psychotherapies such as Dialectic Behavioral Therapy and Mindfulness Therapy are the treatment of choice and have been shown to help with mood/affect lability, anger control, depressive symptoms, and self-harm behavior
--SSRIs and mood stabilizers (eg, Lithium) have been shown to be modestly helpful in reducing symptoms

Front 53

Where does the term "borderline" come from?

Back 53

Historically, it was used to describe individuals who were considered to be on the "borderline" between neurosis and psychosis

Front 54

Are there any gender disparities in the incidence of Histrionic Personality Disorder (HPD)?

Back 54

Yes

It is more common in women

Front 55

DSM-IV Criteria:

Histrionic Personality Disorder (HPD)

Back 55

Pattern of excessive emotionality and attention seeking, present by early adulthood and in a variety of contexts
At least 5 of the following:
--Uncomfortable when not the center of attention
--Inappropriately seductive or provocative behavior
--Uses physical appearance to draw attention to self
--Has speech that is impressionistic and lacking in detail
--Theatrical and exaggerated expression of emotion
--Easily influenced by others or situation
--Perceives relationships as more intimate than they actually are

Front 56

Differential Diagnosis:

Histrionic Personality Disorder (HPD)

Back 56

Other Personality Disorders, particularly BPD and Narcissistic Personality Disorder (NPD)

Front 57

How does one distinguish between BPD and HPD?

Back 57

Patients with BPD are generally more depressed and suicidal than those with HPD

Patients with HPD are generally more functional

Front 58

What are some common defense mechanisms used by people with HPD?

Back 58

--Repression
--Sexualization
--Regression
--Somatization

Front 59

Treatment:

Histrionic Personality Disorder (HPD)

Back 59

Psychotherapy is the treatment of choice

Pharmacotherapy can be used for depressive or anxious symptoms as necessary

Front 60

Are there any gender disparities in the incidence of Narcissistic Personality Disorder (NPD)?

Back 60

Yes

It is 1.5 times more common in men

Front 61

DSM-IV Criteria:

Narcissistic Personality Disorder (NPD)

Back 61

Pattern of grandiosity, need for admiration and lack of empathy beginning in early adulthood and present in a variety of contexts.
5 or more of the following:
--Exaggerated sense of self-importance
--Preoccupied with fantasies of unlimited money, success, brilliance and so on
--Believes that he or she is "special" or unique and can associate only with other high-status individuals
--Needs excessive admiration
--Has sense of entitlement
--Takes advantage of others for self-gain
--Lacks empathy
--Envious of others or believes others are envious of him or her
--Arrogant or haughty

Front 62

Differential Diagnosis:

Narcissistic Personality Disorder (NPD)

Back 62

--Other Personality Disorders, particularly Antisocial or BPD
--Manic or Hypomanic Episodes

Front 63

How does one distinguish between antisocial PD and NPD?

Back 63

Both types of patients exploit others, but the goal of NPD patients is status and recognition, while antisocial PD patients desire material gain or simply the subjugation of others

Front 64

What is "entitlement"?

Back 64

Entitlement is a stable and pervasive sense that one deserves more than others

Front 65

What are some common defense mechanisms used by people with NPD?

Back 65

Idealization (of themselves)

Devaluation (of other people)

Front 66

What is the typical course of Narcissistic Personality Disorder (NPD)?

Back 66

Chronic course

Higher incidence of depression and midlife crises since these patients put such a high value on youth and power

Front 67

Treatment:

Narcissistic Personality Disorder (NPD)

Back 67

Psychotherapy is the treatment of choice

Antidepressants or lithium can be used as needed for comorbid mood disorders

Front 68

DSM-IV Criteria:

Avoidant Personality Disorder

Back 68

Pattern of social inhibition, hypersensitivity and feelings of inadequacy since early adulthood
4 or more of the following:
--Avoids occupation that involves interpersonal contact due to a fear of criticism or rejection
--Unwilling to interact unless certain of being liked
--Cautious of interpersonal relationships
--Preoccupied with being criticized or rejected in social situations
--Inhibited in new social situations because he or she feels inadequate
--Believes he or she is socially inept and inferior
--Reluctant to engage in new activities for fear of embarrassment

Front 69

Differential Diagnosis:

Avoidant Personality Disorder

Back 69

--Social Anxiety Disorder
--Schizoid Personality Disorder
--Dependent Personality Disorder
--Other Personality Disorders

Front 70

How does one distinguish between social anxiety disorder and avoidant PD?

Back 70

Although both disorders involve fear and avoidance of social situations, avoidant PD is an overall fear of rejection and affects many areas of life, while social anxiety disorder is a fear of embarrassment in a particular setting

Front 71

How does one distinguish between schizoid PD and avoidant PD?

Back 71

Patients with avoidant PD desire companionship but fear being rejected, whereas patients with schizoid PD have no desire for companionship

Front 72

Treatment:

Avoidant Personality Disorder

Back 72

Psychotherapy, including assertiveness training, is the treatment of choice

Anxiolytics (eg, beta-blockers) can be used for symptoms of anxiety

Antidepressants can be used for depressive symptoms

Front 73

Are there any gender disparities in the incidence of Dependent Personality Disorder (DPD)?

Back 73

Yes

Women are more likely to have DPD

Front 74

DSM-IV Criteria:

Dependent Personality Disorder (DPD)

Back 74

Pattern of submissive and clinging behavior due to excessive need to be taken care of.
At least 5:
--Difficulty making everyday decisions without reassurance from others
--Needs others to assume responsibility for most areas of his or her life
--Cannot express disagreement because of fear of loss of approval
--Difficulty initiating projects because of lack of self-confidence
--Goes to excessive lengths to obtain support from others
--Feels helpless when alone
--Urgently seeks another relationship when one ends
--Preoccupied with fears of being left to take care of self

Front 75

Differential Diagnosis:

Dependent Personality Disorder (DPD)

Back 75

--Disability resulting from another medical or psychiatric disorder
--Other Personality Disorders, especially avoidant, borderline and histrionic PD

Front 76

How does one distinguish between disabled persons and DPD patients?

Back 76

Many people with debilitating illnesses can develop dependent traits.

However, to be diagnosed with DPD, the features described above must manifest before early adulthood

Front 77

How does one distinguish between dependent PD and avoidant PD?

Back 77

Avoidant PD patients are slow to get involved in relationships, whereas dependent PD patients actively and aggressively seek out relationships

Front 78

How are the relationships of patients with DPD different from those with BPD and HPD?

Back 78

DPD patients generally have a long-lasting relationship with the person on whom they are dependent

BPD and HPD patients are often unable to maintain long-lasting relationships

Front 79

Treatment:

Dependent Personality Disorder (DPD)

Back 79

Psychotherapy and cognitive behavior therapy are effective. The therapist must be careful not to allow the patient to become too dependent on the doctor-patient relationship

Pharmacotherapy can be used for symptoms of depression or anxiety

Front 80

Are there any gender disparities in the incidence of Obsessive-Compulsive Personality Disorder (OCPD)

Back 80

Men are nearly twice as likely to have OCPD

Front 81

What is the risk of OCPD in relatives of those afflicted with this disorder?

Back 81

Increased incidence in first-degree relatives

Front 82

DSM-IV Criteria:

Obsessive-Compulsive Personality Disorder (OCPD)

Back 82

Pattern of preoccupation with orderliness, control and perfectionism at the expense of efficiency, present by early adulthood and in a variety of context.
At least 4:
--Preoccupation with details, rules, lists and organization such that the major point of the activity is lost
--Perfectionism that is detrimental to completion of task
--Excessive conscientiousness and scrupulousness about morals and ethics
--Will not delegate tasks
--Unable to discard worthless objects
--Miserly
--Rigid and stubborn

Front 83

Differential Diagnosis:

Obsessive-Compulsive Personality Disorder (OCPD)

Back 83

--Obsessive-Compulsive Disorder (OCD)
--Other Personality Disorders, especially NPD and PPD

Front 84

How does one distinguish between OCD and OCPD?

Back 84

Patients with OCPD do not have the recurrent obsessions and compulsions that are present in OCD and their symptoms are ego-syntonic, meaning that they may not be aware that they have a problem.

Symptoms in OCD are ego-dystonic, meaning that they cause the patient distress.

Front 85

What are some common defense mechanisms used by people with OCPD?

Back 85

--Intellectualization
--Rationalization
--Isolation of Affect
--Reaction Formation
--Displacement
--Undoing

OCPD patients often have difficulty recognizing or expressing their own anger and they fear losing control of it, thus they use defense mechanisms such as reaction formation and displacement of anger

Front 86

What is the prime issue for OCPD patients in their interpersonal relationships?

Back 86

Control

OCPD patients seek to remain in control of themselves and to control those around them

Front 87

Treatment:

Obsessive-Compulsive Personality Disorder (OCPD)

Back 87

Psychotherapy is the treatment of choice. Group therapy and behavioral therapy can also be useful.

Pharmacotherapy can be used for associated symptoms as necessary

Front 88

DSM-IV Criteria:

Personality Disorder Not Otherwise Specified (NOS)

Back 88

This category is for disorders of personality functioning that do not meet criteria for any specific personality disorder.

An example is the presence of features of more than one specific personality disorder ("mixed personality"), but that together cause clinically significant distress or impairment in one or more important areas of functioning (eg, social or occupational)

Front 89

What are some examples of Personality Disorder NOS?

Back 89

Depressive Personality Disorder

Passive-Aggressive Personality Disorder