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Personality Disorders

Personality Disorders. Back to Basics April 2011 Presenter: Dr. Lyndal Petit, MD, FRCPC. Personality Disorder. Describe the core feature presented in PD: An enduring pattern of behavior and inner experience

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Personality Disorders

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  1. Personality Disorders Back to Basics April 2011 Presenter: Dr. Lyndal Petit, MD, FRCPC

  2. Personality Disorder • Describe the core feature presented in PD: • An enduring pattern of • behavior and • inner experience • Pattern goes against sociocultural norms and affects multiple areas of ones life including (2 of): • Cognition • Impulse control, • Interpersonal functioning • Affect • Inflexible; Pervasive; Across a broad range of personal and social situations • Pattern is stable and lg duration. Traced back to teens or early adulthood • Causes distress or impairment in soc-occ func • Not better accounted for by another mental illness. • Not subs induced or GMC

  3. Cloninger • What are the 4 temperaments with cloninger? • Most affected by biology • Novelty seeking • DA • Harm avoidance (shy...) • 5HT • Reward dependence (warm, affectionate – if low you are cluster A and cold and detached) • NE and 5HT • Persistance • Hippocampus involved

  4. Five Factor Model • Personality charactersitics that remain constant throughout life: (OCEAN) • Openness • Conscientiousness • Extraversion • Agreeableness • Neuroticism

  5. Assessment tools • What tools can you use for PD? • MMPI (Minnesota Multiphasic Personality Inventory) • SCID II (Structured Clinical Interview for DSM) • PDQ (Personality Disorder Questionnaire)

  6. Etiology - PD • Biological Etiology: • All PD’s have a genetic risk • 40-60% heritability

  7. Etiology – PD • Psychosocial etiology: • Single parent • Parental death • Parenting style: Avoidant/Absent/Aversive PD: • Abuse • Low SES/Welfare • Social Isolation

  8. Epidemiology - PD • All are about 1-2% • 9% of population have a PD • Gender is really equal in both (controversial)

  9. Defences - PD • Cluster A • Projection • Fantasy • Denial • Cluster B • Splitting • Dissociation • Denial • Projective identification • Acting out • Cluster C • Isolation of affect • Passive aggression • Undoing • Hypochondriasis

  10. CLUSTER A Schizoid PD Paranoid PD Schizotypal PD

  11. Exclusion criteria for Cluster A • Can’t only be in the course of • SCZ • Mood with psychotic features • PDD • GMC/Subs

  12. Etiology - Cluster A • Cluster A and the familial link to scz: • Schizotypal > Paranoid > Schizoid

  13. Schizoid Personality Disorder

  14. Etiology - Schizoid • Genetics • Possible family link to scz • Introversion = heritable • Psychosocial • Neglectful family, cold • Learned: relationship not worth pursing.

  15. Dx - Schizoid • Core: • Detached Social Relationships • Restriction in emotional expression • 4/7 SIRSAFE • Solitary lifestyle • Indifferent to praise/criticism • Reln not interesting • Sex not interesting • Activities solitary • Few friends • Emotionally cold and detached

  16. DDx - Schizoid • Other cluster A • Avoidant PD • Scz • Delusion Disorder • MDD with psychotic features • Aspergers/PDD • OCPD

  17. Co-Morbidity • Very Brief Psychotic Episodes • Schizotypal, Paranoid, Avoidant Personality Disorders

  18. Course - Schizoid • Onset early in childhood • DSM – improvement with time • However, may also just be stable. • Not known how many eventually develop scz.

  19. Defences - Schizoid • Projection • Intellectualization • Schizoid Fantacy • Devaluation/Idealization

  20. Treatment - Schizoid • Rarely seek tx • Low insight • Low motivation • Questionable degree of suffering • Psychotherapy • Focus: • Supportive therapy • Skills training • Encourage activity • Advice • Often devoted to coming – but distant • Initial distance needed for trust • Fear dependence • Medications • Low dose antipsychotics, antidep, psychostimulants • 5HT agents help for less sensitivity to rejection

  21. Would you say you had a dominant or recessive character?

  22. SchizotypalPeronality Disorder

  23. Epidemiology - Schizotypal • 1-2% • M>F (but supposed to be =) • High rates of family scz

  24. Etiology - Schizotypal • Genetics • Inc family of scz • Have some similar scz findings: • Enlarged ventricles • Saccadic gaze • High HVA in CSF • reduced temp lobe size; impaired exec fnc • But: preserved frontal lobe vol (unlike schizophrenia). • Not related to psychotic affective d/o • Mzg>Dzg • Psychosocial • Low SES • Critical over involved family • Neglect; Physical abuse • Psychotic regression in face of stress

  25. Dx - Schizotypal • Core: • Eccentric Behavior • Cog/Perceptual Distortions • Discomfort in and reduced capacity for relationship • Dx 5/9 • Peculiar and eccentric • Illusions and perceptual abn • Ideas of reference • Suspiciousness/paranoid • Odd beliefs - Claire Voyant; superstition • Speech/thoughts – vague/circumferential • Affect – inappropriate/constricted • Social – reluctant in social settings • Few friends

  26. Co-morbidity Scztypal • Brief psychotic episode • MDD • Schizoid PD • BPD • Avoidant PD • Paranoid • Anxiety disorder

  27. Differential • Delusional Disorder • Schizophrenia • Mood Disorder with Psychotic Features • PDD • Other Cluster A and BPD

  28. Course - Scztypal • 10-20% dev scz • Increased if • Magical thinking • Paranoid • Social isolation • 10% suicide • Some are stable and marry

  29. Defences - Scztypal • Schizoid Fantacy • Distortion • Denial • Projection • Splitting • Idealization

  30. Treatment - Scztypal • Psychodynamic = contraindicated • Supportive = best • Skills training • Give advice • Encourage activity • CBT • Meds • Comorbidities • Olz and Risp: mild to mod improve in +ve and –ve psychotic sx

  31. Paranoid Personality Disorder

  32. Etiology - Paranoid PD • Biological • Genetics • Increase first degree relatives • DD>Scz>General pop • Temperment • Non-adaptive, intense rxn, neg mood, hyperactivity • Psychosocial • Aversive and critical parenting • Excessive parental rage and humiliation  inadequacy and vulnerability  projection of hostility/rage onto others

  33. Epidemiology – Paranoid PD • Other risk factors: • Immigrants • Hearing impaired • Minority groups

  34. Epidemiology – Paranoid PD • 10-30% of inpatients • 2-10% outpts

  35. Dx – Paranoid PD • Core: Malevolent; Suspicious; Distrust; • 4/7 SUSPECT • Spousal infidelity • Unforgiving • Suspicious friends/associates are disloyal/untrustworthy • Perceives attacks on character/reputation – quick to counterattack • Expect exploitation/harm/deceit • Confiding is hard • Threats or demeaning intentions seen in benign statements

  36. Course – Paranoid PD • Not well studied • Life long • Occupation/Marital problems common • Sensitive to criticism • Anger and hostile • Externalize blame for difficulties • Litiginous

  37. Defences – paranoid PD • Projection • Projective Identification • Denial • Splitting • Reaction formation

  38. DDx – Paranoid PD • DDX • Delusional D/O • Scz Spectrum • MDD with psychotic features • Chronic - Substances • Other axis 2: Schizoid; Schzotypal; BPD; Narcisstic; ASPD; Avoidant

  39. Co-morbidity • MDD • Agoraphobia • OCD • Substance abuse/Dependence • Other cluster A, Narcissistic PD, Avoidant PD and BPD

  40. Treatment – Paranoid PD • CBT • Respect, Tact, Patience are key • Increased sense of competence • Address core belief re others • Psychodynamic – rarely indicated • AP may reduce paranoia

  41. Cluster BBorderline PDAntisocial PDnarcissistic PD Histrionic pD

  42. Borderline PD

  43. Borderline PD • How common is BPD? • 1-2% of population • 2F:1M • 10% inpts; 20% outpts

  44. Etiology - BPD • Biological • 5X risk in 1st deg • Dec 5HIAA • Psychosocial • Insecure attachment – abandonment fear • Move from anx/amb to disorg/disoriented • Unable establish concept of self, and to depict feelings/thoughts in self and others • Childhood trauma • Hx of abuse (65% of severe BPD) • But: neither necessary nor sufficient • Childhood sexual abuse most accurate predictor of poor outcome • Family Env • High conflict and unpredictability • Temperment • Vulnerable temperament in invalidating env.

  45. Criteria - BPD • Describe criteria: • Core: Instability in self-image, relationship, affect and impulsivity • 5 of: I DESPAIRR • Identity confusion • Derailed affect • Empty • Suicidal beh • Paranoid ideation • Abandonment • Impulsive • Relationship instability • Rage

  46. defences - BPD • List defences • Projection Identification • Acting out • Splitting • Projection • Denial • Distortion

  47. Differential • Mood Disorder • Histrionic PD • Schizotypal PD • Paranoid PD • Narcissistic PD • ASPD • Dependent PD

  48. Co-Morbidity - BPD • List common co-morbidities with BPD • Mood disorder • Substance abuse/Dep • Anxiety Disorder • PTSD • ADHD • Eating disorder • Other PD

  49. Co-Morbidity - BPD • How is MDD different in BPD • More Atypical presentation • Emptiness is common • Chronic dysphoria • Poor response to antidep

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