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Personality Disorders. Yana M. Van Arsdale, MD, PhD . Personality Traits. Relatively stable PATTERNS of - THINKING, - FEELING, - RELATING Demonstrated in a wide range of situations

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personality disorders

Personality Disorders

Yana M. Van Arsdale, MD, PhD

personality traits
Personality Traits
  • Relatively stable PATTERNS of - THINKING, - FEELING, - RELATING
  • Demonstrated in a wide range of situations
  • Consistently in the individual’s adaptation to life
personality disorder
Personality Disorder
  • Serious problems
    • in work
    • interpersonal relationship

three clusters:

  • A: “Odd or Eccentric”

– prone to ThoughtDisorders

  • B: “Dramatic, Emotional, or Erratic”

– prone to AffectiveDisorders

  • C: “Anxious or Fearful”

– prone to AnxietyDisorders

  • Not Otherwise Specified (NOS)
cluster a
Cluster A
  • Schizoid
  • Schizotypal
  • Paranoid

may be part of the schizophrenic spectrum

cluster b
Cluster B
  • Borderline
  • Histrionic
  • Narcissistic
  • Antisocial

The most difficult patients to deal with

cluster c
Cluster C
  • Avoidant
  • Dependent
  • Obsessive-Compulsive

Inhibition in the assertion of socially acceptable impulses.

Fearful reluctance to express anger or frustration.

Internalization of blame. Anxiety.

not otherwise specified
Not Otherwise Specified
  • Passive-Aggressive
  • Depressive
  • Mixed
general characteristics
General Characteristics
  • Early onset – childhood/adolescence
  • Chronic
  • Stress is poorly tolerated, and can result in brief psychotic episodes
  • Inadequate coping skills
  • Affects mood, cognition, behavior, interpersonal style, relating to others
  • 5-10 % - general population
  • up to 60 % - psychiatric inpatients
basic principles of tx
Basic principles of Tx
  • Establish a collaborativestance
  • Relay that the patient is ultimately responsible for his/her care, and you are a consultant
  • Appreciate that the irritating behavior is a defense against fear/insecurity
basic principles of tx12
Basic principles of Tx
  • Set firm but compassionate limits
  • Donottry torescuethe Pt
  • Let the patient know the rules of treatment
  • Be as consistent as possible
  • Do not attempt to rationally debate with these patients when they are emotionally overwhelmed
basic principles of tx13
Basic principles of Tx
  • Motivate them to make changes - confrontation
  • Patients’ behavior can be irritating to caretakers - countertransference
  • Treat Axis Iillnessfirst.
  • Axis I or/and III illnesscan make traits appear to be disorder of Axis II
basic principles of tx14
Basic principles of Tx
  • PDO is ego-syntonic: maladaptation is not adequately recognized by the individual as a symptom that needs to be “fixed”
  • Goal:Ego-alienation
  • “If you wish to…/not to…, then you…”
  • Ego-dystonicrecognitionof PDOis essential, > effective approachthan empathy and compassion
  • Long term pattern of social isolation
  • Rarely seek treatment
  • Goals:
    • decrease socially isolative behaviors
    • increase socially outgoing behaviors
  • Patient may seem detached or unappreciative
  • Magical thinking, ideas of reference, recurrent illusions, odd behavior
  • Anxietyin social situations
  • Skills oriented psychotherapy
  • Low dose neuroleptics
  • Goals:
    • Help with reality testing
    • Differentiating fantasy from fact
  • Suspiciousness, mistrust, hypervigilance, hypersensitivity to criticism/praise
  • Extremely defensive
  • Ascribe malicious intent to the actions of others and events
  • Hard to develop working relationship in therapy
  • A trusting relationship is essential for adherence to treatment.
  • Paranoid fears are heightened during any illness, including medical
  • If the patient becomes hostile/difficult it is best to acknowledge that the pain and fear are real
  • Cognitive and behavioral techniques
  • Goals:
    • encourage to interface with the environment
    • reevaluate paranoid ideas
  • Stormy interpersonal relationship, behavioral dyscontrol, unstable affect
  • Self-injuring>suicidal behavior
  • Poor work Hx, multiple hospitalizations
  • Abuse Hx>PTSD
  • Comorbidity - depression, anxiety, substance abuse, eating DO
  • Extremely defensive
  • 1-2 % general population
  • 11 % psychiatric outpatients
  • 19 % psychiatric inpatients
  • 33 % personality disorders in outpatient
  • 63 % personality disorders in inpatients
  • Female>male
pharmacotherapy borderline
Pharmacotherapy, Borderline
  • Treat Axis I disorder
  • Low dose neuroleptics - Tx psychotic decompensations
  • TCA are risky because of OD potential
  • SSRI - preferable
  • Benzodiazepines - avoided. SE
    • behavioral disinhibition
    • abuse potential
  • Mood stabilizers
psychotherapy borderline
Psychotherapy, Borderline
  • Firm boundaries, stable framework
  • Pay active attention to deviations from the frame
  • Identify behavior in the therapy to diminish transference distortions
  • Help to see that patient is communicating feelings through behavior
  • Recognize projective identification
  • Educate
psychotherapy borderline23
Psychotherapy, Borderline
  • Pay attention to countertransference feelings
  • Set limits on self-destructive behavior
  • Contain and explore negative feelings from the patient without withdrawing or detachment
  • Distinguish fantasy from reality
  • Do not be drawn in by idealization or devaluation of others - splitting
  • Impulsivity, violence, irresponsibility
  • Criminal behavior without remorse or empathy for others
  • Hostility against authority
  • Manipulative, charming, seductive
  • Comorbidity - affective & anxiety DO, substance abuse
  • Genetic component
  • Conduct DO –childhood/adolescence
  • Decreased functioning of serotonergic & adrenergic systems
  • EEG abnormalities
  • 2-9.4 % general population
  • 3-37 % psychiatric population
  • 75 % prison population
  • Male>female
antisocial tx
Antisocial, Tx
  • Structured or secure/enforced environment
  • Approach: firm, no nonsense, not punitive that conveys streetwise awareness of the patient’s potential for manipulation
  • Respect without aggravating the patient’s hostility
  • Best to work with children to prevent progression to AS-PDO
antisocial tx28
Antisocial, Tx
  • SSRI - Tx agression
  • Neuroleptics, Li, anticonvulsants, other mood stabilizers, beta-blockers, clonidine - Tx violent behavior & explosive rage
  • Patients rarely present voluntarily
  • Grandiosity in fantasy and behavior, need for admiration, lack of empathy for others
  • Unconscious feeling of inadequacy, insecurity
  • Usually high functioning
  • Available for treatment when they are depressed
  • Devastated by illness because it shatters their feeling of invincibility
  • Grandiosity contributes to denial of illness
narcissistic tx
Narcissistic, Tx
  • Respect for sense of self importance
  • Not reinforcing pathological grandiosity
  • Initial approach of support followed by gradual confrontation of vulnerabilities can help to recognize their illness and deal with it
  • Support and confrontation minimize insecurity
  • Results in less defensive obnoxious behavior
  • Attention seeking, dramatic, theatrical, provocative, seductive, excessively emotional, insecure
  • Shallow and rapidly shifting emotional reactions
  • Use physical appearance to draw attention
  • Feel uncomfortable if not the center of attention
  • Highly suggestible
  • Influenced by others
  • 10-15 % psychiatric population
histrionic tx
Histrionic, Tx
  • Long term psychotherapy
  • Set boundaries - seductiveness can lead to inappropriate sexual contact
  • Tactful confrontationto gain a realistic understanding of situation and their illness, and deal with it
histrionic tx34
Histrionic, Tx
  • Treat medical illness - since self-esteem is centered on body image or physical prowess, medical illness can be devastating
  • Treat Axis I illness
  • Address Axis III illness
  • Timidity, hypersensitivity to criticism and rejection, social discomfort
  • Shyness and insecurity
  • Feel anxious, depressed & angry for failing to develop social relationship
  • Comorbidity & strong genetic component with anxiety disorders
  • 10 % psychiatric population
avoidant tx
Avoidant, Tx
  • Approach - consistency, empathy & support
  • Improved cooperation by respecting needsforprivacy & modesty
  • Tx Axis I DO, especially social anxiety
avoidant tx37
Avoidant, Tx
  • Psychotherapy - good response
    • CBT
    • Group
    • Assertiveness
    • Social skills training
  • SSRI and benzodiazepines - very effective
  • Excessive need to be taken care of
  • Submissive and clinging behavior
  • Fear of separation
  • Feel very uncomfortable when alone
  • While depressed or medically ill can become more dependent
  • The most prevalent PDO - psychiatric setting
  • 2.5 % - general population
  • Particularly vulnerable to depression
dependent tx
Dependent, Tx
  • Psychotherapy - very good response to
    • insight oriented
    • CBT
    • social skills training
    • assertiveness training
    • supportive
dependent tx41
Dependent, Tx
  • Team approach
  • Not to foster into dependency
  • Explain clearly the realistic limits of availability
  • Antidepressants - Axis I
  • Address AxisIII
obsessive compulsive
  • Preoccupation with rules and schedules
  • Excessive devotion to work and productivity
  • Stinginess
  • Emotional constriction & intellectualization
  • 5-10 % psychiatric settings
obsessive compulsive tx
Obsessive-Compulsive, Tx
  • Focus on feelings rather than thoughts
  • CBT&group psychotherapy - help to overcome difficultieswithintimacy
  • Educate about illness in scientific and detailed fashion to assume self-monitoring and control
  • Persistently feel unhappy, joyless, cheerless, gloomy, dejected
  • Depressive cognition
  • CBT, group psychotherapy
  • Antidepressants?
passive aggressive
  • Negativistic attitudes & passive resistence to demands for adequate performance
  • Argumentative & authority-disliking
  • Complainers who feel misunderstood by others
  • Group psychotherapy