Personality Disorders

1. Personality Disorders Derek S. Mongold MD

2. Objectives. • Learn how to differentiate between the three major categories of personality disorders. • Identify specific personality disorders within each category. • Learn specific treatments for each personality disorder.

3. Overview. • Definition. • Cluster A disorders. • Cluster B disorders. • Cluster C disorders.

4. Definition1. • An enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individual’s culture in at least 2 of the following areas. • Cognition (i.e., ways of perceiving and interpreting self, others, and events). • Affectivity (range, intensity, labiality, and appropriateness of emotional response). • Interpersonal functioning. • Impulse control.

5. Definition1. • The pattern is enduring, inflexible, and pervasive across a broad range of situations. • Leads to clinically significant distress or impairment in social, occupational, or other important areas of functioning. • Stable, of long duration, and its onset can be traced back at least to adolescence or early adulthood. • Not substance induced or due to another mental, physical, or medical disorder.

6. The Clusters. • Cluster A. • Cluster B. • Cluster C.

7. Cluster A Disorders. • Paranoid. • Schizoid. • Schizotypal.

8. Cluster B Disorders. • Antisocial. • Borderline. • Histrionic. • Narcissistic.

9. Cluster C Disorders. • Avoidant. • Dependent. • Obsessive-compulsive.

10. Mnemonic. • Weird. • Wild. • Worried.

11. Cluster A.

12. Paranoid1. • Pervasive distrust and suspiciousness of others such that their motives are interpreted as malevolent, beginning by early adulthood and present in a variety of contexts, as indicated by 4 or more of the following: • Suspects, without sufficient basis, that others are exploiting, harming, or deceiving them. • Is preoccupied with unjustified doubts about the loyalty or trustworthiness of friends or associates. • Is reluctant to confide in others because of unwarranted fear that the information will be used maliciously against them. • Reads hidden demeaning or threatening meanings into benign remarks or events. • Persistently bears grudges (i.e., is unforgiving of insults, injuries, or slights). • Perceives attacks on his or her character or reputation that are not apparent to others and is quick to react angrily or to counterattack. • Has recurrent suspicions, without justification, regarding fidelity of spouse or sexual partner. • Does not due to something else. • If criteria are met prior to Schizophrenia add “premorbid”.

13. Schizoid1. • A pervasive pattern of detachment from social relationships and a restricted range of expression of emotions in interpersonal settings, beginning by early adulthood and present in a variety of contexts, as indicated by 4 or more of the following: • Neither desires nor enjoys close relationships, including being part of a family. • Almost always chooses solitary activities. • Has little, if any, interest in having sexual experiences with another person. • Takes pleasure in few, if any, activities. • Lacks close friends or confidants other than first-degree relatives. • Appears indifferent to the praise or criticism of others. • Shows emotional coldness, detachment, or flattened affectivity. • Not due to something else. • If criteria are met prior to Schizophrenia add “premorbid”.

14. Schizotypal1. • A pervasive pattern of social and interpersonal deficits marked by acute discomfort with, and reduced capacity for close relationships as well as by cognitive or perceptual distortions and eccentricities of behavior, beginning by early adulthood and present in a variety of contexts, as indicated by 5 or more of the following. • Ideas of reference (excluding delusions of reference). • Odd beliefs or magical thinking that influences behavior and is inconsistent with subcultural norms (e.g. superstitiousness, belief in clairvoyance, telepathy, or “sixth sense”, in children and adolescents, bizarre fantasies or preoccupations). • Unusual perceptual experiences, including bodily illusions. • Odd thinking and speech (e.g., vague, circumstantial, metaphorical, overelaborate, or stereotyped). • Suspiciousness or paranoid ideation. • Inappropriate or constricted affect. • Behavior or appearance that is odd, eccentric, or peculiar. • Lack of close friends or confidants other than first-degree relatives. • Excessive social anxiety that does not diminish with familiarity and tends to be associated with paranoid fears rather than negative judgments about self. • Not due to something else. • If criteria are met prior to Schizophrenia add “premorbid”.

15. Cluster B.

16. Antisocial1. • There is a pervasive pattern of disregard for and violation of the rights of others occurring since age 15 years, as indicated by 3 or more of the following: • Failure to conform to social norms with respect to lawful behaviors as indicated by repeatedly performing acts that are grounds for arrest. • Deceitfulness, as indicated by repeated lying, use of aliases, or conning others for personal profit or pleasure. • Impulsivity or failure to plan ahead. • Irritability and aggressiveness, as indicated by repeated physical fights or assaults. • Reckless disregard for safety of self or others. • Consistent irresponsibility, as indicated by repeated failure to sustain consistent work behavior or honor financial obligations. • Lack of remorse, as indicated by being indifferent to or rationalizing having hurt, mistreated, or stolen from another. • At least 18 years old. • Evidence of Conduct Disorder with onset before age 15. • Does not happen exclusively during a course of Schizophrenia or Manic Episode.

17. Borderline Personality Disorder1. • A pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following. • Frantic efforts to avoid real or imagined abandonment. • A pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation. • Identity disturbance: markedly and persistently unstable self image or sense of self. • Impulsivity in at least two areas that are potentially self damaging (e.g., spending, sex, substance abuse, reckless driving, binge eating). Not suicidal or self-mutilating behavior. • Recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior. • Affective instability due to a marked reactivity of mood (e.g., intense episodic dysphoria, irritability, or anxiety usually lasting a few hours and only rarely more than a few days). • Chronic feelings of emptiness. • Inappropriate, intense anger or difficulty controlling anger (e.g., frequent displays of temper, constant anger, recurrent physical fights). • Transient, stress-related paranoid ideation or severe dissociative symptoms.

18. Histrionic Personality Disorder1. • 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: • Is uncomfortable in situations in which he or she is not the center of attention. • Interaction with others is often characterized by inappropriate sexually seductive or provocative behavior. • Displays rapidly shifting and shallow expression of emotions. • Consistently uses physical appearance to draw attention to self. • Has a style of speech that is excessively impressionistic and lacking in detail. • Shows self-dramatization, theatricality, and exaggerated expressions of emotion. • Is suggestible, I.e., easily influenced by others or circumstances. • Considers relationships to be more intimate than they actually are.

19. Narcissistic Personality Disorder1. • A pervasive pattern of grandiosity (in fantasy or behavior), need for admiration, and lack of empathy, beginning by early adulthood and present in a variety of contexts, as indicated by 5 (or more) of the following: • Has a grandiose sense of self-importance (e.g., exaggerates achievements and talents, expects to be recognized as superior without commensurate achievements). • Is preoccupied with fantasies of unlimited success, power, brilliance, beauty, or ideal love). • Believes that he or she is “special” and unique and can only be understood by, or should associate with, other special or high-status people (or institutions). • Requires excessive admiration. • Has a sense of entitlement, i.e., unreasonable expectations of especially favorable treatment or automatic compliance with his or her expectations. • Is interpersonally exploitative, i.e., takes advantage of others to achieve his or her own ends. • Lacks empathy: Is unwilling to recognize or identify with the feelings and needs of others. • Is often envious of others or believes that others are envious of him or her. • Shows arrogant, haughty behaviors or attitudes.

20. Cluster C.

21. Avoidant Personality Disorder1. • A pervasive pattern of social inhibition, feelings or inadequacy, and hypersensitivity to negative evaluation, beginning by early adulthood and present in a variety of contexts, as indicated by 4 (or more) of the following: • Avoids occupational activities that involve significant interpersonal contact, because of fears of criticism, disapproval, or rejection. • Is unwilling to get involved with people unless certain of being liked. • Shows restraint within intimate relationships because of the fear of being shamed or ridiculed. • Is preoccupied with being criticized or rejected in social situations. • Is inhibited in new interpersonal situations because of feelings of inadequacy • Views self as socially inept, personally unappealing, or inferior to others. • Is unusually reluctant to take personal risks to to engage in any new activities because they may prove embarrassing.

22. Dependent Personality Disorder1. • A pervasive and excessive need to be taken care of that leads to submissive and clinging behavior and fears of separation, beginning by early adulthood and present in a variety of contexts, as indicated by 5 (or more) of the following: • Has difficulty making everyday decisions without an excessive amount of advice and reassurance from others. • Needs others to assume responsibility for most major areas of his or her life. • Has difficulty expressing disagreement with others because of unrealistic fears of loss of support or approval. • Has difficulty initiating projects or doing things on his or her own (because of a lack of self-confidence in judgment or abilities rather than a lack of motivation or energy). • Goes to excessive lengths to obtain nurturance and support from others, to the point of volunteering to do things that are unpleasant. • Feels uncomfortable or helpless when alone because of exaggerated fears of being unable to care for himself or herself. • Urgently seeks another relationship as a source of care and support when a close relationship ends. • Is unrealistically preoccupied with fears of being left to take care of himself or herself.

23. Obsessive-Compulsive Personality Disorder1. • A pervasive pattern of preoccupation with orderliness, perfectionism, and mental and interpersonal control, at the expense of flexibility, openness, and efficiency, beginning by early adulthood and present in a variety of contexts, as indicated by 4 (or more) of the following: • Is preoccupied with details, rules, lists, order, organization, or schedules to the extent that the major point of the activity is lost. • Shows perfectionism that interferes with task completion (e.g., is unable to complete a project because his or her own overly strict standards are not met). • Is excessively devoted to work and productivity to the exclusion of leisure activities and friendships (not accounted for by obvious economic necessity). • Is overconscientious, scrupulous, and inflexible about matters of morality, ethics, or values (not accounted for by cultural or religious identification). • Is unable to discard worn-out or worthless objects even when they have no sentimental value. • Is reluctant to delegate tasks or to work with others unless they submit to exactly his or her way of doing things. • Adopts a miserly spending style toward both self and others; money is viewed as something to be hoarded for future catastrophes. • Shows rigidity and stubbornness.

24. Personality Disorder NOS1. • Meets the general diagnostic criteria for a Personality Disorder, but does not meet criteria for any specific Personality Disorder.

25. Cluster A.

26. Paranoid Personality Disorder.

27. Paranoid Personality Disorder2. • Overview. • Long-standing suspiciousness and mistrust of persons in general. • Often hostile, irritable, and angry. • Often develop into: • Bigots. • Injustice collectors. • Pathologically jealous spouses. • Litigious cranks.

28. Paranoid Personality Disorder1. • Pervasive distrust and suspiciousness of others such that their motives are interpreted as malevolent, beginning by early adulthood and present in a variety of contexts, as indicated by 4 or more of the following: • Suspects, without sufficient basis, that others are exploiting, harming, or deceiving them. • Is preoccupied with unjustified doubts about the loyalty or trustworthiness of friends or associates. • Is reluctant to confide in others because of unwarranted fear that the information will be used maliciously against them. • Reads hidden demeaning or threatening meanings into benign remarks or events. • Persistently bears grudges (i.e., is unforgiving of insults, injuries, or slights). • Perceives attacks on his or her character or reputation that are not apparent to others and is quick to react angrily or to counterattack. • Has recurrent suspicions, without justification, regarding fidelity of spouse or sexual partner. • Does not due to something else. • If criteria are met prior to Schizophrenia add “premorbid”.

29. Paranoid Personality Disorder2. • Epidemiology. • 0.5-2.5% of the general population. • Relatives of patients with schizophrenia show a higher incidence of paranoid personality disorder than controls. • More common in men than women. • Thought to be higher among minority groups, immigrants, and persons who are deaf.

30. Paranoid Personality Disorder2. • Interview. • Formal in manner. • Act baffled about having to seek psychiatric help. • Humorless and serious. • Scan the environment. • Have muscular tension. • Are unable to relax.

31. Paranoid Personality Disorder2. • Interview. • Thought content shows: • Projection. • Prejudice. • Occasional ideas of reference.

32. Paranoid Personality Disorder2. • Clinical features. • Long-standing suspiciousness and mistrust of others. • Interpret actions of others as deliberately demeaning, malevolent, threatening, exploiting, or deceiving and expect to be harmed by them. • Express disdain for those they see as weak, sickly, impaired, or defective and are impressed with, and pay close attention to, power and rank. • They are often hostile, irritable, angry and show pathological jealousy, but can often pull themselves together and appear undistressed during an interview.

33. Paranoid Personality Disorder2. • Differential Diagnosis. • Unlike in delusional disorder, there are no fixed delusions. • Unlike in Schizophrenia, there are no hallucinations or formal thought disorder. • Unlike borderline personality disorder, patents are not in overly close relationships. • No extensive history of antisocial behavior. • Patients with schizoid personality disorder are also withdrawn, but do not have paranoid ideation.

34. Paranoid Personality Disorder2. • Course and Prognosis. • No adequate, systematic long-term studies exist. • In general, patients have lifelong problems working and living with others and occupational and marital problems are common. • Some patients go on to develop Schizophrenia.

35. Paranoid Personality Disorder2. • Treatment. • Psychotherapy. • Treatment of choice. • Therapists need to be straightforward and professional (not overly warm) with honesty and an apology preferable to a defensive explanation for the mistakes patients will often point out. • Since patients may behave threateningly and with delusional accusations, limit setting and dealing with accusations must be done realistically (but gently).

36. Paranoid Personality Disorder2. • Treatment. • Psychotherapy. • Therapists should never offer to take control unless they are willing and able to do so since patients are profoundly frightened when they feel those that are helping them are weak. • Patients do not do well in group psychotherapy. • Many cannot tolerate the intrusiveness of behavior therapy (but it is often used for social skills training).

37. Paranoid Personality Disorder2. • Treatment. • Pharmacotherapy. • Benzodiazepines may help with anxiety. • Antipsychotics may be needed in small dosages for brief periods of time. • Some evidence that pimozide (Orap) may be helpful.

38. Schizoid Personality Disorder.

39. Schizoid Personality Disorder2. • Overview. • Lifelong pattern of social withdrawal. • Discomfort with human interaction, introverted, bland and constricted affect. • Seen by others as: • Eccentric. • Isolated. • Lonely.

40. Schizoid Personality Disorder1. • A pervasive pattern of detachment from social relationships and a restricted range of expression of emotions in interpersonal settings, beginning by early adulthood and present in a variety of contexts, as indicated by 4 or more of the following: • Neither desires nor enjoys close relationships, including being part of a family. • Almost always chooses solitary activities. • Has little, if any, interest in having sexual experiences with another person. • Takes pleasure in few, if any, activities. • Lacks close friends or confidants other than first-degree relatives. • Appears indifferent to the praise or criticism of others. • Shows emotional coldness, detachment, or flattened affectivity. • Not due to something else. • If criteria are met prior to Schizophrenia add “premorbid”.

41. Schizoid Personality Disorder2. • Epidemiology. • Prevalence is unknown but may affect 7.5% of the population. • Sex ratio is unknown but may be 2:1, Male:Female.

42. Schizoid Personality Disorder2. • Interview. • Patients appear ill at ease. • Rarely tolerate eye contact. • Seem eager for the interview to end. • Affect may be constricted, aloof, or inappropriately serious, but fear may be recognized underneath. • Difficult to be lighthearted and their humor may seen adolescent and off the mark.

43. Schizoid Personality Disorder2. • Interview. • Give short answers, avoid spontaneous conversation and may occasionally use unusual figures of speech such as odd metaphors. • May be fascinated with inanimate objects or metaphysical constructs. • May think they have a sense of intimacy with personas they do not know well. • Sensorium is intact, memory functions well, and proverb interpretations are abstract.

44. Schizoid Personality Disorder2. • Clinical Features. • Seem cold, aloof, quiet, distant, seclusive, unsociable. • Have solitary, lonely jobs that involve little or no contact with others (often night shifts). • Show no involvement with everyday events and concerns of others. • Last to be aware of fashion changes.

45. Schizoid Personality Disorder2. • Clinical Features. • Sexual lives are postponed and may only exist in fantasy. • Have a normal capacity to recognize reality, have a lifelong inability to express anger directly and respond to threats with fantasized omnipotence or resignation.

46. Schizoid Personality Disorder2. • Differential Diagnosis. • No positive psychotic symptoms as there is in schizophrenia, delusional disorder, and affective disorders with psychotic features. • Patients with paranoid personality disorder show more social engagement, aggressive verbal behavior, and a greater tendency to project their feelings onto others.

47. Schizoid Personality Disorder2. • Differential Diagnosis. • Patients with obsessive-compulsive and avoidant personality disorders experience loneliness as dysphoric and possess a richer history of past object relations. • Closely resembles Schizotypal personality disorder, but with less positive schizophrenia like symptoms.

48. Schizoid Personality Disorder2. • Course and Prognosis. • Occurs in early childhood. • Long lasting but not necessarily lifelong. • The proportion of patients who develop schizophrenia is unknown.

49. Schizoid Personality Disorder2. • Treatment. • Psychotherapy. • Treated similarly to paranoid personality disorder. • Since they tend toward introspection, they may become devoted, but distant patients. • After trust develops, fantasies, imaginary friends, fears of unbearable dependence, even merging with the therapist may be revealed.

50. Schizoid Personality Disorder2. • Treatment. • Psychotherapy. • In group therapy, patients may be silent for long periods and should be protected against aggressive group members, but eventually become involved. • Other group members become important to the patient and may provide the only social contact they receive.