Personality Dis

8/2/2019 Personality Dis

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Personality Disorders inPrimary Care:

Pearls and Pitfalls

Robert Albanese, MD

Shakaib Rehman, MDDennis Cope, MD


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Empiricist or Rationalist?Empiricist or Rationalist?

Albert Einstein: Theory of Relativity Enrico Fermi: Father ofFission


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The Brain: Rational Hemisphere,Empirical Hemisphere


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What was Freuds mostimportant discovery?

The discovery of theUNCONSCIOUS

Not the

Subconscious.Subconscious is not a

psychiatric term. It is

a lay corruption of theterm Unconscious.


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Freud and Charcot 1885Freud and Charcot 1885

Charcot treats a patient with Hysteria


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UCS

UCS

UCS

UCS

UCSCSUCS

UCS

UCS

UCS

UCS


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Characteristics of the Unconscious:Primary Process

Illogical Dedicated to Wish Fulfillment and Drive

Satisfaction

Has no Ethical System (other than the

Pleasure Principle)

Parameters such as Time have no Meaning Every Persons UCS is Basically the Same


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The Structural Model

EGO

ID WORLD

SUPEREGO


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The Three Harsh Taskmasters

ID: The Monster of

Rage, Lust, Hunger

The World: A Dangerous Placeand often the source of conflict

SuperEgo: The

Demanding Quest

For Perfection


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Principles of Personality Theory:

Fixation Regression

Repetition/Compulsion

That Earlier Lesions tend to be moreDevastating than Later Ones

Ego Defense Mechanisms That in Some Patients, Nurture is MoreImportant than Nature


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DSMDSM--IVIV--TRTR

is anempirical

document that

strives to be

neutral with

respect to theoriesof etiology.


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DSM-IV Classification ofPersonality Disorders

HistrionicObsessive-CompulsiveNarcissisticParanoid

DependentBorderlineSchizoid

AvoidantAntisocialSchizotypal

Cluster C

worried

Cluster B

wild

Cluster A

weird


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Left Shift


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Left Shift Also.

Histrionic

Obsessive-

Compulsive

NarcissisticParanoid



Cluster Cworried

Cluster Bwild

Cluster Aweird

Primary ProcessPrimary Process


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Developmental Psychology


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Freuds Stages of Psychosexual Development

Begins with Onset ofPuberty

Genital Stage

Age 7 to PubertyLatency Stage

Ages 3-6, Oedipal ConflictsPhallic Stage

2nd

Year of LifeAnal Stage

1st Year of LifeOral Stage

Chronological SettingChronological SettingDesignationDesignation


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Margaret Mahlers Stages ofDevelopment

24 TO 36 MONTHSOBJECT

CONSTANCY

FOURTH SUBPHASE

16 TO 24 MONTHSRAPPROCHEMENTTHIRD SUBPHASE

10 TO 16 MONTHSPRACTICINGSECOND SUBPHASE

5 TO 10 MONTHSDIFFERENTIATIONFIRST SUBPHASE

SEPARATION INDIVIDUATION PROPER

4 WEEKS TO 5

MONTHS

NORMAL SYMBIOTIC PHASE

BIRTH TO 4 WEEKSNORMAL AUTISTIC PHASE


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TheNarcissistic Defense Mechanisms

Denial Distortion

Primitive

Idealization Projection

ProjectiveIdentification

Splitting


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TheImmature Defense Mechanisms

Acting out Blocking

Hypochondriasis

Identification

Introjection

Passive-Aggression

Projection

Regression

Schizoid fantasy

Somatization


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TheNeurotic Defense Mechanisms

Controlling

Displacement

Dissociation

Externalization

Inhibition Intellectualization

Isolation

Rationalization

Reaction formation Repression

Sexualization


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TheMature Defense Mechanisms

Sublimation Anticipation

Altruism Suppression

Asceticism Humor


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Margaret Mahlers Stages ofDevelopment--Schizotypal


CONSTANCY

FOURTH SUBPHASE





4 WEEKS TO 5

MONTHSNORMAL SYMBIOTIC PHASE



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Margaret Mahlers Stages ofDevelopment--Schizotypal


CONSTANCY

FOURTH SUBPHASE





4 WEEKS TO 5

MONTHS




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Presumption--

despair

WisdomTo be, through

having been, toface not being

Mankind or

my kind

Integrity vs.

despair

VIII. 50s and

beyond: old adult

Overextension

rejectivity

CareTo make be, to

take care of

Household,

workmates

Generativity

vs. self-

absorption

VII. Late 20s-50s:

middle adult

Promiscuity

exclusivity

LoveTo lose and find

oneself in

another

Partners,

friends

Intimacy vs.

isolation

VI. The 20s:

young adult

Fanaticism--

repudiations

Fidelity, loyaltyTo be oneself, to

share oneself

Peer groups,

role models

Ego identity

vs. role

confusion

V. Ages 12-18:

adolescence

Narrow

virtuosity,

inertia

CompetenceTo complete, to

make things

together

Neighborhood

and school

Industry vs.

inferiority

IV. Ages 7-12:

school age child

Ruthlessness,

ambition

Purpose, courageTo go after, to

play

FamilyInitiative vs.

guilt

III. Ages 3-6:

preschooler

Impulsivity

compulsion

Will,

determination

To hold on, to

let go

ParentsAutonomy

vs. shame

and doubt

II. Ages 2-3:

toddler

Sensory

distortion,

withdrawal

Hope, faithTo get, to give

in return

MotherTrust vs.

mistrust

I. Ages 0-1:

infant

Maladaptions

and

malignancies

Psychosocial

virtues

Psychosocial

modalities

Significant

relations

Psychosocial

crisis

Erik Eriksson:

Stages

(Age)


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Genital Stage



2nd Year of LifeAnal Stage

1st Year of LifeOral StageChronological SettingChronological SettingDesignationDesignation

Hervey Cleckley MD, MCG


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Jonathan Shay: Achilles in Vietnam

In this book, Shayproposes that traumacan have the effect ofbreaking down

established defensesthat are more mature,replacing them with

less adaptive, moreprimitive ego defensemechanisms.


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Margaret Mahlers Stages ofDevelopment


CONSTANCY

FOURTH SUBPHASE





4 WEEKS TO 5

MONTHS




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1995 Drowning Deaths1995 Drowning Deaths

.49%

.72%

.58%

2.34%

Female %

434.3%3992.54%44215-19 yrs

661.8%1761.28%24210-14 yrs

541.7%1681.16%2225-9 yrs

2253.7%371

(~2:1 M:F)

3.04%5960-4 yrs

Female TMale %Male totalTotal %Total #sages

1995 Drowning Statistics in the US (per 100,000 children)

Source: Centers for Disease Control


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Sexual Trauma and Borderline PDO


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Ages 2-3, Empathic ParentingPre-oedipal Stage


Genital Stage






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Genital Stage


Ages 3-6, Oedipal ConflictsPhallic StagePhallic Stage

2nd




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The womb is an animal that

longs to generate children. Ifit remains barren too long

after puberty, it strays about

in the body, choking off the

passages of the respiration,

provoking the sufferer to theextremest of anguish, and

causing all manner of other

symptoms besides.

--Plato, The Timaeus


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Somatization:

In SOMATIZATION, the patient generatessomatic symptoms in order to get

dependency needs met in the setting of the

clinic. The trick is to identify the somatizerand titrate minimum contact to minimum

symptoms.


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Genital Stage



2

nd




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Presumption--

despair

WisdomTo be, through

having been, to

face not being

Mankind or

my kind

Integrity vs.

despair

VIII. 50s and

beyond: old adult

Overextension

rejectivity

CareTo make be, to

take care of

Household,

workmates

Generativity

vs. self-

absorption

VII. Late 20s-50s:

middle adult

Promiscuity

exclusivity

LoveTo lose and find

oneself in

another

Partners,

friends

Intimacy vs.

isolation

VI. The 20s:

young adult

Fanaticism--

repudiations

Fidelity, loyaltyTo be oneself, to

share oneself

Peer groups,

role models

Ego identity

vs. role

confusion

V. Ages 12-18:

adolescence

Narrow

virtuosity,

inertia

CompetenceTo complete, to

make things

together

Neighborhood

and school

Industry vs.

inferiority

IV. Ages 7-12:

school age child

Ruthlessness,

ambition

Purpose, courageTo go after, to

play

FamilyInitiative vs.

guilt

III. Ages 3-6:

preschooler

Impulsivity

compulsion

Will,

determination

To hold on, to

let go

ParentsAutonomy

vs. shame

and doubt

II. Ages 2-3:

toddler

Sensory

distortion,

withdrawal

Hope, faithTo get, to give

in return

MotherTrust vs.

mistrust

I. Ages 0-1:

infant

Maladaptions

and

malignancies

Psychosocial

virtues

Psychosocial

modalities

Significant

relations

Psychosocial

crisis

Erik Eriksson:

Stages

(Age)


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Genital Stage






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Histrionic

Obsessive-

Compulsive

NarcissisticParanoid



Cluster C

worried

Cluster B

wild

Cluster A

weird


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Obsessive-Compulsive

Personality Disorder

Histrionic

Obsessive-

Compulsive Disorder

NarcissisticParanoidPersonality

Disorder

DependentBipolar

Social Anxiety

Disorder

Adult ADDPervasive

DevelopmentalDisorders

Cluster Cworried

Cluster Bwild

Cluster Aweird


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Personality Theory (Systematics)

In personality development, nurture isIn personality development, nurture isat leastat least

asasimportant as nature.important as nature.

Personality disorders are bestPersonality disorders are best understoodunderstoodby aby a

theoretical, rationalistic framework.theoretical, rationalistic framework. Personality disorders can be characterized by aPersonality disorders can be characterized by a

particular ego defense mechanism or a library ofparticular ego defense mechanism or a library of

ego defense mechanisms; characterization of thoseego defense mechanisms; characterization of thosedefense mechanisms facilitates accurate diagnosis.defense mechanisms facilitates accurate diagnosis.

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Personality Dis