Personality DisordersDeanna Mercer MD FRCPC
MSIV March 21 [email protected]
Objectives
• Describe personality disorders: criteria, clusters and core symptoms
• Axis I and Axis II comorbidity
• Understanding self injurious behaviour
• Borderline Personality Disorder: diagnosis and treatment
• Antisocial Personality Disorder: diagnosis and basic treatment
5296 Describe the general diagnostic criteria for a PD. 5297 State the classification of PD in three clusters. 5298 Describe the main enduring pattern of each PD type. 5299 Explain the clinical relevance of comorbity of Axis I and Axis II disorders. 5300 Describe the mental disorders associated with self‐injurious behaviors (SIB) 5301 List the biological, demographic, economic, social and developmental factors associated with SIB. 5302 Describe the pertinent factors in the recognition of the potential of SIB. 5303 List criteria for borderline personality disorder (BPD). 5304 Describe common psychiatric comorbidities asociated with BPD. 5305 Describe a treatment approach to BPD including use of hospitalization, outpatient care, pharmacologicaltreatment and psychotherapy
Good References
• Disordered Personalities
• Field Guide to Disordered Personalities
Dave Robinson MD Rapid Psychler Press
Personality Disorders Introduction
Criteria, clusters and core symptoms
Personality
What is it?
How do you get one?
Personality: Definition
• An individual’s characteristic pattern of response to his/her environment.
• Includes: how one thinks, feels, acts and relates to others.
Personality: Etiology
Temperament X EnvironmentTime
Disorder
• Leads to clinically significant distress or impairment in functioning
DSM IV general criteria for personality disorder
• Enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individual’s culture
• cognition, affectivity, interpersonal functioning and impulse control• Pattern is inflexible and pervasive• Leads to clinically significant distress or
impairment in functioning• Not better accounted for by other mental
disorder
PD’s are Ego Syntonic
• Ego Syntonic: Individual experiences significant distress, but does not feel that their thoughts, emotions or behaviours are the source of their distress
• external locus of control
• Ego Dystonic: Individual sees their disorder as arising from their own thoughts, emotions or behaviours
• internal locus of control
Epidemiology
DSM “informed speculation”
– Any PD 9%– Most PD’s 1-2 %– No sex differences in any PD
• In clinical populations 50 -80%
• Torgersen 2001 Norway, • Lezenweger 2007 National Comorbidity Survey Replication
Prognosis
• All tend to improve over time (years)
• Cluster B the most
• Schizotypal, Borderline and Avoidant have the greatest functional impairment
• Narcissistic, Histrionic, Obsessive Compulsive personality disorders have the least functional impairment
Why make a diagnosis of Personality Disorder?
Why make a PD diagnosis ?
• Axis I with PD
• More impaired, more chronicity
• Overall poorer response to treatment requiring more intensive and prolonged care
• Certain PD’s (BPD, ASPD, Schizotypal PD) have specific treatments or are contraindications for certain treatments
Personality Disorders: Clusters
• Cluster A: oddSchizoid, schizotypal, paranoid
• Cluster B: dramaticBorderline, histrionic, narcissistic, antisocial
• Cluster C: anxiousObsessive compulsive, dependent, avoidant
Cluster A Personality DisordersSchizoid PD
Schizotypal PD
Paranoid PD
Pictures of famous People with Schizoid Personality Disorder
Schizoid Personality Disorder
• “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 settings..”
• “DR” • Detached from relationships• Restricted range of emotional expression
Schizotypal Personality Disorder
Schizotypal PDSchizotypal PD
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
settings
“ACE”• Acute discomfort in close relationships:
paranoia rather than fear of judgment
• Cognitive and perceptual distortions: odd beliefs, unusual perceptions, suspiciousness,paranoia,
odd speech
• Eccentric Behaviours
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
settings
“ACE”• Acute discomfort in close relationships:
paranoia rather than fear of judgment
• Cognitive and perceptual distortions: odd beliefs, unusual perceptions, suspiciousness,paranoia,
odd speech
• Eccentric Behaviours
Paranoid Personality Disorder
Paranoid PD
• “A pervasive distrust and suspiciousness of others such that their motives are interpreted as malevolent, beginning by early adulthood and present in a variety of settings…”
• “DSMM”• Distrusts others, • Suspiciousness • others Motives are interpreted as
Malevolent
How to Remember Cluster A
• Schizoid: looks like negative symptoms of scz
• Schizotypal: looks like positive symptoms of scz (but not full blown psychosis)
• Paranoid PD: looks like delusional disorder, paranoid type ( but no full blown delusions and more pervasive suspiciousness)
All cluster A have: • Increased risk of brief psychotic episodes • Genetic link to schizophrenia:
– Schizotypal>schizoid>ppd
• Few relationships– Schizoid: if any close relationship it is with 1˚ family– Schizotypal: lacks close friends except 1˚ family – Paranoid: few friends with similar beliefs
• Risk of developing scz– Schizotypal: 10-20%
Cluster B
Histrionic PDAntisocial PD
Narcissistic PDBorderline PD
Histrionic Personality Disorder
Histrionic PD
• “A pervasive pattern of excessive emotionality and attention seeking, beginning by early adulthood and present in a variety of contexts…”
• “theatrical”
• Intense but shallow emotions
• Craves being the centre of attention
Antisocial Personality Disorder
Antisocial PD • “Pervasive pattern of disregard for and violation of
the rights of others occurring since age 15 years / must be at least age 18 years”
• Repeated lawbreaking• Deceitfulness• Impulsivity• Irritability and aggressiveness• Reckless disregard for safety of self or others• Consistent irresponsibility• Lack of remorse
ASPD epidemiology
• DSMIV tr 1% females 3% males
• New community based studies 1% M=F
• Highest risk of ASPD: early onset conduct (before age 10) and ADHD
• 75% of conduct disorder resolves by adulthood• Prognosis better if has some connection to a
group• ASPD > Sociopathy ( Tony Soprano) >
Psychopath (Ken Lay)• Decrease impulsivity and criminal behavior, but
continue to be difficult people (poor spouses, parents, employees)
ASPD prognosis
Rarely seek help for distress caused by their actionsMost common reasons for psychiatric contact:
detox, seeking meds with a street value, notes for missing work, assessments to avoid criminal responsibility, military service, work that they see as undesirable
Psychotherapy usually contraindicated, particularly psychopathy
Stay respectful, but avoid emotional investment in patient◦ Confront denial and minimization◦ Restrict focus to possible outcomes of antisocial behaviour◦ Help to find healthier alternatives to acting out
Treatment
http://www.youtube.com/watch?v=s5hEiANG4Uk
Psychopathy
Narcissistic Personality Disorder
Narcissistic PD
“ A pervasive pattern of grandiosity (in fantasy or behaviour) need for admiration, and lack of empathy, beginning by early adulthood and present in a variety of contexts”
• “AGE”– need for Admiration, – Grandiosity (fantasy or behaviour)– lack of Empathy for others
BorderlinePersonality Disorder
Borderline PD
“ 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…”
Cluster C” anxious”
Obsessive CompulsiveAvoidant
Dependent
Obsessive Compulsive Personality Disorder
OCPD
http://www.youtube.com/watch?v=T-GKovedEy4&feature=related
OCPD • “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..”
• “OCP”• Orderliness• Perfectionism• Control : mental and interpersonal
• *Most do not have OCD (only 30%)• Adolescents with strong OCPD traits can grow out
of the diagnosis
Avoidant Personality Disorder
Avoidant PD Avoidant PD
• similar to social phobia, but more pervasive
• similar to social phobia, but more pervasive
“A pervasive pattern of social inhibition, feelings of inadequacy, and hypersensitivity to negative evaluation, beginning by early adulthood and present in a variety of contexts”
Dependent PD Dependent PD • A pervasive and excessive need to be taken
care of that leads to submissive and clinging behaviour and fears of separation, beginning by early adulthood and present in a variety of contexts..”
• “Dependent on relationships”• Difficulty making everyday decisions without a lot of advice,
reassurance from others• unable to disagree with others because fears loss of support,
will do things that are unpleasant, degrading to maintain support
• If person’s fear of retribution realistic (abusive spouse) do not make diagnosis
• A pervasive and excessive need to be taken care of that leads to submissive and clinging behaviour and fears of separation, beginning by early adulthood and present in a variety of contexts..”
• “Dependent on relationships”• Difficulty making everyday decisions without a lot of advice,
reassurance from others• unable to disagree with others because fears loss of support,
will do things that are unpleasant, degrading to maintain support
• If person’s fear of retribution realistic (abusive spouse) do not make diagnosis
BorderlinePersonality Disorder
BPD DSMIV• A pervasive pattern of instability of interpersonal
relationships, self-image and affects, and marked impulsivity
• Affective: emotional lability, problems with anger• Relationships: chaotic, idealizing/devaluing,
fears of abandonment “I hate you, don’t leave me”
• Behaviours: suicide and self harm, impulsive (sex, A&D, binge eating, driving fast, promiscuity)
• Cognitive: emptiness, unstable sense of self, mild psychotic symptoms under stress, dissociation
Self Harm / SIB• Behaviours that inflict harm to one’s body without the
obvious intention of committing suicide• 1-4 % general population• chronic/severe SH 1%• Teens 5- 13 %, college age 17- 35%• Age of onset: 14 - 24• majority (75%) <10 times• Increasing in teens• Increased risk of suicide behaviours • F=M • abrading/scratching> cutting, banging> biting, burning
Risk Factors
• Social: Low SES, adverse events during childhood (abuse and trauma)
• Biological: ↓ serotonin, impulsivity • Psychiatric Disorders (90%) : Personality
disorders (BPD -75%), depression, pervasive developmental delay, dissociative identity disorder, eating disorders,
• Alcohol and substance abuse are common
SIB
• Situational Risk factors: recent negative life events
• Reasons: – relief from intense painful emotions – self punishment– to get significant others to respond
Assessing for SIB
• Suspect in teens and young adults who are presenting with psychological distress
• Important to recognize that SIB is usually an attempt to reduce emotional distress
• Best way to solve the problem is to look for a solution to the event that caused the emotional distress
SIB: intervention
• Start by validating that the prompting problem and the distress are real and that it makes sense to want to reduce emotional pain
• Highlight that while SH does reduce emotional pain in the short term, it is not a great way to solve the problem that got the distress going in the long run
• Invite the person to look at other methods of problem solving
Objective # 5305
Describe a treatment approach to BPD including use of
hospitalization, outpatient care, pharmacological
treatment and psychotherapy
Bio-Social Theory
EMOTION DYSREGULATION
Emotionally Vulnerable individual
InvalidatingEnvironment
Linehan 1993
BPD: prognosis
• With primarily OPD treatment 75% of patients with BPD no longer meet criteria after 6 years
• 75% have history of suicide and self harm attempts. 5 - 10% die by suicide
• Worst prognostic factor: concurrent substance dependence
• Best prognostic factor: GAF at time of diagnosis
BPD: Comorbidity
• Mood disorders : depression 50%, dysthymia 70%. At time of admission 90% MDE
• Bipolar I,II: 18%
• Eating Disorders(An, BN, obesity) : 50%
• Anxiety Disorders: 90%
• Substance Use Disorders: 60%
• Narcissistic PD, antisocial PD: 50%
Treatment of BPD
• Mainstay of treatment is outpatient care and psychotherapy– BPD patients are exquisitely sensitive to what
happens in their environment – treatment has to help them find ways to :
1.Solve problems causing painful emotions
2.Feel better
3.Tolerate both the situation and how they feel about it without making the situation worse
BPD treatment: Psychotherapy
• All empirically based psychotherapies (DBT, MBT, TFP, Schema focused)
– Focus of treatment is to establish connection between actions and feelings
– Therapists manage, pay careful attention to countertransference.
– Therapist has ongoing discussion with colleagues or easy access to consultation
– Here and now focus
BPD: Hospitalization
• Admission indicated: – After a serious suicide attempt– Psychosis/severe disorganization
• May be indicated – loss of significant social support– Worsening depression, substance abuse
• Caution when– Hospital has not been helpful or has made
person worse
Links 2010
BPD: Meds
• Adjunct to psychotherapy, limit expectations (yours and your patient’s!)
• Concurrent MDE: SSRI’s, Effexor• Affective lability: mood stabilizers – Lamotrigine,
Aripiprazole• Insomnia, agitation, brief psychotic symptoms –
low dose quetiapine, olanzapine• Avoid: benzodiazepines, meds that are
dangerous in overdose (lithium, tricyclics)