Personality Disorders in the Disability Review Process

David D. Nowell, Ph.D.

Overview

• Domains of dysfunction• Causes of personality disorder (PD)• Treatment considerations• Diagnosis of PD• “Clusters”• Alternative DSM-5 model of PD• What we look for (and avoid) in the chart review• Following our regulations around PD• Q & A & D

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“Personality”

Enduring pattern of thinking, feeling, and behaving

Neurotic

Borderline

Psychotic

Major domains of dysfunction

1. Distorted thinking patterns2. Problematic emotional responses3. Over- or under-regulated impulse control4. Interpersonal difficulties

Examples of distorted thinking

• extreme black-or-white thinking patterns• patterns of idealizing then devaluing other

people or themselves• patterns of distrustful, suspicious thoughts• patterns that frequently include unusual or odd

beliefs that are contrary to cultural standards• patterns of thoughts that include perceptual

distortions and bodily illusions.

Examples of problematic emotional responses

• Emotional constriction, indifference• Fear of being ridiculed• Fears of being abandoned• Numbness, detachment• Intensity, easily overwhelmed

Impulse Control Problems

• Over-controlled, restricted• Impulsive spending, risky sexual behavior• Binge eating• Regulation of strong affect

Examples of interpersonal difficulties

Causes of Personality Disorder

• Biological factors• Early experiences

King-Casas et al. (2008)

Gregory, S. et al. (2012)

Schulze et al. (2013)

Disorders that contribute to impaired insight

• Drug and alcohol dependence

• Mania• Psychosis• Personality

disorders

• Delirium• Dementia• ADHD• Conversion disorder

Treatment

• Pharmacotherapy• Psychotherapeutic approaches

Pharmacotherapy

1) Manage co-occurring disorders 2) Reduce discomfort until they can make lasting changes 3) Promote a more rapid experience of recovery, which may increase motivation for other treatment4) Increase ability to attend therapy and participate in a meaningful way5) Manage symptoms which might interfere with the ability to learn and practice new skills

Treatment considerations

• How optimistic can we be?• Why don’t they just stop it?• What is the presenting complaint?

Diagnosis of personality disorder

A. Enduring pattern of experience and behavior manifested in cognition or affectivity or interpersonal functioning or impulse control

B. Pervasive pattern C. Clinically significant distress or impairmentD. Long duration, onset in adolescence or early

adulthoodE. Not better accounted for by another disorderF. Not attributable to effects of a substance or a

medical condition

Cluster A

• Paranoid• Schizoid• Schizotypal

Cluster B

• Antisocial • Borderline• Histrionic • Narcissistic

Cluster C

• Avoidant • Dependent• Obsessive-compulsive Personality Disorder

Diagnosis of personality disorder

• Looking for the “footprints in the butter”– Work history– Relationship history

• Mental status exam• Clinicians’ response to the claimant• Treatment team interactions (splitting)• Our response to the chart

Diagnosis of personality disorder

• Features of the history vs presentation in the diagnostic interview– Countertransference?

Alternative DSM-5 Model for Personality Disorders

General Criteria for Personality Disorder• Impairment in personality (self/interpersonal) functioning.• One or more pathological personality traits.• Inflexible and pervasive across a broad range of personal and

social situations.• Stable across time, with onsets that can be traced back to at least

adolescence or early adulthood.• Not better explained by another mental disorder.• Not solely attributable to the physiological effects of a substance

or another medical condition.• Not understood as normal for an individual’s developmental stage

or sociocultural environment.

Alternative DSM-5 Model for Personality Disorders

General Criteria for Personality Disorder

• Impairment in personality (self/interpersonal) functioning.• One or more pathological personality traits.• Inflexible and pervasive across a broad range of personal and

social situations.• Stable across time, with onsets that can be traced back to at least

adolescence or early adulthood.• Not better explained by another mental disorder.• Not solely attributable to the physiological effects of a substance

or another medical condition.• Not understood as normal for an individual’s developmental stage

or sociocultural environment.

Alternative DSM-5 Model for Personality Disorders

Elements of personality functioning• Self:

– 1. Identity: Experience of oneself as unique, with clear boundaries between self and others; stability of self-esteem and accuracy of self-appraisal; capacity for, and ability to regulate, a range of emotional experience.

– 2. Self-direction: Pursuit of coherent and meaningful short-term and life goals; utilization of constructive and prosocial internal standards of behavior; ability to self-reflect productively.

• Interpersonal:– 1. Empathy: Comprehension and appreciation of others’ experiences and

motivations; tolerance of differing perspectives; understanding the effects of own behavior on others.

– 2. Intimacy: Depth and duration of connection with others; desire and capacity for closeness; mutuality of regard reflected in interpersonal behavior.

Alternative DSM-5 Model for Personality Disorders

General Criteria for Personality Disorder• Impairment in personality (self/interpersonal) functioning.

• One or more pathological personality traits.• Inflexible and pervasive across a broad range of personal and social

situations.• Stable across time, with onsets that can be traced back to at least

adolescence or early adulthood.• Not better explained by another mental disorder.• Not solely attributable to the physiological effects of a substance or

another medical condition.• Not understood as normal for an individual’s developmental stage or

sociocultural environment.

Alternative DSM-5 Model for Personality Disorders

Pathological personality trait domains• Negative affectivity (vs. stability)• Detachment (vs. extroversion)• Antagonism (vs. agreeableness)• Disinhibition (vs. conscientiousness)• Psychoticism (vs. lucidity)

Alternative DSM-5 Model for Personality Disorders

Pathological personality trait domains• Negative affectivity (vs. stability)• Detachment (vs. extroversion)

• Antagonism (vs. agreeableness)• Disinhibition (vs. conscientiousness)• Psychoticism (vs. lucidity)

Alternative DSM-5 Model for Personality Disorders

Pathological personality trait facets• Antagonism (vs. agreeableness)– Manipulativeness– Deceitfulness– Grandiosity– Attention seeking– Callousness– Hostility

Alternative DSM-5 Model for Personality Disorders

Specific personality disorders1. Antisocial2. Avoidant3. Borderline4. Narcissistic5. Obsessive-Compulsive PD6. Schizotypal7. Personality Disorder – Trait Specified

Alternative DSM-5 Model for Personality Disorders

Let’s look at Borderline PD through this lens…

Elements of personality functioning• Self:– 1. Identity:– 2. Self-direction:

• Interpersonal:– 1. Empathy: – 2. Intimacy:

Pathological personality trait domains

• Negative affectivity (vs. stability)• Detachment (vs. extroversion)

• Antagonism (vs. agreeableness)

• Disinhibition (vs. conscientiousness)• Psychoticism (vs. lucidity)

What we look for in record review

• Formal diagnosis of personality disorder– With description of functional impairment

• Functional impact of co-occurring conditions– PTSD– Mood disorders

What we avoid in record review

• Punitive responses• Counter-transference

Following our regulations around PD

• Document all diagnoses per problem list development guidelines

• Provide full documentation on all applicable listings/standards and reference at step IIIA or IIIB of worksheet- including L(8) and 12.08 as appropriate

• Assuring that functional impact of PD is addressed in psych RFC

• What if no dx of PD is offered but is suspected?

Q & A & D