FCP05 PD Flaum

Personality Disorders: An Introduction: 

Personality Disorders: An Introduction Michael Flaum MD Department of Psychiatry 1-401 MEB Tel: 353-4340 michael-flaum@uiowa.edu www.icmentalhealth.org

Learning Objectives: 

Learning Objectives At the conclusion of this lecture the student will be able to: Distinguish the terms 'Personality' vs. 'Personality Disorders' Describe how PD’s are categorized and diagnosed in DSM-IV, including what is meant by 'Axis II' disorders Describe the core characteristics of antisocial personality disorder Describe the core characteristics of borderline personality disorder

Personality : 

Personality All of us have personalities; i.e., our overall temperament, and the characteristic ways in which we respond to others, to our environment, to stressors, to pleasures, etc. Personality traits are enduring patterns of perceiving, relating to, and thinking about the environment and oneself that are exhibited in a wide range of social and personal contexts Personality traits are formed by early adulthood, persist throughout life and affect every aspect of day to day behavior. Together, they make up one’s personality

Personality Disorder: 

Personality Disorder Personality traits are diagnosed as a Personality Disorder* only when that amalgam of stable traits are consistently maladaptive and inflexible, and cause significant functional impairment or subjective distress *Note: This is the case with any psychiatric disorder in our current nosology, i.e., the signs and symptoms must result in some functional impairment or distress

Example: DSM-IV Criteria for Narcissistic Personality Traits / Disorder: 

Example: DSM-IV Criteria for Narcissistic Personality Traits / Disorder 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 five (or more) of the following:  (1) has a grandiose sense of self-importance (e.g., exaggerates achievements and talents, expects to be recognized as superior without commensurate achievements)  (2) is preoccupied with fantasies of unlimited success, power, brilliance, beauty, or ideal love  (3) 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)  (4) requires excessive admiration  (5) has a sense of entitlement, i.e., unreasonable expectations of especially favorable treatment or automatic compliance with his or her expectations  (6) is interpersonally exploitative, i.e., takes advantage of others to achieve his or her own ends  (7) lacks empathy: is unwilling to recognize or identify with the feelings and needs of others  (8) is often envious of others or believes that others are envious of him or her  (9) shows arrogant, haughty behaviors or attitudes

Personality and Temperament areStable over the Lifespan: 

Personality and Temperament are Stable over the Lifespan Longitudinal Research – Chess and Thomas Began in 1950’s Longitudinal follow-up of temperament from birth through middle age Show remarkable consistency of temperament from infancy throughout the lifespan Source: Stella Chess and Alexander Thomas Origins And Evolution of Behavioral Disorders: From Infancy to Adult Life

Personality Disorders in DSM-IVCategorical vs. Dimensional: 

Personality Disorders in DSM-IV Categorical vs. Dimensional DSM-IV has adopted a categorical scheme 10 specific disorders (diagnostic categories) Non-hierarchical, i.e., many people meet criteria for more than one disorder 3 'clusters' Examples of dimensional approaches to describing personality Introversion vs. extroversion Closedness vs. openness to experience Antagonism vs. agreeableness

3 Clusters of PD’s in DSM-IV: 

3 Clusters of PD’s in DSM-IV Cluster A: Paranoid, Schizoid, Schizotypal Core features: Odd or Eccentric Cluster B: Antisocial, Borderline, Histrionic, Narcissistic Core features: Dramatic, emotional, erratic Cluster C: Avoidant, Dependent, Obsessive-Compulsive Core features: Anxious or fearful

Brief Descriptions: Cluster A – Odd or Eccentric: 

Brief Descriptions: Cluster A – Odd or Eccentric Paranoid PD: a pervasive pattern of distrust and suspiciousness such that others’ motives are interpreted as malevolent. Schizoid PD: a pervasive pattern detachment from social relationships and a restricted range of emotional expression Schizotypal: a pervasive pattern of cognitive or perceptual distortions and eccentricities of behavior

Brief Descriptions: Cluster B – Dramatic, emotional, erratic: 

Brief Descriptions: Cluster B – Dramatic, emotional, erratic Antisocial PD: a pervasive pattern of disregard for, and violation of, the rights of others. Borderline PD: a pervasive pattern of instability in interpersonal relationships, self-image, and affects, and marked impulsivity Histrionic PD: a pervasive pattern of excessive emotionality and attention seeking Narcissistic PD: a pervasive pattern of grandiosity, need for admiration, and lack of empathy

Brief Descriptions: Cluster C – Anxious, fearful: 

Brief Descriptions: Cluster C – Anxious, fearful Avoidant PD: a pervasive pattern of social inhibition, feelings of inadequacy, hypersensitivity to negative evaluation Dependent PD: a pervasive pattern of submissive and clinging behavior related to an excessive need to be taken care of Obsessive-Compulsive: a pervasive pattern of preoccupation with orderliness, perfectionism, and control

Axis II and its interaction with Axes I and III: 

Axis II and its interaction with Axes I and III Axis II disorders are those that tend to be lifelong and stable by definition, e.g., personality disorders and metal retardations Axis II may 'color' the clinical manifestation of axis I disorders I.e, the presentation of major depressive disorder may look very different in person with obsessive-compulsive traits, than it would in a person with antisocial traits, than it would in a person who is mentally retarded, etc. Axis II may also 'color' the clinical appearance of Axis III (i.e., general medical) disorders

2 Personality Disorders most commonly seen in health care environments: 

2 Personality Disorders most commonly seen in health care environments Antisocial Personality Disorder Borderline Personality Disorder

Antisocial Personality Disorder: Characteristics: 

Antisocial Personality Disorder: Characteristics History of severe conduct problems as a kid; fights, stealing, fire setting, cruelty to animals. As adults, behavior that does not recognize the rights of others…. Aggressive, destructive behavior, e.g., fighting , reckless driving, endangering others Illegal activities, e.g., stealing, destroying property, drug abuse Fails to honor social obligations Impulsiveness - Fails to plan ahead Limited regard for the truth Limited sense of guilt or remorse

Antisocial Personality Disorder: Epidemiology: 

Antisocial Personality Disorder: Epidemiology 3% of males, 1 % of females Often seen in lower socio-economic conditions (but high functioning also seen). High rates of co-occuring Drug and Alcohol diosorders. Fleeting depressive episodes and impulsive suicide acts – 7% suicide rate.

Antisocial Personality: Causes : 

Antisocial Personality: Causes Genetic Component Twins raised apart in adoption situations. Soft Neurological Signs Mildly abnormal EEGs Probably exacerbated by traumatic brain injury Childhood Development and Learning Abusive environment Violence as a means of getting your way. Little conscience is developed

Antisocial Personality Disorder Interface with Health Care: 

Antisocial Personality Disorder Interface with Health Care Trauma Fights, recklessness, MVAs, thrill seeking Substance Abuse and Complications Alcohol, Methamphetamine, Cocaine Psychiatry Units Impulsive suicide attempts, homicidal threats, Get out of jail Sexually Transmitted Diseases/Blood Borne Pathogens Hepatitis B and C common Domestic Violence Harm others, Infects others Child Abuse Harm children Etc.

Antisocial Personality Disorder: Treatment: 

Antisocial Personality Disorder: Treatment Corrections Settings Group therapy in jail of like individuals. ASPD can burn out some as they get older. Substance Abuse Treatment Any Co-existing Psychiatric Disorder Firm Limit Settings Court orders Limited narcotics for objective pain control

Films Depicting Antisocial Personality: 

Films Depicting Antisocial Personality Natural Born Killers Fargo Cape Fear In Cold Blood One Flew Over The Cuckoo's Nest Smokey and the Bandit

Summary for Antisocial Personality Disorder: 

Summary for Antisocial Personality Disorder Condition in which lack of regard for others and impulsive / reckless behaviors can cause numerous medical complications for patient and those around them. Treatment is limited but requires attention to the possibility of being manipulated and firm limit setting.

Films Depicting Borderline PD: 

Films Depicting Borderline PD Fatal Attraction Frances Girl, Interrupted

Borderline Personality Disorder:Characteristics: 

Borderline Personality Disorder: Characteristics (1) Frantic efforts to avoid real or imagined abandonment Crisis = relationship break-up, new doctors, being alone. (2) Unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation  Splitting: 'You are the best doctor I’ve ever had; but she’s the worst nurse' (3) Identity disturbance: markedly and persistently unstable self-image or sense of self  Goals, values, sexual identity may change frequently (4) impulsivity in at least two areas that are potentially self-damaging e.g., spending, sex, substance abuse, reckless driving, binge eating

Borderline Personality Disorder: Characteristics (cont.): 

Borderline Personality Disorder: Characteristics (cont.) (5) recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior Common : Cutting, burning, swallowing sharp object to 'feel the pain' Physical pain preferable to emotional pain (6) 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)  (7) chronic feelings of emptiness  (8) inappropriate, intense anger or difficulty controlling anger e.g., frequent displays of temper, constant anger, recurrent physical fights (9) transient, stress-related paranoid ideation or severe dissociative symptoms

Borderline Personality Disorder can look like…..: 

Borderline Personality Disorder can look like….. Schizophrenia (hallucinations, illusions, paranoia) Bipolar Affective Disorder ( mood lability and anger) Major Depressive Disorder (suicidal, depressed) Antisocial Personality Disorder (legal problems)

Borderline Personality Disorder:Epidemiology : 

Borderline Personality Disorder: Epidemiology 2 % of the general population. Females 4 times the rate of males. 11 % of psychiatry outpatients. 25 % of acute psychiatry inpatients. 50 % of long term psychiatry inpatients. 60 % with co-existing Major Depressive Disorder 7% complete suicide. ( 7 X General population).

Borderline PersonalityInterface with Health Care System: 

Borderline Personality Interface with Health Care System Inpatient Psychiatric Units Top diagnosis for re-admissions to psych hopsitals Emergency Rooms Cutting, burning, suicidal threats Intensive Care Units and medical inpatient units Overdoses and other sequelae of suicidal or parasuicidal behavior Outpatient primary care setting Psychosomatic complaints Doctor shopping

Borderline Personality Disorder: Treatment: 

Borderline Personality Disorder: Treatment Combination of Treatment works best Medications: symptom-driven Depressive – antidepressants Mood instability – mood stabilizers Psychotic – antipsychotic Anxiety – ? avoid benzodiazepines if possible Group therapy and rehabilitation: skills to cope with the illness (e.g., STEPS group) Balance Compassion and Limit Setting.

What’s in a name ? : 

What’s in a name ? Borderline: On the 'borderline' between 'neurosis' and 'psychosis' Not an accurate term though – and not relevant to current nosology Current trend is to call it 'Emotional Intensity Disorder' Better accepted by patients – more meaningful

Summary for Borderline Personality Disorder: 

Common Disorder, you will see often. Can look like many other psychiatric illnesses. Unstable moods and relationships. Treatment involves combination of medication, counseling and rehabilitation. Don’t get mad but don’t get sucked in with these patients…it is not good for them. Balance!!!! Summary for Borderline Personality Disorder

Take Home Points: 

Take Home Points Personality traits are diagnosed as a personality disorder when they are inflexible, maladaptive and cause impairment or distress DSM-IV employs a categorical rather than a dimensional approach to diagnosing personality disorders Axis II in DSM-IV involves life-long, stable features, which can 'color' the appearance of Axis I and Axis III disorders Antisocial personality disorder is characterized by a lack of 'conscience' and disregard for the rights of others Borderline personality disorder is characterized by emotional intensity and lability and splitting the world into blacks and whites vs. grays.