Personality Disorders: How Do They Affect HIV Care?: Personality Disorders: How Do They Affect HIV Care? Paula K. Gibbs, M.D. andamp; Jann DeWitt, Ph.D.


Personality Disorders and HIV: Personality Disorders and HIV The 2001-2002 National Epidemiological Survey on Alcohol and Related Conditions (NESARC) has shown that an estimated 14.9% of Americans 18 years or older (30.8 million persons) meet standard diagnostic criteria for at least one personality disorder as defined by DSM-IV


Personality Disorders and HIV: Personality Disorders and HIV The NESARC was the first national survey conducted in the US to estimate the prevalence of personality disorders. The NESARC is a representative survey of noninstitutionalized Americans aged 18 and older; more than 43,000. Designed to assess prevalence and co-morbidity, or co-occurrence, of multiple mental disorders. www.psychiatrist.com/


Personality Disorders and HIV: Personality Disorders and HIV NESARC finding: OCPD 7.9% (16.4 million persons) Paranoid PD 4.4% (9.2 million persons) Antisocial PD 3.6% (7.6 million persons) Schizoid PD 3.1% (6.5 million persons) Avoidant PD 2.4 % (4.9 million persons) Histrionic PD 1.8% (3.8 million persons) Dependent PD 0.5 (1 million persons)


Personality Disorders and HIV: Personality Disorders and HIV Prior studies have estimated the prevalence rate of personality disorders in the US as 10-15%. Paranoid PD 0.5-2.5% Schizotypal PD 3% Antisocial PD 3% of men, 1% of women Borderline PD 2% Histrionic PD 2-3% Narcissistic PD less than 1% Avoidant PD 0.5-1% OCPD 1%


Personality Disorders and HIV: Personality Disorders and HIV There is a significantly higher prevalence of personality disorders in HIV-infected individuals (19-36%) than HIV-negative individuals (15%). The prevalence of personality disorders for individual with HIV-risk ranges from 15-20%. The most common personality disorders among HIV-infected individuals are antisocial and borderline. Am J Psychiatry 1993; 150:309-315


Personality Disorders and HIV: Personality Disorders and HIV HIV-infected individual with a personality disorder (compared to those without a personality disorder) have greater mood disturbance, utilized denial and feel helpless when coping with the threat of AIDS, have greater co-morbid substance abuse disorders and have greater social conflict. Recognition of the impact of personality disorder on the coping with HIV infection is important for comprehensive, sensitive and effective clinical care.


What is a Personality?: What is a Personality? Personality traits consists of enduring patterns of perceiving, relating to and thinking about the environment, people and oneself. Personality changes with experience, maturity and external demands in a way that promotes adaptation.


What is a Personality?: What is a Personality? Personality is affected by genetic and psychosocial factors. A personality disorder is diagnosed when personality traits become inflexible, pervasive and maladaptive to the point where these traits cause significant interpersonal, social and occupational dysfunction. Am Psychiatric Ass: DSM-IV; 2000


Personality Disorder: Personality Disorder Features of personality disorders include: 1. Deeply ingrained and inflexible nature 2. Maladaptive pattern especially in interpersonal relationships 3. Relatively stable over time without much change 4. Significantly impairs the ability of the person to function 5. Distresses those close to the person


Personality Disorder: Personality Disorder An essential component of personality disorders are the behaviors are egosyntonic to the patient. Those close to the patient perceive these behaviors as extremely difficult to deal with and are egodystonic.


Personality Disorder: Personality Disorder All of us have experienced feeling hypervigilant, destructive, suspicious, paranoid, shy, isolative, entitled, vain, arrogant, perfectionistic, dramatic, too needy, lonely, impulsive, resentful of authority, seductive and moody. None of these behaviors alone warrant a diagnosis of a personality disorder, however clusters of behaviors existing over time with inflexiblity, in the light of the patient’s poor level of functioning make the diagnosis of personality disorder.


Personality DisorderGeneral Characteristics: Personality Disorder General Characteristics 1. Personality traits consist of enduring patterns of perceiving, relating to, and thinking about the environment, other people and oneself. 2. A Personality Disorder is diagnosed when personality traits become inflexible, pervasive and maladaptive to the point where they cause significant social or occupational dysfunction, or subjective distress.


Personality DisorderGeneral Characteristics: Personality Disorder General Characteristics 3. Personality patterns must be stable and date back to adolescence or early adulthood. Therefore, personality disorders are not generally diagnosed in children. 4. Patterns of behavior and perception cannot be due to stress, another mental disorder, drug or medication effect, or due to a medical disorder.


Personality DisorderGeneral Characteristics: Personality Disorder General Characteristics 5. Personality disorders are commonly seen in medical and psychiatric practice. 6. In general, patients have little or no insight into their disorder. Am Psychiatric Ass: DSM-IV; 2000


Slide16: Each of the personality disorders has between seven and nine diagnostic criteria. The DSM-IV attempts to provide diagnostic uniformity and a more accurate means for describing psychopathology. A maxim in psychiatry is that no single symptom is exclusive to a particular diagnosis. The personality disorders, particularly in the same cluster, share overlapping symptoms. It is important not to 'label' patients but to provide an accurate diagnosis, so appropriate treatment plans can be designed to address medical, social and psychological factors inpatients with HIV.


Descriptions of Personality Disorders: Descriptions of Personality Disorders Cluster A - Odd or Eccentric: Paranoid, Schizoid, Schizotypal Cluster B - Dramatic, Emotional or Erratic: Antisocial, Borderline, Histrionic, Narcissistic Cluster C - Anxious or Fearful: Avoidant, Dependent, Obsessive-Compulsive


Cluster A: Cluster A Paranoid: Pervasive pattern of mistrust and suspiciousness. Begins in early adulthood. Presents in a variety of contexts Schizoid: Detachment from social relationships. Restricted range of emotional expressions. Schizotypal: Social and interpersonal deficits. Cognitive or perceptual distortions and eccentricities.


Cluster B: Cluster B Antisocial: Disregard for rights of others. Violation of rights of others. Lack of remorse for wrongdoing. Lack of empathy. Borderline: Instability of interpersonal relationships, self-image, and affects. Marked impulsivity.


Cluster B: Cluster B Histrionic: Excessive emotionality. Attention-seeking behavior. Narcissistic: Grandiosity. Need for admiration.


Cluster C: Cluster C Avoidant: Social inhibition. Feelings of inadequacy. Hypersensitivity to criticism Dependent: Excessive need to be taken care of. Submissive behavior. Fear of separation. Obsessive-Compulsive: Preoccupation with orderliness and perfection. Mental and interpersonal control.


Descriptions of Personality Disorders: Descriptions of Personality Disorders Most of the personality theories depict individuals along dimensions of extroversion-introversion and stability-instability (independent-enmeshed). The dimension of extroversion-introversion refers to the individual’s basic tendency to respond to stimuli with either excitation or inhibition.


Extroverted Individuals: Extroverted Individuals Extroverted individuals are generally: Present-oriented Feelings-directed Reward-seeking


Extroverted Individuals: Extroverted Individuals The chief focus of extroverts is their immediate and emotional experience. Feelings predominate over thoughts. Predominant motivation is immediate gratification or relief of discomfort. Extroverts are sociable, crave excitement, risk-takers and impulsive.


Introverted Individuals: Introverted Individuals Introverted individuals are generally: Future and Past-oriented Cognition-directed Consequence-avoidant


Introverted Individuals: Introverted Individuals Logic and function predominate over feeling. Introverts are motivated by appraisal of past experiences and avoidance of future negative consequences. They have a hard time relaxing and enjoying pleasurable activities, especially if there is potential negative consequences.


Introverted Individuals: Introverted Individuals Introverted people are quiet, dislike excitement and distrust the impulse of the moment. They tent to be rigid , inflexible, organized, reliable and somewhat pessimistic.


Stability-instability Dimension: Stability-instability Dimension The second personality dimension, stability-instability, defines the degree of emotional liability. Emotional states of the stable individual are slow to be aroused, minimally intense and return to baseline quickly. Emotional states of the unstable individual are intense and they act out on them impulsively and in irrational ways.


Personality disorders and HIV: Personality disorders and HIV About 60% of HIV/AIDS patients seeking psychiatric treatment have a blend of extroversion and emotional instability. The second most common personality combination are stable extroverts (25%). The third most common personality combination are unstable introverts (14%). The remaining 1% of patients with HIV are stable introverts. Hutton H. Treisman GJ. Primary Psychiatry.Vol.6 No. 5 1999.


Personality disorders and HIVTreatment Implications: Personality disorders and HIV Treatment Implications Medical and psychiatric treatments of patients with extroverted and emotionally unstable personalities are challenging for all providers of HIV services. Such patients are frustrating and difficult to manage for physicians and HIV service providers because of their impulsive nature. Such patients tend to have primitive coping strategies such as splitting, denial, acting out, projection/projection identification, passive-aggression, somatization, regression, magical thinking or schizoid fantasy.


Antisocial Personality Disorder: Antisocial Personality Disorder DSM-IV Diagnostic Criteria A. Since the age of 15 years old, the patient continues to display disregard for, and violation of, the rights of others, indicated by at least three of the following: 1. Failure to conform to social norms by repeatedly engaging in unlawful activity. 2. Deceitfulness: Repeated lying, use of aliases, or 'conning ' others for personal profit or pleasure.


Slide32: 3. Impulsivity or failure to plan ahead. 4. Irritability and aggressiveness, as indicated by repeated physical fights or assaults. 5. Reckless disregard for the safety of self or others. 6. Consistent irresponsibility: Repeated failure to sustain work behavior or honor financial obligations. 7. Lack of remorse for any of the above behavior.


Slide33: B. A history of some symptoms of conduct disorder before the age of 15 as indicated by: 1. Aggression to people and animals. 2. Destruction of property. 3. Deceitfulness or theft. 4. Serious violation of rules. Am Psychiatric Ass: DSM-IV; 2000.


Clinical Features of ASPD: Clinical Features of ASPD A. Interaction with others are typically exploitative or abusive. B. Lying, stealing, fighting, fraud, physical abuse, substance abuse, drunk driving are common. C. Patients may be arrogant, but are capable of superficial charm. D. These patients can also resort to threatening behavior. E. These patients have no capacity of empathy.


Epidemiology of ASPD: Epidemiology of ASPD A. the male-to-female ratio is 3:1. B. More common in the first-degree relatives of those with the disorder.


Differential Diagnosis of ASPD: Differential Diagnosis of ASPD A. Adult Antisocial Behavior: This diagnosis is limited to the presence of illegal behavior only and lacks the pervasive patterns required for the disorder. B. Substance Abuse Disorder: Substance abuse/dependence is common in ASPD and crimes may be committed to obtain drugs, or to obtain money for drugs. Consider both diagnoses if chronic drug abuse and antisocial acts are present.


Slide37: C. Narcissistic Personality Disorder: Narcissistic patients also lack empathy and are exploitive, however, they are not as aggressive or deceitful as Antisocials. D. Borderline Personality Disorder: These patients are impulsive and manipulative, however, they are emotionally unstable and less aggressive. The manipulativeness of Borderlines are aimed at getting emotional gratification rather than aimed at financial or power motives.


Borderline Personality Disorder: Borderline Personality Disorder DSM-IV Diagnostic Criteria A pervasive pattern of unstable interpersonal relationships, unstable self-image, unstable affects, and poor impulse control beginning by early adulthood and indicated by at least five of the following: 1. Frantic efforts to avoid real and imagined abandonment. 2. Unstable and intense interpersonal relationships, alternating between extremes of idealization and devaluation.


Slide39: 3. Identity disturbance: unstable self-image or sense of self. 4. Impulsivity in at least two areas that are potentially self-damaging (e.g. spending, promiscuity, substance abuse, reckless driving, binge eating). 5. Recurrent suicidal behavior, gestures or threats; or self-mutilating behavior. 6. Affective instability (e.g. sudden intense dysphoria, irritability, or anxiety of short duration). 7. Chronic feeling of emptiness.


Slide40: 8. Inappropriate, intense anger or difficulty controlling anger. 9. Transient, stress-related paranoid ideation or severe dissociative symptoms. Am Psychiatric Ass: DSM-IV: 2000.


Clinical Features of BPD: Clinical Features of BPD A. Clinical presentation is highly variable. B. Chronic dysphoria is common. C. Desperate dependence on others is caused by inability to tolerate being alone. D. Chaotic interpersonal relationships are characteristic. E. Self-destructive or self-mutilatory behavior is common. F. Childhood history of abuse or parental neglect is common.


Epidemiology of BPD: Epidemiology of BPD A. The female-male ratio id 2:1. B. Five times more common in first degree relatives. C. Prevalence is is 2%, however, it occurs in 30-60% of psychiatric inpatients.


Differential diagnosis of BPD: Differential diagnosis of BPD A. Adolescence: Identity disturbance and emotional labiality of normal adolescence may have characteristics of BPD, however, a persistent pattern is not present. Histrionic Personality Disorder: These patients are also manipulative and attention seeking, however, they do not display self-destructiveness or anger.Psychosis and dissociation are typically not present in Histrionic patients.


Differential Diagnosis of BPD: Differential Diagnosis of BPD C. Dependent Personality disorder: When faced with abandonment, Dependent patients will increase their submissive behavior rather than display rage as do BPD. D. Personality disorder due to a Medical Condition or Substance Abuse disorder: Acute symptoms are temporally related to medications, drugs or a medical condition.


Personality Disorders and HIVTreatment Implications: Personality Disorders and HIV Treatment Implications Medical and psychiatric treatments of patients with extroverted and emotionally unstable personalities (ASPD and BPD) are challenging for all providers of HIV services. A cognitive-behavioral approach is more effective in treating these patients.


Personality Disorders and HIVTreatment implications: Personality Disorders and HIV Treatment implications 1. Focus on thoughts, not feelings. Unstable extroverts benefit from learning how they are predisposed to act in certain patterns. Mental health professionals can help these patients gain an awareness that their chaotic and often irrational behavior is triggered by intense emotional states that these patient act on without thinking. The goal is to encourage these patients to utilize thought over feeling to determine action.


Personality Disorders and HIVTreatment Implications: Personality Disorders and HIV Treatment Implications 2. Use behavioral contracts. 3. Emphasize rewards. Positive outcomes, not adverse consequences, are important to unstable extroverts. 4.Coordinate care through thorough case management with the medical and psychiatric teams. Mental health providers can provide support for the medical providers and service providers to prevent burn-out with this difficult population.


Personality Disorders and HIVTreatment Implications: Personality Disorders and HIV Treatment Implications 5. Tolerate the patient’s affect (anger, anxiety and need to control). Be firm and kind with these emotions. Avoid being punitive or over-invested. 6. Identify and treat underlying Axis I disorders. 7. Educate the patient clearly about medical and psychiatric illnesses and document what was explained and how the patient responded. 8. Appreciate the patient’s possible attachment to medical symptoms. Be complete in the workup of the patient’s complaints and when in doubt, give the patient the benefit of the doubt.


Personality Disorders and HIVTreatment Implications: Personality Disorders and HIV Treatment Implications 9. Avoid arguments with patients who make unreasonable demands. Utilize time (24 hour rule) to make judgments and always consult colleagues, both medical and psychiatric. 10. Know and accept the limits of your tolerance of a patient’s personality. 11. Don’t worry about being used by patients, because all patients use their providers to some extent. Utilize case management meeting to staff difficult cases with a multispecialty team.