Personality Disorders Deanna Mercer MD FRCPC MSIV March 21 2012 dmercer@toh.on

1. Personality Disorders Deanna Mercer MD FRCPC MSIV March 21 2012 dmercer@toh.on.ca

2. 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

3. 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, pharmacological treatment and psychotherapy

4. Good References • Disordered Personalities • Field Guide to Disordered Personalities Dave Robinson MD Rapid Psychler Press

5. Personality Disorders Introduction Criteria, clusters and core symptoms

6. Personality What is it? How do you get one?

7. Personality: Definition • An individual’s characteristic pattern of response to his/her environment. • Includes: how one thinks, feels, acts and relates to others.

8. Personality: Etiology Temperament X Environment Time

9. Disorder • Leads to clinically significant distress or impairment in functioning

10. 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

11. 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

12. 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

13. 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

14. Why make a diagnosis of Personality Disorder?

15. 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

16. Personality Disorders: Clusters • Cluster A: odd Schizoid, schizotypal, paranoid • Cluster B: dramatic Borderline, histrionic, narcissistic, antisocial • Cluster C: anxious Obsessive compulsive, dependent, avoidant

17. Cluster A Personality Disorders Schizoid PD Schizotypal PD Paranoid PD

18. Pictures of famous People with Schizoid Personality Disorder

19. Schizoid Personality Disorder • “A pervasive pattern of detachment from social relationships and a restrictedrange 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

20. Schizotypal Personality Disorder

21. Schizotypal 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

22. Paranoid Personality Disorder

23. Paranoid PD • “A pervasive distrust and suspiciousness of others such that their motives areinterpreted as malevolent, beginning by early adulthood and present in a variety of settings…” • “DSMM” • Distrusts others, • Suspiciousness • others Motives are interpreted as Malevolent

24. 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)

25. 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%

26. Cluster B Histrionic PD Antisocial PD Narcissistic PD Borderline PD

27. Histrionic Personality Disorder

28. 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

29. Antisocial Personality Disorder

30. 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

31. ASPD epidemiology • DSMIV tr 1% females 3% males • New community based studies 1% M=F

32. ASPD prognosis • 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)

33. Treatment • Rarely seek help for distress caused by their actions • Most 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

34. Psychopathy http://www.youtube.com/watch?v=s5hEiANG4Uk

35. Narcissistic Personality Disorder

36. 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

37. Borderline Personality Disorder

38. 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…”

39. Cluster C” anxious” Obsessive Compulsive Avoidant Dependent

40. Obsessive Compulsive Personality Disorder

41. OCPD http://www.youtube.com/watch?v=T-GKovedEy4&feature=related

42. OCPD • “A pervasive pattern of preoccupation with orderliness, perfectionism, and mentaland 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 : mentaland interpersonal • *Most do not have OCD (only 30%) • Adolescents with strong OCPD traits can grow out of the diagnosis

43. Avoidant Personality Disorder

44. Avoidant PD “A pervasive pattern of social inhibition, feelings of inadequacy, andhypersensitivity to negative evaluation, beginning by early adulthood and present ina variety of contexts” • similar to social phobia, but more pervasive

46. Dependent PD • A pervasive and excessive need to be taken care of that leads to submissive andclinging behaviourand 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

47. Borderline Personality Disorder

48. 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

49. 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

50. 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