DSM-IV-TR Personality Disorders: Recognition and Treatment

1. DSM-IV-TR Personality Disorders: Recognition and Treatment Presentation to Guam AIMFT Association September 2006 By Archana G. Leon-Guerrero, MD General and Addiction Psychiatry Diplomate, American Board of Psychiatry and Neurology Member, American Society of Addiction Medicine 671-646-2908

2. Overview of Personality Disorders: Why is it important to know about them? • Very prevalent in clinical practice, particularly in couples/family and other interpersonal problem presentations, and in those with depression/anxiety disorders on Axis I • Almost never is the presenting complaint “I have a personality disorder”. You must learn to recognize it. • If not recognized, will likely lead to treatment dropout/failure. • High rate of bad outcomes such as suicide, violence, substance abuse, legal problems. These bad outcomes may be lessened by proper recognition/treatment. Downward drift in socioeconomic status may also be prevented if caught early.

3. Overview of Personality Disorders:What is a Personality Disorder? • DSM: “An enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individual’s culture, is pervasive and inflexible, has an onset in adolescence or early adulthood, is stable over time, and leads to distress* or impairment.” • *note that, depending on which personality disorder we are talking about, the distress is often felt by others more than the person with the d/o

4. Axis I: Clinical Syndromes Temporary State vs. Ongoing Trait Something I “have” rather than I “am” Easier to Recognize Easier to Treat Better insight Axis II: Personality DO Ongoing Trait vs. Temporary State Something I “am” rather than I “have” Harder to recognize Harder to treat Little insight, see others as the problem Can lead to Axis I depression, anxiety, substance abuse Can be a “mild case” of Axis I disorders Overview of Personality Disorders: How are these different than Axis I Clinical Syndromes?

5. Personality D/O: Assessment • Source of info: client PLUS COLLATERALS • Look for patterns: • Trouble getting along with people prior to presenting incident. • Blaming others. • Trouble maintaining jobs/relationships prior to presenting incident. • If see these patterns, ask questions more specific to PD you suspect OR about substance abuse.

6. Paranoid PD Borderline PD Avoidant PD Histrionic PD Schizotypal PD Obsessive/Compulsive PD Obsessive/Compulsive D/O Cyclothymic D/O Schizophrenia Delusional D/O Social Phobia Somatization D/O Note: there may be more than one right match to any PD listed Overview of Personality Disorders: Matching Game: Match the Personality Disorder with the Related Axis I Syndrome that it is on a spectrum with

7. Classification of Personality Disorders DSM classification is based on similarities in presentations Cluster A: Odd/Eccentric Paranoid, Schizoid, Schizotypal Cluster B: Dramatic/Emotional/Erratic Antisocial, Borderline, Histrionic, Narcissistic Cluster C: Anxious/Fearful Avoidant, Dependent, Obsessive-Compulsive Not Otherwise Specified Mixed, Codependent, Passive-Aggressive

8. Cluster A:Eccentric: Paranoid PD • Pattern of distrust and suspiciousness of people in general (doubting loyalty, reading in hidden meanings, misinterpret compliments, bear grudges, easily angry/jealous, contolling in relationships to avoid betrayal). Often present for couple’s issues. • Strong biological relationship in family studies to delusional disorder and schizophrenia. False beliefs less fixed. Less bizarre behavior. No hallucinations.(Danish adoption study) • Treatment: • Courtesy, honesty, respect: ie honestly apologize for being late. • No group or confrontive therapy, including confronting the false belief. • Empathy: “if that is true, you must be very upset about it” • Low dose antipsychotic medication: “I know that your problems are due to how others treat you. Medication will help you deal with the stress of that.” • Discuss the possibility that belief may have been false only AFTER medication has softened it up.

9. Cluster A: Eccentric: Schizoid PD • Pattern of detachment from social relationships, restricted emotions • Lack of desire for intimacy: loners, cold, aloof • Strong biological relationship in family studies to Schizophrenia. • Treatment: Rarely needed because these individuals are not distressed, nor do they enter into interpersonal relationships so don’t distress anyone else. They choose occupations in which they can be loners.

10. Cluster A: Eccentric: Schizotypal PD • Pattern of interpersonal deficits marked by discomfort with close relationships and cognitive/perceptual distortions as well as behavioral eccentricities. • Ideas of reference, magical thinking, superstitious, sensory illusions (not hallucinations). • Loners not by choice as in Schizoid, but due to mild paranoia which causes anxiety. • Strong biological relationship in family studies to Schizophrenia. • Treatment: Psychoeduction. Social Skills Training, Case Management, Antipsychotic Medication.

11. Cluster B: Erratic: Antisocial • Pattern of disregard for rights of others. • Can’t be dx under age 18, likely because of frequent legal involvement: BUT must have had some aspects of conduct disorder before age 15. • Illegal actions, conning, lying, frequent fighting, recklessness, irresponsibility, lack of remorse, promiscuity without pleasure in women, STD’s, frequent unwanted pregnancies. • Much higher in men than women. • Can be charming at times, mostly to get their way. • Treatment: usually only successful with court mandates/consequences. Group therapy/involvement in therapeutic communities, religious groups, self-help groups much more helpful than individual therapy.

12. Cluster B: Erratic: Borderline PD • Pattern of unstable relationships, self-image and affects, together with impulsivity in many contexts. • Fear of abandonment, alternating between idealizing and devaluing others, impulsive in self-damaging ways (sex, driving, substance abuse, binge eating, spending), recurrent suicidality or self-mutilation, marked mood lability rective to environment, empty feelings, intense anger, stress-related paranoia or dissociation. • Biological relationship in family studies to depression, bipolar, substance abuse: NOT schizophrenia. • Most have a marked trauma history

13. Cluster B: Borderline PD (continued) • Treatment: • Far better than the rest: Dialectical Behavior Therapy, a form of cognitive/behavioral therapy focusing on teaching techniques to self-regulate affect. More info at www.brtc.psych.washington.edu • Also very good: Eye Movement Desensitization and Reprocessing—an innovative technique applying a neurologic procedure to cognitive/behavioral therapy. More info at www.emdr.com. I am trained in this. • Medications may be helpful for the short-term, targeted to the problem symptom at the time (depression, impulsivity, anxiety)

14. Cluster B: Erratic: Histrionic PD • Pattern of excess emotionality and attention-seeking behavior • Seductiveness, concern with physical appearance, exaggerated emotional expression, self-centered, naïve. • Associated with somatization disorder. • Becoming more recognized as a mild variant of Bipolar Disorder, hypomanic type without the tendency to depression. • Treatment: Insight-oriented psychotherapy, mood-stabilizing medication.

15. Cluster B: Erratic: Narcisstic PD • Pattern of grandiosity, need for admiration, lack of empathy. • Fantasies of unlimited success, sense of entitlement, exploits others, arrogant. • Fragile self-esteem, subject to “injury” from criticism. They often feel humiliated and react with rage. • May be a variant of Bipolar Hypomanic, although this needs further research. • Treatment: Almost impossible. They almost always “fire” the therapist. If proves to be a type of Bipolar DO, then mood-stabilizing meds may help. • Education of family can help them cope, which indirectly helps the client. Be careful about confidentiality when doing this.

16. Cluster C: Anxious: Avoidant PD • Pattern of social inhibition and feelings of inadequacy due to hypersensitivity to negative evaluation. • Loners, but WANT relationships. • Won’t get involved with people or activities due to fear of being ridiculed, rejected. • May actually be a natural byproduct of social phobia. Current research is being done, and this PD diagnosis may be eliminated soon. • Treatment: assertiveness training, anxiety medication, behavioral therapy teaching techniques to regulate anxiety (relaxation, deep breathing, imagery)

17. Cluster C: Anxious: Dependent PD • Pattern of execcive need to be taken cafre of that leads to submissive and clingy behavior. • Trouble making decisions without advice, won’t express disagreement, lacks initiative, fear of being alone, urgently seeks another relationship when one ends. • Often tolerate abuse. • Often have a history of being abused. • Treatment: Assertiveness training, Safety plan, EMDR for prior and current trauma.

18. Cluster C: Anxious: Obsessive-Compulsive PD • Preoccupation with orderliness, perfectionism, and control, at the expense of flexibility, openness and efficiency. • Can’t “see the forest for the trees”, too detailed, works too much, rigid moral values, “my way or no way”, hoards money and objects, stubborn. • Not in touch with feelings, sense that they are missing something, less likely to blame others than other PD’s. • Some overlap with Obsessive-Compulsive Disorder • Treatment: psychodynamic therapy focusing on insight into feelings, Behavioral therapy (preferably group) teaching social skills.

19. Closing • Personality Disorders are very prevalent in clinical populations, jails, social service settings etc. ie….where we all work! • People with Personality Disorders are hard to deal with. The very things that make them hard to deal with are the things they need help with! • Rarely do they tell us “I have a personality disorder”. It is incumbent upon us to recognize it. • Once we recognize it, treatment can help with most of the disorders. • Good luck!