Patrick J Enking, PA-C, MS Physician Assistant program University of new england

1. Patrick J Enking, PA-C, MSPhysician Assistant programUniversity of new england Personality Disorders

2. Concept of Personality and Personality Disorders • Personality • is the “style” of how one deals with the world • Personality traits • Stylistic peculiarities of how one deals with world especially in times of stress or external pressures. • May change in adulthood as develop more coping skills • Personality Disorders – 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.

3. Characteristics ofPersonality Disorders • a long-term pattern of inner experience and behavior that is out of context from the expectations of ones own culture • These patterns exhibit themselves in the way that people see themselves, their impulse control, and their affective instability. • Becomes a problem if it interferes with normal daily functioning

4. Personality DisordersEtiology • Upbringing/parenting – within their own culture, ethnic and social background. • Personal and social development – sudden change in living situation • Genetics • Biological factors • If later in life: rule out medical causes or substances.

5. Characteristics ofPersonality Disorders • Inflexible, maladaptive responses to stress • Disability in working and loving • Avoidance and fear of rejection • Blurred boundaries between self and other • Insensitivity to needs of others • Demanding and fault finding • Lack of accountability • Evoke intense interpersonal conflict

6. Prevalence and Co-morbidity • Prevalence: 10–15% in general population • Up to 50% in psychiatric patients with co-morbidity • Often co-occur with depression & anxiety • Often more than one diagnosis concurrently • Substance abuse • Somatization • Eating disorders • PTSD • That’s why it’s important to do a thorough evaluation of personality in the psych assessment

7. Biological Theories of Personality Disorders • Biological • No single cause identified • Genetics – play a role in Schizotypal, Schizoid and paranoid personality disorders • Neurobiological factors – Borderline PD related to abnormality in Prefrontal, corticostriatal and limbic systems • Psychological • Childhood abuse and trama • Learned • Cognitive

8. DSM IV Diagnostic Criteria A. An enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individual's culture. This pattern is manifested in two (or more) of the following areas:  • (1) cognition (i.e., ways of perceiving and interpreting self, other people, and events) (2) affectivity (i.e., the range, intensity, lability, and appropriateness of emotional response) (3) interpersonal functioning (4) impulse control  • B. The enduring pattern is inflexible and pervasive across a broad range of personal and social situations.  • C. The enduring pattern leads to clinically significant distress or impairment in social, occupational, or other important areas of functioning.  • D. The pattern is stable and of long duration and its onset can be traced back at least to adolescence or early adulthood.  • E. The enduring pattern is not better accounted for as a manifestation or consequence of another mental disorder.  • F. The enduring pattern is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition (e.g., head trauma).

9. Question: Where do we document Personality Disorders in the Axis? • Axis II – Personality Disorders

10. DSM Clusters of Personality Disorders • Cluster A: odd or eccentric • Related to Schizophrenia • Suspicious and quick to take offense • Cluster B: dramatic, emotional, erratic interpersonal interactions • Manipulation is common • Blaming others • Attention seeking • Moods are labile and often shallow • Cluster C: anxious or fearful • Related to Axis I diagnosis of anxiety d/o • Internalize blame for problems in life • Often overcontrolled

11. Cluster A: Odd or Eccentric • Paranoid - A chronic, suspicious distrust of others • Schizoid - Pattern of social detachment and decrease range of emotions • Schizotypal - Reduced capacity for close relationships, perceptual distortions and peculiar behavior

12. Paranoid Personality Disorder • The Caine Mutiny • Steve X • Guarded/Suspicious • Overly sensitive to setbacks and rebuffs • Self-important • Easily shamed/humiliated • Close relationships • Withdraws from others • More common in males

13. Schizoid Personality Disorder • Pattern of social detachment • decrease range of emotions. • Neither desires nor enjoys human relationships. • Fixated on personal thought/fantasies. • Demonstrates emotional coldness, detachment, and flat affect. • Indifferent to praise or criticism. • Chooses solitary activities. • No desire to interact with others • NOT FEAR BASED • Dr Hahn

14. Schizotypal Personality disorder • Reduced capacity for close relationships. • perceptual distortions similar to schizophrenia • peculiar behavior and appearance • elaborate style of dressing, speaking, and interacting. • Magical thinking manifested. • Lacks close friends and think they may be harmful. • Excessive and unrelieved social anxiety. • Develop ideas of reference • Eccentric thinking • FEAR • Not Psychotic • Dr Hahn

15. Differences and similarities between Schizoid and Schizotypal PD • There are many similarities between the Schizotypal and Schizoid personalities. • Most notable of the similarities is the inability to initiate or maintain relationships (both friendly and romantic). • The difference between the two seems to be: • Schizotypal avoid social interaction because of a deep-seated fear of people. • Schizoid individual simply feels no desire to form relationships, because they quite literally see no point in sharing their time with others. • An important distinction is that people with Schizoid Personality don't typically experience the perceptual distortions, paranoia or illusions typical of Schizotypal Personality or the psychotic episodes of Schizophrenia. • Comparisons in film

16. Cluster B: Dramatic, Emotional, Erratic • Antisocial - Failure to conform to the norms of society, amoral behavior, chronic irresponsibility and unreliability. Lack of regard for the law or rights of others. Must be over 18 y/o. M>W , Turbulant , fiery relationships, McDonalds Triad (bedwetting, animal cruelty, pyromania) in adolescents. CRIME. • Borderline - Unstable pattern of mood, emotions, relationships, and impulsivity. Issues of abandonment. Splitting behaviors. Recurrent suicide attempts. Feel empty and bored. Intense anger when ignored or mistreated. Self mutilating behaviors. May have brief psychotic episodes but short. Mood swings. Frequent suicide attempts (up to 10% complete it). • Histrionic - Excessive emotional and dramatic. Superficial and over reactive. Sexually provocative. Lack of remorse hurting others. Exaggerate and manipulative. Crave attention/excitement and approval of others. Women>Men. Cycle of rejection>histrionic behavior>rejection>histrionic…. • Narcissistic - Grandiose sense of self importance. Attention Grabbing behaviors. Manipulation of others. Arrogant manner toward others. Expectation of special treatment. Envious of others with belief they are envious of him/her.

17. Antisocial Personality disorder *This diagnosis is not made before age 18. *Must not be made in the context of substance use. *Before age 15, for 12 months or more the person repeatedly violates rules, age appropriate societal norms or the rights of others. As shown by at least three of the following: • Agression toward people or animals • Destruction of Property • Lying or Theft • Serious rule violation

18. Borderline Personality Disorder • Attempts to prevent abandonment • Unstable relationships • Identity disturbance • Self damaging impulsiveness • Self mutilating behavior or suicidal thoughts or threats • Severe reactivity of mood leading to marked instability • Chronic feelings of emptiness • Anger that is out of control or inappropriate and intense • Brief paranoid ideas or severe dissociative symptoms related to stress • My Story

19. Histrionic personality disorder Beginning in early adult life, emotional excess and attention-seeking behaviors are present in a variety of situations and shown by at least five of these: • Discomfort with situations in which the person is not the center of attention. • Relationships that are frequently fraught with inappropriately seductive or sexually provocative behavior • Expression of emotion that is shallow and rapidly shifting • Frequent focusing of attention on self through use of physical appearance • Speech that is vague and lacks detail • Overly dramatic expression of emotion • Easy suggestibility (influenced by others) • Belief that relationships are more intimate than they really are

20. Narcissistic Personality disorder Beginning in early adult life, grandiosity, lack of empathy, and need for admiration are present in a variety of situations and shown by at least five of these: • Grandiose sense of self importance • Preoccupation with fantasies of beauty, brilliance, ideal love, power or limitless success • Belief that personal uniqueness renders the person fit only for association with people or institutions of rarefied status • Need for excessive admiration • A sense of entitlement • Exploitation of others to achieve personal goals • Lack of empathy • Frequent envy of others or belief that others envy the person • Arrogance in attitude or behavior • Dr Bowler

21. Cluster C: Anxious or Fearful • Avoidant - Socially inhibited, wants contact with others but fearful of rejection or criticism. Easily wounded by criticism that they hesitate to become involved. Embarrassed easily. No close friends. Alone. • Obsessive/Compulsive (anankastic) - preoccupation with orderliness, perfectionism rules. Interferes with normal routines/rigid. Can be indecisive and preoccupied with detail. Have difficulty expressing affection. Jack. • Dependent - Difficulty taking responsibility for life. Need approval of others. Agree with others even when they don’t agree. Fear abandonment.

22. Assessment and Diagnosis • Common Risk evaluations • Ineffective coping skills • Risk for other-directed violence • Risk for suicide • Risk for self-mutilation • Social isolation • Disturbed thought processes • Hopelessness • Chronic low self-esteem • Other common complications • Depression • Substance use • Accidents • Self-harm and suicide • Unemployment • Homelessness • Crime/legal issues

23. Treatments for Personality Disorders • Some are outgrown with time i.e. Borderline Pers D/o • Crisis plan/support/monitoring • Psychodynamic psychotherapy • Cognitive-behavioral therapy • Dialectical behavior therapy (DBT)

24. Treatment for Personality Disorders • Therapeutic community – positive interactions • Ideals regarding self awareness, interdependence, mutual respect, responsibility. • Daily involvement for long time • Medications with low toxicity • Antidepressants (SSRIs) • Lithium carbonate • Anticonvulsants • Low-dose antipsychotics • Hospitalizations should be discouraged unless there is a danger to self or others

25. Summary Of Personality Disorders • Diagnosing PD should include: • Verify the duration of the symptoms and that the criteria are met • May need to interview other informants • Are these symptoms interfering with life in some way? • Sometimes requires a judgment call but try to be as objective as possible. • Rule out Axis I pathology • The General Criteria are very important as the basis for the diagnosis • Sometimes there are several criteria for different PD so it may appear more as a cluster

26. DSM IV Diagnostic Criteria A. An enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individual's culture. This pattern is manifested in two (or more) of the following areas:  • (1) cognition (i.e., ways of perceiving and interpreting self, other people, and events) (2) affectivity (i.e., the range, intensity, lability, and appropriateness of emotional response) (3) interpersonal functioning (4) impulse control  • B. The enduring pattern is inflexible and pervasive across a broad range of personal and social situations.  • C. The enduring pattern leads to clinically significant distress or impairment in social, occupational, or other important areas of functioning.  • D. The pattern is stable and of long duration and its onset can be traced back at least to adolescence or early adulthood.  • E. The enduring pattern is not better accounted for as a manifestation or consequence of another mental disorder.  • F. The enduring pattern is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition (e.g., head trauma).