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Personality Disorders

Personality Disorders. Mark Kimsey, M.D. March 8, 2014. Objectives. Understanding personality disorders using criteria from DSM-5. Learn approaches for separating personality disorders from other major illnesses. Review non-pharmacologic treatment approaches. General Information.

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Personality Disorders

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  1. Personality Disorders Mark Kimsey, M.D. March 8, 2014

  2. Objectives • Understanding personality disorders using criteria from DSM-5. • Learn approaches for separating personality disorders from other major illnesses. • Review non-pharmacologic treatment approaches.

  3. General Information • Data from 2001-2002 National Epidemiological Survey on Alcohol and Related Conditions suggest that 15% of U.S adults have at least one personality disorder. • People frequently have more than one co-occurring personality disorder • It is extremely common for people with other psychiatric problems to also have personality disorders

  4. DSM-5 • Recent update of the Diagnostic and Statistical Manual of Mental Disorders • Personality disorders discussed in 2 sections. • Section II- Diagnostic criteria and Codes • Same diagnoses and criteria as DSM-IV • Categorical model that sees personality disorders as distinct clinical syndromes • Section III- Emerging Measures and Models • Dimensional model- personality disorders vary and merge into each other and into normality.

  5. General Personality Disorder • Enduring pattern of inner experience and behavior that deviates markedly from expectations of the individual’s culture. • Manifested in 2 or more of 4 areas: • Cognition- (ways of perceiving and interpreting self, others, and events). • Affectivity- (range, intensity, lability, and appropriateness of emotional response). • Interpersonal Functioning • Impulse Control

  6. General Personality Disorder (cont’d) • Enduring pattern is inflexible and pervasive across a broad range of personal/social situations. • Enduring pattern leads to significant distress or impairment in social, occupational, or other important areas of functioning. • Stable and of long duration, beginning in at least adolescence or early adulthood.

  7. General Personality Disorder (cont’d) • Enduring pattern not better explained by another mental disorder. • Enduring pattern not attributable to effects of a substance or medical condition.

  8. DSM-5 Organization • No longer coded as 5 Axis system. • May code more than one diagnosis if fits criteria. • Broken down into 3 clusters • Cluster A-Paranoid, Schizoid, Schizotypal • Cluster B- Antisocial, Borderline, Histrionic, Narcissistic • Cluster C- Avoidant, Dependent, Obsessive-Compulsive • Also- Other, unspecified, due to another medical condition

  9. Cluster A- Odd/Eccentric • Paranoid P.D. (2.3-4.4%) Pattern of distrust and suspiciousness. Sees others as malevolent. • Schizoid P.D. (3.1-4.9%) Detachment from social relationships and a restricted range of emotional expression. • Schizotypal P.D.(3.9-4.6%) Eccentric behaviors, discomfort in close relationships, ideas of reference, odd beliefs.

  10. Cluster B- Dramatic • Antisocial P.D. (0.2-3.3%) Conduct disorder before age 15 yrs. Pervasive pattern of disregard and violation of rights of others. Criminal, lying, impulsivity, aggression, disregard for safety of self/others, irresponsible, lack of remorse.

  11. Cluster B- Dramatic • Borderline P.D.(1.6-5.9%) Severe, pervasive pattern of instability in several areas. Fear of abandonment, unstable/intense interpersonal relationships, identity disturbance, impulsivity, suicidal ‘gestures’, intense affective instability, feelings of emptiness, transient paranoia or dissociative sx’s. (Prevalence 6% in primary care settings, 10% in outpatient MH, 20% Inpatient psych)

  12. Cluster B- Dramatic • Histrionic P.D. (1.84%) Center of attention, provocative, shallow, dramatic, considers relationships to be more intimate than they really are. • Narcissistic P.D. (0-6.2%) Grandiose self importance, preoccupation with fantasies of unlimited success, etc., ‘special’, Requires excessive admiration, entitled, exploitative, no empathy, envious.

  13. Cluster C- Anxious/Avoidant • Avoidant P.D. (2.4%) Severesocial inhibition, poor self esteem/image. • Dependent P.D. (0.49-0.6%) Sees themselves as needing others, to point of submission, clinging, and fears of separation. • Obsessive-Compulsive P.D. (2.1-7.9%) Differentiatefrom OCD. • OtherPersonality D/O’s

  14. Differential Diagnosis • Separating and merging different personality disorders, shortcomings of current system • Going beyond the chief complaint(s) • Longitudinal versus cross-sectional viewpoint • Traits versus Personality Disorders • Effects of stress, substance abuse, other primary diagnoses, and general medical problems

  15. Differential Diagnosis • In general, there’s no rush to make a personality disorder diagnosis. • May have suspicions on the initial contact, but keep an open mind about other issues/dx’s. • Personality Disorders are often ‘cured’ with the appropriate medication. • Cutting is not synonymous with Borderline PD.

  16. Treatment Approaches • Pharmacologic • No FDA approved medications for “Personality Disorders”. • Often based on symptom management. • ‘Kitchen sink’ approach. Throw whatever medications into the mix that seem to reduce symptoms. • “Medicine is the art of entertaining the patient while the body heals itself.”- Voltaire

  17. Non-pharmacologic Treatments • Most emphasis has been placed on Borderline Personality Disorder. • Many challenges to treatment • Insurance limitations- ‘Axis II’. • Who’s distressed? • Dropout from treatment. (lack of motivation, too painful) • Lack of consistency from one therapist to the next. • Dialectical behavior therapy (DBT) and Cognitive therapy (CT). • Analytically oriented psychotherapy. • Interpersonal psychotherapy. • Group therapy

  18. Dialectical behavior therapy (DBT) • Weekly one-on-one counseling sessions and group therapy. • Development of skills. • Improved distress tolerance. • Increased interpersonal effectiveness. • Improved regulation of emotions • Mindfulness skills. • Has shown significant reduction of self harm and lower rate of dropout than ‘therapy as usual’.

  19. Cognitive therapy (CT) • Targets dysfunctional core beliefs about the self, others and the world. • Usually weekly sessions with therapist. • Workbooks, homework assignments, worksheets. • Related to Cognitive Behavioral Therapy (CBT). • CBT aimed at a wide variety of mood, anxiety, and personality disorders.

  20. Alternative DSM-5 Model • New approach that was proposed to address numerous shortcomings in prior model. • PD’s are characterized by impairments in personality functioning and pathological personality traits. • Fewer PD’s • Antisocial, avoidant, borderline, narcissistic, obsessive-compulsive, and scizotypal. • Also PD-TS- personality d/o- trait specified.

  21. Alternative DSM-5 Model • General Criteria • Moderate or greater impairment in personality (self/interpersonal) functioning • Impairments are pervasive and inflexible • Stable over time • Exclusionary criteria • Elements of personality functioning • Self- Identity, self-direction • Interpersonal- Empathy, intimacy

  22. Alternative DSM-5 Model • Personality traits divided into 5 broad domains • Negative affectivity • Detachment • Antagonism • Disinhibition • Psychoticism • Further divided into 25 specific trait facets

  23. Negative Affectivity (vs. emotional stability)

  24. Detachment (vs. Extraversion)

  25. Antagonism (vs. Agreeableness) • Manipulativeness • Deceitfulness • Grandiosity • Attention Seeking • Callousness • Hostility

  26. Disinhibition (vs. Conscientiousness) • Irresponsibility • Impulsivity • Distractibility • Risk taking • Rigid perfectionism (also lack of)

  27. Psychoticism • Unusual beliefs and experiences • Eccentricity • Cognitive and perceptual dysregulation

  28. Example- Antisocial PD • Personality Functioning- • Identity- Egocentrism • Self- direction- failure to conform to law/culture • Empathy- lack of empathy/remorse • Intmacy- exploitative, dominance • Pathological Traits • Antagonism- manipulativeness, callousness, deceitfulness, hostility • Disinhibition- Risk taking, impulsivity, irresponsibility

  29. Example- Narcissistic PD • Personality functioning • Identity- Needs others for self-definition and self-esteem regulation, extremes • Self-direction- goal setting based on gaining approval, personal standards too high or low • Empathy- severly impaired • Intimacy- Superficial relationships, need for personal gain • Personality traits- Antagonism- grandiosity, attention seeking

  30. Questions?

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