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Personality Disorders in a Hospital Setting

Personality Disorders in a Hospital Setting. Personality. The totality of emotional and behavioral traits characterizing a person’s day-to-day living. Relatively stable and predictable under ordinary conditions. Personality Disorders. Inflexible, maladaptive, exaggerated traits

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Personality Disorders in a Hospital Setting

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  1. Personality Disordersin a Hospital Setting

  2. Personality The totality of emotional and behavioral traits characterizing a person’s day-to-day living. Relatively stable and predictable under ordinary conditions

  3. Personality Disorders • Inflexible, maladaptive, exaggerated traits • Pattern of behavior deeply ingrained and maladaptive in perceiving self, others, environment

  4. DSM-IV-TR Axis I Major mental disorder Axis II Personality disorders Cluster A, B, C

  5. Cluster A • Paranoid • Schizoid • Schizotypal

  6. Cluster B • Antisocial • Borderline • Histrionic • Narcissistic

  7. Cluster C • Avoidant • Dependent • Obsessive-compulsive • Not Otherwise Specified (NOS)

  8. Personality Disorder ClassificationControversial, Problematic • Diagnostic unreliability • Preferential personality (co-existing conditions?) • Shared characteristics (excessive number of PDs) • Heterogeneity • Inconsistent, unstable, arbitrary boundaries • Inadequate literature coverage • Too frequent use of NOS category

  9. Proposal 1 Dimensional profile: narrative description of case, not only diagnostic classification, identifying fundamental maladaptive personality traits underlying its functioning

  10. Proposal 2 Integrate the various personality disorders into Axis I diagnostic classification: e.g., depressive personality disorder will change to dysthymia, early onset.

  11. Factors in behavior Genetic, temperamental, biological, psychological factors determine reaction of an individual towards others and environment throughout life and help form a pattern of behaviors typical for the individual.

  12. Defense Mechanisms Unconscious mental processes that the ego (self) employs to free itself from conscious anxiety generated during interactions with others, its own instincts, reality, conscience Used to avoid an increase in conscious anxiety and/or depression

  13. Defense Mechanism Types • Fantasy • Dissociation • Denial • Isolation • Projection • Splitting • Passive-Aggressive • Acting out • Projective identification

  14. Fantasy • Fear of intimacy • Schizoid behavior • Aloofness • Loneliness • Creating imaginary life, companions Fears should be recognized in a reassuring, non-confrontational, not insistent manner.

  15. Denial - Dissociation Unconscious covers-up for anxiety/other unpleasant emotions (e.g., fear) via exhibiting histrionic superficiality. Makes little of problems. May not remember important events of life and medical history. Caution to not make them more defensive Caution in not accepting histrionics at face value Allow to ventilate feelings and anxiety

  16. Isolation • Obsessive-compulsive • Orderly • Relates well • Tells unnecessary details about self in cool collected manner Responds well to precise, systematic, rational information. Wants punctuality. Demands interest from physician, others. Often intelligent, able to control own care.

  17. Projection • Attribution of own feelings to others • Fault-finding • Prejudicial • Hyper-vigilant • Distrustful Avoid confrontation. Normal but concerned approach. May be useful to establish alliance and expose him/her to interpretations of other reasons for suspiciousness.

  18. Splitting • Divides people into good and bad • Some staff members may be idealized • Some staff members disparaged • Disruptive behavior Gentle confrontation – no one is totally good or bad.

  19. Passive-Aggression • Anger turned against self (masochism) • Shows as self-demeaning or self-destructive behavior (wrist-cutting) • Hostility may be part of provocative behavior • Often viewed as sadistic Allow ventilation of anger.

  20. Acting Out (I) • Tantrums • Expression of ambivalent feelings conscious or unconscious • Assaults without motivation, at times sudden • Different types of abuse (physical, sexual, adults, children) • At times no apparent guilt feelings • Homicide may take place in uncontrolled aggression

  21. Acting Out (II) Interviewer must be calm, good listener. Realize patient lost control and is agitated. How can I help if you keep screaming or being so upset?

  22. Projective Identification • Mainly present in Borderline Personality Disorder Aspect of self projected onto other. Coercion of the other to identify with the projected aspect. Projector and recipient feel some kind of union.

  23. Paranoid Personality Disorder (I) • Frequency – 0.5-2.5% • Referrals from spouse, family, employer • More frequent in men • Higher in immigrants • Higher in deaf • Appears serious, humorless, suspicious • Speech logical but with false premises • Prejudice, projection, ideas of reference

  24. Paranoid Personality Disorder (II) • Fear of exploitation • Jealous • Disdains weak and impaired • Businesslike, efficient • Questions trustworthiness of friends A chronic condition that poses difficulty in living with spouse, friends, co-workers.

  25. Schizoid Personality Disorder (I) About 7.5% of population Social withdrawal Discomfort in relating to people Introversion Constricted affect Isolated Lonely Prefers solitary job, also at night

  26. Schizoid Personality Disorder (II) • Avoids eye contact • Fearful • Short answers • Minimal spontaneous speech • Flattened affect • Unable to relate • Lives in fantasy world • Repressed intimacy and sexuality

  27. Schizoid Personality Disorder (III) • Unable to express anger • Pseudo-philosophizes • Excessive day-dreaming Good patients in hospital who, absorbed in self, need protection from other patients (dyscontrolled or paranoid). If staff is able to establish rapport, they will uncover a plethora of day-dreaming.

  28. Schizotypal Personality Disorder • 3% of general population • Odd, strange magical thinking • Ideas of reference • Illusions • Peculiarity of thinking, behavior, appearance • 10% commit suicide

  29. Antisocial Personality Disorder (I) • 3% male – 1 % female • Nonconforming • Antisocial • Criminal behavior • Callous • Remorseless • Prone to lying, irritability, rage • Conduct disorder in childhood

  30. Antisocial Personality Disorder (II) • May have a veneer of normality, seductiveness Must be dealt with firmness and by establishing clear staff-patient rapport.

  31. Borderline Personality Disorder (I) • Previously called Ambulatory Schizophrenia, Psychotic Character, or Pseudoneurotic Schizophrenia • 1-2% of general population • More common in women • Unable to establish lasting relationships • Love-hate tendencies • Fluctuation of mood

  32. Borderline Personality Disorder (II) • Proclivity to move into psychosis under intense stress • Always in a state of crisis • Argumentative, depressed • No feelings • Micropsychotic episodes • Unpredictable Behavior

  33. Borderline Personality Disorder (III) • Repetitive self-destructive acts • Self-mutilation- expresses anger Do well in hospital setting because of attention received, avoiding intrafamilial problems. Limits posed to behavior (self-destructive acts) in a supervised protected environment. Suicide attempts frequent.

  34. Histrionic Personality Disorder (I) • 2-3% of general population • More frequent in women • Found especially in mental institutional settings • Colorful • Extroverted • Dramatic behavior • Excitable • Flamboyant

  35. Histrionic Personality Disorder (II) • Attention-seeking • Frequently somatize • Use drugs/alcohol • Gesturing • Eager to express and communicate in colorful way • Some tangentiality and forgetfulness • Magnify importance of events

  36. Histrionic Personality Disorder (III) • Mood swings and tears to make point • Seductive, flirtatious, inconsistent • Sensation seeking • May get into trouble with law

  37. Narcissistic Personality Disorder (I) • 1% of general population • Larger number in clinical setting • Exaggerated sense of self-importance • Enraged by criticism or completely ignores it • Ambitious • Continuous search for recognition • Needs reassurance

  38. Narcissistic Personality Disorder (II) • Superficial relationships • No empathy • Cunning and exploitative • Fragile self-esteem • May become depressed • Often rejected because of behavior Need structured firmness, clear understanding of procedures.

  39. Avoidant Personality Disorder (I) • 1-2% of general population • Sensitive to rejection • Lonely • Very timid • Inferiority feelings • Anxious/tense • Need acceptance • Vulnerable to comments about self

  40. Avoidant Personality Disorder (II) • Misperceives interviewing statements • Needs and wants companionship • May express fears of rejection • Phobic avoidance Should be approached with friendly acceptance, made to feel wanted and appreciated.

  41. Dependent Personality Disorder (I) • Lack of self-confidence • Relies on others • Does not assume responsibility • Passive, pessimistic, suggestible • Lack emotional endurance • Submissive • Fear of expressing sexual/aggressive feelings

  42. Dependent Personality Disorder (II) • Unable to make decisions on their own • Subject to abuse by others Patient should be told what has to be done. Should undergo behavior and assertiveness therapy/training.

  43. Obsessive-Compulsive Personality Disorder (I) • Perfectionist • Obsessed with orderliness • Obsessive thoughts • Affect constricted • Stiff, formal, rigid, stubborn • Anal stage of development • Want to be in control • Detailed answers when interviewed

  44. Obsessive-Compulsive Personality Disorder (II) • Rationalization • Intellectualizations • Doing-undoing/ritualistic behavior Should be dealt with in matter-of-fact, rigid routine and a formal relationship.

  45. Personality Disorder NOS • Passive-aggressive • Depressive • Sado-masochistic • Sadistic

  46. Personality Changes due to a General Medical Condition Significant changes of habitual pattern of premorbid behavior ICD-10 Personality and Behavioral Disease due to: Brain disease Brain damage Brain dysfunction Post-encephalopathy Syndrome Post-concussion Syndrome

  47. Personality Changes due to a Medical Condition (I) • Head trauma • Cerebrovascular disease • Cerebral tumor • Epilepsy (partial complex epilepsy) • Huntington’s Disease • Multiple Sclerosis • Endocrine disorders

  48. Personality Changes due to a Medical Condition (II) • Heavy metal poisoning (manganese, mercury) • Neurosyphillis • Acquired Immune Deficiency Syndrome (AIDS)

  49. Organic Personality DisorderDiagnostic Criteria (I) • Alteration of habitual pattern of behavior • Emotions, impulses and needs are affected • Defective cognitive function consequences of actions/planning

  50. Organic Personality DisorderDiagnostic Criteria (II) • Perseverance in goal-directed activity reduced • Unable to postpone gratification • Emotional lability • Euphoria, inappropriate jocularity • Sudden shift from cheerfulness to irritability • Outbursts of anger and aggression

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