PERSONALITY DISORDERS

1. PERSONALITY DISORDERS Robert A. Bashford, M.D. Associate Professor Michael Hill, M.D. Associate Professor UNC Department of Psychiatry

2. What is a personality?? • A generally consistent (but personal) style of interacting with the world and other people • Our ‘character’ is reflected in how we think, what and who we like, and how we respond to life • It is generally stable over timeallows some predictability • Types of personality traits are limited and can be conceptualized as dimensional • No trait or style is automatically indicative of disorder or disease (don’t confuse eccentricity with disorder)

3. What is a disorder? • Implies functional impairment / failure to achieve what is expected and/or significant and persistent emotional distress • In the case of Personality Disorders this is by definition a result of a ‘maladaptive’ personality style

4. What are the most ‘basic’ expectations of our culture • Indepedence

5. What are the most ‘basic’ expectations of our culture • Indepedence • Follow the rules

6. What are the most ‘basic’ expectations of our culture • Indepedence • Follow the rules • Maintain long-term relationships

7. Personality Disorders An enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individual’s culture. Manifested in two or more of the following: • (1) cognition • (2) affectivity • (3) interpersonal functioning • (4) impulse control

8. Personality Disorders • Pattern is enduring, inflexible, pervasive • Pattern is stable, of long duration • Not better accounted for by another mental disorder • Not due to substance or medical condition

9. Personality Disorders • Maladaptive behavior leads to poor life functioning • Ego syntonic (others are the root of all problems) • High incidence of co-morbidities (depression, anxiety, substance abuse) • Axis I disorders in PD patients are harder to treat • Difference between health and pathology one of degree (personality traits vs personality disorder)

10. How do personality disorders develop? • Genetic predispositions + environmental influences (including parenting, life experiences) + time = Personality formation • Obviously in a Personality disorder something in this complicated formula has gone wrong to lead to a maladaptive personality, but it is always very hard to pinpoint specific or simple causes.

11. What are the problems with Personality Disorders as a diagnostic category? • Labels are often pejorative • Diagnosis is contextual and thus somewhat arbitrary • Bad, obnoxious, hard-to-treat patients often get these labels whether justified or not • Treatment may be mis-directed

12. Personality Disorder Clusters • Cluster A - Odd, eccentric • Cluster B - Dramatic, emotional, erratic • Cluster C - Anxious, fearful

13. Cluster A Personality Disorders(‘odd & eccentric’) • Paranoid • Schizoid • Schizotypal • May be premorbid to schizophrenia in some cases

14. Paranoid Personality Disorder(diagnostic criteria) Pervasive distrust and suspiciousness, sees motives of others as malevolent. Four or more of the following: • (1)suspects, without sufficient basis, that others are exploiting, harming, or deceiving him or her • (2) preoccupied with unjustified doubts about the loyalty or trustworthiness of friends or associates • (3) reluctant to confide in others b/c lack of trust

15. Paranoid Personality Disorder • (4) persistently bears grudges, i.e., is unforgiving of insults, injuries, or slights • (5) reads hidden demeaning or threatening meanings into benign remarks/events • (6) Perceives attacks on character or reputation that are not apparent to others and responds with counterattacks • (7) has recurrent suspicions, without justification, regarding fidelity of spouse or sexual partner

16. Characteristics of Paranoid Personality Disorder • Aloof, emotionally cold • Unjustified suspiciousness, hostility • Hypersensitivity to slights, jealousy • Rigid, unforgiving, sarcastic, litigious • Prevalence: 1-2%; M>F • Therapy, including meds, of little value – trusting relationship is key but hard to come by b/o ‘self-fulfilling prophecy’

17. Schizoid Personality Disorder(diagnostic criteria) Pervasive detachment from social relationships and a restricted range of emotional expression interpersonally. Four or more of the following: • (1) neither desires nor enjoys close relationships, including being part of a family • (2) almost always chooses solitary activities

18. Schizoid Personality Disorder • (3) little interest in having sexual experiences with another person • (4) takes pleasure in few, if any, activities • (5) lacks close friends or confidants • (6) appears indifferent to the praise or criticism of others • (7) emotionally cold, detached

19. Characteristics of Schizoid Personality Disorder • Can perform well in solitary activities (computers, night watchman) • Limited emotional range, detached, daydream a lot • NO increased risk for schizophrenia but many may actually suffer from autism-spectrum disease • “Loners” not necessarily schizoid, unless functioning impaired (traits vs disorder) • Treatment of little help • Prevalence 2%; M>F

20. Schizotypal Personality Disorder(diagnostic criteria) Little capacity for close relationships accompanied by cognitive or perceptual disturbances and eccentricities of behavior • (1) ideas of reference • (2) odd beliefs or magical thinking, inconsistent with cultural norms • (3) unusual perceptual experiences, including bodily illusions

21. Schizotypal Personality Disorder • (4) odd thinking and speech (e.g.,vague, circumstantial,metaphorical,over elaborate) • (5) suspiciousness or paranoid ideation • (6) inappropriate or constricted affect • (7) behavior or appearance that is odd, eccentric, or peculiar • (8) lack of close friends or confidants • (9) excessive social anxiety r/t paranoid fears

22. Characteristics of Schizotypal Personality Disorder • Isolated, anhedonic, aloof but also “peculiar” • Strange intra-psychic experiences, odd and magical beliefs • Reason in odd ways (ideas of reference) • Anxious, detached • NOT psychotic proportions • 3% incidence; M=F

23. Schizotypal Personality Disorder • This is the closest DX to ‘Hollywood mental illness’ • Increased incidence of schizophrenia in family members • Low dose antipsychotic meds may help with more peculiar sx (but if so then what diagnosis do they really have??)

24. Cluster B Personality Disorders(‘emotional, dramatic, erratic’) • Antisocial • Borderline • Histrionic • Narcissistic

25. Antisocial Personality Disorder(diagnostic criteria) Pervasive pattern of disregard for and violation of rights of others since age 15 indicated by 3 or more of the following: • (1) repeatedly breaking the law • (2) deceitfulness - repeated lying, use of aliases, conning others for personal profit or pleasure • (3) impulsivity or failure to plan ahead

26. Antisocial Personality Disorder • (4) irritability and aggressiveness, as indicated by repeated physical fights or assaults • (5) reckless disregard for safety of self or others • (6) consistent irresponsibility - inconsistent work behavior, doesn’t pay bills/debts

27. Antisocial Personality Disorder • (7) lack of remorse, as indicated by being indifferent to or rationalizing having hurt,mistreated, or stolen from another • B. The individual is at least age 18 years. • C. There is evidence of Conduct Disorder with onset before age 15 years. • D. Antisocial behavior does not occur exclusively during Schizophrenia or a Manic Episode

28. Characteristics of Antisocial Personality Disorder • Aggressive, irresponsible, truant as teens. Get into fights, abuse substances, run away, cruel to animals, set fires, do poorly in school, repeated lying. • As adults see criminality, assaultiveness, impulsivity, substance abuse • More than 50% of prison population has ASPD, 3% of population, M:F 3-5:1

29. Antisocial Personality Disorder • Childhoods: rejection, neglect, abandonment, poverty, inconsistent discipline • 30% of fathers criminals, 50% of fathers alcoholics, chronically unemployed • Male first degree relatives have increased incidence of antisocial personality disorder, substance abuse

30. Antisocial Personality Disorder • Female first degree relatives have increased incidence of Somatization Disorder • Possible genetic component – gender effects may be relevant (BPD in women) • Increased incidence of non-specific EEG changes (increased slow-wave activity) • May be charming, manipulative

31. Antisocial Personality Disorder • The terms Antisocial PD, sociopathy (sociopath) and psychopathy (psychopath) are, for the most part, interchangeable • “Antisocial” does not mean asocial • Rarely seek help for personality change • Treatment is unsuccessful – which is why we often discount this diagnosis

32. Borderline Personality Disorder (diagnostic criteria) Pervasive instability of interpersonal relationships, self-image and affect with marked impulsivity by early adulthood. Five or more of the following: • (1) Frantic efforts to avoid real or imagined abandonment • (2) Pattern of intense and unstable interpersonal relationships, alternating b/w extremes of idealization and devaluation

33. Borderline Personality Disorder • (3) identity disturbance: markedly and persistently unstable self-image or sense of self • (4) impulsivity in at least two potentially self-damaging areas (sex, spending, substance abuse, reckless driving, binge eating) • (5) recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior • (6) affective instability w/ marked reactivity of mood, lasting few hours to few days • (7) chronic feelings of emptiness

34. Borderline Personality Disorder • (8) inappropriate, intense anger • (9) transient, stress-related paranoid ideation or severe dissociative symptoms (micro-psychotic episodes)

35. Characteristics of Borderline Personality Disorder • Death by suicide in 8% • 2%-4% incidence, M:F 1:2 • Tend to stabilize in their 40’s or 50’s • Increased prevalence of major depression and substance abuse in first degree relatives • The “borderland” between neurosis and psychosis

36. Borderline Personality Disorder • Almost always seem in a state of crisis • Unpredictable, impulsive behavior • Can’t tolerate being alone • Splitting and projective identification as defenses • High incidence of major depression • Treatment is psychotherapy and symptom-targeted pharmacotherapy, DBT • Comprise 10-20% of all psychiatry admissions

37. Histrionic Personality Disorder(diagnostic criteria) Pervasive excessive emotionality and attention seeking. Five or more of these: • (1) is uncomfortable in situations in which he or she is not the center of attention • (2) interaction with others is often characterized by inappropriate sexually seductive or provocative behavior

38. Histrionic Personality Disorder • (3) displays rapidly shifting and shallow expression of emotions • (4) consistently uses physical appearance to draw attention to self • (5) has a style of speech that is excessively impressionistic and lacking in detail • (6) shows self-dramatization, theatricality, and exaggerated expression of emotion • (7) is suggestible, i.e., easily influenced by others • (8) considers relationships to be more intimate than they actually are

39. Characteristics of Histrionic Personality Disorder • Colorful, dramatic, extroverted behavior in excitable, emotional persons • Inability to maintain deep, long-lasting attachments • Prevalence 2-3%, F>>M • Exaggeration of thoughts and feelings - everything is catastrophic or of extreme importance

40. Histrionic Personality Disorder • Temper tantrums, tears, seductive behavior, coy and flirtatious behavior • Endless need for reassurance • Superficial relationships, vain, self-absorbed • Treatment is directed towards clarification of inner feelings, psychoanalytically oriented psychotherapy

41. Narcissistic Personality Disorder(diagnostic criteria) Pervasive grandiosity, need for admiration, lack of empathy. Five or more: • (1) grandiose sense of self-importance, expects to be recognized as superior • (2) preoccupied with fantasies of unlimited success, power, brilliance, beauty, or ideal love • (3) believes he/she is “special,” unique and can only be understood by or should associate with other special people

42. Narcissistic Personality Disorder • (4) requires excessive admiration • (5) sense of entitlement • (6) interpersonally exploitative, i.e., takes advantage of others to achieve his or her own ends • (7) lacks empathy: is unwilling to recognize or identify with the feelings and needs of others • (8) is often envious of others or believes that others are envious of him or her • (9) shows arrogant, haughty behaviors or attitudes

43. Characteristics of Narcissistic Personality Disorder • <1% of general population; M>F • Become enraged at criticism • Fragile self-esteem, prone to depression • Their behavior produces interpersonal difficulties, rejection, loss, occupational problems, which they can’t handle • Chronic, difficult to treat • Aging is handled poorly • Treatment: psychotherapy; poor prognosis

44. Cluster C Personality Disorders(‘fearful and anxious’) • Avoidant • Dependent • Obsessive-Compulsive

45. Avoidant Personality Disorder(diagnostic criteria) Pervasive social inhibition, feelings of inadequacy, hypersensitivity to negative evaluation. Four or more: • (1) avoids occupational activities that involve significant interpersonal contact b/c of fears of criticism, disapproval or rejection • (2) is unwilling to get involved with people unless certain of being liked

46. Avoidant Personality Disorder • (3) shows restraint within intimate relationships because of the fear of being shamed or ridiculed • (4) is preoccupied with being criticized or rejected in social situations • (5) is inhibited in new interpersonal situations because of feelings of inadequacy • (6) views self as socially inept, personally unappealing, or inferior to others • (7) is unusually reluctant to take personal risks or to engage in new activities for fear of embarrassment

47. Characteristics of Avoidant Personality Disorder • Extreme sensitivity to rejection leads to socially withdrawn life • They have “an inferiority complex” • Uncertain, lack self-confidence, self-effacing • Withdraw and feel hurt if a request is refused or if they feel rejected or ridiculed • 0.5-1.0%; M=F

48. Avoidant Personality Disorder • Often take jobs “on the sidelines,” shy and eager to please • Subject to depression, anxiety, anger, phobic avoidance • Unlike schizoid, long for relationships • Treatment: Group or individual psychotherapy, SSRIs • Diagnosis overlaps greatly with Generalized Social Phobia

49. Dependent Personality Disorder(diagnostic criteria) Pervasive and excessive need to be taken care of, leads to submissive and clinging behavior and fears of separation. Five or more: • (1) has difficulty making everyday decisions without an excessive amount of advice and reassurance from others • (2) needs others to assume responsibility for most major areas of his or her life • (3) has difficulty expressing disagreement

50. Dependent Personality Disorder • (4) has difficulty initiating or doing things on own • (5) goes to excessive lengths to obtain nurturance and support from others • (6) feels uncomfortable or helpless when alone because of exaggerated fears of being unable to care for himself or herself • (7) urgently seeks another relationship as a source of care and support when a close relationship ends • (8) is unrealistically preoccupied with fears of being left to take care of himself or herself