777 final Personality Disorders

Question 1

Personality Disorders

Answer 1

An enduring pattern of inner experience and behavior that manifests in two or more of the following:
cognition (i.e., ways of perceiving and interpreting self and others); Affectivity (i.e., range, intensity, lability) ;Interpersonal functioning; Impulse control

The enduring pattern is inflexible
It leads to significant distress or impairment in functioning
The pattern is stable and can be traced back to adolescence or early adulthood

Question 2

Why should you look for personality disorders?

Answer 2

Prevalence estimated between 6-13% of the adult population in the United States has a personality disorder!!
Recognizing personality disorders can guide your approach to them
Identifying a personality disorder allows you to assess for comorbities including Axis I disorders and suicide risk

Question 3

Knowing how to approach these patients helps with:

Answer 3

understanding confusion about why patients do not act as you expect them to
the emotional distress they can illicit
protecting you from inappropriate relationships and engaging in medical practice outside your standard of care

Question 4

Etiology

Answer 4

Likely multi-factorial like almost all other psychiatric diagnoses.
Genetic and environmental factors such as chaotic home environment and abuse have been implicated in development of maladaptive behavioral patterns.

Question 5

Genetics of PD

Answer 5

For comparison heritability of normal personality traits is approximately 0.5
Molecular genetics studies of PDs indicate that genes linked to neurotransmitter pathways, particularly the serotonergic and dopaminergic systems are involved.

Question 6

? Cultural influences ?

Answer 6

Studies have found that in Norway compared to US, Germany and UK avoidant personality 3-4X more prevalent, dependent personality 2-3X more prevalent and schizoid is 2X more prevalent. Borderline is

Question 7

Personality Disorder Clusters

Answer 7

Cluster A: (weird)
Cluster B: (wild) dramatic
Cluster C: (wimpy)

Question 8

Personality Disorder Clusters

Answer 8

Cluster A: suspicious, odd
Paranoid, Schizoid, Schizotypal
Cluster B: dramatic
Antisocial, borderline, histrionic, narcissistic
Cluster C: anxious
Avoidant, dependent, obsessive-compulsive

Question 9

Paranoid Personality disorder

Answer 9

A pervasive distrust and suspiciousness of others such that their motives are interpreted as malevolent.
Suspects others are exploiting or deceiving him
Preoccupied with unjustified doubts of loyalty
Is reluctant to confide in others because he believes they will use the information against him

Question 10

Paranoid Personality Disorder cont.

Answer 10

Reads hidden demeaning meanings into benign remarks
Persistently bears a grudge
Perceives attacks on his character
Recurrent suspicions regarding fidelity of spouse or sexual partner

Question 11

Schizoid Personality Disorder

Answer 11

Pervasive pattern of detachment from social relationships and restricted expression of emotion with 4 or more the following:
Neither desires nor enjoys close relationships
Almost always chooses solitary activities
Little if any interest in sexual experiences with another person
Takes pleasure in few in any activities
Lacks close friends other than first-degree relatives
Appears indifferent to the praise or criticism of others
Shows emotional coldness or flattened affect

Question 12

Schizotypal Personality Disorder, part 2

Answer 12

A pervasive pattern of social and interpersonal deficits with reduced capacity for close relationships as well as cognitive or perceptual distortions and eccentricities of behavior with 5 or more of the following:
Ideas of reference
Odd beliefs or magical thinking
Unusual perceptual experiences including bodily illusions
Odd thinking and speech
Suspiciousness or paranoid ideation
Inappropriate or constricted affect
Behavior or appearance that is odd or eccentric
Lack of close friends other than first-degree relatives
Excessive social anxiety that does not diminish with familiarity

Question 13

Antisocial Personality Disorder

Answer 13

A pervasive pattern of disregard for and violation of the rights of others occurring since the age of 15 years as indicated by 3 or more of the following:
Failure to conform to social norms with respect to lawful behaviors
Deceitfulness and conning others for personal profit or pleasure
Impulsivity or failure to plan ahead
Irritability or aggressiveness as indicated by repeated fights or assaults
Reckless disregard for safety of self or others
Consistent irresponsibility
Lack of remorse
There is evidence of Conduct Disorder with onset before age 15

Question 14

Neuroimaging and psychopathy

Answer 14

Study by Blair found person with psychopathic tendencies showed decreased amygdala and orbitofrontal cortex responses to emotionally provocative stimuli which the author felt was suggestive of difficulties with basic forms of emotional learning and decision making.

Question 15

Borderline Personality Disorder

Answer 15

Pervasive pattern on instability of interpersonal relationships, self image and affects and marked impulsivity as indicated by 5 or more of the following:
Frantic efforts to avoid abandonment
Unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation

Question 16

Borderline Personality Disorder continued

Answer 16

Identity disturbance
Impulsivity in at least two areas that are potentially self-damaging
Recurrent suicidal behaviors, gestures or threats or self-mutilating behaviors
Affective instability due to a marked reactivity of mood
Chronic feelings of emptiness
Inappropriate anger
Transient, stress-related paranoia

Question 17

Histrionic Personality Disorder

Answer 17

Pervasive pattern of excessive emotionality and attention seeking indicated by >5 of the following:
Uncomfortable in situations in which he is not the center of attention
Interaction with others often characterized by inappropriate sexually seductive behavior
Displays rapidly shifting and shallow expression of emotion

Question 18

Histrionic Personality Disorder (cont)

Answer 18

Consistently uses physical appearance to draw attention to self
Has a style of speech that is excessively impressionistic and lacking in detail
Shows self-dramatization and exaggerated emotion
Is suggestible
Considers relationships to be more intimate than they are

Question 19

Narcissistic Personality Disorder

Answer 19

A pervasive pattern of grandiosity (in fantasy or behavior), need for admiration, lack of empathy as indicated by >5 of the following:
Grandiose sense of self-importance
preoccupied with fantasies of unlimited success, power, brilliance or beauty
Believes he is special and can only be understood or should associate with other special or high status people
Requires excessive admiration
Has a sense of entitlement
Is interpersonally exploitive
Lacks empathy
Is often envious of others and believes others are envious of him
Shows arrogant, haughty behaviors or attitudes

Question 20

Avoidant Personality Disorder

Answer 20

A pervasive pattern of social inhibition, feelings of inadequacy and hypersensitivity to negative evaluation as indicated by >4 of the following:
Avoids social occupations that involve significant interpersonal contact
Is unwilling to get involved with people unless certain of being liked
Is preoccupied with being criticized in social situations
Shows restraint in intimate relationships because of fear of being shamed or ridiculed
Inhibited in new interpersonal situations because of feeling inadequate
Views self as socially inept and unappealing
Is unusually reluctant to take personal risks or engage in any new activities because they may prove embarrassing

Question 21

Dependent Personality Disorder

Answer 21

A pervasive and excessive need to be taken care of that leads to submissive and clinging behaviors and fears of separation as indicated by >5 of the following:
Has difficulty making everyday decisions without an excessive amount of reassurance
Needs others to assume responsibility for most major areas of his life
Has difficulty expressing disagreement with others because of fear of loss of approval
Difficulty initiating projects on his own because of lack of self confidence
Goes to excessive lengths to obtain nurturance and support from others
Feels uncomfortable or helpless when alone
Urgently seeks another relationship as a source of care and support when a relationship ends
Is unrealistically preoccupied with fears of being left to take care of himself

Question 22

Obsessive-Compulsive Personality Disorder

Answer 22

A pervasive pattern of preoccupation with orderliness, perfectionism and mental and interpersonal control at the expense of flexibility, openness as indicated by >4 of the following:
Preoccupied with details, rules, lists, order or schedules to the extent that the major point of the activity is lost
Shows rigidity and stubbornness
Perfectionism that interferes with task completion
Excessively devoted to work and productivity to the exclusion of leisure activity and friends
Over conscientious and inflexible about matters of morals or ethics
Is unable to discard worn or worthless objects even those without sentimental value
Reluctant to delegate tasks
Adopts miserly spending style toward self and others

Question 23

Treatment

Answer 23

Can reduce symptomatology, improve social and interpersonal functioning, reduce frequency of maladaptive behaviors and decrease hospitalizations.
Always screen for comorbid psych dx
If the personality disorder is ego-syntonic (eg. Antisocial and Narcissistic) it will be hard to engage the patient in treatment

Question 24

Medication Treatment

Answer 24

Increasing serotonin levels may reduce depression, impulsiveness, rumination and may enhance a sense of well being
Low dose neuroleptics and mood stabilizers can may be effective in modulating affective stability

Question 25

Therapy

Answer 25

For BPD DBT, Schema-focused therapy, transference-focused therapy and Mentalization-based treatment have all been found to be effective.
Therapy for other disorders limited to a small number of open labeled trials and case studies. These findings have been positive.

Question 26

Screening for comorbid disorders

Answer 26

Antisocial PD: Alcohol dependence and depressive disorders
BPD: alcohol and drug dependence, mood disorders, anxiety disorders inc PTSD
Histrionic PD: alcohol dependence, somatization disorder
Avoidant PD: social phobia
Any PD puts pt at higher risk than the gen population for Etoh and drug dep.