Personality D/O

Question 1

temperament and early personality

Answer 1

• genes determein 50% of temperament
• inhibition and attachment and reward reinforcement are linked with genes
• temperament is stable my 2 y/o
• personality molded by interaction between temerament, experienced factors (neglect or abuse), and societal expectations

Question 2

what are stability factors of personality traits?

Answer 2

• stability increases over time
• reaches plateau by age 50 with only slight change after that
• stability of traits is involved in processing of 1) forming and maintaining self idnetity and 2) niche building in which ppl create, seek out, or find themselves in environments that fit with their personality traits

Question 3

what are the changing concepts of personality?

Answer 3

1. Early: psychodynamic theory: personality and temparment is determined by id, ego, superego
2. later: personality d/o are related to serious mental illnesses like schizophrenia, anxiety or mood d/o
3. recent: personality d/o are genetically influenced
4. personality d/o improve over time

Question 4

epidemiology of personality d/o

Answer 4

• 20% in US

- last 20 years that has been an increase in the most severe: antisocial and borderline

Question 5

social cultural factors of personality d/o

Answer 5

• the development of personality d/o are effected by the conflict of the personality traits and social cultural demands
• socially sensitive traits = enhanced, contained or buffered and in turn are externalized behaviors like antisocial and borderline
• socially insensitive traits are internalized; like depression and anxiety

Question 6

etiology

Answer 6

• there is some genetic influence on the vulnerability of personality traits
• there is 4 times more likely to develop personality d/o related to childhood maltreatment
  1. genes: they influence how vulnerable pt is, they also influence degree to which they place themselves at risk; genetically propelled individuals create their own enviornment and relationships

Question 7

personality cluster most likely to do tx

Answer 7

Cluster C (avoidant, dependent, OCD)

• borderline w/ anxiety and depressive fx
• milder forms of histrionic d/o

Question 8

medications and personality

Answer 8

meds do not change personality

meds are only used for sx managment in those w/ personality d/o

Question 9

cluster A

Answer 9

paranoid, schizotypal, and schizoid

• characterized by cognitive disturbances, suspiciousness, emotional flatness
• usually have odd behaviors, guarded, usually lack empathy

Question 10

paranoid personality d/o

Answer 10

• pervasive distrust of others
• 2.5% in general population; more common in men; may be part of schizophrenia specturm d/o or delusional d/o; strong heritability of suspiciousness and paranoid traits;
• parenting: sadistic, hostile, controlling, harsh punishment
• maternal verbal abuse and neglect during infancy increases risk of developing PPD as adults; child learns to be fearful mistrusting and vigilant for cues of impending sadistic tx from caregivers
• clinical presentation: rarely seek tx but may seek for anxiety or mood px or substance use or social conflict; view world as dangerous, unsafe place, they are suspicious w/out cause, usually think SO is unfaithful; they are reluctant to reveal information about selves and fear it would be used against them
• often feel mistreated or misjudged, hold onto grudges, hypersensitive, read into things,
• severe sx: percusatory beliefs, pathological jealousy, psychosis under stress
• may have low self esteem but appear grandiose
• may have increased risk for developing schizophrenia

Question 11

PPD in adolescents

Answer 11

-hypervigilant, social anxiety, social isolation, anger, hostility, peculiar thoughts

Question 12

PDD in adults, older adults

Answer 12

• adults: poor interpersonal relationships, px with work and px with living with others
• older adults: often make accusations of theft, barricade selves in room,

Question 13

schizoid personality d/o

Answer 13

• characterized by aloofness, lack of interest in forming relationships, detached for social relationships, restricted range of emotions, little desire for friends
• less than 1% of population; possible genetic link with schizophrenia, have abnormal PFC functioning, may be related to nutritional deficits inutero that lead to impaired brain development
• clinical presentations: don’t want to be close to others, isolate selves, don’t care about criticism from others, cold and aloof, don’t respond to social cues, structure lives to avoid others
• most likely work in non competitive jobs, isolate selves, avoid eye contact, don’t start or contribute to spontaneous conversation, hobbies are non human interests like math, astonomy, or animals,
• differential dx: autism/aspergersin in SZPD they do not have as severe impairment in social interactions or steriotypal movements
• if meds used: risperidone has been helpful in improving social relationships and other antipsychotics and antidepressants have helped
• usually onset is in childhood w/ social isolation; it stabilizes overtime; may have increased risk of schizophrenia

Question 14

schizotypal personality d/o (STPD)

Answer 14

• characterized by cognitive distortions and perceptions and deficits in relationships
• positive sx are similar to those in schizophrenia but to a lesser degree
• paranoid ideas, ideas of reference, odd beliefs and expereinces are all stable
• impaired functioning is less than in schizophrenia
• 1.2% general population
• 61% heretability and strong genetic link to schizophrenia and brain abnormalities similar to that of schizophrenia
• can have hx of birth complications (breathing, breech)
• childhood tx is high risk factor
• px with executive functioning, hyperarousal, impairment of eye tracking movement, elevated levels of DA and cortisol levels
• clinical presentations: difficulty with social skills, anxious in social situations, disturbances in thinking, superstitious or claim powers; they may have ideas of reference and unusual perceptions like bodily illusions but they do NOT have delusions or hallucinations
• differes from shcizophrenia, delusional d/o or mood d/o because don’t have long lasting psychosis;
• lack of desire for relationships
• antispychotics for psychotic like features and/or anxiety

Question 15

course of STPD

Answer 15

-childhood: social isolation, peculiar behaviors, px w/ school and fantasies
-adults: depression, dysthymia, anxiety d/o
20% may develop schizophrenia
-predicotrs for development of schizophrenia: magical thinking, paranoid ideation, social isolation
-10% commit suicide

Question 16

cluster B

Answer 16

• antisocial, borderline, histrionic, narcissistic

- tend to show dramatic, emotional, and impulsive behaviors

Question 17

antisocial personality d/o (ASPD)

Answer 17

–often reckless and do not learn form mistakes, do not anticipate consequences of their behavior, decieve others, crave constant novelty and excitement, have difficulty controlling their aggressive impulses
-3% ment 1% women
-has nearly doubled in last 15 years in US among young ppl
-some are high achievers; they do good in companies that are not rigid but instead are chaotic and have rapid change
-genetics account for 69%; children w/ one parent w/ ASPD have 16% chance developing; family hx of alcoholism, paternal criminality, conflict, divorce and poverty; parenting characterized by physical punishment, rejection, poor communication, lack of supervision; abandonment and physical and sexual abuse during first 5 years are associated with developing
-protective factors: conscience, constraint, intellegence, and absence of substance abuse
-may have slight brain abnormalities, have soft neurological signs, dysregulation of DA and SE systems; reduced PFC volume and functioning,
-presentation: child may bed wet, hit others, lying, aggressive, fire setting, cruel to animals, truancy; adults: irresponsible, impulsive, reckless, exploit, manipulate;
-may appear self centered, arrogant, usually do not show anxiety, depression or irrational thinking
-motivated by revenge
MOST difficult to tx of personality d/o
lack motivation to change,

Question 18

course of ASPD

Answer 18

childhood: CD, 40% of boys and 25% of girls with CD will later develop ASPD,
teenagers: engage in shop lifting, stealing cars,
young adults: impoverished, homeless, or incarcerated
30-40 year olds are unable to maintain employment or relatinships, may be involved in robbery or rape
-drink too much, cheat their employer, may be charming and successful in their careers
-impulsivity decreases by age 38
-cost to socity: crime, swindling, assault, abuse of family, failure to pay child support and scams

Question 19

characterization of personality d/o

Answer 19

• rapid maladaptive ways of responding to expereinces
• difficulty with interpersonal relationships
• px with self identity and difficulty with meeting the challenges of each stage of life

Question 20

Borderline personality disorder (BPD)

Answer 20

“border between neurosis and psychosis”

• affective instability, anger, impulsivity frequent
• identity distrubance, abandonment fears, self-injury are less frequent
• epidemiology: 1.5% of general population, onset early adulthood, 75% females,
• men who0 have similar sx are usually dx as ASPD or narcissitic
• etiology: genetically influenced personality traits (temperament characterized by high harm avoidance and high novelty seeking), neurodevelopmental vulnerabilities; presence of abuse, neglect, early unstable environments, parental psychopathology;
• 69% heritability, high in females, fx hx (substance use, ASPD, CD, learning d/o, mood d/o)
• usually have experienced unpredictable or abusive parenting; sexual abuse increases risk 3x

Question 21

abuse and BPD

Answer 21

• neglect in childhood is strongly associated with chronic self-harm
• pyshcially abused children may become violent but are less likely to self-harm
• sexual abuse is associated with multiple suicide attempts
• sexual abuse w/ incest rape causes guilt and rage; physical doesn’t cause guilt
• incest affects persons’s entire life and causes a distortion of all interactions

Question 22

biology and BPD

Answer 22

• 60% of pts have neurological soft signs indicating diffuse brain damage
• damage is seen in loearning disabilities and developmental delays
• pts w/ BPD have high rate of birth complications
• have high rate of childhood acquired brain injuries that may also compromise brain development
• there are abnormalities of brain structures involved in fear, aggression and creating socially appropriate responses
• trauma and stress may alter PFC and destroy hippocampal cells
• hyperresponsiveness of HPA axis is believed to be due to childhood abuse rather than pathology related to BPD

Question 23

presentation of BPD

Answer 23

• odd reasoning, px with information processing and memory,
• all black or white thinking
• unusual perceptions
• dissociation
• paranoia
• transient psychotic thoughts
• use maladaptive defense mechanism, splitting dissociation, denial, distortion, projective indentification
• emotional dysregulation: may use verbal tirades to display their intense anger, describe frustation, hurt and dissappointment, or complain of boredom or emptyness
• half of adult pts use transitional objects like stuffed animals or pillows to sooth selves, manage anxiety
• behavior dysregulation: impulsive behaviors (substance use, promiscuity, self harm); hx of repeated suicide attempts,
• unstable sense of self or identity confusion, unstable goals or values or types of friends
• chaotic relationshiops (see ppl as all good or all bad)
• close to someone then can become angry if something happens in relationship to frustrate them
• have difficulty being alone

Question 24

comorbidities w/ BPD

Answer 24

-greatest is GAD then MDD, Social phobia, PTSD, substance abuse

Question 25

differential dx w/ BPD

Answer 25

• not bipolar becuase usually a result of social relationships or interpersonal stressors
• not MDD because usually fx of emptiness, abandonment fear, and self destruction
• not schizophrenia because do not have prolonged psychotic episodes or thought d/o
• not histrionic, schizotypal, paranoid, narcissitic, or dependent or antisocial becuase they are self-destructive, anger in relationships, leading to termination of relationships, and feelings of emptiness

Question 26

pharmacology in BPD

Answer 26

• SSRIs effective for anger, anxiety, chronic emptiness, themper-outbursts, impulsive behaviors, decrease SI, facilitate psychotherapy but reducing sx
• lithium, depakote, carbamazepine may be used for irritability, impulsivity, mood swings
• some pt have good response to lamotrigne
• antipsychs may be used for transient psychotic sx may be used for sx of impulsivity and hostility, recklessness

Question 27

course of BPD in different populations

Answer 27

• children: impulsive, angry, hostile, learning px, behavior dyscontrol, social alienation
• adolescents: sx increases, imcomplete education, px relationships, substance abuse
• late adolescents: increased attempts at self harm, hospital admissions, difficulties in relationships, emotional instability
• adults: unstable emotions, crises due to impulsive decisions, unstable relationships, employment px
• mood and impulsivity decline some after 30 y/o; about half of pts have remission sx within two years; suicide risk highest in first 6 years of tx; risk for SI highest w/ those w/ depressive sx and substance abuse
• usually by 50 y/o only 10% meet criteria for dx

Question 28

histrionic personality d/o (HPD)

Answer 28

• poor understanding of cause and effect; theatrical/exagerative; flirtatious; temper tantrums or outburts; possible self destructive behavior; do not like to follow routines; seek new expereinces and thrills or relationships;
• epidemiology: 2-3%; dx more frequent in women, age of onset before 25 usually; common to have somatization d/o, conversion d/o, hypochondriasis, borderline, narcissitic, dependent
• etiology: increased rate in first degree; possiblity of genetic link w/ impulsivity and novelty seeking of ASPD; development of HPD may be due to deveiations in brain fx and expereinced factors; hyperresponsiveness of noradrenrgic systems is involved in emotional reactivity; hyperresponsiveness may contribute to sensitivity to rejection; the child was made to feel their value was dependent upone how attractive or pleasant and entertaining they were; family was chaotic and dramatic and often involved in performing arts; charm of child may distract the father from abusing mother or siblings; child is not pretty or entertaining enough to control father the family situation could become dangerous; child learns the survival value of being pretty distracting or entertaining

Question 29

biology of HPD

Answer 29

• cognitive processing: pts are thought to be right brain dominant (instead of answering questions they give you vivid detail)
• at infancy they may appear to find more gratification from external stimuli than others
• they recieve brief-highly charged and irregular reinforcemtn from multiple caregivers (learn to recieve gratification from short, concentration reinforcement)

Question 30

presentation of HPD

Answer 30

-exagerate thoughts and feelings; speech is dramagic; impressionistic; lack detail; express emotions exaggeratively or theatrically; physical appearance is to draw attention; prefer to be center of attention; uncomfortable when not in attention or display temper tantrums; behavior and interactions w/ others inappropriate
-HPD has continuum: mild end, a neurotic organization of personality and severe end, a primitive organization of personality
-pts w/ neurotic organization display seduction and fall in love w/ unavailable ppl and have good impulse control
pts w/ primitive organization are more dramatic and aggressive in seduction and have poor impulse control

Question 31

differential dx of HPD

Answer 31

-not narcissitic because they have to be center of attention nor just recieve praise or entitlement

Question 32

course of HPD

Answer 32

• adults form new relationships easily but unable to maintain them; fall in and out of love quickly
• employment may be adversely affected by their emotional instability and tendencey to become emotionally involved w/ co-workers
• w/ age they show few sx but sensation and attention seeking behaviors may get them into trouble w/ the law
• may abuse substance and act promiscuously

Question 33

narcissitic personality d/o (NPD)

Answer 33

• high sense of self-importance; entitlement; grandiose; lack empathy; difficulty accepting success of others; condescending attitude; hypersensitivity to critism; difficulty maintaining self esteem; many fantasies but few accomplishments; readily blame others and highly self referential
• epidemiology: 1%; men dx 3x more than women; traditional societies suppress narcissim; children taught to put families and community ahead of personal goals; more likely to develop in families that allow or actively encourage children to be self centered
• etiology: genetics influence high energy, over conscientiousness, and low tolerance for anxiety; not linked to axis I d/o; early expereinced factors are believed to be involved in development of NPDp

Question 34

clinical presentation of NPD

Answer 34

• features of NPD are attitudes rather than sx due to impairment of cognition, moods ovulation, anxiety, or impusilivity
• attitudes toward self (can be grandiosity and entitlement) to others (can be belittling, callous, or lack empathy)
• they are arrogant, entitled, grandiose, indicate they deserve special treatment, preoccupied with their power, view others as either superior or inferior to them, may seem indifferent to criticism while they hide feelings of low self esteem or have rage and anger of being criticised
• become angry, despondent, or dejected if entitlement is not supported
• impair fx of intimate relationships, work and social life
• suicidality can occur with px in those paradigms
• w/ age more px with work and social relationships

Question 35

differential dx of NPD

Answer 35

• not hypomania because NPD lacks elevated mood sx and not MDD because lacks severity and duration
• not ASPD because NPD is grandiosity, less encounters with justice system
• not BPD because they are less anxious, less chaotic life, and less fear of abandonment and SI attempts
• not HPD because they less likely to flirt or exhibit behaviors for attention

Question 36

course of NPD

Answer 36

• childhood: belief that they are special, unique, superior, and others should recognize that
• adolescents: self centered, assertive, domineering, arrogant
• adults: may be high achievers but often have difficulty in relationships with others
• because beauty, strength and youthful attributes are highly valued, pts struggle to stay young and positive changes in midlife are due to achievements, new stable friendships and ability to manage disappointments

Question 37

Avoidant Personality d/o (AVPD)

Answer 37

• central theme is shame, guilt, fear of rejection
• characterized b avoidance of social activities because of shyness, inadequacy and fear of being ridiculed; fear of rejection; have feelings of inadequacy, social ineptness, and being defective and have a tendency to avoid work and activities that involve contact w/ other ppl
• epidemiology: 3% of general population; high rates of co-occuring social phobia; can have PTSD, MDD, BPD, PPD, SZPD
• etiology: low heritability; some evidence suggest genetic link w/ social anxiety d/o; experienced factors are rejection, belittlement, criticism by parents may have increased risk for developing AVPD; childhood hx of emotional neglect, isolation, rejection has been reported

Question 38

biological basis of AVPD

Answer 38

• right hemisphere is abnormally developed; hyper-arousal of SNS (tachycardia, pupillary dilation, laryngeal tightness)
• increased levels of cortisol and abnormalities of cognitive processing

Question 39

clinical presentation of AVPD

Answer 39

• extreme sensitivity to rejection; desire a warm secure relationship but avoid interaction w/ others because fear of rejection
• avoid work stations involving contact w/others; often first born or an only child, usually unmarried and male
• live alone or w/ parents; tend not to have friends; socially isolated; px interaction w/ peers and strangers unless they are sure that they are going to be liked and accepted

Question 40

treatment of AVDP

Answer 40

• pharmacology: SSRI’s are first line for anxiety and rejection sensitivity and they seem to decrease the core sx of avoidant personality d/o, interpersonal hypersensitivity, and to improve social and performance anxiety
• one third of pts with avoidant personality disorder who receive SSRIs will be very much improved and another third will be improved
• second line meds include gabapentin and wellbutrin and some BZD; beta blocker atenolol may be used to manage ANS hyperactivity; antidepressant meds improve some core features of AVPD; some greater improvement w/ combo tx of meds and psychotherapy

Question 41

course of AVPD

Answer 41

• able to fx in protected environment; some marry but many limit their social network to family; may develop social anxiety d/o; may become depressed and anxious if social support systems fails; severity of sx lessens w/ age
• positive achievement experiences during childhood or adolescents are associated w/ remission and the greater number of positive experiences the better prognosis

Question 42

dependent personality d/o (DPD)

Answer 42

• they feel inadequate, incompetent, helpless
• difficulty making decisions; believe someone else must take care of them; separation from care provider is very frightening; strategies used to maintain relationships w caregiver are appearing to helpless and vulnerable and using threats of self harm and being ingratiating and providing help and then making the other person feel indebted
• because pts w/ DPD are afraid of disagreement they lead to rejection and this causes them to stay in bad or abusive situations, refuse to leave bad marriages, tolerate exploitative roommates or coworkers and perform demeaning jobs to be in the group
• epidemiology and etiology: 1.5%-5%; more common in women; heritability 57%; chroni physical illnesses in childhood increase risk; parental over protectiveness may prevent child from developing independent and autonomous behaviors;

Question 43

clinical presentations of DPD

Answer 43

-the core feature is the need to obtain and maintain nurturing supportive relationships; they experience distress if alone; preoccupied with fears of being left to care for themselves and doubt their ability to manage; appear submissive or passive; difficulty starting projects because lack of confidence and difficulty disagreeing w/ others; remain in abusive relationships in order to not disturb the attachment relationship

Question 44

differential dx for DPD

Answer 44

• not HPD or BPD because they have hx of long term relationships w/ one person unlike the others
• their fears of abandonment are not characteristic of BPD
• their need for approval and reassurance are not related to for the need to be center of attention like in HPD

Question 45

course of DPD

Answer 45

-severity of sx decrease w/ age; limited vocational achievement; risk for depression if they lose the person they depend on; risk for physical and sexual abuse and exploitation; w/ tx prognosis is favorable

Question 46

obsessive-compulsive personality d/o (OCPD)

Answer 46

preoccupied w/ orderliness, perfectionism and details; over conscientious, reluctant to delegate tasks, miserly and rigid; most prevalent and stable sx are rigidity, px with delegating work or tasks and perfectionism

• the perfectionism interferes w/ family life, socializing, completing a task and reaching goals
• epidemiology and etiology: 2% of population; men dx with it two times as often as women; more common in oldest children of family; heritability is 78%, moderately high; possible genetic fx between OCD and OCPD;

Question 47

clinical presentation of OCPD

Answer 47

• pt often present w/ stiff or rigid manner; try to control evaluation; responses are detailed
• preoccupied with lists, rules, regulations, orderliness, neatness, details, perfection
• pt veiw traits as ridid, obstancy, excessive orderliness, hoarding and parisomny as egosyntronic, not requiring tx
• in response to severe stressor they may develop depression or SI

Question 48

differential dx of OCPD

Answer 48

• not OCD because OCD has obsessions and compulsions
• not OCD because they are ego-dystonic, acceptable and not seen as problematic
• not NPD because it they can have doubts worries and self criticism and pts with NPD do not usually

Question 49

pharmacology in OCPD

Answer 49

• SSRIs like citaolpram and paroxetine are associated with increase cooperating and socializing w/ others and decrease in hostility and aggressive behaviors
• BZD like clonazepam has been found to reduce sx in OCD but its use in OCPD is not known

Question 50

course of OCPD

Answer 50

-unpredictable; some pts may develop OCD, some adolescents evolve into warm, open and loving adults; in others it can be prodromal stage of schizophrenia, or later development of MDD