personality disorders Flashcards
Enduring patterns of perceiving, relating to, and thinking about the environment
and oneself
Personality
Exhibited across numerous social and personal contexts
personality traits are inflexible and maladaptive enough to cause significant distress and impairment of functioning
Personality Disorder
Personality Disorders are much higher among who?
sub-groups
1. Psychiatric patients - 50%
2. Criminals - up to 85%
3. Alcohol-dependent patients - up to 70%
4. Drug-dependent patients - up to 90%
epidemiology of personality disorders
- Male overall - some types MC in females
- younger
- poorly educated
- unemployed
what is Personality Disorders’s Impact on Patients
↑ risk of many comorbidities and negative outcomes
- Reckless or impulsive behavior
- Physical injury from fights or accidents
- Suicide attempts
- Unplanned pregnancies
- High risk sexual behaviors - Psychiatric comorbidities
- Anxiety disorder, mood disorder, and/or substance use
- Less favorable responses to treatment - Functional impairment
- Self-care, occupational, social - Noncompliance with treatment
screenings for personality disorder
- Minnesota Multiphasic Personality Inventory-2 Restructured Form (MMPI-2-RF)
- Millon Clinical Multiaxial Inventory-III (MCMI-III)
which personality disorder screening has
338 T/F grouped into 10 scales
Developed to aid with mental disorder diagnosis but often used to get an idea of personality
MMPI-2-RF
which personality disorder screening has
175 T/F covering 4 scales
Information on personality style and patterns
Based off psych pts, not general pts
MCMI-III
how does personality disorder affect clinical relationships?
- Challenging to develop provider-patient rapport
- Patients often externalize difficulties
- Believe their own behavior is appropriate - More likely to see problems with:
- Patient distrust or irritability
- Poor communication skills
- Dependency and/or excessive demands - Increased risk of:
- After-hours phone calls and visits
- Angry outbursts from patient
- Repeated visits or hospital admissions
- Signing out AMA
- Noncompliance with medical treatment
how to improve patient-provider relationship with personality disorder
Develop and modify treatment plan with input from patient and caretakers
Present treatment plan carefully, without judgement
Step away from case if needed
Be aware of personal bias
Choose therapists experienced with personality disorders
how to improve communication in clinical relationship with personality disorder
Guidelines about when and how to contact the clinician
May be efficient to have patient call and speak to a nurse
in clinical relationships, be aware that personality disorder patients tend to:
- Have a greater sensitivity to side effects
- Take more of a drug than prescribed
- Be more likely to take alternative treatments
- Be at a higher risk for illicit substance use and alcohol
which cluster of personality disorder
Often do not seek tx unless dealing with acute problems
High levels of mistrust and interpersonal discomfort
Strong affirmation and careful handling can help rapport
Cluster A - schizotypal, schizoid, paranoid
which cluster of personality disorder
Often test and push limits of professional relationship
Power struggles, provocative behavior, self-harm gestures
Use caution not to cross appropriate boundaries while building relationship
Often the most challenging to maintain a therapeutic relationship
Cluster B - borderline, narcissistic, antisocial, histrionic
which cluster of personality disorder
More likely to take responsibility for their problems
More likely to readily engage in a dialogue to try to solve problems
Can be sensitive, stubborn, and need frequent affirmation
Cluster C - dependant, avoidant, obsessive-compulsive
which personality disorder
suspicious; overly sensitive; mistrustful; secretive; hyperalert
Paranoid - cluster A
which personality disorder
shy; introverted; withdrawn; avoids close relationships
Schizoid - Cluster A
which personality disorder
superstitious; socially isolated; suspicious; eccentric behaviors and speech
Schizotypal - Cluster A
Paranoid Personality Disorder is MC in who?
psychiatric inpatients
Slightly more common in women
Paranoid Personality Disorder
etiology is uncertain, but is seen in …
Increased in patients with parents who had irrational outbursts of anger
More common in pts with (+) FMHx of schizophrenia or delusional disorder, persecutory type
pt shows
Generalized distrust or suspiciousness of others such that their motives are interpreted as malevolent
they’re exhibiting cardinal symptoms of what disorder
Paranoid Personality Disorder
Feel they have been treated unfairly
Project blame to others
Hold long-lasting grudges
Read hidden meaning into benign remarks or events
Preoccupied with doubts about trustworthiness of others
Often no successful intimate relationships
High autonomy - hostile to those who they think are trying to control them, sometimes to the point of violence
emotionally, how are paranoid personality disorders?
defensive, oversensitive, secretive, suspicious, hyperalert, with limited emotional response
during exam, how would Paranoid Personality Disorder behave?
formal, businesslike, skeptical, mistrustful, poor eye contact or fixated eye contact
tx for Paranoid Personality Disorder
- pharm - little data; can try low-dose antipsychotics
- If acute decompensation and frank delusions = antipsychotics - Therapy - difficult due to mistrust and suspicion
prognosis of Paranoid Personality Disorder
- Pts usually have more adaptive capacity than other
personality disorders with severe social detachment - Under stress - withdraw, avoid attachments
- Can become overtly psychotic
Schizoid Personality Disorder is MC in who?
men - may be more severe too
Rare in clinical setting - avoid others
cause of schizoid personality disorder
Uncertain
1. Possible genetic predisposition
2. Pregnancy during famine may be a risk factor
3. May be related to environment devoid of nurturing
4. May be related to autism
Detachment from relationships, introversion, and restricted range of emotional expression
these are cardinal symptoms of?
Schizoid Personality Disorder
Does not necessarily cause distress to patient
Does not desire or enjoy close relationships, including family
Preference for solitary pursuits with no emotional involvement
Pleasure in few, if any, activities
Few to no intimate relationships and little apparent interest in others
Intact reality testing but often impaired interpretation of social interactions
how are Schizoid Personality Disorder emotionally?
distant, shy, introverted, withdrawn, avoid forming relationships with others
how do Schizoid Personality Disorder present on exam
formal, stiff, aloof, difficult to engage, no obvious desire to get to know others, impaired social skills
tx for Schizoid Personality Disorder
- Pharmacologic - little data
- If associated anxiety/depression = antidepressants - Therapy - often do not feel distressed
- Family/Group - can help clarify other’s expectations for pt and allow for social skill development; however pt will usually have minimal interaction
- Individual - pt often does not feel necessary due to no distress; emotional detachment can limit efficacy; however may have some usefulness
prognosis Schizoid Personality Disorder
Pts often have social detachment fairly early in life
Less likely to have anxiety/depression than most personality disorders
Avoiding situations that tax their social skills can help
epidemiology of Schizotypal Personality Disorder
3% (general population)
1. Up to 30% of general psychiatric pts have 1+ traits
2. Seen with mood, anxiety, and substance use disorders
3. Slightly more common in men
cause of Schizotypal Personality Disorder
Likely genetic link to schizophrenia
Much MC in relatives of schizophrenic pts
Believed to have similar etiologies with schizophrenia
Peculiar thoughts, speech and behavior, magical beliefs, and social difficulties
are cardinal symptoms for what personality disorder
Schizotypal Personality Disorder
Negative or poor rapport
Social dysfunction, social anxiety, and often social isolation
Often have depression and anxiety symptoms
No delusions or hallucinations; may experience illusions
Fascinated by unusual ideas but will consider other ideas if contradictory facts are presented
how are Schizotypal Personality Disorder emotionally
eccentric, superstitious, suspicious, social anxiety
how do Schizotypal Personality Disorders present on exam
inappropriate or constricted affect, odd beliefs, odd speech mannerisms, often go off on tangents
May have paranoid ideas (not delusions), believe clinician is judging/uncaring
tx for Schizotypal Personality Disorder
- Pharm - may try low-dose antipsychotics
- Mood stabilizers such as lithium may also be useful - Therapy
- Group - can help with social skill development
- Individual - supportive approach; emphasis on reality testing and recognizing cognitive distortions
prognosis of Schizotypal Personality Disorder
Anywhere from 10-25% progress to schizophrenia
Poor prognosis associated with paranoid ideation, social isolation, magical thinking, functional decline
Manipulative; selfish; lacks empathy; explosive anger; legal problems
what personality disorder
Antisocial
Dependent; demanding; unstable relationships, self image, and affect; impulsive, micropsychosis
what personality disorder
Borderline
dramatic; attention seeking; emotional; superficial
what personality disorder
histrionic
self-important; arrogant; grandiose; needs admiration; lacks empathy
what personality disorder
narcissistic
Antisocial Personality Disorder is MC in who?
- men
- Prisoners - >75%
- Alcoholics - >70%
Antisocial Personality Disorder has comorbids with what?
mood, anxiety and substance use disorders, ADHD, pathological gambling, learning disabilities, and other personality disorders
cause/risk factors of Antisocial Personality Disorder
Likely genetic and environmental
1. Genetics - 5x MC among first-degree relatives of pts with antisocial personality disorder
- Monozygotic twins - 67%; dizygotic twins - 31%
2. Environment - abusive/absent parents, or parents with poor parenting skills
- Erratic or inappropriate discipline, inadequate supervision
Low socioeconomic status also a risk factor
recurrent disregard for and violation of the rights and feelings of others that begins in early childhood and pervades all parts of the patient’s life; poor job performance; marital instability
these are cardinal symptoms of ?
Antisocial Personality Disorder
pts with Antisocial Personality Disorder often are diagnosed with what during childhood?
conduct disorder
Impulsive behavior, aggression towards others, school discipline problems, breaking the law
pts with Antisocial Personality Disorder often are diagnosed with what during Adolescence into adulthood
struggle with age-appropriate roles
- Poor job performance
- Pathological lying and the use of aliases
- Sexual activity and promiscuity at a younger age than their peers
- Unstable marriages - may see abuse, separation and/or divorce
what are additional symptoms of antisocial personality disorder?
Superficial, short-lived relationships with others
Commonly use illegal substances
Easily bored and impulsive
May exploit others for personal benefit
Rationalize behavior as necessarily defensive to avoid being exploited
how does Antisocial Personality Disorder present emotionally
selfish, callous, promiscuous, manipulative, unsympathetic, impulsive, unable to learn from past mistakes
how do Antisocial Personality Disorder present on exam
manipulative, can attempt to be charming, lack of empathy or remorse for actions, untrustworthy, difficult
tx for Antisocial Personality Disorder
- pharm - little evidence
- May use medication for adjunctive treatment of symptoms - Therapy - socially based interventions with others of similar temperaments and problems are tx of choice
- Group - can help the patients feel a sense of belonging
- Individual - generally ineffective; CBT may be helpful
prognosis of Antisocial Personality Disorder
- Most treatment-refractory personality disorder
- Behavioral problems peak in late adolescence-early adulthood
- 30-40% show significant improvement by mid-30s and 40s
- Tendency toward chronic alcoholism and late-onset depression
Borderline Personality Disorder is MC in who?
- 2-3x more common in women
- underdiagnosed in men → failure to seek tx - certain pt groups
- Psych outpatients - 9.3%, Psych inpatients - 20%
- ER pts - 20-30% - May be MC in Hispanic
which personality disorder makes up ⅓ or more of personality disorder pts
Borderline Personality Disorder
which personality disorder has up to 80% attempt suicide; 8-12% succeed
High drug abuse rate
Borderline Personality Disorder
cause of borderline personality disorder
Likely due to combination of genetics and environment
1. Genetics - More common in families of BPD pts
- Monozygotic twins - 35-36%; dizygotic twins - 7-19%
2. Environment - Often see history of childhood trauma
- Childhood sexual abuse - up to 71%
- Childhood physical abuse - up to 73%
- Other parental neglect, poor parental emotional interactions, and overindulgence of child may be associated
Impaired relatedness with others (“stormy relationships”), labile mood, impulsivity, self-injurious behavior, poor self-image
are cardinal symptoms of what personality disorder
Borderline Personality Disorder
Intense, unstable relationships - can go from seeing someone as perfect to cruel, betraying
Strongly resistant to partner leaving
Tend to view others as “all good” or “all bad”
Often interpret neutral events, words, or expressions as negative
Repeated and marked mood changes throughout the day
Impulsivity - substance abuse, binge eating, unsafe sex, wasting money, driving recklessly, quitting a job, ending a relationship
Suicide - threats are very common, but also high incidence of suicide
Chronic feelings of emptiness, boredom
Self-injurious behavior - cutting, burning - especially if hx of sexual abuse
additional symptoms of Borderline Personality Disorder
- substance abuse
- other psych disorders - PTSD, eating disorders, anxiety, depression
- other personality disorders
- Poor self-esteem and difficulty with self-identity
- Lack of self-control and self-fulfillment
- Occasional psychotic decompensation
how do Borderline Personality Disorder present emotionally
dependent, demanding, rapidly changing mood, inappropriate anger, paranoia, aggression
how does Borderline Personality Disorder present on exam
labile mood, difficult, dependent, demanding, may feel irrational attachment or fear abandonment
tx for borderline personality disorder
- Pharm
- Lithium - ↓ anger, irritability, self-mutilation
- Carbamazepine - ↑ behavior control, ↓ anger and impulsivity
- Antipsychotics - ↓ paranoia, aggression, impulses, depression
- SSRIs - ↓ labile mood, aggression, maladaptive behavior - Therapy
- Group/Family - can help interpersonal problems, avoid attachment to one specific person (i.e. therapist)
- Individual - Difficult; emphasis on stress tolerance, coping skills, self-management can help
prognosis for borderline personality disorder
- Self-destructive behavior can be lethal if it progresses
- Patients sometimes will “sabotage” treatment that is going well
- Impulsive/dangerous behaviors usually decline in middle age
- Poor prognosis → antisocial behaviors, chronic anger,
over-involvement in family relations, overuse of medical facilities - Good prognosis → higher intelligence, better self-discipline, superior social supports
Histrionic Personality Disorder is MC in who?
women - up to 12% of females
overlooked in men
Much higher rates in clinical settings
Likely to seek treatment
cause of Histrionic Personality Disorder
- Some evidence for genetic link
- Associated with antisocial personality disorder in particular - Problematic parent-child relationships may contribute
Deliberate use of excessive, superficial emotionality and sexuality to draw attention, evade unpleasant responsibilities, and control others
are cardinal symptoms of what personality disorder
Histrionic Personality Disorder
Enjoy being the center of attention
May become disappointed or sulk if something draws attention away
Labile mood - temper tantrums, tearful outbursts, dramatic accusations
Seek to provoke guilt, sympathy or acquiescence from others
Often very concerned with their physical appearance
Frequently act seductively, flirtatiously, or provocatively
Enjoy superficial qualities of relationships but often have trouble sustaining long-lasting, meaningful relationships
how are Histrionic Personality Disorders emotionally
dependent, insecure, seductive, egocentric, superficial
how are Histrionic Personality Disorders on exam?
may act inappropriately seductive, demands attention, can become quickly dependent on provider; seeks instant gratification
tx for Histrionic Personality Disorder
- pharm - little evidence; MAOIs may be helpful
- tx of comorbid anxiety/depression (e.g., SSRIs) often useful - Therapy
- Group - therapy with like-minded individuals can provide a mirror for the patient’s own behavior
- Couple/Marital - difficult; often don’t like to give up control in relationship
- Individual - can be difficult due to patient’s labile nature and dependency
prognosis of Histrionic Personality Disorder
Fairly good; patients tend to improve over time regardless of treatment
Can become depressed if they feel abandoned, but often short-lived
Poorer prognosis if they meet criteria for other cluster B disorders
Narcissistic Personality Disorder is MC in who?
Esp common in psychiatric pts - 2-16%
MC in men
cause of Narcissistic Personality Disorder
Theorized that parents do not show clear appreciation of a child’s accomplishments
May also be linked to excessive attention and over-gratification concerning a child’s accomplishments
Grandiosity, notable lack of empathy, lack of consideration for others, and a sense of entitlement
are cardinal symptoms of which personality disorder
Narcissistic Personality Disorder
Hypersensitivity to criticism and evaluation
Feel as if they deserve special treatment and admiration
Frequently boastful - appear haughty, arrogant, and irritating
May be superficially charming
Self absorbed - often struggle with commitment
Prone to externalize their problems
Often vain of their appearance and struggle with aging
Can become depressed and withdraw if their self-image is damaged
how do Narcissistic Personality Disorder present emotionally
arrogant, vain, selfish, unsympathetic, craves attention
how do Narcissistic Personality Disorder present on exam
“spoiled” or entitled, selfish, respond poorly to criticism, often do not accept blame, desire admiration and attention
tx for Narcissistic Personality Disorder
- Pharm - little data
- Can use medication for comorbid disorders - depression, anxiety, etc. - Therapy
- Group - therapy with like-minded individuals can provide a mirror for the patient’s own behavior; can become difficult if pt is criticized by others
- Couple/Marital - often willing to attend; therapist must take care not to solely place blame on narcissistic patient
- Individual - difficult; often have high expectations of therapist and respond poorly to criticism and being confronted with their behavior
anxious; fears rejection; overly sensitive; poor social skills
which personality disorder
avoidant
clinging; submissive; self-sacrificing; needs to be taken care of; passive
which personality disorder
dependent
preoccupied with orderliness, perfectionist, need for control
which personality disorder
obsessive-compulsive
Avoidant Personality Disorder is MC in who?
women
cause of Avoidant Personality Disorder
May be in part due to “stagnation” when going through the normal developmental stage of shyness and fear of strangers
Young people often outgrow social awkwardness - caution when diagnosing in children and adolescents
Persistent pattern of avoidance due to anxiety that causes a restricted lifestyle, and introversion with limited social interactions
are cardinal symptoms of which personality disorder
Avoidant Personality Disorder
Introverted, inhibited, anxious individuals
Low self-esteem and sensitive to rejection
Awkward and uncomfortable in social situations - afraid of being embarrassed or acting foolish
Anxious discussing problems - may see innocent questions as criticism
Avoid unfamiliar situations
Fears of rejection cause social withdrawal (not disinterest in others)
Few relationships; tend to have a passive role
how does Avoidant Personality Disorder present emotionally
anxious, withdrawn, sensitive, feelings of inadequacy
how does Avoidant Personality Disorder present on exam
restrained, anxious, shy, respond poorly to criticism
tx for Avoidant Personality Disorder
- pharm - SSRIs, MAOIs and BB - anxiety
- Other anxiolytics can also be useful - buspirone, BZDs - Therapy
- Group - can help patient overcome fears in a controlled setting
- Individual - essential to establish trust with patient as they may be reluctant to disclose personal information for fear of rejection
what makes the prognosis bad for avoidant personality disorder
other personality disorders, poor environment
Dependent Personality Disorder is MC seen in who?
Very high proportion in clinical setting - seek tx
More common in women
cause of Dependent Personality Disorder
May be related to childhood environment where dependent behaviors were rewarded and independent activities discouraged
Possible genetic influence
Lifelong interpersonal submissiveness
is the cardinal symptom of which personality disorder
Dependent Personality Disorder
Poor self-esteem and feelings of inadequacy
Rely heavily on others to get their needs met
Strong fear of abandonment - represses displeasure or anger with
others to avoid driving them away
Lack of self confidence and difficulty doing things alone
Often seek to be in a new relationship as soon as an old one ends
Often have difficulty making decisions alone
Will outwardly agree with others when they really do not
how does Dependent Personality Disorder present emotionally
submissive, agreeable, needy, clingy, indecisive
how does Dependent Personality Disorder present on exam
often engage easily but withhold personal information for fear of alienating the provider; seek input from others
tx for Dependent Personality Disorder
- pharm - SSRIs or TCAs - fatigue, malaise and anxiety, in times of separation
- Therapy - patients often do not feel distressed
- Family/Couples - recruit others to reinforce patient’s attempts at autonomy
- Group - considerable benefit; helps patient try out new and more constructive interpersonal behaviors in a safe environment
- Individual - assertiveness training, decision making skills
prognosis of Dependent Personality Disorder
good prognosis, especially if no other comorbid diagnoses
More capacity for empathy and trust than other disorders
Obsessive-Compulsive Personality Disorder is MC in who
- Seen more in clinical setting, but not as much as some personality disorders
- often see their own traits as desirable - MC in men
cause of Obsessive-Compulsive Personality Disorder
- Possibly related to overly controlling parenting
- Possible stagnation in “anal stages” of development
- Genetics - more common in first degree relatives
Rigidity, constricted affect, inflexibility, stubbornness, need for orderliness and control
are cardinal symptoms of which personality disorder
Obsessive-Compulsive Personality Disorder
Perfectionism and over-conscientiousness are common
Difficulty in personal relationships - do not like to compromise or submit
Occupational difficulty - often refuse to work with others
Muted emotional tones and responses
Often frugal - may have miserly spending habits and show problems throwing out worthless objects even without sentimental value
Can be excessively devoted to work to the exclusion of leisure activities
May display preoccupation with lists, organization, schedules
how do Obsessive-Compulsive Personality Disorder present emotionally?
stubborn, rigid, perfectionist, controlling
how do Obsessive-Compulsive Personality Disorder present on exam?
can seem inflexible and high-strung, perfectionist, formal, stiff, self-conscious, desire to be a “good patient”
tx for Obsessive-Compulsive Personality Disorder
- pharm - no strong indication for medication
- SSRIs - helps lessen perfectionism and associated anxiety/depression - Therapy - patients often do not feel distressed
- Family/Couples - attempt to help patient relinquish control over others
- Group - difficult; attempt to ally themselves with the therapist and treat the other group members, who have the “real” problems
- Individual - desires to be good patient but has distrust and constriction, often highly critical of self or of therapy
Obsessive-Compulsive Personality Disorder are prone to develop what other disorders
anxiety and depression
