Personality Disorders 2 Flashcards
f•Tx of choice is individual psychotherapy
•Unlikely to seek tx unless under increased stress or pressure in life.
Tx usually short-term in nature until they have solved the immediate crisis or problem → patient will then likely terminate therapy
•Goals of tx are often solution-focused, using brief therapy approaches.
Tx for Schizoid PD
- Consistent irresponsibility, as indicated by repeated failure to sustain consistent work behavior or honor financial obligations.
- Lack of remorse, as indicated by being indifferent to or rationalizing having hurt, mistreated, or stolen from another.
Antisocial PD
Does not occur exclusively during the course of:
- schizophrenia
- bipolar disorder or depressive disorder with psychotic features
- another psychotic disorder
- autism spectrum disorder
- not attributable to the physiological effects of another medical condition.
Schizoid PD
- Personality style → mercurial
- Predominant theme → instability of interpersonal relationships, self-image, affects, and control over impulses
Borderline PD
A pervasive pattern of disregard for and violation of the rights of others, occurring since age 15 years
Antisocial PD
- Impulsivity or failure to plan ahead.
- Irritability and aggressiveness, as indicated by repeated physical fights or assaults.
- Reckless disregard for safety of self or others.
Antisocial PD
•Because of the tendency to blame others, low tolerance for frustration, impulsivity and inability to form trusting relationships, working with these individuals is difficult.
Antisocial PD
- Usually seek treatment for associated anxiety and depression rather than the PD
- Over 50% admitted to clinical setting have a concurrent major depressive disorder
Schizotypal PD tx
- Often react passively to adverse circumstances
- Difficulty responding appropriately to important life events
- Occupational functioning may be impaired, (particularly if interpersonal involvement is required)
- may do well when they work under conditions of social isolation
Schizoid PD
Mnemonic for Antisocial PD
C – cannot follow law
O – obligations ignored
R – remorselessness
R – recklessness
U – underhandedness
P – planning deficit
T – temper
- Frustration about patient’s misinterpretation of illness
- Not wanting to connect with an odd and eccentric patient
Problematic behavior of provider caring for Schizotypal PD pt
- Does not desire/enjoy close relationships (family)
- Almost always chooses solitary activities
- Little interest if any in sex
- Pleasure in few activities
- Lacks close friends other than 1st degree relatives
- Indifferent to praise/criticism
- Emotional coldness, detachment, flattened affect
Schizoid PD
Often present in to the Emergency Department (ED)
- Utilize crisis hotline, or contact their therapist or treating provider directly
- Caution with treating patient with this disorder in blind conjunction with another set of providers.
- Every attempt should be made to contact the patients provider or primary therapist as soon as possible → ideally before the administration of medication
Tx for Borderline PD
- Pervasive pattern of detachment from social relationships
- Restricted range of expression of emotions in interpersonal settings
- Beginning by early adulthood, present in variety of contexts
Schizoid PD
- Inappropriate or constricted affect.
- Behavior or appearance that is odd, eccentric, or peculiar.
- Lack of close friends or confidants other than first-degree relatives.
Schizotypal PD
Schizoid PD Mnemonic
S – shows emotional coldness
O – omits close relationships
L – lacks close friends or confidants
I – involved in solitary activities
T – takes pleasure in few activities
A – appears indifferent to praise or criticism
R – restricted interest in sexual experiences
Y – yanks himself / herself from social relationships
Mnemonic for Borderline PD
A – abandonment
M – mood instability (marked reactivity of mood)
S – suicidal or self-mutilating behavior
U – unstable and intense relationships
I – impulsivity
C – control of anger
I – identity disturbance
D – dissociative or paranoid symptoms that are transient and stress related
E – emptiness
- Respond with inappropriate anger when faced with unavoidable change
- Frequent shifts of allegiance
- Cannot tolerate being alone and will frantically search for companionship no matter how unsatisfactory
Borderline PD
Pharmacotherapy
- SSRI Antidepressants → help to promote sense of well being and reduce depression, impulsiveness, rumination
- Sertraline (Zoloft)
- Fluoxetine (Prozac)
- Mood stabilizerrs → help to modulate affective instability
- Lamotrigine (Lamictal)
Tx for Borderline PD
A pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity, beginning by early adulthood and present in a variety of contexts
Borderline PD
- Frantic efforts to avoid real or imagined abandonment. (Note: Do not include suicidal or self-mutilating behavior covered in Criterion 5.)
- A pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation.
Borderline PD
There is overlap among which 3 things?
- Antisocial PD
- Psychopathy
- Criminality
Mnemonic for schizotypal PD
M – magical thinking that influences behavior, superstitiousness or the paranormal
E – eccentric behavior or appearance
P – paranoid ideation
E – experiences unusual perceptions
C – constricted affect
U – unusual thinking & speech
L – lacks friends
I – ideas of reference
A – anxiety (socially)
R – rule out psychotic disorders
What is the difference between antisocial PD and antisocial behavior?
There IS a difference.
- Overzealous attempts to connect with patient
- Frustration at feeling unappreciated
Problematic behavior of provider treating schizoid pt
- Try not to be turned off by patient’s odd appearance
- Try to educate patient about the illness and its treatment
- Do not become overly involved in trying to provide social support
Provider strategies for tx Schizotypal PD pt
- Excessive social anxiety that does not diminish with familiarity and tends to be associated with paranoid fears rather than negative judgments about self.
- Does not occur exclusively during the course of schizophrenia, a bipolar disorder or depressive disorder with psychotic features, another psychotic disorder, or autism spectrum disorder.
Schizotypal PD
- Help patient understand how they create their own problems and how their distorted perceptions prevent him from seeing themselves the way others view them
- How to control behaviors
Cognitive behavioral therapy for Antisocial PD
- The individual is at least age 18 years.
- There is evidence of conduct disorder with onset before age 15 years.
- The occurrence of this type of behavior is not exclusively during the course of schizophrenia or bipolar disorder.
Antisocial PD
- May have difficulty expressing anger, even in response to direct provocation (contributes to the impression that they lack emotion)
- May experience brief psychotic episodes in time of stress
- Proverb interpretation is abstract
Schizoid PD
- Central feature is instability
- Difficulty controlling anger
- Feelings of chaos and emptiness
- Thoughts of self-destruction
- Marked impulsivity
Borderline PD
- Succumbing to patient’s manipulation
- Angry, punitive reaction when manipulation is discovered
Problematic behavior of provider treating pt w/ Antisocial PD
Individuals often appear dramatic, emotional, or erratic
- Antisocial
- Borderline
- Histrionic
- Narcissistic
Cluster B
- Mood and anxiety disorders, substance abuse disorders
- Paranoid PD, schizotypal PD
Comorbid disordes or Borderline PD
- Irresponsible, impulsive, or dangerous health behavior, without regard for consequences to self or others
- Angry, deceitful, or manipulative behavior
- Often lack the motivation to improve and are notoriously poor self-observers → they simply do not see themselves as others do.
Problematic behavior of pt with Antisocial PD
- May delay care because of odd and magical beliefs about symptoms, may not recognize symptoms as a sign of illness
- May appear odd and eccentric and paranoid toward others
Problematic behavior of Schizotypal PD pt
-
Low dose antipsychotics
- Risperidone (Risperdal)
- Olanzapine (Zyprexa)
-
Long-acting anxiolytics for social anxiety
- Clonazepam (Klonopin)
Tx for Schizotypal PD
- Lack of regard for society’s moral or legal standards and an impulsive and risky lifestyle
- Irresponsible, impulsive, and deceitful
- Lack a conscience, empathy, and remorse
Antisocial PD
- Can fool even the most experienced clinicians, appear composed and credible, but beneath the veneer there is tension, hostility, irritability and rage
- Poor job performance, academic failure, illegal activities, impulsive behavior, reckless
Antisocial PD
Psychotherapy has been the treatment of choice
- Dialectical Behavior Therapy (DBT) – most effective
- Schema focused therapy
- Transference focused therapy
Tx for Borderline PD
- Personality style → adventurous / non-conforming
- Predominant theme → disregard for and violating the rights of others, lying, stealing, defaulting on debts, neglect of children or other dependents
Antisocial PD
- Mistrust of providers and delay in seeking treatment
- Intense fear of rejection and abandonment
- Abrupt shifts from idealizing to devaluing caregivers; splitting
- Self-destructive threats and acts
Problematic behavior of pt w/ Borderline PD
- Ideas of reference (excluding delusions of reference).
- Odd beliefs / magical thinking that influences behavior and is inconsistent with subcultural norms (superstitiousness, belief in clairvoyance, telepathy, or “sixth sense”; in children and adolescents, bizarre fantasies or preoccupations).
- Unusual perceptual experiences, including bodily illusions (perceptual distortions)
- Odd thinking and speech (vague, circumstantial, metaphorical, overelaborate, or stereotyped).
- Suspiciousness or paranoid ideation.
Schizotypal PD
- See things differently from other people / seems impossible to relate to them
- Odd beliefs, behavior, appearance, and interpersonal style
- Unable to negotiate the full range of affects and interpersonal cuing required for successful relationships
Schizotypal PD
- Identity disturbance: markedly and persistently unstable self-image or sense of self.
- Impulsivity in at least two areas that are potentially self-damaging (e.g., spending, sex, substance abuse, reckless driving, binge eating). (Note: Do not include suicidal or self-mutilating behavior covered in Criterion 5.)
Borderline PD
- Schizotypal PD → premorbid personality of patient with schizophrenia
- Major depressive disorder (MDD), bipolar I and II disorders, social and specific phobias, post-traumatic stress disorder
- Schizoid PD, borderline PD
Comorbid disorders of Schizotypal PD
- Carefully, respectfully investigate patient’s concerns and motives
- Communicate directly; avoid punitive reactions to patient
- Set clear limits in context of medically indicated interventions
Provider strategies for pts w/ Antisocial PD
If criteria are met prior to the onset of schizophrenia, add “premorbid,” e.g., “______ personality disorder (premorbid).”
Schizotypal
- Recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior.
- Affective instability due to a marked reactivity of mood (e.g., intense episodic dysphoria, irritability, or anxiety usually lasting a few hours and only rarely more than a few days).
Borderline PD
- Failure to conform to social norms with respect to lawful behaviors, as indicated by repeatedly performing acts that are grounds for arrest.
- Deceitfulness, as indicated by repeated lying, use of aliases, or conning others for personal profit or pleasure.
Antiscocial PD
- Don’t get too close to patient
- Schedule frequent periodic check-ups
- Provide clear, nontechnical answers to questions to counter scary fantasies
- Tolerate periodic angry outbursts, but set limits
- Be aware of patient’s potential for self-destructive behavior
- Discuss feelings with coworkers and schedule multidisciplinary team meetings
Provider strategies for Borderline PD
- Personality style → solitary
- Predominant theme → detachment from social relationships and a restricted range of expression of emotions in interpersonal settings
Schizoid PD
- Succumbing to patient’s idealization and splitting
- Getting too close to patient causing overstimulation
- Despair at patient’s self-destructive behaviors
- Temptation to punish patient angrily
Problematic behavior of provider tx patient / Borderline PD
- Chronic feelings of emptiness.
- Inappropriate, intense anger or difficulty controlling anger (e.g., frequent displays of temper, constant anger, recurrent physical fights).
- Transient, stress-related paranoid ideation or severe dissociative symptoms.
Borderline PD
- May delay seeking care until symptoms become severe, out of fear of interacting with others
- May appear detached and unappreciative of help
Pt w/ schizoid PD
•Legal term, not a psychological concept
Criminal
- Personality style → idiosyncratic
-
Predominant theme →
- social and interpersonal deficits marked by acute discomfort with, and reduced capacity for, close relationships
- cognitive or perceptual distortions and eccentric behavior
Schizotypal PD
If criteria are met prior to the onset of ______, add “premorbid,” i.e., “_____ personality disorder (premorbid).”
- Schizophrenia
- Schizoid
- Rarely tolerates eye contact
- Speech is goal-directed
- Short answers to questions
- Avoid spontaneous conversation
Schizoid PD
A pervasive pattern of social and interpersonal deficits marked by:
- acute discomfort w/ or reduced capacity for, close relationships
- cognitive or perceptual distortions and eccentricities of behavior, beginning by early adulthood and present in a variety of contexts
Schizotypal PD
- Major depressive disorder (MDD), anxiety disorders, schizophrenia*, delusional disorders
- Paranoid PD, schizotypal PD, avoidant PD
Comorbid disorders of Schizoid PD
Severe aggression
- Antipsychotics (1st line)
- Risperidone (Risperdal)
- Olanzapine (Zyprexa)
- SSRI Antidepressants (2nd line)
- Sertraline (Zoloft)
- Fluoxetine (Prozac)
Tx for Antisocial PD
•Conduct disorder*, social phobia, generalized anxiety disorder, substance abuse disorders
Comorbid disorders for Antisocial PD
•Illegal or immoral behavior such as stealing, lying, or cheating
Antisocial behavior
Provider strategy for which disorder?
- Appreciate need for privacy / maintain a low-key approach
- Focus on technical elements of tx (better tolerated)
- Encourage pt to maintain daily routines
- Do not become overly personally involved or too zealous in trying to provide social supports
Schizoid PD
