Personality Disorders
Personality Personality Style: lifelong way of coping, manifested in how a person thinks, feels and behaves
Personality Stable and predictable Flexible and adaptive
We continue to shape our personality all our life. If we knew ourselves perfectly, we should die Albert Camus
Personality Style vs Disorder Matter of degree Style is stable but can be modified Disorder rigid extreme maladaptive damaging to self or others leading to functional impairment
History of long-term difficulties Ego-syntonic Lack of empathy Developmental fixation Immaturity Anxiety underneath the protective armor
Epidemiology Prevalence : 9.1% for any PD (DSM V) First evident in late adolescence / early adulthood
Etiology Multifactorial Genetics Perinatal injury, encephalitis, head trauma History of family dysfunction, abuse
Course and Prognosis Usually stable or deteriorating but some patients do improve over time.
Everyone is a moon, and has a dark side which he never shows to anybody Mark Twain
PERSONALITY DISORDERS CLUSTER A CLUSTER B CLUSTER C PARANOID SCHIZOID SCHIZOTYPAL ANTISOCIAL BORDERLINE NARCISSISTIC HISTRIONIC OBSESSIVE-COMP AVOIDANT DEPENDENT
Paranoid P D Tendency to attribute malevolent motives to others Persistently bears grudges Jealous, Secretive Genetic component Defenses: projection, denial, rationalization
Schizoid P D Isolated life style without overt longing for others Lack of interest in sexual experiences Men > women Genetic factors, family dysfunction Diff dx: Autism
Schizotypal P D Odd & eccentric Magical thinking No close relationships Social anxiety Paranoia Precursor to schizophrenia Men > women
Antisocial P D Disregard and violation of the rights of others Familial pattern Hx of parental abandonment, abuse Conduct disorder prior to age 15 Death by violence, SA, suicide Lack of remorse
Borderline PD Instability, Impulsivity Splitting Primitive idealization Projective identification Fear of abandonment Self-hate Emptiness, object hunger Dissociation
Borderline PD Need for transitional object Women > Men Frequent hx of physical, sexual abuse Transference psychosis Suicide threats, self-mutilation Co-occuring: affective disorders,substance use, eating disorders, PTSD
Histrionic P D Dramatic, emotional style Seductive Center of attention Shallow affect Women > Men Co-occuring with Somatization, Conversion Disorder
Narcissistic P D Grandiosity, sense of entitlement Lack of empathy Feels special Envy, manipulation Compensation for sense of inferiority Early rejection, loss
Obsessive-Compulsive P D Perfectionism, inflexibility Miserly spending style Excessive devotion to work Preoccupation with details Fixation during anal period Men > Women
Avoidant P D Shy, timid personality Fear of rejection Feels inferior to others Fear of negative evaluation Co-occuring with Social Phobia Risk-aversion Desire for companionship
Dependent P D Predominantly dependent and submissive Fear of separation Lack of self-confidence Difficulty making independent decisions Women > men Unresolved separation issues
Diagnostic Tools Minnesota Multiphasic Personality Inventory (MMPI) Structured Clinical Interview for DSM for Axis II Disorders (SCID-II and soon SCID-5-PD)
Reactions to the Patient Countertransference Intense feelings Fantasies Atypical Behaviors
There is nothing so dangerous for anyone who has something to hide as conversation. A human being, Hastings, cannot resist the opportunity to reveal himself and express his personality, which conversation gives him. Every time, he will give himself away. Agatha Christie: Hercule Poirot
Management Learn to listen Stabilize the external environment Stabilize the internal environment: medications Set limits Accept the patient`s limitations Question irrational beliefs Enlist family support
Pharmacotherapy Options SSRIs Low-dose atypical antipsychotics Lithium and anticonvulsant mood stabilizers Benzodiazepines should be avoided, if possible
Treatment Psychotherapy Dialectical Behavioral Therapy Cognitive Therapies Psychodynamic Therapies
Remember to Pay attention to your own emotional reaction to the patient Use consultation, referral and support Maintain good boundaries Treat patients with patience and empathy
Men acquire a particular quality by constantly acting a particular way. You become just by performing just actions, temperate by performing temperate actions, brave by performing brave actions. Aristotle