personality disorders deanna mercer md frcpc msiv march 21 2012 dmercer@toh.on.ca

Personality DisordersDeanna Mercer MD FRCPC

MSIV March 21 2012dmercer@toh.on.ca

Objectives

• Describe personality disorders: criteria, clusters and core symptoms

• Axis I and Axis II comorbidity

• Understanding self injurious behaviour

• Borderline Personality Disorder: diagnosis and treatment

• Antisocial Personality Disorder: diagnosis and basic treatment

5296 Describe the general diagnostic criteria for a PD. 5297 State the classification of PD in three clusters. 5298 Describe the main enduring pattern of each PD type. 5299 Explain the clinical relevance of comorbity of Axis I and Axis II disorders. 5300 Describe the mental disorders associated with self‐injurious behaviors (SIB) 5301 List the biological, demographic, economic, social and developmental factors associated with SIB. 5302 Describe the pertinent factors in the recognition of the potential of SIB. 5303 List criteria for borderline personality disorder (BPD). 5304 Describe common psychiatric comorbidities asociated with BPD. 5305 Describe a treatment approach to BPD including use of hospitalization, outpatient care, pharmacologicaltreatment and psychotherapy

Good References

• Disordered Personalities

• Field Guide to Disordered Personalities

Dave Robinson MD Rapid Psychler Press

Personality Disorders Introduction

Criteria, clusters and core symptoms

Personality

What is it?

How do you get one?

Personality: Definition

• An individual’s characteristic pattern of response to his/her environment.

• Includes: how one thinks, feels, acts and relates to others.

Personality: Etiology

Temperament X EnvironmentTime

Disorder

• Leads to clinically significant distress or impairment in functioning

DSM IV general criteria for personality disorder

• Enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individual’s culture

• cognition, affectivity, interpersonal functioning and impulse control• Pattern is inflexible and pervasive• Leads to clinically significant distress or

impairment in functioning• Not better accounted for by other mental

disorder

PD’s are Ego Syntonic

• Ego Syntonic: Individual experiences significant distress, but does not feel that their thoughts, emotions or behaviours are the source of their distress

• external locus of control

• Ego Dystonic: Individual sees their disorder as arising from their own thoughts, emotions or behaviours

• internal locus of control

Epidemiology

DSM “informed speculation”

– Any PD 9%– Most PD’s 1-2 %– No sex differences in any PD

• In clinical populations 50 -80%

• Torgersen 2001 Norway, • Lezenweger 2007 National Comorbidity Survey Replication

Prognosis

• All tend to improve over time (years)

• Cluster B the most

• Schizotypal, Borderline and Avoidant have the greatest functional impairment

• Narcissistic, Histrionic, Obsessive Compulsive personality disorders have the least functional impairment

Why make a diagnosis of Personality Disorder?

Why make a PD diagnosis ?

• Axis I with PD

• More impaired, more chronicity

• Overall poorer response to treatment requiring more intensive and prolonged care

• Certain PD’s (BPD, ASPD, Schizotypal PD) have specific treatments or are contraindications for certain treatments

Personality Disorders: Clusters

• Cluster A: oddSchizoid, schizotypal, paranoid

• Cluster B: dramaticBorderline, histrionic, narcissistic, antisocial

• Cluster C: anxiousObsessive compulsive, dependent, avoidant

Cluster A Personality DisordersSchizoid PD

Schizotypal PD

Paranoid PD

Pictures of famous People with Schizoid Personality Disorder

Schizoid Personality Disorder

• “A pervasive pattern of detachment from social relationships and a restricted range of expression of emotions in interpersonal settings beginning by early adulthood and present in a variety of settings..”

• “DR” • Detached from relationships• Restricted range of emotional expression

Schizotypal Personality Disorder

Schizotypal PDSchizotypal PD

A pervasive pattern of social and interpersonal deficits

marked by acute discomfort with, and reduced capacity

for, close relationships as well as by cognitive or

perceptual distortions and eccentricities of behavior,

beginning by early adulthood and present in a variety of

settings

“ACE”• Acute discomfort in close relationships:

paranoia rather than fear of judgment

• Cognitive and perceptual distortions: odd beliefs, unusual perceptions, suspiciousness,paranoia,

odd speech

• Eccentric Behaviours

A pervasive pattern of social and interpersonal deficits

marked by acute discomfort with, and reduced capacity

for, close relationships as well as by cognitive or

perceptual distortions and eccentricities of behavior,

beginning by early adulthood and present in a variety of

settings

“ACE”• Acute discomfort in close relationships:

paranoia rather than fear of judgment

• Cognitive and perceptual distortions: odd beliefs, unusual perceptions, suspiciousness,paranoia,

odd speech

• Eccentric Behaviours

Paranoid Personality Disorder

Paranoid PD

• “A pervasive distrust and suspiciousness of others such that their motives are interpreted as malevolent, beginning by early adulthood and present in a variety of settings…”

• “DSMM”• Distrusts others, • Suspiciousness • others Motives are interpreted as

Malevolent

How to Remember Cluster A

• Schizoid: looks like negative symptoms of scz

• Schizotypal: looks like positive symptoms of scz (but not full blown psychosis)

• Paranoid PD: looks like delusional disorder, paranoid type ( but no full blown delusions and more pervasive suspiciousness)

All cluster A have: • Increased risk of brief psychotic episodes • Genetic link to schizophrenia:

– Schizotypal>schizoid>ppd

• Few relationships– Schizoid: if any close relationship it is with 1˚ family– Schizotypal: lacks close friends except 1˚ family – Paranoid: few friends with similar beliefs

• Risk of developing scz– Schizotypal: 10-20%

Cluster B

Histrionic PDAntisocial PD

Narcissistic PDBorderline PD

Histrionic Personality Disorder

Histrionic PD

• “A pervasive pattern of excessive emotionality and attention seeking, beginning by early adulthood and present in a variety of contexts…”

• “theatrical”

• Intense but shallow emotions

• Craves being the centre of attention

Antisocial Personality Disorder

Antisocial PD • “Pervasive pattern of disregard for and violation of

the rights of others occurring since age 15 years / must be at least age 18 years”

• Repeated lawbreaking• Deceitfulness• Impulsivity• Irritability and aggressiveness• Reckless disregard for safety of self or others• Consistent irresponsibility• Lack of remorse

ASPD epidemiology

• DSMIV tr 1% females 3% males

• New community based studies 1% M=F

• Highest risk of ASPD: early onset conduct (before age 10) and ADHD

• 75% of conduct disorder resolves by adulthood• Prognosis better if has some connection to a

group• ASPD > Sociopathy ( Tony Soprano) >

Psychopath (Ken Lay)• Decrease impulsivity and criminal behavior, but

continue to be difficult people (poor spouses, parents, employees)

ASPD prognosis

Rarely seek help for distress caused by their actionsMost common reasons for psychiatric contact:

detox, seeking meds with a street value, notes for missing work, assessments to avoid criminal responsibility, military service, work that they see as undesirable

Psychotherapy usually contraindicated, particularly psychopathy

Stay respectful, but avoid emotional investment in patient◦ Confront denial and minimization◦ Restrict focus to possible outcomes of antisocial behaviour◦ Help to find healthier alternatives to acting out

Treatment

http://www.youtube.com/watch?v=s5hEiANG4Uk

Psychopathy

Narcissistic Personality Disorder

Narcissistic PD

“ A pervasive pattern of grandiosity (in fantasy or behaviour) need for admiration, and lack of empathy, beginning by early adulthood and present in a variety of contexts”

• “AGE”– need for Admiration, – Grandiosity (fantasy or behaviour)– lack of Empathy for others

BorderlinePersonality Disorder

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…”

Cluster C” anxious”

Obsessive CompulsiveAvoidant

Dependent

Obsessive Compulsive Personality Disorder

OCPD

http://www.youtube.com/watch?v=T-GKovedEy4&feature=related

OCPD • “A pervasive pattern of preoccupation with

orderliness, perfectionism, and mental and interpersonal control, at the expense of flexibility, openness, and efficiency, beginning by early adulthood and present in a variety of contexts..”

• “OCP”• Orderliness• Perfectionism• Control : mental and interpersonal

• *Most do not have OCD (only 30%)• Adolescents with strong OCPD traits can grow out

of the diagnosis

Avoidant Personality Disorder

Avoidant PD Avoidant PD

• similar to social phobia, but more pervasive

• similar to social phobia, but more pervasive

“A pervasive pattern of social inhibition, feelings of inadequacy, and hypersensitivity to negative evaluation, beginning by early adulthood and present in a variety of contexts”

Dependent PD Dependent PD • A pervasive and excessive need to be taken

care of that leads to submissive and clinging behaviour and fears of separation, beginning by early adulthood and present in a variety of contexts..”

• “Dependent on relationships”• Difficulty making everyday decisions without a lot of advice,

reassurance from others• unable to disagree with others because fears loss of support,

will do things that are unpleasant, degrading to maintain support

• If person’s fear of retribution realistic (abusive spouse) do not make diagnosis

• A pervasive and excessive need to be taken care of that leads to submissive and clinging behaviour and fears of separation, beginning by early adulthood and present in a variety of contexts..”

• “Dependent on relationships”• Difficulty making everyday decisions without a lot of advice,

reassurance from others• unable to disagree with others because fears loss of support,

will do things that are unpleasant, degrading to maintain support

• If person’s fear of retribution realistic (abusive spouse) do not make diagnosis

BorderlinePersonality Disorder

BPD DSMIV• A pervasive pattern of instability of interpersonal

relationships, self-image and affects, and marked impulsivity

• Affective: emotional lability, problems with anger• Relationships: chaotic, idealizing/devaluing,

fears of abandonment “I hate you, don’t leave me”

• Behaviours: suicide and self harm, impulsive (sex, A&D, binge eating, driving fast, promiscuity)

• Cognitive: emptiness, unstable sense of self, mild psychotic symptoms under stress, dissociation

Self Harm / SIB• Behaviours that inflict harm to one’s body without the

obvious intention of committing suicide• 1-4 % general population• chronic/severe SH 1%• Teens 5- 13 %, college age 17- 35%• Age of onset: 14 - 24• majority (75%) <10 times• Increasing in teens• Increased risk of suicide behaviours • F=M • abrading/scratching> cutting, banging> biting, burning

Risk Factors

• Social: Low SES, adverse events during childhood (abuse and trauma)

• Biological: ↓ serotonin, impulsivity • Psychiatric Disorders (90%) : Personality

disorders (BPD -75%), depression, pervasive developmental delay, dissociative identity disorder, eating disorders,

• Alcohol and substance abuse are common

SIB

• Situational Risk factors: recent negative life events

• Reasons: – relief from intense painful emotions – self punishment– to get significant others to respond

Assessing for SIB

• Suspect in teens and young adults who are presenting with psychological distress

• Important to recognize that SIB is usually an attempt to reduce emotional distress

• Best way to solve the problem is to look for a solution to the event that caused the emotional distress

SIB: intervention

• Start by validating that the prompting problem and the distress are real and that it makes sense to want to reduce emotional pain

• Highlight that while SH does reduce emotional pain in the short term, it is not a great way to solve the problem that got the distress going in the long run

• Invite the person to look at other methods of problem solving

Objective # 5305

Describe a treatment approach to BPD including use of

hospitalization, outpatient care, pharmacological

treatment and psychotherapy

Bio-Social Theory

EMOTION DYSREGULATION

Emotionally Vulnerable individual

InvalidatingEnvironment

Linehan 1993

BPD: prognosis

• With primarily OPD treatment 75% of patients with BPD no longer meet criteria after 6 years

• 75% have history of suicide and self harm attempts. 5 - 10% die by suicide

• Worst prognostic factor: concurrent substance dependence

• Best prognostic factor: GAF at time of diagnosis

BPD: Comorbidity

• Mood disorders : depression 50%, dysthymia 70%. At time of admission 90% MDE

• Bipolar I,II: 18%

• Eating Disorders(An, BN, obesity) : 50%

• Anxiety Disorders: 90%

• Substance Use Disorders: 60%

• Narcissistic PD, antisocial PD: 50%

Treatment of BPD

• Mainstay of treatment is outpatient care and psychotherapy– BPD patients are exquisitely sensitive to what

happens in their environment – treatment has to help them find ways to :

1.Solve problems causing painful emotions

2.Feel better

3.Tolerate both the situation and how they feel about it without making the situation worse

BPD treatment: Psychotherapy

• All empirically based psychotherapies (DBT, MBT, TFP, Schema focused)

– Focus of treatment is to establish connection between actions and feelings

– Therapists manage, pay careful attention to countertransference.

– Therapist has ongoing discussion with colleagues or easy access to consultation

– Here and now focus

BPD: Hospitalization

• Admission indicated: – After a serious suicide attempt– Psychosis/severe disorganization

• May be indicated – loss of significant social support– Worsening depression, substance abuse

• Caution when– Hospital has not been helpful or has made

person worse

Links 2010

BPD: Meds

• Adjunct to psychotherapy, limit expectations (yours and your patient’s!)

• Concurrent MDE: SSRI’s, Effexor• Affective lability: mood stabilizers – Lamotrigine,

Aripiprazole• Insomnia, agitation, brief psychotic symptoms –

low dose quetiapine, olanzapine• Avoid: benzodiazepines, meds that are

dangerous in overdose (lithium, tricyclics)