Personality Disorders An Introduction - PowerPoint Presentation

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Personality DisordersAn Introduction

Maxym Choptiany, MD FRCPC

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What is a personality disorder?

Chronic, inflexible, and maladaptive pattern of relating to the world.

Evident in the way a person thinks, feels, and behaves.

The most noticeable and significant feature is their negative effect on interpersonal relationships.

Relationships they do form are often fraught with problems and difficulties.

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What is a personality disorder?

Often those with personality disorders who experience difficulties in their relationships or in their functioning don’t believe that there is anything wrong with them (

egosyntonic

).

If anything, believe society (not them) should change

–

alloplastic thinking.

As a result maladaptive behaviour is repeated.

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What is a personality disorder?

Differ from personality traits (

ie

. features of personality that do not meet threshold for a PD).

Diagnosis is warranted only if personality traits are:

Inflexible, maladaptive, and enduring.

Start in childhood/adolescence.

Cause functional impairment/subjective distress.

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History

First formal attempt to classify personality disorders occurred in 1952 with the publication of DSM-I.

7 personality disorders identified.

Classification in various form throughout history.

Hippocrates described 4 temperaments:

earth, air, fire, and water

the optimistic sanguine, the irritable choleric, the sad melancholic, and the apathetic phlegmatic.

Variation on the temperaments up to 20

th

Century.

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Epidemiology

Up to 10-20% of the general population.

Greater in psychiatric samples

–

up to 30-50%.

Antisocial Personality Disorder is the only PD with an age specification (18 years) and that certain childhood

behaviours

be present (conduct disorder).

Some more frequent in men (ASPD).

Some more frequent in women (BPD).

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Epidemiology

Associated with impaired social, personal, and occupational adjustment.

Family life, marriage, academic and work difficulties.

Increased rates of unemployment, homelessness, divorce and separation, domestic violence and substance misuse.

Increased rates of healthcare utilization.

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Epidemiology

Individuals suffering from personality disorders are at high risk of early death from suicide or accident.

Suicide rate is as high as that seen for major depression.

Although personality disorders tend to be stable, some studies have shown that they tend to improve as a patient ages.

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Epidemiology

Presence of personality disorder is associated with poorer response to treatment, particularly antidepressant medication and electroconvulsive therapy.

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Etiology

Historical psychoanalytical view theorized that personality disorders occurred when an individual failed to progress through appropriate psychosexual stage of development.

Adverse childhood experience (abuse, maltreatment, or neglect) is associated with risk for development of personality disorder.

Genetic association (

eg

. schizotypal and schizophrenia).

Slide11

Etiology

Neurobiological correlates

–

eg

. low levels of 5-hydroxyindoleacetic acid (5-HIAA) a metabolite of serotonin

–

linked to impulsivity and aggression (ASPD and BPD)

Chronic nervous system under-arousal is thought to contribute to thrill seeking, impulsivity and dangerousness in ASPD.

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Etiology

Interaction between an individual’s genetic predisposition towards certain traits and an individual’s early experiences.

Over time people develop habits of interpreting and responding to the environment that influence the way they experience and interpret their world ("personality traits”).

Once these patterns have formed, they are maintained and become fairly stable. 

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Etiology

Overdeveloped and underdeveloped

behavioural

strategies specific to each personality disorder that are used across situations and across time; even when the strategies are dysfunctional.

Strategies are developed to cope with highly negative core beliefs.

Strategies may have been adaptive when first developed.

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DSM-5 Diagnostic Criteria

An enduring pattern of inner experience and

behaviour

that deviates markedly from the expectations of the individual's culture.

Enduring pattern is inflexible and pervasive across range of personal and social situations.

Has an onset in adolescence or early adulthood and is stable over time.

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DSM-5 Diagnostic Criteria

Symptoms must cause impairment in social, occupational, or other important areas of functioning (

ie

. difficult for them to function well in society) and /or subjective distress.

Not better explained as a manifestation of another mental disorder.

Not attributable to substance or other medical condition (

eg

. head trauma).

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DSM-5 Diagnostic Criteria

NOT diagnosed in children due to the requirement that personality disorders represent enduring problems across time.

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DSM-5 Diagnostic Criteria

This enduring pattern manifests in 2 or more of the following areas:

Thinking

 - distorted thinking patterns

Feeling

- problematic emotional responses

Impulse control

– over/under regulated impulse control

Interpersonal functioning

- problematic relationships)

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Distorted Thinking Patterns

Distortions in the way they interpret and think about the world, and in the way they think about themselves. 

Thinking patterns may be extreme and distorted. 

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Distorted Thinking Patterns

Black-or-white thinking patterns

Idealizing then devaluing other people or themselves.

Distrustful, suspicious thoughts.

Unusual or odd beliefs (contrary to cultural standards).

Perceptual distortions and bodily illusions.  

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Diagnosis

Thorough personal and social history

Mental Status Exam

Collateral information

–

especially where the individual denies or is unaware of their maladaptive traits.

Caution in diagnosing when individual is suffering from another mental disorder

–

eg

depression (anxious, dependent).

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Diagnosis

Objective psychological testing may be of assistance in diagnosing personality disorder.

Eg

. Minnesota Multiphasic Personality Inventory II

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DSM-5

10 specific personality disorders

3 clusters of personality disorders

Each disorder has a set criteria of observable characteristics.

Diagnosis requires that a minimum number of criteria are met.

Can be co-occurrence/overlap in personality disorders.

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Clusters

Cluster A - odd, eccentric

Cluster B - dramatic, emotional, erratic

Cluster C - anxious, fearful

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Cluster A (Odd, Eccentric)

Paranoid

Schizoid

Schizotypal

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Cluster B (Dramatic, Emotional, Erratic)

Antisocial

Borderline

Histrionic

Narcissistic

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Cluster C (Anxious, Fearful)

Avoidant

Dependent

Obsessive-Compulsive

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Other Personality Disorders

Personality Change Due to Another Medical Condition

Other Specified Personality Disorder

Symptoms characteristic of PD predominate but do not meet full diagnostic criteria.

Unspecified Personality Disorder

Mixed or atypical traits that do not fit into better-defined categories.

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Cluster A (Odd, Eccentric)

Paranoid

Schizoid

Schizotypal

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Cluster A

Characterized by a pervasive pattern of abnormal cognition (

eg

. suspiciousness), self-expression (

eg

. odd speech), or relating to others (

eg

.

seclusiveness

).

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Cluster A – Paranoid PD

SUSPECT (4 criteria).

S: Spouse fidelity suspected

U: Unforgiving (bears grudges)

S: Suspicious of others

P: Perceives attacks (and reacts quickly)

E: "Enemy or friend" (suspects associates, friends)

C: Confiding in others feared

T: Threats perceived in benign events

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Cluster A – Paranoid PD

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Cluster A – Paranoid PD

Expect exploitation.

Misinterpret statements or acts as hostile

Isolate to protect themselves.

Rarely seek treatment because of their suspiciousness of others (including therapists and psychiatrists).

Tend to be identified when presenting for a mood or anxiety disorder.

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Cluster A – Paranoid PD

Prevalence ~4%. More common in males.

Treatment involves supportive approach, treating the main complaint, and once rapport is established alternative explanations for misperceptions can be offered.

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Cluster A – Schizoid PD

DISTANT (4 criteria).

D: Detached (or flattened) affect

I: Indifferent to criticism and praise

S: Sexual experiences of little interest

T: Tasks (activities) done solitarily

A: Absence of close friends

N: Neither desires nor enjoys close relations

T: Takes pleasure in few activities

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Cluster A – Schizoid PD

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Cluster A – Schizoid PD

Profound defect in the ability to form personal relationships and to respond to others in a meaningful way.

No close relationships.

Choose solitary activities

Rarely experience strong emotions.

Express little desire for sexual experience with another person.

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Cluster A – Schizoid PD

Indifferent to praise or criticism.

Display constricted affect.

Prevalence ~3%.

Uncommon in psychiatric setting because they rarely seek out psychiatric help except for co-occurring depression, anxiety, substance abuse, etc.

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Cluster A – Schizoid PD

Treat the identified disorder (

eg

. mood)

May benefit from day or drop in programs.

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Cluster A – Schizotypal PD

ME PECULIAR (5 criteria).

M: Magical thinking or odd beliefs

E: Experiences unusual perceptions

P: Paranoid ideation

E: Eccentric behaviour or appearance

C: Constricted (or inappropriate) affect

U: Unusual (odd) thinking and speech

L: Lacks close friends

I: Ideas of reference

A: Anxiety in social situations

R: Rule out psychotic disorders and pervasive developmental disorder

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Cluster A – Schizotypal PD

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Cluster A – Schizotypal PD

Considered to be part of the schizophrenia spectrum.

Characterized by a pattern of peculiar behaviour, odd speech and thinking, and unusual perceptual experiences.

Socially isolated

Magical beliefs

–

eg

. 6

th

sense, supernatural experience

Mild paranoia

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Cluster A – Schizotypal PD

Inappropriate or constricted affect

Social anxiety

Prevalence of 3-5% (common)

Mood, anxiety, and substance use disorders common.

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Cluster A – Schizotypal PD

Treat the identified disorder.

May benefit from social skills training.

Goal is to help individual develop insight into their

behaviours

and to develop repertoire of social skills.

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Cluster B (Dramatic, Emotional, Erratic)

Antisocial

Borderline

Histrionic

Narcissistic

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Cluster B (Dramatic, Emotional, Erratic)

Characterized by a pervasive pattern of violating social norms (

eg

. criminal behaviour), impulsivity, excessive emotionality, grandiosity, “acting out” (

eg

. tantrums, self-abusive behaviour, angry outbursts), or violating the rights of others (

eg

. criminal behaviour).

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Cluster B - ASPD

CORRUPT (3 criteria).

C: Conformity to law lacking

O: Obligations ignored

R: Reckless disregard for safety of self or others

R: Remorse lacking

U: Underhanded (deceitful, lies, cons others)

P: Planning insufficient (impulsive)

T: Temper (irritable and aggressive)

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Cluster B - ASPD

Pervasive pattern of disregard for and violation of the rights of others occurring since age 15 years.

The individual is at least age 18 years.

There is evidence of conduct disorder with onset before age 15 years.

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Cluster B - ASPD

Conduct Disorder - TRAP

T: Theft – B&E, deceiving, non-confrontational stealing

R: Rule Breaking – running away, skipping school, out late

A: Aggression – people, animals, weapons, forced sex

P: Property Destruction

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Cluster B - ASPD

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Cluster B - ASPD

First recognized in the early 19

th

century.

“Mania without delirium”

“Moral insanity”

Described immoral or guiltless behaviour in the absence of impaired reasoning.

20

th

Century

–

termed psychopathic personality

DSM-I

–

sociopathic personality

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Cluster B - ASPD

DSM-III

–

antisocial personality disorder.

Described in Hervey

Cleckley’s

–

The Mask of Sanity (1941)

–

identified 16 traits descriptive of the disorder.

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Cluster B - ASPD

Typical childhood behaviour of fighting, lying, cheating, stealing, fire setting, and cruelty to animals and other children.

As antisocial youth achieves adulthood, problems reflect age-appropriate responsibilities

–

uneven job performance, domestic abuse.

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Cluster B - ASPD

Unreliability, reckless behaviour, inappropriate aggression, criminal behaviour, pathological lying, and use of aliases are characteristic.

Often act impulsively without thinking of long-term consequences. Legal issues common.

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Cluster B - ASPD

2-4% of men.

0.5 -1% of women.

Higher amongst psychiatric, prison, and homeless population.

Chronic disorder but worse early on.

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Cluster B - ASPD

Comorbid substance use disorders, mood and anxiety disorders, ADHD, pathological gambling and other PDs (BPD).

Alcohol and SUD - 12 month prevalence

AUD 28.6%, SUD 47.7%

Any alcohol or SUD 84% lifetime

Depression and Anxiety (1 study)

35% MDE

27% phobic disorder

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Cluster B - ASPD

High death rate

–

suicide, accidents, homicides.

No standard treatment.

Target aggression

–

eg

. mood stabilizer and antipsychotics.

CBT to target distorted beliefs and attitudes.

Emotion regulation / anger management.

Difficult to treat due to treatment interfering traits

–

lie, blame others, impulsive, low frustration tolerance.

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Psychopathy

Psychopathy is a personality construct involving a combination of both personality traits and

behaviours

.

Most offenders who are psychopaths meet criteria for ASPD.

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Psychopathy

3 key symptom groupings:

Arrogant, interpersonally exploitative and deceitful interpersonal style of relating.

Shallow/deficient way of experiencing and expressing affect.

Irresponsible, impulsive, antisocial

behavioural

lifestyle

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Psychopathy

PCL-R is an operationalized checklist of

Cleckley’s

clinical observations consisting of 20 items, composed of 2 factors (4 facets)

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Psychopathy

Factor 1 (Affective/Interpersonal)

Interpersonal:

Glib/superficial

Grandiose self-worth

Pathological lying

Conning/manipulative

Affective:

Lack of remorse/guilt

Shallow affect

Callous/lack of empathy

Fail to accept responsibility for own actions

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Psychopathy

Factor 2 (

Behavioural

/Antisocial)

Behavioural

(lifestyle)

Stimulation seeking

Parasitic lifestyle

Lack of realistic goals

Impulsivity

Irresponsibility

Antisocial

Poor

behavioural

controls

Early behaviour problems

Juvenile delinquency

Revocation of conditional release

Criminal versatility

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Psychopathy

2 additional items:

Promiscuous sexual behaviour

Many short term relationships

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Cluster B - BPD

“Stably unstable” Pervasive pattern of:

Mood instability

Unstable and intense interpersonal relationships

Impulsivity

Inappropriate or intense anger

Lack of control of anger

Recurrent suicidal threats and gestures

Self-mutilating behaviour

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Cluster B - BPD

Marked and persistent identity disturbance

Chronic feelings of emptiness or boredom

Frantic efforts to avoid real or imagined abandonment

Transient paranoid or dissociative symptoms

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Cluster B - BPD

AM SUICIDE (5 criteria).

A: Abandonment

M: Mood instability (marked reactivity of mood)

S: Suicidal (or self-mutilating) behaviour

U: Unstable and intense relationships

I: Impulsivity (in two potentially self-damaging areas)

C: Control of anger

I: Identity disturbance

D: Dissociative (or paranoid) symptoms that are transient and stress-related

E: Emptiness (chronic feelings of)

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Cluster B - BPD

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Cluster B - BPD

DSM-I

–

emotionally unstable personality

Borderline schizophrenia

–

transient episodes of psychosis

1-2% in general population

10% of psychiatric outpatients

15-25% of psychiatric inpatients

Account for up to 50% of all persons with PDs.

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Cluster B - BPD

Etiology

unknown.

Likely interaction between genetic vulnerability, life experiences, reinforced interpersonal behaviours.

Emotionally vulnerable temperament 
transacting with an invalidating environment -

Linehan

1993.

Slide69

Cluster B - BPD

3:1 female to male

Up to ¾ engage in in deliberate self-harm (cutting, burning, over-dose)

Reasons for SIB: to cause physical pain, control feelings, express anger, overcome numbness

SIB: cutting>bruising, biting, burning, head banging

Up to 10% will commit suicide.

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Cluster B - BPD

Frequent comorbid MDD, anxiety, and substance misuse.

PTSD?

Burnout with age

–

maturity, skills.

Positive prognostic indicators: higher intelligence, self-discipline, social support, lack of substance abuse, and lack of history of abuse.

Negative prognostic indicators: anger, antisocial behaviour, suspiciousness, and vanity traits.

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Cluster B - BPD

Treatment involves targeting mood, anxiety etc.

DBT

–

reduces self-harm, hospitalization rates, and emotional

dyscontrol

.

DBT

–

targets dysfunctional attitudes and beliefs and improves coping skills, stress tolerance, and emotion regulation.

Frequent acting out in therapy.

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Cluster B - BPD

Treatment on an out-patient basis where patients can deal with their issues.

Hospitalization for acute/emergent issues. Risk of regression/acting out/destabilization in hospital.

Psychoeducation

.

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Cluster B – Histrionic PD

PRAISE ME (5 criteria)

P: Provocative (or sexually seductive) behaviour

R: Relationships (considered more intimate than they are)

A: Attention (uncomfortable when not the center of attention)

I: Influenced easily

S: Style of speech (impressionistic, lacks detail)

E: Emotions (rapidly shifting and shallow)

M: Made up (physical appearance used to draw attention to self)

E: Emotions exaggerated (theatrical)

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Cluster B – Histrionic PD

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Cluster B – Histrionic PD

Show a pattern of excessive emotionality and attention-seeking behaviour.

Excessive concern with appearance.

Wanting to be the

centre

of attention.

Superficially charming.

Manipulative, vain, demanding.

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Cluster B – Histrionic PD

Prevalence

–

2% general population

More common in women.

Seek out medical attention and make use of health services.

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Cluster B – Histrionic PD

Treatment

Supportive, problem solving, CBT to counter distorted thinking.

IPT to assist in targeting meaningful relationships.

Group therapy to target provocative, attention seeking behaviour.

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Cluster B – NPD

SPECIAL (5 criteria).

S: Special (believes he or she is special and unique)

P: Preoccupied with fantasies (of unlimited success, power, brilliance, beauty, or ideal love)

E: Entitlement

C: Conceited (grandiose sense of self-importance)

I: Interpersonal exploitation

A: Arrogant (haughty)

L: Lacks empathy

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Cluster B – NPD

Introduced in DSM-III

Named after Narcissus from Greek mythology, who fell in love with his own reflection.

Characterized by grandiosity, lack of empathy, and hypersensitivity to evaluation by others.

Tend to be egotistical, inflate their accomplishments, and manipulate/exploit those around them for their own aims.

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Cluster B – NPD

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Cluster B – NPD

Have an exaggerated sense of entitlement.

Expect love and admiration but have little empathy for others.

Tend to have little insight into their own narcissism.

1% prevalence. More common in males.

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Cluster B – NPD

No consensus on treatment.

Difficult to work with.

Present after narcissistic injury sustained

–

anger or depression post humiliation in a situation that they did not get what they felt they were entitled to.

CBT, dynamic psychotherapy.

Treat comorbidities.

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Cluster C (Anxious, Fearful)

Avoidant

Dependent

Obsessive-Compulsive

Slide84

Cluster C (Anxious, Fearful)

Characterized by a pervasive pattern of abnormal fears involving social relationships, separation, and need for control.

Slide85

Cluster C – Avoidant PD

CRINGES (4 criteria).

C: Certainty (of being liked required before willing to get involved with others)

R: Rejection (or criticism) preoccupies one's thoughts in social situations

I: Intimate relationships (restraint in intimate relationships due to fear of being shamed)

N: New interpersonal relationships (is inhibited in)

G: Gets around occupational activity (involving significant interpersonal contact)

E: Embarrassment (potential) prevents new activity or taking personal risks

S: Self viewed as unappealing, inept, or inferior

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Cluster C – Avoidant PD

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Cluster C – Avoidant PD

Predecessor

–

inadequate personality

Tend to be inhibited, introverted, and anxious.

Tend to have low self-esteem

Rejection hypersensitivity

Apprehensive and mistrustful

Socially awkward and timid

Fear being embarrassed or acting foolish in public.

Overlap with social anxiety disorder.

Slide88

Cluster C – Avoidant PD

Treatment:

Assertiveness and social skills training.

CBT

–

focus on sensitization to treat anxiety, shyness and introversion.

CBT

–

to target dysfunctional attitudes / thought distortion.

Antidepressants (SSRIs) to target anxiety.

Slide89

Cluster C – Dependent PD

RELIANCE (5 criteria).

R: Reassurance required for decisions

E: Expressing disagreement difficult (due to fear of loss of support or approval)

L: Life

responsibilites

(needs to have these assumed by others)

I: Initiating projects difficult (due to lack of self-confidence)

A: Alone (feels helpless and discomfort when alone)

N: Nurturance (goes to excessive lengths to obtain nurturance and support)

C: Companionship (another relationship) sought urgently when close relationship ends

E: Exaggerated fears of being left to care for self

Slide90

Cluster C – Dependent PD

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Cluster C – Dependent PD

Predecessor

–

subtype of DSM-1 passive-aggressive personality

Characterized by a pattern of relying excessively on others for emotional support.

Comorbid psychiatric disorders are common

–

mood, anxiety, etc.

Tend to have poor social supports because their dependency promotes conflict.

Slide92

Cluster C – Dependent PD

Treatment

Little consensus.

Target associated mental disorder (mood, anxiety, etc.)

CBT

–

assertiveness, effective decision making, and independence.

Assertiveness training and social skills training.

Slide93

Cluster C - OCPD

LAW FIRMS (4 criteria).

L: Loses point of activity (due to preoccupation with detail)

A: Ability to complete tasks (compromised by perfectionism)

W: Worthless objects (unable to discard)

F: Friendships (and leisure activities) excluded (due to a preoccupation with work)

I: Inflexible, scrupulous,

overconscientious

(on ethics, values, or morality, not accounted for by religion or culture)

R: Reluctant to delegate (unless others submit to exact guidelines)

M: Miserly (toward self and others)

S: Stubbornness (and rigidity)

Slide94

Cluster C - OCPD

Slide95

Cluster C - OCPD

Characterized by obstinacy, parsimony, and orderliness.

Lifelong pattern of perfectionism and inflexibility, associated with over-conscientiousness and constricted emotions.

No 1:1 relationship with OCD.

Very common. In one study prevalence was estimated at up to 8% of the general population.

Slide96

Cluster C - OCPD

Patients suffering from OCPD are prone to major depression.

Difficult to treat.

CBT to target black and white thinking.

Antidepressants to target mood, anxiety, and possibly ritualized behaviour.

Slide97

Summary

Personality Disorders encompass maladaptive, pervasive, and deeply ingrained behaviour.

Given the enduring, long-term nature of the maladaptive patterns of behaviour, they cannot be easily reversed.