Personality disorders

IMPORTANCE of PDs:
1) Common
2) IPR problems: , ,
, instability, doctor interaction
3) Leads to other disorders
4) Affect outcome of Rx = Rx
resistance
5) risk: accidents, police
contact, admissions, suicide,
drug abuse
6) affect physical and mental
health
7) affect health seeking behaviour
8) Premature mortality ( 18
years)
9) Seldom diagnosed
10) costs

DEFINITIONS:
Personality:

characteristic or pattern of
thought, feeling (internal)
and behaviour (external)

OR how you interpret

experiences and your
emotional and behavioural
responses to this
2 divisions:
(1) Temperament

DSM-5
A. enduring pattern of inner experience and behaviour deviating
markedly from cultural norm manifested in 2:
1. cognition: ways of thinking about self, others, world
2. affect: range, intensity, liability, appropriateness
3. interpersonal functioning
4. impulse control
B. inflexible and pervasive
C. significant distress or impaired functioning
D. stable and of long duration; early onset
E. not due to MMS
Ddx:
Co-morbidities:

personality traits
Co-morbidities = the norm!!

mood d/o

psychotic disorders

anxiety d/o

mood disorders

substance abuse

anxiety d/o

relationship problems

OCD

somatoform d/o

Substance induced d/o

eating d/o

Medical conditions

non-compliance
CHARACTERISTICS:

comorbid = worse outcome

Dysfunctional schemas:

self
Difficult assessment:

others

patients request help for Sx

relationships

categorical approach problem

difficulties in:
Assessment:

self-appraisal

how do you think about

self-regulation
yourself? (identity)

impaired IPR

tell me about your relationships

cut off point between normal and
and friendships in life since
abnormal personality is relative
childhood (IP functioning)
o how important/many
Mild PD:
Problems in IPR and functioning,
but
some
relationships
are

TREATMENT:
General Principles

limited insight, difficulty making

Dx, often not possible after one
consultation, collateral info
and/or more time needed

reason for consultation often

another psychiatric illness, or
referral by partner

co-morbid conditions need Rx,

this can at times dissolve the
Personality problems
Types of Psychotherapy:
Individual

supportive

CBT

Psychodynamic

Dialectical behaviour Tx

Mentalization-based Tx
Group therapy

Difficult; takes years

Pharmacotherapy:

Medication modestly helpful for

schizotypal and BPD

May be paranoid and avoidant

Otherwise little evidence for

prescription

Long
term
use
of
antipsychotics S/E and
CVD

Limit antidepressant use for

clinical depression

Nonetheless: SSRIs can be

used for some patients

Borderline PD

mood stabilizers (valproate,

lamotrigine, topiramte) and
SGA might help for mood
instability
and
impulsive
behaviour (Flupentixol depot)

antidepressants ineffective

careful for drugs dangerous in

OD

be aware of C-tf feelings of

negativity, helplessness or
feeling overwhelmed

specialist
clinics
for PD
prescribe less medication for
shorter periods

medication does not change

core sx
Management as a GP:

understand pts personality

is there a PD? Influence on

other dx and Rx?

Rx comorbidity (psychiatric/
medical)

Attend to how you act with this

personality type, C-tf, think
whether you need to change
your approach

Understand resistance to Rx

Consider referral

Conclusion:

assessment often neglected,

linked to anxiety that PD might

Innate predisposition to
behave in a particular
manner (a given)
(2) Character

Shaped by interaction
between temperament and
experiences

disposition
of
will,
Values, attitudes, coping
strategies
Personality trait:

enduring
patterns
of
perceiving, relating to and
thinking about oneself and
the environment

predictable regularities in
a persons behaviour

maintained and some roles are

carried out:

few friendships

intermittent/
frequent
minor conflicts with peers
and/or co-workers

withdrawn, isolate

capable and willing to

sustain employment

meaningful relationships
with some family
members, avoids others
or has conflict with them

how do you interact

with others

tell me about your work history

and how you feel about working
(occupational
and
social
functioning)

are you able to have some

control over your feelings and
actions? Or impulsive, even
reckless?
Are you overly controlling?
Yourself and others?
o

Hospitalization:

PD not indication for admission

BPD: suicide

Suicide threats or self-harm

Risk: reinforce dependency,

disrupt therapeutic alliance

A.

Mad

Weird

Odd,
detached,
aloof,
eccentric

Schizoid

schizotypal

B.

Bad

Wonderful

Dramatic,
impulsive,
erratic
Antisocial

Borderline

Guarded, defensive, distrustful, suspicious

Feels persecuted
Hyper-vigilant to motifs of others
Indifferent, remote, solitary
Does not desire relationships
Minimal awareness of feelings of self or others
eccentric, bizarre
peculiar mannerisms and behaviours
odd beliefs
blurs line between fantasy and reality
muted version of schizophrenia?

Impulsive, irresponsible, deviant

Meets social obligations only when self-serving
Disrespect social rules, customs, standards
>18 years, h/o conduction d/o
most criminals have ASPD

unpredictable, unstable
fears abandonment, isolation
fluctuating moods

Characteristic
Paranoid

Defence mechanism

Projection

Withdrawal
intellectualization

acting out
substance abuse

splitting

be intractable, chronic
lack of proper care
personality d/o change over
time
substantial numbers achieve
full remission: but core
problems can remain in many
natural course of recovery
can be accelerated by
psychotherapy years
Rx of co-morbid ds might lead
to change

Misc.

Psychopath ASPD

More severe

Less
capable
of
any
emotional attachment

More ruthless

No regard for feelings and

concern of others
C-tf: Intense, problems in the
team

Histrionic

Narcissistic

Avoidant

C.

Sad

Worried

Anxious,
fearful

Dependent

Obsessive compulsive

dramatic, seductive, shallow, stimulus seeking, vain

sees self as attractive and charming

egotistical, arrogant, grandiose

sees self as admirable and superior
entitlement to special service
underlying ego weakness (jelly inside crust)
Hesitant, embarrassed, self-conscious, anxious
Tense in social situations, fears rejection
Sees self as unappealing, inferior
Feels alone
helpless, incompetent, submissive
immature
withdraws from adult responsibilities
sees self as weak or fragile
restrained, conscientious, respectful, rigid
rule-bound lifestyle
sees self as reliable, devoted, productive

exhibitionism
as
means of securing
attention and favours

C-tf:
Sexualized
transference
C-tf

Fantasy
withdrawal

vs. schizoid PD
vs. social phobia

OCPD vs. OCD

or

erotic