Personality Disorders - Wales Counseling Center,PLLC

Report
Personality Disorders
Amanda Hamilton, LMSW
October, 2013
Table of Contents
 Definition of Personality Disorders
 Statistical Data
 Indicators of a Personality Disorder
 DSM IV vs DSM V
 Overview of Each Personality Disorder
 Treatment of Personality Disorders
 Q&A
Personality
A set of enduring behavioral and
mental traits that distinguish
Human beings.
Definition of Personality Disorders
 Classes of social disorders characterized by enduring
maladaptive patterns of behavior, cognition and inner
experience, exhibited across many contexts and deviating
markedly from those accepted by the individual's culture.
 Patterns of behavior develop early, are inflexible and are
associated with significant distress or disability.
 Patterns of behavior impact at least 2 of 4 areas:
 Cognition: Ways of perceiving and interpreting self, other people
and events.
 Affectivity: The range, intensity, lability, and appropriateness of
emotional response.
 Interpersonal functioning
 Impulse control
Statistics
 Personality disorders are diagnosed in 40-60% of psychiatric
patients.
 9.1% of adults are estimated to have a personality disorder.
 39% of adults with personality disorders are estimated to be
receiving treatment.
 2-3% have the more common personality disorders:
Schizotypal, Antisocial, Borderline, Histrionic.
 0.5-1% have the least common personality disorders:
Narcissistic and Avoidant.
Tasman, Allan et al (2008). Psychiatry. Third Edition. John
Wiley & Sons, Ltd.
Statistics: Gender Prevalence
Disorder
Gender Prevalence
Paranoid Personality Disorder
Male
Schizoid Personality Disorder
Male
Schizotypal Personality Disorder
Male
Antisocial Personality Disorder
Male
Borderline Personality Disorder
Female
Histrionic Personality Disorder
Female
Narissistic Personality Disorder
Male
Avoidant Personality Disorder
Equal
Dependent Personality Disorder
Female
Obsessive-Compulsive Personality Disorder
Male
Tasman, Allan et al (2008). Psychiatry. Third Edition. John Wiley &
Sons, Ltd.
Diagnosing
 Generally, must individual must be 18 years or older.
 Rule-out other causes for the behavior: Substance abuse,
organic causes, other diagnoses or medical conditions.
 Behaviors are present in a variety of contexts in the
individuals life.
 DSM IV vs DSM V
 DSM IV has Personality Disorders on Axis 2. DSM V combines
Axis 1-3.
 DSM V shows ICD -9 and ICD-10 coding. ICD-10 is to be
implemented beginning October 1, 2014.
Clusters
Personality disorders are categorized into three clusters that
differentiate them by type.
 Cluster A: Odd or eccentric disorders (Paranoid, Schizoid,
Schizotypal)
 Cluster B: Dramatic, emotional, or erratic disorders
(Antisocial, Borderline, Histrionic, Narcissistic)
 Cluster C: Anxious or fearful disorders (Avoidant, Dependent,
Obsessive-compulsive)
Cluster A
 Odd or eccentric disorders (Paranoid, Schizoid, Schizotypal)
 May be first apparent in childhood and adolescence (Attract
teasing): Poor peer relationships, social anxiety,
underachievement, peculiar thoughts and language
Disorder
Paranoid
Personality
Disorder
Schizoid
Personality
Disorder
Schizotypal
Personality
Disorder
ICD-9
301.0
ICD-10
F60.0
301.20
F60.1
301.22
F21
Cluster B
 Dramatic, emotional, or erratic disorders (Antisocial,
Borderline, Histrionic, Narcissistic)
 Severity may lessen as the person gets to age 30-40
(Particularly with Borderline and Antisocial PD)
Disorder
Antisocial
Personality
Disorder
Borderline
Personality
Disorder
Histrionic
ICD-9
ICD-10
301.7
F60.2
301.83
F60.3
Personality
301.50
F60.4
301.81
F60.81
Disorder
Narissistic
Personality
Disorder
Cluster C
 Cluster C: Anxious or fearful disorders (Avoidant, Dependent,
Obsessive-compulsive)
 May show symptoms in infancy and childhood, but make
sure it’s not developmentally appropriate particularly with
Dependent PD.
Disorder
ICD-9
ICD-10
Avoidant Personality 301.82
Disorder
F60.6
301.6
Dependent
Personality Disorder
F60.7
301.4
ObsessiveCompulsive
Personality Disorder
F60.5
Cluster A: Paranoid
Pervasive distrust and suspiciousness
of others such that their motives are
interpreted as malevolent, beginning by
early adulthood and present in a
variety of contexts as indicated by four
or more of the following:
Cluster A: Paranoid
Suspects that others are exploiting,
harming, or deceiving them.
Preoccupied with doubts about loyalty or
trustworthiness of others.
Reluctant to confide in others because of
fear that information will be used against
them.
Reads hidden meanings into remarks or
events.
Cluster A: Paranoid
Persistently bears grudges.
Perceives attacks on his or her character
and is quick to react or counterattack.
Recurrent suspicions regarding fidelity of
spouse or partner.
Cluster A: Paranoid Treatment
Reduced levels of trust can hinder rapport
building with patient
Psychotherapy
Antidepressants
Antipsychotics
Anti-anxiety medications
Cluster A: Schizoid
Pervasive pattern of detachment from
social relationships and restricted
range of expression of emotions in
interpersonal settings, beginning by
early adulthood and present in a
variety of contexts as indicated by four
or more of the following:
Cluster A: Schizoid
Neither desires or enjoys close
relationships, including being part of a
family.
Chooses solitary activities.
Little interest in having sexual experiences.
Takes pleasure in few activities.
Cluster A: Schizoid
Lacks close friends or confidants other than
immediate family.
Indifferent to praise or criticism of others.
Shows emotional coldness, detachment, or
flat affect.
Cluster A: Schizoid Treatment
Atypical antipsychotics (Risperidone, etc)
are commonly used to treat the negative
symptoms such as anhedonia and blunted
affect
Anti-anxiety medications
Antidepressants
Therapy
Socialization groups
Cluster A: Schizotypal
Pervasive pattern of social and interpersonal
deficits marked by acute discomfort with and
reduced capacity for close relationships.
Cognitive or perceptual distortions and
eccentricities of behavior, beginning by early
adulthood and present in a variety of
contexts, as indicated by five or more of the
following:
Cluster A: Schizotypal
Ideas of reference.
Odd beliefs or magical thinking that
influence behavior.
Usual perceptual experiences.
Suspiciousness or paranoid ideation.
Cluster A: Schizotypal
Inappropriate or constricted affect.
Behavior or appearance that is odd.
Lacks close friends or confidants other than
immediate family.
Excessive social anxiety.
Cluster A: Schizotypal Treatment
Atypical antipsychotics
Anti-anxiety medications
Antidepressants
Therapy
Group therapy is recommended only if well
structured and supportive. However, may
have a lot of difficulty in groups even with
high structure if paranoia is high.
Cluster B: Antisocial
Pervasive pattern of disregard for and
the violation of the rights of others
occurring since age 15 years, as
indicated by three or more of the
following:
Cluster B: Antisocial
Failure to conform to social norms with
respect to lawful behaviors.
Deceitfulness, as indicated by repeated
lying, use of aliases, or conning others
for personal profit or pleasure.
Impulsivity or failure to plan ahead.
Irritability and aggressiveness.
Cluster B: Antisocial
Irritability and aggressiveness.
Reckless disregard for safety of others.
Consistent irresponsibility.
Lack of remorse.
Cluster B: Antisocial Treatment
Difficult to treat due to lack of remorse.
Some studies have shown outpatient
treatment not likely to be successful and
often has to be forced by parole.
Residential programs that offer carefully
controlled environments and supervision
along with peer confrontation have been
recommended.
Schema Therapy is being investigated as a
treatment modality.
Cluster B: Borderline
Pervasive pattern of instability of
interpersonal relationships, self-image, and
affects and marked impulsivity beginning by
early adulthood. Present in a variety of
contexts, as indicated by 5 or more of the
following:
Cluster B: Borderline
Frantic efforts to avoid real or imagined
abandonment.
Pattern of unstable or intense
interpersonal relationships.
Identity disturbance.
Impulsivity in at least two areas that are
potentially self-damaging.
Cluster B: Borderline
Recurrent suicidal behavior or selfmutilation.
Instability due to marked reactivity of mood.
Chronic feelings of emptiness.
Inappropriate intense anger or problems
controlling anger.
Stress related paranoid ideation or severe
dissociative symptoms.
Cluster B: Borderline Treatment
Long term therapy (Mentalization Based
Treatment, Transference Focused
Treatment, Dialectical Behavior Treatment,
Schema Therapy)
Medications (Antipsychotics,
Antidepressants, Anti-anxiety)
Mindfulness meditation
Acute services and hospitalizations
Cluster B: Histrionic
Pervasive pattern of excessive
emotionality and attention seeking,
beginning by early adulthood and
present in a variety of contexts as
indicated by 5 or more of the following:
Cluster B: Histrionic
Uncomfortable in situations which they are
not the center of attention.
Inappropriate sexually seductive or
provocative behavior.
Rapidly shifting and shallow expression of
emotions.
Usage of physical appearance to draw
attention.
Cluster B: Histrionic
Speech that is excessively impressionistic
and lacking detail.
Self-dramatization, theatricality, and
exaggerated expression of emotion.
Easily influenced.
Considers relationships more intimate than
they really are.
Cluster B: Histrionic Treatment
Treatment often prompted by depression
associated with dissolved relationship.
Antidepressants for treatment of
depression.
Cognitive therapy.
Cluster B: Narcissistic
Pervasive pattern of grandiosity, need
for admiration, and lack of empathy,
beginning by early adulthood and
present in a variety of contexts, as
indicated by five or more of the
following:
Cluster B: Narcissistic
Grandiose sense of self-importance.
Preoccupied with fantasies of unlimited
success, power, brilliance, beauty, and
ideal love.
Belief he or she is special and should only
associate with or be understood by highstatus people.
Requires excessive admiration.
Cluster B: Narcissistic
Sense of entitlement.
Interpersonally exploitive.
Lacks empathy.
Envious of others or feels people are
envious of them.
Shows arrogant, haughty behaviors, or
attitudes.
Cluster B: Narcissistic Treatment
Individual may resist therapy or not go due
to unconscious fears of exposure or
inadequecy
Schema Therapy
Medication if needed
Cluster C: Avoidant
Pervasive pattern of social inhibition,
feelings of inadequacy, and
hypersensitivity to negative evaluation,
beginning by early adulthood and
present in a variety of contexts, as
indicated by four or more of the
following:
Cluster C: Avoidant
Avoids occupational activities that involve
significant personal contact, because of
fears of criticism, disapproval, or rejection.
Unwilling to get involved with people unless
certain of being liked.
Shows restraint within intimate
relationships because of the fear of being
shamed or ridiculed.
Preoccupied with being criticized or
rejected in social situations.
Cluster C: Avoidant
Inhibited in new interpersonal situations
because of feelings of inadequacy.
Views self as socially inept, personally
unappealing, or inferior to others.
Unusually reluctant to take personal risks
or to engage in any new activities because
they may prove embarrassing.
Cluster C: Avoidant Treatment
Social skills training
Cognitive Therapy
Group Therapy
Barrier to therapy is getting gaining
individuals trust and keeping it
Cluster C: Dependent
Pervasive and excessive need to be
taken care of that leads to submissive
and clinging behavior and fears of
separation, beginning by early
adulthood and present in a variety of
contexts, as indicated by five or more
of the following:
Cluster C: Dependent
Difficulty with making everyday decisions
without an excessive amount of advice and
reassurance from others.
Needs others to assume responsibility for
most major areas of his or her life.
Difficulty expressing disagreement with
others because of fear of loss of support or
approval.
Difficulty initiating projects or doing things
on his or her own.
Cluster C: Dependent
Goes to excessive lengths to obtain nurturance
and support from others, to the point of
volunteering to do things that are unpleasant.
Feels uncomfortable or helpless when alone
because of exaggerated fears of being able to
care for themselves.
Urgently seeks another relationship as a
source of care and support when a close
relationship ends.
Preoccupied with fears of being left to take
care of himself or herself.
Cluster C: Dependent Treatment
Therapy
Medication used with therapy
Cluster C: Obsessive-Compulsive
Pervasive pattern of preoccupation with
orderliness, perfectionism, and
interpersonal control, at the expense of
flexibility, openness, and efficiency,
beginning by early adulthood and present
in a variety of contexts, as indicated by
four or more of the following:
Cluster C: Obsessive-Compulsive
Preoccupied with details, rules, lists, order,
organization, or schedules to the point
major activity is lost.
Shows perfectionism that interferes with
task completion.
Excessively devoted to work and
productivity to the exclusion of leisure
activities and friendship.
Unable to discard worn-out or worthless
objects even when they have no
sentimental value.
Cluster C: Obsessive-Compulsive
Reluctant to delegate tasks or to work with
others unless they submit to exactly his or
her way of doing things.
Adopts miserly spending style towards self
and others. Money is viewed as something
to be hoarded.
Shows rigity and stubbornness.
Cluster C: Obsessive-Compulsive
Treatment
Cognitive-Behavioral Therapy
Self-help
Treatment may be complicated if person
does not feel they have a problem or that
behaviors shouldn’t be changed
Medication can be used with therapy
Treatment of Personality Disorders
Treatment varies on personality disorder
type
Each disorder has it’s own barriers to being
able to treat the individual
Be aware of countertransference
(Redirection of therapists feelings towards
the individual)
Refer individual out when needed.
References
 American Psychiatric Association (2013). Diagnostic and
Statistical Manual of Mental Disorders (Fifth ed.). Arlington,
VA: American Psychiatric Publishing. pp. 646–649.
 Lenzenweger MF, Lane MC, Loranger AW, Kessler RC
(2007). DSM-IV personality disorders in the National
Comorbidity Survey Replication. Biological Psychiatry, 62(6),
553-564.
 Tasman, Allan et al (2008). Psychiatry. Third Edition. John
Wiley & Sons, Ltd.
 Kendler KS, Czajkowski N, Tambs K et al. (2006).
"Dimensional representations of DSM-IV cluster A personality
disorders in a population-based sample of Norwegian twins:
a multivariate study". Psychological Medicine 36 (11): 1583–
91
References
 Derefinko, Karen J.; Thomas A. Widiger (2008). "Antisocial
Personality Disorder". The Medical Basis of Psychiatry
 American Psychiatric Association, 2013
Question
and
Answer

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