Personality Disorders - HIV Training Track

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Personality Disorders
Deepti Chopra
Fellow Psychosomatic Medicine
Yale University
People at the Party (Dr.Suler)

Winston spent most of the time talking about his trip to
Europe, his new Mercedes and his favorite French
restaurants. People seemed bored being around him, but he
kept right on talking. When he made a critical remark about
how one of the woman was dressed and hurt her feelings, he
could not apologize for his obvious blunder. He tried to talk
his way around it, and even seemed to be blaming her for
being upset.

Peter arrived at the party exactly on time. He made a point
of speaking to every guest for five minutes. He talked mostly
about technology and finance and avoided any inquiries about
his personal life. He left precisely at 10pm because he had
work to do at home.
What is Different about them?
Trait vs State
 Personality Trait

An enduring pattern of perceiving, relating and thinking
about the environment and oneself, that is seen in a wide
range of social and personal situations
Personality Disorder
A) An enduring pattern of inner experience and behavior that
deviates markedly from the expectations of individual's culture.
This pattern is manifested in > 2/4 areas.
i) Cognition, Affectivity, Interpersonal Functioning, Impulse
Control.
i) Cognition: manner of perceiving and interpreting self, others and
events.
ii) Affectivity: i.e. Range, intensity, lability, appropriateness of emotional
response
iii) Interpersonal functioning: i.e. Difficulty with maintaining boundaries.
iv)Impulse control.
Personality Disorder
B) The enduring pattern is inflexible and pervasive across broad
range or personal and social situations.
C) The pattern leads to clinically significant distress or impairment
in social, occupational or other important areas of functioning.
D) The enduring pattern is stable and of long duration, and its onset
can be traced back to at least to adolescence or early adulthood.
E) The enduring pattern is not better accounted for as a manifestation
or consequence of another mental disorder.
F) The enduring pattern is not due to direct physiological effects of a
substance (eg a drug of abuse , or medication) or a gmc (eg head
trauma).
Epidemiology
Classification
Hippocrates:
 Based on Body Humor ( ? Biological origin)
Black Bile--- Sad, anxious- Melancholic
Blood--- Warm hearted, optimistic Sanguine
Yellow Bile – Quick tempered, angry  Choleric
Phlegm– Slow, lethargic, calm Phelgmatic


Eysenck’s Theory:
measures dimensions of personality
Eysenck’s Dimensional Classification
Classification per DSM IVTR
Cluster A: "Eccentric" "Weird" "Odd"
Paranoid personality disorder
Schizoid personality disorder
Schizotypal personality disorder
Cluster B: "Erratic" "Wild" "Emotional"
Borderline personality disorder
Histrionic personality disorder
Antisocial personality disorder
Narcissistic personality disorder
Cluster C: "Edgy" "Wimpy" "Anxious"
Avoidant personality disorder
Dependent personality disorder
Obsessive Compulsive personality disorder
Etiology: Biological
Cluster A:
 FH of schizophrenia seen in Schizotypal pd.
Cluster B:
 FH of depression in borderline pd. (mood disorder)
↑ testosterone in aggression.
↓ 5-HIAA in persons who attempt suicide, impulsive.
Cluster C:
 Obsessive compulsive traits more common in mono
zygotic twins.
Etiology: Psychological
Sigmund Freud:
Fixation in psychosexual stage
of development.
Example: Oral stage- dependent pd.

 Anna
Freud & Wilhelm Reich:
Characteristic defensive style
produce ego syntonic behavior.
example: paranoid- project.
Object relations theory:
Self= subject, Other person=object,
self representation, object
representation.
 Melanie Klein:
Paranoid schizoid position -->
Depressive position.

Heinz Kohut:
External relations help maintain
self esteem and self cohesion.
Mirror transference and idealizing
transference.

Attachment theory: Ainsworth,
Fonagy, Bowlby.
Strange situation- secure:
- insecure:
avoidant, anxious ambivalent and
disorganized types.

The above conflicts /deficits will
be enacted during therapy.
Cluster B Case (DSM case bk)
19 yo M with punk hairstyle, was agitated, argumentative when
brought into ER, by his friend. He had irregular breath, rapid pulse,
dilated pupils. His mom arrived later, reportedthat he was
disobedient, resentful to authority, unwilling to participate in
family activities & violently argumentative when confronted about
partying all night. He has h/o being arrested twice, for shoplifting and
drunken driving.
His parents divorced when he was 15, so he had no stable father
figure, and it was difficult for his mother to discipline him. As per
mother he was a fairly good student and a star member of the basket
ball team. ( However, in reality pt never completed high school due
to poor failing grades and never played basket ball.)
Diagnosis of Antisocial Personality
A) Pattern of disregard for and violation of rights of
others occurring since age of 15, and indicated by >3/7 :
"CORRUPT"
Cannot follow norm or law.
Obligations of work& finances ignored.
Reckless disregard for self & others.
Remorsefulness.
Untruthfulness
Planning deficits ( impulsivity, failure to plan ahead)
Temper tantrums ( irritability, frequent fighting)
Pt is at least 18 yrs.
Etiology: Antisocial PD
 Biological:
FH positive, then risk 5 times in 1st degree relatives
↓ in prefrontal gray matter
↓in callosal thickness (Raine et al 2005)
↓ 5- HIAA level.
low Autonomic nervous system responsiveness.

Psychological:
Lacks super ego due to impairment in internalization .
Defense mechanisms: externalization.

Social:
negative or conflicting parenting style in adolescent.
Epidemiology
Prevalence:
*General population- 2-3%.
*Males-3%, Females-1%, prisoners-75%.
* ↑ ADHD , Substance use and Somatization d/o co-morbid.
Course & Prognosis:
common in poor urban area + high school drop outs.
Impulsivity may improve with age, but continue to have trouble
with working, parenting and romantic partners.
Treatment
Important to identify ASPD, BUT difficult to treat successfully.

Medications:

Psychotherapy: Difficult
Impulsivity -Depakote/ Tegretol.
Aggression-Beta blockers
◦ Outpatient individual therapy- not useful.
* Should be initiated in structured settings- eg special units in
prison, nonmedical community residential program etc.
* Impulse--> Thought-->Action
◦
Inpatient: Disruptive for hospital settings.
Cluster B Case Example

38 yo single AAF, living alone c/o depression secondary to
social stressors. Her stress includes unemployment and
caring for her ill sister and father. She has had 70jobs till
now, but has been unable to find employment as she wants
to work as a bus driver only and all other jobs
are“useless”. She has h/o suicide attempt at age 16 , when
she broke up with her boyfriend. Since then she is always
attracted to married men, and was involved in 5
relationships till now. She avoids interacting with Afro
American men as she does not trust them. Her sister was
molested as a child, but pt denies any personal h/o abuse or
trauma. On evaluation she is loud and irritable, talks
incessantly about how everybody ill treats her.
Diagnosis of Borderline pd
A pervasive pattern of instability of interpersonal
relationships, self image, and affects, marked by impulsivity
indicated by >5/9 :
“PRAISE”
Paranoid ideation
Relationship instability
Affective instability
Angry outbursts
Abandonment Fears
Impulsivity
Identity disturbance
Suicidal behavior
Emptiness

Etiology Borderline pd

Biological:
Heritability suggested, if mother with BPD, risk of bpd in child.
Hyper-responsiveness 2’ry to early traumatic experience, ↑
ACTH& cortisol secretion noticed.
Serotonergic involvement suspected.
fMRI reveals enhanced amygdala activation, ↓hippocampal &
amygdala volume in BPD

Psychological:
Lack of object constancy ( Kernberg)
Rapproachment- constantly in infantile crisis. ( Mahler/
Kernberg)
Inability to mentalize ( Fonagy)
Etiology cont’d

Defense mechanisms:
splitting, primitive idealization/devaluation,
projective identification.

Social:
Childhood trauma and abuse are important contributors.
Chaotic home environment.
Epidemiology of Borderline pd

Prevalence
◦ General population: 0.7-1.8%
◦ Inpatient: 51% of all PD, Outpatient: 27% of all PD.
◦ Female: Male: 2:1
Diagnosed before age 40.

Course & Prognosis:
◦
◦
◦
◦
Fairly stable , no changes.
Continue to have occupational and marital difficulties.
↑Eating disorder, substance use and PTSD.
10% commit suicide before 30 yo.
Treatment

Identify personality disorder , more early recognition
◦ First visit to finally finding a “good doctor”
◦ Chaotic lifestyle pattern

Anticipate Future problems
◦ Demands : Set limits on the behavior.
◦
: Repetition is crucial.
◦
: Avoid confrontation
◦ Overdose: Minimal amount of medications with NO RF
: Prefer meds with less addictive potential.
• Open staff communication essential
Treatment

Medication and psychotherapy now standard

Medication:
◦ One medication at a time.
◦ Symptomatic management, popular choice SSRI.

Psychotherapy:
◦ Dialectical Behavioral Therapy
◦ Involves Mentalization, behavior and dialectics
Cluster B Case (Gabbard)

A male patient seeing a female therapist for the last
time prior to her departure at the end of her
residency. He tells her that he saw a movie the night
before, in which the female psychiatrist kissed one
of her male patients. Furthermore, the patient in the
movie seemed to benefit from the therapist’s affection
and asked his therapist, if she might do the same. After
an initial anxious reaction to the request, the therapist
asked him whether the unexpected request might be
related to termination of the therapy.
Diagnosis : Histrionic PD

Diagnosis made is pattern of excessive emotionality and
attention seeking is manifested in >5/8.

“PRAISE ME”
Provocative/ seductive behavior
Relationships , considered more intimate that they are.
Attention, must be center of
Influenced easily.
Speech impressionistic , lacking detail.
Exaggerated emotions- theatrical.
Make –up: physical appearance used to draw attention to
self.
Emotion lability, shallowness.
Epidemiology Histrionic PD

Prevalence
General population: 2-3%
Clinical population: 10-15%
Female > Male:
Associated with somatization and alcohol use.

Course & Prognosis:
Symptoms decline with age.
Sensation seeker, thus likely to get in trouble with the law.
Treatment Histrionic PD
Unlike other pd’s , they will seek treatment.
 Medications:
DepressionSSRI’s, Anxiety Anxiolytics
Dissociation antipsychotics.
 Psychotherapy: help expression of repressed memories
via language.
*Mindful of erotic transference.
*Acknowledge physical & affective display.
*Help identify proper sense of self .

Cluster B Case (Gabbard)

Mr. F came to initial therapy after 3 previously failed attempts at
therapy. Mr. F denigrated the previous therapeutic experience as
“a complete waste of time” & could not even remember
his therapist’s name (previous treatment lasted for 3 years).
He further reported that “doctor what’s his name”
interrupted him a lot and was not a good listener. Mr. F talked at
length about his need for a “special” therapist & speculated
that there might not be anyone who could really understand
him. During session, he would ramble at length about his
achievements & successful career. He would not allow
therapist to intervene," Just let me finish this train of thought
first.” Later, when the therapist tried to redirect him, he got
upset and left.
Diagnosis: Narcissistic PD

Pervasive pattern of grandiosity (in fantasy or behavior),
need for admiration, and lack of empathy, indicated by
>5/9.
◦ “GRANDIOSE”
Grandiose sense of self importance
Requires excessive admiration
Arrogant attitudes, behavior.
Nasty preoccupation with fantasies of unlimited success, power
and ideal love.
Demands “special” treatment.
Interpersonal exploitative.
Often envious.
Special, believes he is
Empathy lacking
Etiology Narcissistic PD

Psychological:
Kohut (Hypervigilant): requires special response
from the environment, to maintain cohesive self.
Considered as arrest in developmental stage.
Kernberg (Oblivious): Self is a pathological
structure, composed of fusion of ideal self, the ideal
object & real self.
Epidemiology: Narcissistic PD


Prevalence:
General population: <1 %
Clinical settings: 1-16%.
Course & Prognosis
Chronic course
Unable to handle aging.
Vulnerable to midlife crisis depression.
Treatment : Narcissistic PD
Difficult to treat (You cannot fix awesome)
 Psychotherapy
*Kohut: empathic validation.
*Kernberg: interpretations and confrontation early.


Pharmacotherapy
Lithium for mood swings.
SSRI for depression.
Cluster C Case Example

45 yo M, lawyer sought treatment as his wife insisted. She was fed
up with their marriage, she could no longer tolerate his
emotional coldness, rigid demands, bullying behavior,
sexual disinterest, long work hours & frequent business trips.
Pt did not feel that his marriage was not working well. During the
session, it was evident that he was troubled by many work
problems, he was the youngest full partner, famous for handling
many cases at the same time. But lately, he was finding it difficult
to keep up. His coworkers were upset as he paid too much
attention to minute details, & he did not delegate work
responsibility to others. He was the son of two upwardly mobile,
extremely hardworking parents. He grew up feeling, he never
worked hard enough. He was a “bookworm”, a superior but
awkward student in school.
Diagnosis OCPD

Pattern of orderliness, perfectionism, mental &
interpersonal control, indicated in >4/8 .

“Law Firms”
Loses point of activity ( preoccupied with detail)
Ability to complete tasks ( compromised by perfection)
Worthless objects ( unable to discard)
Friendships & leisure activities excluded (preoccupied with work)
Inflexible, over conscientious ( ethics, values or morality)
Reluctant to delegate
Miserly
Stubbornness.
Etiology OCPD

Biological:
1st born child. M>F.
1st degree relatives ( frequent)

Psychological:
Highly punitive superego->defenses like isolation of affect,
intellectualization, reaction formation, undoing, displacement.
Most recent: great deal of self doubt.

D/D: OCD ( ego dystonic)
Treatment OCPD

Greatly improved with psychoanalysis or individual
psychotherapy with an expressive emphasis.
* help them explore their feelings
* sometimes patient try to be the“perfect patient”.

Pharmacotherapy
Clomipramine
Benzodiazipines
Fluoxetine 60-80mg for OCD s/s.
References

Kaplan and Sadock’s: Synopsis of psychiatry.

Hales RE, Yudofsky S: Textbook of Clinical Psychiatry.4th Ed.

Gabbard G :Psychodynamic Psychiatry in Clinical Practice 4th Ed.

Opi Akunnusi MD, lecture on Personality disorders for mnemonics

Cases –Dr Suler J, dsm case book.

Schwarcz G. Halaris A “Identifying and Managing Borderline Personality
Patients” The American Family Physician. 1984 (29) 203-208.

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