Michelle Mathias, MA, MD, FRCPCApril 3, 2013

B2B: Personality Disorders

Special thanks…

… to Dr. Deanna Mercer

Objectives

General:Differentiate between PD and other mental illness, recognizing the high prevalence of co-morbidities

Formulate appropriate management plan

Objectives

Specific:List & interpret critical clinical findings, inc:

Sufficient clinical info (e.g. MSE) to dx type of PDRisk factors associated with PDs (e.g. SI, substance)Any co-existing psych conditions (e.g. mood d/o)

Construct an effective initial management plan, inc:Proper management for pt needing immediate

intervention (e.g. suicide risk, risk to others)Judicious use of pharmacotherapy, with consideration

of risk for abuse or overdoseReferral for multi-disciplinary and/or specialized care,

if needed

2-pass approach

Criteria/overview By objective/detailed

B2B… PDs from the start

…definitions & diagnostic criteria!

Definitions

Personality:Individual’s characteristic pattern of

response to his/her enviroIncludes: how one…

Thinks (cognitive)Feels (affective)Acts (behavioural)Relates to others (interpersonal)

Etiology: transactional modelTemperament (bio) + Environmental (social)

time

Definitions (cont’d)

Personality Disorders:Clinically significant distress or impairment in

functioningEnduring pattern of inner experience and

behaviour that deviates markedly from expectations of individual’s culture

Impacts: 2 or more cognition, affectivity, interpersonal fxn & impulse control

Pattern:Inflexible & pervasive across broad range of personal and

social situationsNot better accounted for by other mental

disorder, GMC or substance

Definitions (cont’d)

Personality Disorders:Ego-syntonic:

Individual experiences sig distress, but doesn’t feel their thoughts, emotions or behaviors are source of their problem

Locus of control: externalE.g. OCPD

VSEgo-dystonic:

Individual sees their disorder as arising from their own thoughts, emotions or behaviours

Locus of control: internalE.g. OCD

Definitions (cont’d)

Personality Disorder Clusters: 3-4-3Cluster A: ODD

Schizoid, Schizotypal, ParanoidCluster B: Dramatic

Borderline, Histrionic, Narcissistic, Antisocial

Cluster C: AnxiousObsessive Compulsive, Dependent,

Avoidant

Cluster A

Paranoid, Schizoid, Schizotypal

Paranoid PDPervasive pattern of:

Distrust and suspiciousness of othersMotives of others are interpreted as

malevolent… beginning by early adulthood and present in various settings

Practically:Looks like delusional d/o (paranoid type),

butNo full blown delusionsMore pervasive suspiciousness

Schizoid PDPervasive pattern of:

Detachment from social relationshipsRestricted range of expression of emotions in

interpersonal settings

… beginning by early adulthood and present in various settings

Practically:Mostly solitary activitiesFew friends other than first degreeCold & detachedLittle or no interest in relations; solitary lifestyleIndifferent to praise or criticism

Schizotypal PDPervasive pattern of:

Social and interpersonal deficitsAcute discomfort with and reduced capacity for close

relationshipsCognitive or perceptual distortions or eccentricities

of behaviour… beginning by early adulthood and present in various settings

Practically:Eccentric behavioursOdd beliefs, unusual perceptions, suspiciousness,

paranoia, odd speechDiscomfort in close relationships - paranoia

(not b/c of fear of judgment)

Flashback…

Flashback…

Schizo ypal

Flashback…

Schizo ypal

Devoid…Schizoid

Cluster B

Antisocial, Borderline, Histrionic, Narcissistic

Antisocial PDPervasive pattern of:

Disregard for and violation of rights of others… since age of 15 (must be at least 18yo)

Practically:Repeated lawbreakingDeceitfulnessImpulsivityIrritability and aggressivenessDisregard for safety of self or othersConsistent irresponsibilityLack of remorse

Borderline PD

Borderline PDPervasive pattern of:

Instability of interpersonal relationshipsInstability of self-image and affectsMarked impulsivity… beginning by early adulthood and present in various contexts

Practically:Efforts to self-harm or end lifeUnstable relationshipsMood lability

Histrionic PDPervasive pattern of:

Excessive emotionalityAttention seeking… beginning by early adulthood and present in various settings

Practically:TheatricalIntense but shallow emotionsCraves being centre of

attention

Narcissistic PDPervasive pattern of:

Grandiosity (in fantasy or behaviour)

Need for admirationLack of empathy… beginning by early adulthood and present in various contexts

Cluster C

Avoidant, Dependent, Obsessive Compulsive

Avoidant PD

Pervasive pattern ofSocial inhibitionFeelings of inadequacyHypersensitivity to negative evaluation

… beginning by early adult and present in various contexts

Practically:Similar to social phobia, but more

pervasive

Dependent PDPervasive and excessive need to be taken care

of, leads to:Submissive and clinging behaviourFears of separation

… beginning by early adult and present in various contexts

Practically:Dependent on relationshipsDifficulty making everyday decisions without a lot of

advice, reassurance from othersUnable to disagree with others because fears loss of

supportWill do things that are unpleasant, degrading to

maintain support

Obsessive Compulsive PDPervasive pattern of preoccupation with:

OrderlinessPerfectionismMental and interpersonal control

… at the expense of flexibility, openness and efficiency… beginning by early adult and present in various contexts

Practically:Controlling of others, inflexibleExcessively devoted to workReluctant to delegate tasksEmotionally constricted

2-pass approach

Criteria/overview By objective/detailed

Objectives

Specific:List & interpret critical clinical findings, inc:

Sufficient clinical info (e.g. MSE) to dx type of PDRisk factors associated with PDs (e.g. SI, substance)Any co-existing psych conditions (e.g. mood d/o)

Construct an effective initial management plan, inc:Proper management for pt needing immediate

intervention (e.g. suicide risk, risk to others)Judicious use of pharmacotherapy, with

consideration of risk for abuse or overdoseReferral for multi-disciplinary and/or specialized

care, if needed

ObjectivesSpecific:

List & interpret critical clinical findings, inc:Criteria (done) & MSERisk factors associated with PDs (e.g. SI,

substance)Any co-existing psych conditions (e.g. mood d/o)

Construct an effective initial management plan, inc:Proper management for pt needing immediate

intervention (e.g. suicide risk, risk to others)Judicious use of pharmacotherapy, with

consideration of risk for abuse or overdoseReferral for multi-disciplinary and/or specialized

care, if needed

ObjectivesSpecific:

List & interpret critical clinical findings, inc:MSERisk factors & prognosisAny co-existing psych conditions (e.g. mood d/o)

Construct an effective initial management plan, inc:Proper management for pt needing immediate

intervention (e.g. suicide risk, risk to others)Judicious use of pharmacotherapy, with

consideration of risk for abuse or overdoseReferral for multi-disciplinary and/or specialized

care, if needed

ObjectivesSpecific:

List & interpret critical clinical findings, inc:MSERisk factors & prognosisComorbidities

Construct an effective initial management plan, inc:Proper management for pt needing immediate

intervention (e.g. suicide risk, risk to others)Judicious use of pharmacotherapy, with

consideration of risk for abuse or overdoseReferral for multi-disciplinary and/or specialized

care, if needed

ObjectivesSpecific:

List & interpret critical clinical findings, inc:MSERisk factors & prognosisComorbidities

Construct an effective initial management plan, inc:Risk assessment & acute management (safety)Judicious use of pharmacotherapy, with

consideration of risk for abuse or overdoseReferral for multi-disciplinary and/or

specialized care, if needed

ObjectivesSpecific:

List & interpret critical clinical findings, inc:MSERisk factors & prognosisComorbidities

Construct an effective initial management plan, inc:Risk assessment & acute management (safety)PharmacotherapyReferral for multi-disciplinary and/or

specialized care, if needed

ObjectivesSpecific:

List & interpret critical clinical findings, inc:MSERisk factors & prognosisComorbidities

Construct an effective initial management plan, inc:Risk assessment & acute management

(safety)PharmacotherapyNon-pharm treatment

Objectives

List & interpret critical clinical findings, inc:MSERisk factors & prognosisComorbidities

Construct an effective initial management plan, inc:Risk assessment & acute management

(safety)PharmacotherapyNon-pharm treatment

General Word on Tx approach

Bio Psycho SocialAcute – safety(self & others)

Short-term(stabilizati

on)

Long-term (maintenan

ce)

Cluster A

Paranoid, Schizoid, Schizotypal

Paranoid PD(refresher… which one is this?)

MSE: evasive, minimal answers, suspicious,

paranoid thought content, serious, humourless affectively restricted, lack warmth

Risk factors & prognosis:Relatives often have SchizophreniaLifelong problem working & living with others

Comorbidities:Other cluster A PDs, mood disorder, substance

use, agoraphobia, OCD

Paranoid PD(refresher… which one is this?)

Risk assessment & acute management (safety):Suicide attempters in ER: 9% with PPD

Pharmacotherapy:Antidepressants as indicatedLow dose antipsychotic for brief psychotic

episodes (increased stress)Non-pharm treatment:

Rarely seek help – insufficient trust to engage in process

CBT – address core beliefsGroup therapy – tend not to tolerate

Schizoid PD(refresher… which one is this?)

MSE:Cold, constricted, aloof, difficulty gaining rapport, odd

metaphors, ill at ease, difficulty tolerating eye contact

Risk factors & prognosis:Parents – cold, neglectful, suggest

relationships not worth pursuingIntroversion Possible family link – schizophreniaChildhood onset, likely stable course

Comorbidities:other cluster A PDs, mood d/o, anxiety d/o

Schizoid PD(refresher… which one is this?)

Risk assessment & acute management (safety):Low insight, low motivation… not usually self-

directed for txSuicide attempters in ER: 4%

Pharmacotherapy:Low-dose antipsychotic, antidepressants

Non-pharm treatment:PsychoeducationTherapeutic distance needed for pt to tolerate

relationshipSocial skills training

Schizotypal PD(refresher… which one is this?)

MSE:Superstitious, difficulty identifying own feelings,

odd mannerisms and interests, prone to minimal responses (use open-ended questions), peculiar speech, appear unusual

Risk factors & prognosis:10% commit suicide; pre-morbid personality of

schizophrenia (or milder version of); 10-20% develop schizophrenia

14% have schizophrenia in familyComorbidities:

Other cluster A PDs, depression, possible Borderline PD traits (poor interpersonal relationships)

Schizotypal PD(refresher… which one is this?)

Risk assessment & acute management (safety):SI assessment; intensity of delusion-like beliefs

Pharmacotherapy:Treat comorbiditiesMild-mod improvement with low-dose

antipsychoticsNon-pharm treatment:

Supportive psychotherapySocial skills trainingEncourage activity, but does not have to be

social

Cluster B

Antisocial, Borderline, Histrionic, Narcissistic

Antisocial PD(refresher… which one is this?)

MSE:Try to impress MD, good verbal intelligence; possibly

demandingAppear composed & credible (underneath = tension,

hostility… may need to push to discover)

Risk factors & prognosis:Px better if connected to some groupDecrease impulsivity & criminal behaviour, but continue

to be difficult people++ substance risk; ++ legal involvement

Comorbidities: Substance use disorders; other cluster B PDs, impulse

control disorders, ADHD

Antisocial PD(refresher… which one is this?)

Risk assessment & acute management (safety):Harm to others!! Legal risk

Pharmacotherapy:Mood stabilizers for impulsivityStimulants for ADHDTx comorbid depression, anxiety

Non-pharm treatment:Firm limitsRational Emotive Therapy (CBT alternative)PsychoeducationProbation officers

Borderline PD(refresher… which one is this?)

MSE:Manipulation, splitting, inconsistencies, avoiding,

deflecting, dramatic, poor problem solving, insight varies, poor judgment, thought process can vary and be significantly impaired in great distress

Risk factors & prognosis:Abusive upbringing, substance use disordersCan decrease over time, but less so than other PDs

Comorbidities:Other cluster B PDs, somatization disordersMood disorders (BPD vs Bipolar), anxiety disorders

(social anxiety)Brief psychotic episodesSubstance use disorders

Borderline PD(refresher… which one is this?)

Risk assessment & acute management (safety):SAFETY!!! Self-harm, suicide attempts, aggressive acts

towards othersHospitalization if needed… try to avoidDBT support; ACT teams

Pharmacotherapy:Avoid TCAs (lethal in OD); SSRIs; mood stabilizersAntipsychotics for psychotic sx (derealization)

Non-pharm treatment:DBT (modified CBT); individual + groupPsychoeducation… give them the diagnosis!Psycho-analytic – NOT appropriateSocial skills trainingFamily & couples therapy

Histrionic PD(refresher… which one is this?)

MSE:Dramatic, temper tantrums, superficial (nil

when go deeper), dramatic appearance (often sexual, esp clothing), eye contact varies

Risk factors & prognosis:As age, sx decreaseHistory of sexual abuseSubstance use

Comorbidities:Other cluster B PDs, brief psychotic episodes,

somatization, DID

Histrionic PD(refresher… which one is this?)

Risk assessment & acute management (safety):Substance useSuicide attempts and ideationHeteroagressive ideation (“heat of passion”)

Pharmacotherapy:Treat comorbidities: antidepressants (depression,

anxiety, somatic complaints)Anti-psychotics: for derealization & illusions

Non-pharm treatment:Psychoanalysis is idealInsight-orientedPsychoeducationFamily & couples therapy

Narcissistic PD(refresher… which one is this?)

MSE:Want their own way, no empathy, fake

sympathy, superficial rapport; vague answers or avoiding

Risk factors & prognosis:Substance useUpbringing with limited support and warmth

Comorbidities:Substance use, mood disorders, anxiety

disordersOther Cluster B PDs, sexual disorders

Narcissistic PD(refresher… which one is this?)

Risk assessment & acute management (safety):Rejection, loss, occupational problems, interpersonal

problemsSubstance use

Pharmacotherapy:AntidepressantsTreat comorbidities (substance use disorders treatment)

Non-pharm treatment:Insight-oriented therapyProbation officersFamily & couples therapySocial skills training – learn how to develop empathic

response for others

Cluster C

Avoidant, Dependent, Obsessive Compulsive

Avoidant PD(refresher… which one is this?)

MSE:Timid, lack self-confidence, afraid to speak, ++

anxiety during interview, hypersensitive to disapproval or rejection

Do not express wishes, opinions, needsRisk factors & prognosis:

Genetic link with social phobiaParents – inconsistent, absent, abusive,

discouragingComorbidities:

Anxiety d/o (social phobia - generalized, agoraphobia)

Depression, dysthymia

Avoidant PD(refresher… which one is this?)

Risk assessment & acute management (safety):Risk comes from associated anxiety and

depressionRisk of substance use – to cope with anxiety

Pharmacotherapy:Treat comorbidities: anti-depressantBeta adrenergic receptor antagonists (Atenolol):

decrease autonomic arousalNon-pharm treatment:

Assertiveness & social skillsCBT – core beliefsMindfulness

Dependent PD(refresher… which one is this?)

MSE:Submissiveness; rapport is easy, but deeper exploration

is difficult; easy to interview… want you to like them… watch for boundary violations

Lack of self-confidence, pessimistic, helpless, childlike, ++ anxiety

Risk factors & prognosis:Pts with chronic physical illnessesCan’t fxn independently; limited social relationsSuicide risk: termination of Dependent relationship -

Comorbidities:Mood disorders (MDD, adjustment d/o), anxiety

disorders (social phobia, agoraphobia)BPD, histrionic PD, avoidant PD

Dependent PD(refresher… which one is this?)

Risk assessment & acute management (safety):Suicide risk, safetyIsolation

Pharmacotherapy:Treat comorbidities: anti-depressants

Non-pharm treatment:Psychodynamic approachCBTSocial skills trainingFamily/ couples therapy

OCPD(refresher… which one is this?)

MSE:Stiff, formal, rigid demeanor, lack spontaneity; stickler for

rulesDetailed answers; constricted affect; eager to please (esp

MD)Routine disturbed = anxiety; indecisive (fear of making

mistake)

Risk factors & prognosis:Parental control, perfectionism, shame, criticismPressures can lead to mood & anxiety d/o… suicide concern

Comorbidities:Other anxiety disorders Depressive disorders, dysthymiaVs OCPD (egodystonic): 30% OCPD have OCD (not same in

reverse)NPD, Schizoid, somatoform d/o

OCPD(refresher… which one is this?)

Risk assessment & acute management (safety):Status of mood and anxietySubstance use – less prevalent (against rules; makes

more anxious)

Pharmacotherapy:AntidepressantsBenzos… bad for anxiety disorders; some use short-

term

Non-pharm treatment:CBT… careful for the perfect homework!PsychoeducationFamily & couples therapy

Resources

“Brain Calipers”“Field Guide to Disordered

Personalities”

(David Robinson, Rapid Psychler Press)

Thank You

… questions? comments?

Michelle Mathiasmmath051@uottawa.ca