Personality Disorder – AAFP 2011

Personality Disorder

1. Enduring pattern of inner experience and behavior that deviates markedly from the norm of the individual’s culture
2. Impairment in social, occupational, or other important areas of functioning
3. Stable & inflexible and pervasive across a broad range of personal and social situations
4. Onset traceable to at least adolescence or early adulthood
5. Pt have intact reality testing and abstract abilities w/o any thought disorder

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CCFP Objectives: 

1 Clearly establish and maintain limits in dealing with patients with identified personality disorders. For example, set limits for: appointment length, drug prescribing, accessibility.

2 In a patient with a personality disorder, look for medical and psychiatric diagnoses when the patient presents for assessment of new or changed symptoms. (Patients with personality disorders develop medical and psychiatric conditions, too.)

3 Look for and attempt to limit the impact of your personal feelings (e.g., anger, frustration) when dealing with patients with personality disorders (e.g.,stay focused, do not ignore the patient’s complaint).

4 In a patient with a personality disorder, limit the use of benzodiazepines but use them judiciously when necessary.

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Cluster A, characterized as “mad / weird“, odd or eccentric personalities:

• Familial association with psychotic disorder
• Common defense mechanisms: intellectualization, projection, magical thinking 

1. paranoid – pervasive distrust and suspiciousness of others
   • Risk Factors: family h/o schizophrenia & delusional d/o, paranoid type; child hood abuse, minority, immigrant, deaf
   • Approach:
     • Provide a formal, honest, and professional discussion without being too friendly, too warm, or too humorous.
     • Physicians should expect belittling comments, accusations, and potentially litigious threats from these patients, yet they should allow these patients to express grievances without confirming or confronting the paranoid beliefs.
   • Tx: CBT & insight-oriented counselling
   • Meds: low dose antipsychotics, SSRI (if comorbid depression, OCD, or agoraphobia)
2. schizoid– detachment from social relationships
   • Risk Factor: male, family h/o schizophrenia, troubled family relationships
   • Approach: Adapt a professional stance, provide clear explanations, tolerate odd beliefs and behaviors, and avoid over involvement in the patient’s personal or social issues.
   • Tx of choice = insight psychotherapy
   • Tx: supportive therapy: ID emotions
   • Meds: antipsychotics, antidepressants, psychostimulants
3. schizotypal – acute discomfort with and reduced capacity for close relationships, as well as cognitive or perceptual distortions and behavioral eccentricities
   • Risk Factors: relative with schizophrenia, genetic (monozygotic >dizygotic twin)
   • Approach: Pt may have intense anxiety in social situations with unfamiliar people, it is important to establish a therapeutic relationship
   • Tx like residual schizophrenia
   • Tx: insight-oriented, supportive tx, milieu therapy
   • Meds: low dose neuroleptic (pimozide), haloperidol for eccentric thoughts

Cluster B, characterized as “bad”, dramatic, emotional, or erratic personalities:

• Familial association with mood disorder
• Common defense mechanisms: denial, acting out, regression (histrionic), splitting (borderline), projective identification, idealization/devaluation

1. antisocial – disregard for and violation of the rights of others
   • associated with substance abuse, acute anxiety, delusional states, and factitious disorders
   • Risk factors: familial, maternal depression, lower SES; abandonment or abuse, repeated harsh punishments; 100% conduct /o as child
   • Approach:
     • This disorder may have social, legal, and financial implications; therefore, multiple treatment options must be considered.
     • Because of the risk of manipulative behaviors by the patient, the physician should use caution (especially in dealing with new, ill-defined illnesses), be fair and consistent, and set clear limits
   • Tx: CBT
   • Assess spousal/child abuse, drunk driving
2. borderline– instability of interpersonal relationships and self-image, with marked impulsivity
   • Risk factors: childhood abuse / neglect, abandonment; 5x ↑ if d/o present in 1° relative
   • Approach:
   • • second-generation antipsychotics, mood stabilizers, and dietary supplementation with omega-3 fatty acids have some beneficial effects
     • Avoid excessive familiarity with these patients because it can lead to mistrust
     • Understand that although angry outbursts may occur, limits must be set, a venue for frequent follow-up (e.g., telephone or office visits) must be created, and clear explanations without technical jargon must be provided
   • Tx: CBT
   • Meds: SSRIs (aggression/anger), low-dose antipsychotics (impulsivity & psychotic episodes)
   • Assess suicide risk often
3. histrionic – excessive emotionality and attention-seeking behavior
   • Risk factors: pt often seek Tx, but are emotionally needy & hesitant to stop therapy
   • Approach:
     • Pt require empathy with boundary setting to limit potentially manipulative behaviors, such as suicidal gestures
     • Emphasizing objective data while maintaining a professional concern for the patient’s feelings and emotions may be helpful
   • Tx: insight-oriented psychotherapy
   • Meds: SSRIs – aware pt can use it to OD
   • Assess suicide risk
4. narcissistic– grandiosity, need for admiration, and lack of empathy
   • Risk Factors: childhood abuse & neglect
   • Approach:
     • focus on concrete points and attempt to channel patient traits into improving their health (demanding, with an attitude of entitlement and “specialness)
     • acknowledge that the patient’s behavior is protective of his or her sense of internal control and self-esteem
     • constructive criticism to patients with narcissistic personality disorder should be carefully worded, because these patients may interpret this as humiliating or degrading and react with disdain, or they may counteract
   • Tx: CBT
   • Meds: SSRI (impulsivity or depression), mood stabilizers (impulse or bipolar)

Cluster C disorders, characterized as “sad”, anxious or fearful, are more prevalent:

• Familial association with anxiety disorder
• Common defense mechanisms: isolation, avoidance, hypochondriasis

1. Avoidant – social inhibition, feelings of inadequacy, and hypersensitivity to negative evaluation\
   • Risk Factors: childhood abuse or neglect
   • Approach:
     • Pt routinely respond to direct questions with “I’m not sure,” and may seem evasive.
     • Encouraging the patient in a nonjudgmental manner to report symptoms and validating the patient’s concerns are helpful
   • Tx of choice: individual psychotherapy – improve self-esteem
   • Tx: behavioural therapy
   • Meds: MAOI, beta-blocker, stimulant
2. Dependent – submissive and clinging behavior, and fears of separation
   • Risk Factors: chronic physical illness in childhood or separation anxiety d/o, early childhood parental loss
   • Approach: Provide reassurance and schedule routine follow-up (e.g., telephone or office visits) with the understanding that the patient may feel that urgent evaluations are necessary based on his or her sense of need, rather than on the medical necessity of the situation
   • Tx of choice: insight-oriented CBT
   • Tx: anxiety management, assertive training
   • Tx: Set Limits
   • Meds: TCA, MAOI, BDZ for s/sx
   • relatively favourable prognosis
3. obsessive-compulsive – preoccupation with orderliness, perfectionism, and mental and interpersonal contro
   • OCD the symptoms are ego-dystonic (i.e. the patient realizes the obsessions are not reasonable) whereas in OCPD the symptoms are ego-syntonic (i.e. consistent with the patient’s way of thinking).
   • Risk Factors: genetic: monozygotic > dizygotic, 1º with OCD or Tourette syndrome
   • Approach:
     • Be thorough with examinations and explanations, but should not focus on variables or uncertainties.
     • Psychotherapeutic therapies, including short-term inpatient therapy, have been successful
     • Treatment with SSRI may be helpful, especially if anxiety is present
   • Tx: CBT, r/o coexisting Tourette syndrome
   • Meds: SSRI or clomipramine

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 5 When seeing a patient whom others have previously identified as having a personality disorder, evaluate the person yourself because the diagnosis may be wrong and the label has significant repercussions. (DSM5)

Paranoid Personality Disorder

Pervasive distrust and suspiciousness of others, interpret motives as malevolent (blame problems on others); Dx req ≥ 4 SUSPECT Spousal infidelity suspected, without justification Unforgiving – persistently holds grudges Suspicious – Suspects that others are exploiting or deceiving them Perceives attacks – not apparent to others and is quick to counterattack Enemy or friends? – unjustified doubts about trustworthiness of acquaintances Confiding in others is feared – Reluctant to confide in others Threats perceived in benign remarks

Schizoid Personality Disorder

Lifelong pattern of social withdrawal – neither desires nor enjoys close relationship, including being a part of a family, prefers to be alone. Dx req ≥ 4 DISTANT Detached or flattened affect – shows emotional coldness Indifference to the praise or criticism of others Sexual activity of little to no interest Tasks done solitary – chooses solitary activities Absence of close friend Neither desire nor enjoys close relationships, including being part of a family Takes pleasure in few, if any, activities

Schizotypal Personality Disorder

Eccentric behaviours , peculiar thought patterns, dx req ≥ 5 ME PECULIAR Magical Thinking – odd beliefs inconsistent with cultural norm Experience Unusual perceptions,  including odily illusions Paranoid ideation or suspiciousness Eccentric behavior or appearance (involved in cults) Constricted or inappropriate affect Unusual thinking and speech (e.g. vague, circumstantial, metaphorical, overelaborate, or stereotyped) Lack of close friends or confidants other than first-degree relatives Ideas of reference (excluding delusions of reference) Anxiety in social situations that does not diminish with familiarity R/o psychotic or pervasive developmental d/o

Antisocial Personality Disorder

Violation of the rights of others occurring since age 15 years, as indicated by ≥3: CORRUPT

1. Can’t conform to social norms / laws by committing unlawful acts
2. Obligations ignored – Irresponsibility, can’t sustain work or honor financial obligations
3. Reckless disregard for safety of self or others
4. Remorseless,  being indifferent to or rationalizing having hurt, mistreated, or stolen from others
5. Underhanded – Deceitfulness, repeated lying, use of aliases, or conning others for personal gain
6. Planning insufficient – Impulsivity or failure to plan ahead
7. Temper – Irritability and aggressiveness, repeated physical fights or assaults

B. The individual is at least age 18 years.

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

Borderline Personality Disorder

Instability of interpersonal relationships, self-image, and affects, and marked impulsivity beginning by early adulthood; dx ≥ 5 DESPAIRER

1. Disturbance of identity – Unstable self-image or sense of self
2. Emotionally labile – Affective instability due to a marked reactivity of mood
3. Suicidal behavior, gestures, threats, or self-mutilating- recurrent – 10% suicide rate!
4. Paranoia or dissociation – transient, stress-related
5. Abandonment – Frantic efforts to avoid real or imagined abandonment
6. Impulsivity: ≥2 areas that are self-damaging (e.g., spending, sex, substance abuse, reckless driving, binge eating)
7. Relationships – Unstable – alternating between extremes of idealization and devaluation
8. Emptiness – chronic feeling
9. Rage – Inappropriate, intense anger or difficulty controlling anger

Histrionic Personality Disorder

Excessive emotionality and attention seeking; dx ≥ 5 ACTRESSS

1. Appearance focused – uses physical appearance to draw attention to self
2. Center of attention – Not comfortable unless the center of attention
3. Theatrical – Shows self-dramatization and exaggerated expression of emotion
4. Relationships – Considers to be more intimate than they actually are
5. Easily influenced – Is suggestible by others or circumstances)
6. Sexually seductive or provocative behavior – inappropriate
7. Shallow expression of emotions- rapidly shifting
8. Speech that is excessively impressionistic and lacking in detail

Narcissistic Personality Disorder

Grandiosity (in fantasy or behavior), need for admiration, and lack of empathy; ≥ 5: GRANDIOSE

1. Grandiosity (e.g., exaggerates achievements and talents)
2. Requires excessive admiration / ATTENTION
3. Arrogant – haughty behaviors or attitudes
4. Need to be “special” and should associate with, other special or high-status people
5. Dream of unlimited success, power, brilliance, beauty, or ideal love
6. Interpersonally exploitative (i.e., takes advantage of others to achieve his or her own ends)
7. Others: Lacks empathy; is unwilling to recognize or identify with the feelings and needs of others
8. Sense of entitlement (i.e., unreasonable expectations of especially favorable treatment)
9. Envious of others or believes that others are envious of him or her

Avoidant Personality Disorder

Timid & socially awkward, Social inhibition, feelings of inadequacy, and hypersensitivity to negative evaluation; ≥ 4: CRINGES Criticism or rejection preoccupies thoughts in social situations Restraint within intimate relationships because of the fear of being shamed or ridiculed Inhibited in new interpersonal situations because of feelings of inadequacy Needs to be sure of being liked before engaging socially Gets around occupational activities with need for interpersonal contacts Embarrassment prevents new activity or taking risks Self viewed as socially inept, personally unappealing, or inferior to others

Dependent Personality Disorder

A pervasive and excessive need to be taken care of that leads to submissive and clinging behavior and fears of separation; ≥ 5: RELIANCE Reassurance required – difficulty making everyday decisions without an excessive amount of advice and reassurance from others Expressing disagreement difficulty – fear of loss of support or approval Life responsibilities assumed by others for most major areas of life Initiating projects difficulty or doing things on his or her own (because of a lack of self-confidence in judgment or abilities rather than a lack of motivation or energy) Alone – feel uncomfortable or helpless when alone because of exaggerated fears of being unable to care for oneself Nurturance – goes to excessive lengths support from others Companionship sought urgently when a relationship ends Exaggerated fears of being left to take care of onself

Obsessive-Compulsive Personality Disorder

Preoccupation with orderliness, perfectionism, and mental and interpersonal control, at the expense of flexibility, openness, and efficiency; ≥ 4: SCRIMPER Stubborn & Rigidity Cannot discard worthless objects of no sentimental value Rule obsessed –  details, rules, lists, order, organization, or schedules to the extent that the major point of the activity is lost Inflexible about matters of morality, ethics, or values (not accounted for by cultural or religious identification) Miserly spending style toward both self and others; money is viewed as something to be hoarded for future catastrophes Perfectionism that interferes with task completion Excessively devoted to work and productivity to the exclusion of leisure activities and friendships Reluctant to delegate tasks or to work with others unless they submit to exactly his/her way of doing things

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Reference:

• Am Fam Physician. 2011 Dec 1;84(11):1253-1260 (http://www.aafp.org/afp/2011/1201/p1253.html)