DSM-IV-TR Personality Disorders: Recognition and

Treatment

Presentation to Guam AIMFT Association September 2006By Archana G. Leon-Guerrero, MDGeneral and Addiction Psychiatry

Diplomate, American Board of Psychiatry and NeurologyMember, American Society of Addiction Medicine

671-646-2908

Overview of Personality Disorders: Why is it important to know about them?

Very prevalent in clinical practice, particularly in couples/family and other interpersonal problem presentations, and in those with depression/anxiety disorders on Axis I

Almost never is the presenting complaint “I have a personality disorder”. You must learn to recognize it.

If not recognized, will likely lead to treatment dropout/failure.

High rate of bad outcomes such as suicide, violence, substance abuse, legal problems. These bad outcomes may be lessened by proper recognition/treatment. Downward drift in socioeconomic status may also be prevented if caught early.

Overview of Personality Disorders:What is a Personality Disorder? DSM: “An enduring pattern of inner

experience and behavior that deviates markedly from the expectations of the individual’s culture, is pervasive and inflexible, has an onset in adolescence or early adulthood, is stable over time, and leads to distress* or impairment.”

*note that, depending on which personality disorder we are talking about, the distress is often felt by others more than the person with the d/o

Overview of Personality Disorders: How are these different than Axis I Clinical

Syndromes? Axis I: Clinical Syndromes Temporary State vs.

Ongoing Trait Something I “have” rather

than I “am” Easier to Recognize Easier to Treat Better insight

Axis II: Personality DO Ongoing Trait vs. Temporary

State Something I “am” rather

than I “have” Harder to recognize Harder to treat Little insight, see others as

the problem Can lead to Axis I

depression, anxiety, substance abuse

Can be a “mild case” of Axis I disorders

Personality D/O: Assessment

Source of info: client PLUS COLLATERALS Look for patterns: Trouble getting along with people prior to

presenting incident. Blaming others. Trouble maintaining jobs/relationships prior

to presenting incident. If see these patterns, ask questions more

specific to PD you suspect OR about substance abuse.

Overview of Personality Disorders: Matching Game: Match the Personality Disorder with the

Related Axis I Syndrome that it is on a spectrum with

Paranoid PD Borderline PD Avoidant PD Histrionic PD Schizotypal PD Obsessive/Compulsive PD

Obsessive/Compulsive D/O Cyclothymic D/O Schizophrenia Delusional D/O Social Phobia Somatization D/O

Note: there may be more than one right match to any PD listed

Classification of Personality Disorders

DSM classification is based on similarities in presentations

Cluster A: Odd/Eccentric

Paranoid, Schizoid, Schizotypal

Cluster B: Dramatic/Emotional/Erratic

Antisocial, Borderline, Histrionic, Narcissistic

Cluster C: Anxious/Fearful

Avoidant, Dependent, Obsessive-Compulsive

Not Otherwise Specified

Mixed, Codependent, Passive-Aggressive

Cluster A:Eccentric: Paranoid PD Pattern of distrust and suspiciousness of people in general (doubting

loyalty, reading in hidden meanings, misinterpret compliments, bear grudges, easily angry/jealous, contolling in relationships to avoid betrayal). Often present for couple’s issues.

Strong biological relationship in family studies to delusional disorder and schizophrenia. False beliefs less fixed. Less bizarre behavior. No hallucinations.(Danish adoption study)

Treatment: Courtesy, honesty, respect: ie honestly apologize for being late. No group or confrontive therapy, including confronting the false belief. Empathy: “if that is true, you must be very upset about it” Low dose antipsychotic medication: “I know that your problems are due

to how others treat you. Medication will help you deal with the stress of that.”

Discuss the possibility that belief may have been false only AFTER medication has softened it up.

Cluster A: Eccentric: Schizoid PD

Pattern of detachment from social relationships, restricted emotions

Lack of desire for intimacy: loners, cold, aloof Strong biological relationship in family studies

to Schizophrenia. Treatment: Rarely needed because these

individuals are not distressed, nor do they enter into interpersonal relationships so don’t distress anyone else. They choose occupations in which they can be loners.

Cluster A: Eccentric: Schizotypal PD

Pattern of interpersonal deficits marked by discomfort with close relationships and cognitive/perceptual distortions as well as behavioral eccentricities.

Ideas of reference, magical thinking, superstitious, sensory illusions (not hallucinations).

Loners not by choice as in Schizoid, but due to mild paranoia which causes anxiety.

Strong biological relationship in family studies to Schizophrenia.

Treatment: Psychoeduction. Social Skills Training, Case Management, Antipsychotic Medication.

Cluster B: Erratic: Antisocial

Pattern of disregard for rights of others. Can’t be dx under age 18, likely because of frequent legal

involvement: BUT must have had some aspects of conduct disorder before age 15.

Illegal actions, conning, lying, frequent fighting, recklessness, irresponsibility, lack of remorse, promiscuity without pleasure in women, STD’s, frequent unwanted pregnancies.

Much higher in men than women. Can be charming at times, mostly to get their way. Treatment: usually only successful with court

mandates/consequences. Group therapy/involvement in therapeutic communities, religious groups, self-help groups much more helpful than individual therapy.

Cluster B: Erratic: Borderline PD

Pattern of unstable relationships, self-image and affects, together with impulsivity in many contexts.

Fear of abandonment, alternating between idealizing and devaluing others, impulsive in self-damaging ways (sex, driving, substance abuse, binge eating, spending), recurrent suicidality or self-mutilation, marked mood lability rective to environment, empty feelings, intense anger, stress-related paranoia or dissociation.

Biological relationship in family studies to depression, bipolar, substance abuse: NOT schizophrenia.

Most have a marked trauma history

Cluster B: Borderline PD (continued)

Treatment: Far better than the rest: Dialectical Behavior Therapy,

a form of cognitive/behavioral therapy focusing on teaching techniques to self-regulate affect. More info at www.brtc.psych.washington.edu

Also very good: Eye Movement Desensitization and Reprocessing—an innovative technique applying a neurologic procedure to cognitive/behavioral therapy. More info at www.emdr.com. I am trained in this.

Medications may be helpful for the short-term, targeted to the problem symptom at the time (depression, impulsivity, anxiety)

Cluster B: Erratic: Histrionic PD

Pattern of excess emotionality and attention-seeking behavior

Seductiveness, concern with physical appearance, exaggerated emotional expression, self-centered, naïve.

Associated with somatization disorder. Becoming more recognized as a mild variant of

Bipolar Disorder, hypomanic type without the tendency to depression.

Treatment: Insight-oriented psychotherapy, mood-stabilizing medication.

Cluster B: Erratic: Narcisstic PD

Pattern of grandiosity, need for admiration, lack of empathy. Fantasies of unlimited success, sense of entitlement, exploits

others, arrogant. Fragile self-esteem, subject to “injury” from criticism. They often

feel humiliated and react with rage. May be a variant of Bipolar Hypomanic, although this needs

further research. Treatment: Almost impossible. They almost always “fire” the

therapist. If proves to be a type of Bipolar DO, then mood-stabilizing meds may help.

Education of family can help them cope, which indirectly helps the client. Be careful about confidentiality when doing this.

Cluster C: Anxious: Avoidant PD

Pattern of social inhibition and feelings of inadequacy due to hypersensitivity to negative evaluation.

Loners, but WANT relationships. Won’t get involved with people or activities due to

fear of being ridiculed, rejected. May actually be a natural byproduct of social phobia.

Current research is being done, and this PD diagnosis may be eliminated soon.

Treatment: assertiveness training, anxiety medication, behavioral therapy teaching techniques to regulate anxiety (relaxation, deep breathing, imagery)

Cluster C: Anxious: Dependent PD

Pattern of execcive need to be taken cafre of that leads to submissive and clingy behavior.

Trouble making decisions without advice, won’t express disagreement, lacks initiative, fear of being alone, urgently seeks another relationship when one ends.

Often tolerate abuse. Often have a history of being abused. Treatment: Assertiveness training, Safety

plan, EMDR for prior and current trauma.

Cluster C: Anxious: Obsessive-Compulsive PD Preoccupation with orderliness, perfectionism, and

control, at the expense of flexibility, openness and efficiency.

Can’t “see the forest for the trees”, too detailed, works too much, rigid moral values, “my way or no way”, hoards money and objects, stubborn.

Not in touch with feelings, sense that they are missing something, less likely to blame others than other PD’s.

Some overlap with Obsessive-Compulsive Disorder Treatment: psychodynamic therapy focusing on

insight into feelings, Behavioral therapy (preferably group) teaching social skills.

Closing

Personality Disorders are very prevalent in clinical populations, jails, social service settings etc. ie….where we all work!

People with Personality Disorders are hard to deal with. The very things that make them hard to deal with are the things they need help with!

Rarely do they tell us “I have a personality disorder”. It is incumbent upon us to recognize it.

Once we recognize it, treatment can help with most of the disorders.

Good luck!