personality disorders
DESCRIPTION
Personality Disorders. Mark Kimsey, M.D. March 8, 2014. Objectives. Understanding personality disorders using criteria from DSM-5. Learn approaches for separating personality disorders from other major illnesses. Review non-pharmacologic treatment approaches. General Information. - PowerPoint PPT PresentationTRANSCRIPT
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Personality Disorders
Mark Kimsey, M.D.March 8, 2014
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Objectives
• Understanding personality disorders using criteria from DSM-5.
• Learn approaches for separating personality disorders from other major illnesses.
• Review non-pharmacologic treatment approaches.
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General Information
• Data from 2001-2002 National Epidemiological Survey on Alcohol and Related Conditions suggest that 15% of U.S adults have at least one personality disorder.
• People frequently have more than one co-occurring personality disorder
• It is extremely common for people with other psychiatric problems to also have personality disorders
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DSM-5
• Recent update of the Diagnostic and Statistical Manual of Mental Disorders
• Personality disorders discussed in 2 sections.– Section II- Diagnostic criteria and Codes• Same diagnoses and criteria as DSM-IV• Categorical model that sees personality disorders as
distinct clinical syndromes– Section III- Emerging Measures and Models• Dimensional model- personality disorders vary and merge
into each other and into normality.
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General Personality Disorder
• Enduring pattern of inner experience and behavior that deviates markedly from expectations of the individual’s culture.
• Manifested in 2 or more of 4 areas:– Cognition- (ways of perceiving and interpreting self,
others, and events).– Affectivity- (range, intensity, lability, and
appropriateness of emotional response).– Interpersonal Functioning– Impulse Control
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General Personality Disorder (cont’d)
• Enduring pattern is inflexible and pervasive across a broad range of personal/social situations.
• Enduring pattern leads to significant distress or impairment in social, occupational, or other important areas of functioning.
• Stable and of long duration, beginning in at least adolescence or early adulthood.
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General Personality Disorder (cont’d)
• Enduring pattern not better explained by another mental disorder.
• Enduring pattern not attributable to effects of a substance or medical condition.
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DSM-5 Organization
• No longer coded as 5 Axis system.• May code more than one diagnosis if fits criteria.• Broken down into 3 clusters– Cluster A-Paranoid, Schizoid, Schizotypal– Cluster B- Antisocial, Borderline, Histrionic, Narcissistic– Cluster C- Avoidant, Dependent, Obsessive-Compulsive
• Also- Other, unspecified, due to another medical condition
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Cluster A- Odd/Eccentric
• Paranoid P.D. (2.3-4.4%) Pattern of distrust and suspiciousness. Sees others as malevolent.
• Schizoid P.D. (3.1-4.9%) Detachment from social relationships and a restricted range of emotional expression.
• Schizotypal P.D.(3.9-4.6%) Eccentric behaviors, discomfort in close relationships, ideas of reference, odd beliefs.
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Cluster B- Dramatic
• Antisocial P.D. (0.2-3.3%) Conduct disorder before age 15 yrs. Pervasive pattern of disregard and violation of rights of others. Criminal, lying, impulsivity, aggression, disregard for safety of self/others, irresponsible, lack of remorse.
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Cluster B- Dramatic
• Borderline P.D.(1.6-5.9%) Severe, pervasive pattern of instability in several areas. Fear of abandonment, unstable/intense interpersonal relationships, identity disturbance, impulsivity, suicidal ‘gestures’, intense affective instability, feelings of emptiness, transient paranoia or dissociative sx’s. (Prevalence 6% in primary care settings, 10% in outpatient MH, 20% Inpatient psych)
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Cluster B- Dramatic
• Histrionic P.D. (1.84%) Center of attention, provocative, shallow, dramatic, considers relationships to be more intimate than they really are.
• Narcissistic P.D. (0-6.2%) Grandiose self importance, preoccupation with fantasies of unlimited success, etc., ‘special’, Requires excessive admiration, entitled, exploitative, no empathy, envious.
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Cluster C- Anxious/Avoidant
• Avoidant P.D. (2.4%) Severe social inhibition, poor self esteem/image.
• Dependent P.D. (0.49-0.6%) Sees themselves as needing others, to point of submission, clinging, and fears of separation.
• Obsessive-Compulsive P.D. (2.1-7.9%) Differentiate from OCD.
• Other Personality D/O’s
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Differential Diagnosis
• Separating and merging different personality disorders, shortcomings of current system
• Going beyond the chief complaint(s)• Longitudinal versus cross-sectional viewpoint• Traits versus Personality Disorders• Effects of stress, substance abuse, other
primary diagnoses, and general medical problems
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Differential Diagnosis
• In general, there’s no rush to make a personality disorder diagnosis.
• May have suspicions on the initial contact, but keep an open mind about other issues/dx’s.
• Personality Disorders are often ‘cured’ with the appropriate medication.
• Cutting is not synonymous with Borderline PD.
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Treatment Approaches
• Pharmacologic– No FDA approved medications for “Personality
Disorders”.– Often based on symptom management.– ‘Kitchen sink’ approach. Throw whatever
medications into the mix that seem to reduce symptoms.
– “Medicine is the art of entertaining the patient while the body heals itself.”- Voltaire
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Non-pharmacologic Treatments• Most emphasis has been placed on Borderline Personality
Disorder.• Many challenges to treatment
– Insurance limitations- ‘Axis II’.– Who’s distressed?– Dropout from treatment. (lack of motivation, too painful)– Lack of consistency from one therapist to the next.
• Dialectical behavior therapy (DBT) and Cognitive therapy (CT).• Analytically oriented psychotherapy.• Interpersonal psychotherapy.• Group therapy
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Dialectical behavior therapy (DBT)
• Weekly one-on-one counseling sessions and group therapy.
• Development of skills.– Improved distress tolerance.– Increased interpersonal effectiveness.– Improved regulation of emotions– Mindfulness skills.
• Has shown significant reduction of self harm and lower rate of dropout than ‘therapy as usual’.
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Cognitive therapy (CT)
• Targets dysfunctional core beliefs about the self, others and the world.
• Usually weekly sessions with therapist.• Workbooks, homework assignments,
worksheets.• Related to Cognitive Behavioral Therapy (CBT).• CBT aimed at a wide variety of mood, anxiety,
and personality disorders.
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Alternative DSM-5 Model
• New approach that was proposed to address numerous shortcomings in prior model.
• PD’s are characterized by impairments in personality functioning and pathological personality traits.
• Fewer PD’s– Antisocial, avoidant, borderline, narcissistic,
obsessive-compulsive, and scizotypal.– Also PD-TS- personality d/o- trait specified.
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Alternative DSM-5 Model
• General Criteria– Moderate or greater impairment in personality
(self/interpersonal) functioning– Impairments are pervasive and inflexible– Stable over time– Exclusionary criteria
• Elements of personality functioning– Self- Identity, self-direction– Interpersonal- Empathy, intimacy
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Alternative DSM-5 Model
• Personality traits divided into 5 broad domains– Negative affectivity– Detachment– Antagonism– Disinhibition– Psychoticism
• Further divided into 25 specific trait facets
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Negative Affectivity (vs. emotional stability)
Emotional lability Perseveration
Anxiousness Depressivity (also under Detachment)
Separation Insecurity Suspiciousness (also under Detachment)
Submissiveness Restricted Affectivity
Hostility
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Detachment (vs. Extraversion)Withdrawal Suspiciousness
Intimacy Avoidance
Anhedonia
Depressivity
Restricted Affectivity
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Antagonism (vs. Agreeableness)
• Manipulativeness• Deceitfulness• Grandiosity• Attention Seeking• Callousness• Hostility
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Disinhibition (vs. Conscientiousness)
• Irresponsibility• Impulsivity• Distractibility• Risk taking• Rigid perfectionism (also lack of)
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Psychoticism
• Unusual beliefs and experiences• Eccentricity• Cognitive and perceptual dysregulation
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Example- Antisocial PD
• Personality Functioning-– Identity- Egocentrism– Self- direction- failure to conform to law/culture– Empathy- lack of empathy/remorse– Intmacy- exploitative, dominance
• Pathological Traits– Antagonism- manipulativeness, callousness,
deceitfulness, hostility– Disinhibition- Risk taking, impulsivity, irresponsibility
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Example- Narcissistic PD
• Personality functioning– Identity- Needs others for self-definition and self-
esteem regulation, extremes– Self-direction- goal setting based on gaining approval,
personal standards too high or low– Empathy- severly impaired– Intimacy- Superficial relationships, need for personal
gain• Personality traits- Antagonism- grandiosity, attention
seeking
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Questions?