Personality Disorders

Personality Formation

Personality - A confrontation between biologically determined building blocks and powerful environmental influences

50-55% genetics
genetics play a strong component in anxiety, compusliveness and sense of self (intimacy has a weak genetic component)

Premise

Theories of the mind should follow biological concepts
Personalities are the framework of mental function
Personalities maintain the natural equilibrium

Principle of Constancy - The mind attempts to maintain mental equilibrium.

This is equivalent to the body’s attempt to maintain homeostasis.

Biopsychosocial Framework

Circularity of personality formation: Genes affect Temperament, which affects both Parent and Child Outcome

Goodness of Fit - how well the primary care giver (usually mom) associates with a child

it is important that a primary caregiver understand a child’s developmental stage and not push beyond their abilities
a primary care giver who does push a child beyond their developmental stage is doing the child a disfavor

Good Enough Parenting - children without developmental difficulties do not need additional or special help
average parents are all that is needed for the children to reach developmental markers

Definitions

Egosyntonic - self-perceived as something good to do with your personality

Egodystonic - self-perceived as having something bad to do with your personality

Approaches to Personality Disorders

(1) DSM IV - atheoretical (i.e., no assumption of etiology)

Personality Traits (DSM-IV definition) - "enduring patterns of perceiving, relating to and thinking about the environment and oneself." When such traits become maladaptive and inflexible, they lead to personality disorders.

Personality Disorder (DSM-IV definition) - "enduring pattern of inner experience and behavior that deviates markedly from the expectations of an individual’s culture." Pattern is inflexible, pervasive, stable over time (with onset by early adulthood), causes significant subjective distress or impairment in a person’s social or occupational function, and affects two or more of the following:

cognition
affect
interpersonal function
impulse control.

(2) Psychodynamic - proposes an etiology, which affects treatment design

unlike the DSM-IV, this approach to personality disorders looks beyond symptoms to patient’s unconscious conflicts, internal distortions, and object relations (object=loved person from past, relations=postive or negative interactions with that person which somehow affected patient’s development)
analysts diagnose and treat transference and counter-transference in their patient’s with personality disorder.

Object relations - Psychodynamic theory that states that all important interpersonal relationships, especially those with parents, are transformed into internalized representations of the relationships that stay with the person and affect one’s development.

Transference - Patients experience others, especially authority figures, as significant figures from their past and unconsciously reenact affects from the prior relationships in current relationship.

Counter-transference - Physician’s unconscious response to patient

Personality disorders usually have co-morbidity.

Three Classifications (Clusters) of Personality Disorders

CLUSTER A: "odd or eccentric". Egosyntonic disorders

(1) Paranoid Personality Disorder - pervasive pattern of distrust and suspiciousness; see possible threats everywhere

hidden meanings in everything (people say one thing but probably mean another)
no delusions or psychosis (though may see some transient ones if you press them hard enough)
extremely rigid and unvarying and need control over those around them
strong need to be autonomous and self-sufficient; carry grudges for a long time
patients are loners unless find others with some disorder

Example: Militia members

Defense mechanisms:

Projection - unacceptable impulses are attributed to others

Splitting - people or events are either totally bad or totally good

(2) Schizoid Personality Disorder - lifelong pattern of social withdrawal without psychosis

work better with machines than people; don’t take pleasure with things
sense of detachment from normal emotional life; inter-personal relationships don’t matter to them
tendency to be premorbid to schizophrenia
uncommon.

(3) Schizotypal Personality Disorder - pervasive pattern of social and interpersonal deficits, characterized by discomfort with close relationships, as well as cognitive/perceptual distortions and eccentricities of behavior

no psychosis, but preoccupied with magical thinking, ideas of reference, and illusions
rich fantasy life (live Dungeons and Dragons); peculiar dress

Continuum of odd behavior and psychosis from paranoid to schizoid to schizotypal to schizophrenia

CLUSTER B: "dramatic, emotional or erratic". Egosyntonic and Egodystonic combinations.

(1) Antisocial Personality Disorder - older description: psychopaths, sociopaths

irresponsible, lack of remorse, professional con-artists, no empathy, no attachment to others, manipulators, deceitful, overrepresented in criminal justice system (#2 after drug disorders), violate rights of others

Only personality disorder that has age requirement - at least 18 years old (called Conduct Disorder if younger)
didn’t develop superego so have no anxiety about breaking rules
can be very charming and form good relationships; very intelligent, good at monitoring people and manipulating this information
associated with bedwetting, setting fires, and torturing animals in childhood

Example: some are very functional: e.g., high level executives ("greed is good")

Comorbidity: substance abuse, violence, depression. More common in males.

(2) Borderline Personality Disorder - patients are ‘stably unstable’

feel unstable anger, chronic emptiness, and no sense of internal self

try to define themselves by relationships with others, so relationships can be intense, turbulent, and difficult for everyone involved

chronic feelings of emptiness lead to depression or anxiety; when very stressed can become a little psychotic

para-suicidal behavior used for relief of tension, causes them to feel better, endogenous opioids get released (ex: patients may slash themselves with a razor because they enjoy the pain)

Psychodynamic: poor self-identity blurs boundary between self and other people (relationships), self-destructive acts (pain) reaffirm boundary

fear of abandonment and attempt to avoid it; use transitional objects (teddy bears, etc)

Comorbidity: depression, drug abuse, panic disorder, PTSD (from childhood abuse). More common in females.

Defense mechanisms: Splitting Þ leads to contradictory behavior and contradictory views of self, projection, idealization, devaluation.

(3) Histrionic personality disorder - flamboyant, get angry when they are not the center of attention, not comfortable unless they are in the spotlight

shallow affect; inappropriately charming and seductive
some overlap with borderline personality but without emptiness. No emotional richness, all impressionistic
will say "that was the greatest party!", but don’t explain why

(4) Narcissistic personality disorder - grandiosity, need for admiration, lack of empathy; very vulnerable to criticism

patient’s performance can be significantly disrupted by their intolerance of wounds to their fragile self-esteem (if you offend an anti-social he will break your knee cap without hurt feelings. narcissistic will feel wounded)
self-love to the exclusion of all else; manipulative, ruthless, other people exist to serve them
young patients complain of poor quality of intimate relationships, older patients experience great distress with normal aging
become easily depressed and anxious

How is narcissism different from normal self-love? - quality of patient’s relationships: narcissists have a genuine inability to love others, and see people as objects to be used and discarded as needed without regard for feelings

CLUSTER C: "anxious or fearful"

(1) Avoidant Personality Disorder - have pervasive pattern of social inhibition, feelings of inadequacy and hypersensitivity to negative evaluation

anxious and timid about social relationships, don’t want to get hurt; fear of humiliation/rejection paralyzes them
desire affection, but avoid relationships which may have painful consequences
sensitive to people around them, look to see if they are being accepted/rejected
patients have to feel that people are around them have to think they’re ok

Comorbidity: Frequently comorbid with dependent personality disorder and social phobia, generalized type

(2) Dependent Personality Disorder - People with pervasive and excessive need to be taken care of

leads to submissive and clinging behavior and fears of separation
often pessimistic and belittle their abilities and assets; have a need for reassurance
chronic childhood illness can lead to this
often associated with dysthymia, depression, anxiety

(3) Obsessive-compulsive personality disorder - this disorder ("OCP") is distinct from OCD (see below)

pattern of preoccupation with orderliness, perfectionism and mental and interpersonal control, at the expense of flexibility, openness and efficiency; bureaucrats from hell
find decision making very difficult and time-consuming when rules or procedures do not dictate a correct answer
Egosyntonic
attentive to relative status in hierarchies and display great deference to authorities they respect
Harsh superego. Rigidity.

Differentiating OCP from OCD:

OCP - egosyntonic, reflects enduring character traits.

OCD - egodystonic, requires particular clinical symptoms: obsessions and compulsions.

Summary

Mneumonic: CLUSTER A, B, and C Þ Weird, Wild, and Wimp

Cluster B Personality Disorder	symptoms
Antisocial Personality Disorder	Pervasive pattern of disregard for and violation of the rights of others. Deceit and manipulation are central features. Often a history of child abuse. Failure to develop and superego.
Borderline Personality Disorder	"Stably Unstable" Self-abusive behavior, Projection, and Splitting are cardinal features. Often a history of childhood abuse/neglect. A lack of object constancy and difficulty with separation and individuation. Patients are more secure with transitional objects rather than with human relationships.
Histrionic Personality Disorder	A pervasive pattern of excessive emotionality and attention seeking behavior. Often bored with routine and angry when not the center of attention. Shallow and labile emotionally, with the characteristics of dependency and self-dramatization.
Narcissistic Personality Disorder	Pervasive pattern of grandiosity, need for admiration, and lack of empathy. Narcissists have a marked vulnerability to criticism. Narcissists see people as objects to be used and discarded as needed.

Clinical Implications

Diagnosis of Personality Disorders - certain personality types are associated with specific co-morbid disorders

Compulsive Disorder Þ anxiety, depression (no substance abuse)

Antisocial Disorder Þ substance abuse

Borderline Disorder Þ anxiety, depression, somatiform disorders, substance abuse

Complications in Diagnosis

Environmental factors may change a person’s personality

example: stress within the hospital may cause people to regress
personality disorders often require longitudinal history for diagnosis

Change in personality may be due to underlying brain pathology; ex. stroke, neurodegeneration, dementia

Frontal Lobe Syndrome - characterized by lack of motivation, flat affect and infrequent flares of rage

The personality of the patient may influence the physician patient relationship

Example: Borderline Personality Disorder - May project different feelings and emotions toward different people in the medical staff so that one group may feel that the patient is a pain in the ass and another group may feel that she is a nice person who has been unlucky to have fallen ill. The psychiatrist’s role is to educate the medical team about the person’s disorder and explain ways of dealing with her.

Example: Paranoid Personality Disorder - This person is often suspicious of the doctor’s intentions and the best way of dealing with him is to explain all procedures before they occur.

Example: Narcissistic Personality Disorder - This patient may insist on seeing chief attending and refuse treatment by the resident or med student. He has a fragile external shell and if the physician does not recognize this and demands actions from the patient the patient will either become overwhelmed and fall apart or will attempt to gain more power over the physician. The physician obviously wants to avoid a power struggle. To deal with the patient the doctor should ensure that the patient will get the best possible care and then set up a plan working with the patient to see that he receives the care that he needs and wants. The resident can be involved if the physician explains to the patient that, "This is my best resident and she and I will be working together to ensure that you have the best possible care". This patient may sue the hospital if he does not get better because he feels his declining health is not his own fault.

Example: Schizoid Personality Disorder - This patient needs her distance, but may be scared and deserves the medical attention that she needs.

Example: Dependent Personality - This patient often does not want to be involved in the decision making and just wants to be told what is best for her.

Example: Obsessive Compulsive Personality Disorder - This patient often wants to be involved in the decision making process.