Personality disorders

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  • The PDs are placed in three clusters based on descriptive similarities\n\nA: Odd aloof features\n
  • Dramatic impulsive and erratic features\n
  • Anxious and fearful features\n
  • Cluster A PD more common in biological relatives of patients with schizophrenia than in control groups. More relatives with schizotypal PD occur in family histories of persons with schizophrenia than in control groups. Less correlation of schizoid and paranoid.\n\nCluster B PDs have genetic base. Antisocial personality d/o is associated with alcohol use d/o.\nDepression is common in the family backgrounds of pts with borderline PD. Pts with borderline PD have higher incidence of depression, as do their families. Strong association between histrionic PD and somatization d/o. \n\nCluster C PD may also have a genetic base. Pts with Avoidant PD often have high anxiety. OCD traits are more common in monozygotic twins than in dizygotic twins, and pts with ODC PD show some signs associated with depression such as shortened rapid eye movement latency and dexamethasone suppression tests.\n\nBiological: Those with impulse control problems often have higher testosterone levels. \nPlatelet monoamine oxidase is lower in pts with shizotypal d/o\nSmooth pursuit eye movements are saccadic (jumpy) in persons introverted who have low self esteem, and tend to withdraw and have shizotypal PD. \n\nNeurotransmitters: There are postulations that endorphins, serotonin, and dopamine may be related to personality traits. Raising serotonin levels \n
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  • According to DSM criteria, \n
  • According to DSM\n
  • According to DSM.\n
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  • This is a manual used by psychoanalysts.\nPut out by\nAmerican Psychoanalytic Association\nInternational Psychoanalytical Association\nDivision of Psychoanalysis of the Am. Psychological Assoc\nAm Academy of psychoanalyssi and Dynamic Psychiatry\nNational Membership Committee of psychoanalysis and clinical soc. work\n
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  • Flexibility: look at problem from a number of different angles and adapt one of several possible ways of coping with it.\n\n
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  • More disturbed end are people who respond to stress in rigidly inflexible ways (relying on only one or two coping strategies, and/or have marked deficits in sense of identity, relations wiht others, reality testing, adaptation to stress, moral functioning or affective range, recognition, expression and regulation\n
  • The PDM suggests that personality disorder categories are still in the early stages. Drawn on extensive empirical and clinical literature to derive the best classification: complex, literature incomplete, so it is provisional. \n
  • Must have report from patient or other/s that patient’s psychology has \n
  • Differentiate from:\n
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  • Throughout 20th century, therapists described this group of patients. Borderline fared poorly with treatment for neurosis, as they would unexpectedly develop intense, problematic and often rapidly shifting attitudes toward therapist. Although they did not exhibit psychosis outside of therapy, they developed an intractable “psychotic transference” ie they would experience the therapist as omnipitently good or melavolently bad, or as exactly like a person from their past. Could not be persuaded that this impression was not fully warrented.\n
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  • Separates from delusional disorder as there is absence of fixed delusions\nUnlike people with paranoid schizophrenia they have no hallucinaitons or formal thought disorder. Differentiate from borderline, as they are not capable of overinvolved tumultuous relationships. Lack the long history of antisocial behavior. Those with schizoid personality disorder are withdrawn and aloof, and do not have paranoid ideation.\n
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  • 1. Schizoid does not have psychosis but these do.\n2. paranoid share many traits, but are more history of more social engagement, history of aggressive behavior, greater tendency to project their feelings onto others.\n3. OC pd experience loneliness as dysphoric, have a richer history of past object relations, and do not engage as much in autistic reverie.\n4. Shizotypal: more like schizophrenia in terms of oddities of perception, thought, behavior.\n5. Avoidant: Strongly wish to participate\n6. Aspergers or autism, more severly impaired social interactions\n\n\n\n\n\n\n
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  • Pt’s who are schizoid tend to introspection. As trust develops they may share a plethora of imaginary friends, fantasies, and unbearable fear of dependence, even of merging iwth the therapist. Group therapy. They may be silent. Need to be protected from attack for silence. \n\n
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  • speech vague, circumstantial, metaphorical, overelaborate or stereotypical\n\nLack close except first degree relatives\nSoc anx does not diminish with familiarity usually assoc w/ paranoid fears rather than harsh judgement\nDoes not occur exclusively during the course of schizophrenia, a mood disorder with psychotic features, another psychotic d/o or pervasive develpmental delay.\n
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  • Proband is a person who is the starting point for a genetic study\n
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  • Affective instability usually lasts only a few hours and only hours, and rarely more than a few days.\n
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  • Variable\nFolow for 10 years, no longer meet criteria\n
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  • 1. Exaggerates achievements and talents, expects to be recognized as superior w/o commensurate achievements\n\n
  • Entitlement: unreasonable expectations or especially favorable treatment or automatic compliance with his or her expectations\nEmpathy: unwilling to recognize or identify with feelings and needs or others \n\n
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  • OCD is anxiety disorder characterized by intrusive thoughts, associated with anx or tensionand or repetitive purposeful mental or physical actions aimed at reducing fears and tensions caused by obsessions\n
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  • Personality disorders

    1. 1. Personality Disorders
    2. 2. Personality Traits• Enduring patterns of perceiving, relating to and thinking about the environment, oneself or others• They become a disorder when they are inflexible and maladaptive, and cause functional impairment or subjective distress• Severe personality traits that do not meet criteria for PD may be listed on Axis II
    3. 3. Personality Disorder• Enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individual’s culture
    4. 4. Personality Disorder• The pattern is manifested in two or more of the following areas:• Cognition• Affectivity• Interpersonal Functioning• Impulse control
    5. 5. Enduring Pattern• Inflexible• Pervasive• Across broad range of personal and social situations
    6. 6. Enduring Pattern• leads to clinically significant distress or impairment in social, occupational or other important areas of functioning
    7. 7. Enduring Pattern• Stable and of long duration• Onset traced back to adolescence or early adulthood
    8. 8. Enduring Pattern• Not better accounted for as a manifestation or consequence of another mental disorder• Not due to direct physiological effects of a substance or general medical condition
    9. 9. Culture, Age, Gender• Take into account persons ethnic, cultural and social background• May be applied to children who have traits that appear to be pervasive, persistent, unlikely to be limited to particular stage or Axis I diagnosis• Traits of PD that present in childhood may not last
    10. 10. Culture, Age, Gender• To diagnose in childhood traits must be present for at least one year• PD must be diagnosed no later than early adulthood, but people may not come to attention• Must rule out PD due to general medical condition
    11. 11. Axis I• A PD should not be diagnosed during an episode of mood disorder or anxiety disorder• PD should not be diagnosed if it occurs exclusively during an episode of an Axis I disorder• Consider PTSD rather than PD after extreme stress
    12. 12. Cluster A• Schizotypal• Schizoid• Paranoid
    13. 13. Cluster B• Narcissistic• Borderline• Antisocial• Histrionic
    14. 14. Cluster C• Obsessive Compulsive• Dependent• Avoidant
    15. 15. Etiology• Genetic Factors• Biological Factors
    16. 16. • Childhood and adolescent disorder correlate strongly with adult personality disorders• Conduct disorder>>>Antisocial PD adult• Schizoid PD childhood>>>Schizoid PD Adult• Oppositional disorder
    17. 17. • Earlier concepts suggested PDs were egosyntonic• Current thought is that they cause significant distress and there are high rates of depression and anxiety
    18. 18. • Patients with personality disorders are at higher risk for Axis I disorders• Flare ups are often during times of occupational or personal stresses, or at developmental milestones
    19. 19. How can you tell if it isa personality disorder? Neruosis? Psychosis?
    20. 20. Neurotic or Personality Disordered• Neurotic patients have autoplastic defenses: What’s wrong with me?• Persoality Disordered patients have alloplastic defenses: What’s wrong with the world?
    21. 21. Neurotic or Personality Disordered?• Neurotic patients perceive personal shortcomings as egodystonic; unacceptable, objectionable• Personality Disordered patients disavow responsibility for hurting others
    22. 22. Psychotic orPersonality Disordered• Persistent psychotic features are not present• Exception is patients with borderline personality disorder: psychotic symptoms are short lived, are directly related to a given situation, do not require hospitalization or medications.
    23. 23. Organic MentalDisorder or Personality• Patients with personality disorders have clear sensorium, are oriented to time and place, and show normal intellectual function
    24. 24. PsychodynamicDiagnostic Manual
    25. 25. • Dimension I: Personality Patterns and Disorders----P Axis• Dimension II: Mental Functioning----M Axis• Dimension III: Manifest Symptoms and Concerns---S Axis
    26. 26. Dimension I:Personality Patterns and Disorders
    27. 27. • Personality: Relatively stable ways of thinking, feeling, behaving, and relating to others.• Thinking: belief systems, ways of making sense of self and others, moral values and ideals.• Ways in which we habitually try to accommodate to the exigencies of life, to reduce anxiety, grief, threats to self esteem
    28. 28. • People differ in how they adapt to circumstance and defend against threat and in their abilities to integrate these special efforts seamlessly into the conduct of every day behavior so that the special efforts do not show as xuch.
    29. 29. • Depending cultural surround and myriad of other factors, some patterns are more adaptive than others.• When our particular ways of thinking, feeling, acting and being with others contribute to our living satisfying lives, enjoying mutually satisfying relationships, and pursuing socially useful goals, OK.
    30. 30. Healthy Personality• Engaged in satisfying relationships• Experience a full range of age expected feelings and thoughts• Function flexibly when stressed by external forces or internal conflict• Clear sense of personal identity• Well adapted to life circumstances
    31. 31. Healthy Personality• Neither experience significant distress nor impose it on others.
    32. 32. Unhealthy Personality• Rigid/Inflexible• Deficits in Identity• Deficits in Relations with Others• Difficulty with reality testing, adaptation to stress• Deficits Moral Functioning or Affective Range (recognition, expression, regulation)
    33. 33. Differential Diagnosis of Personality Disorders• When someone’s personality is so rigid or so marked by deficit that he/she has persistent problems in living = personality disorder.• Human functioning falls on a continuum• Well functioning people with stable personalities may have many features of pathological personality types
    34. 34. Differential Diagnosis of Personality Disorder • Caused significant distress to self or others • Is of longstanding duration • Is so much a part of the patient’s consistent experience that he/she cannot remember, or easily imagine being different
    35. 35. Differential Diagnosis of Personality Disorders• Symptom syndromes• Effects of injury to the brain• Psychosis
    36. 36. Differential Diagnosis of Personality Disorders• Ritualized behavior could represent single obsessive-compulsive problem• Constitute a pervasive obsessive- compulsive personality problem• Be the result of brain injury• Express a psychotic delusion
    37. 37. Level of Personality Organization
    38. 38. Neurosis• Minor or major psychopathology• Capacity to assess reality is not compromised
    39. 39. Psychosis• Serious impairments in reality-testing
    40. 40. New Category• Too disturbed to be labeled neurotic• Too anchored in reality to be considered psychotic• Borderline: Between psychoses and neuroses
    41. 41. Cluster A
    42. 42. Paranoid Personality Disorder
    43. 43. • A pervasive distrust and suspiciousness of others such that their motives are interpreted as malevolent, beginning by early adulthood and present in a variety of contexts, as indicated by four or more of the following:
    44. 44. • Suspects w/o sufficient basis that others are exploiting, harming or deceiving him/her• Is preoccupied with unjustified doubts about the loyalty or trustworthiness of friends or associates• Is reluctant to confide in other because of unwarranted fear that th einformation will be used maliciously against him/her
    45. 45. • Reads hidden demeaning or threatening meanings into benign remarks or events• Persistently bears grudges, i.e., is unforgiving of insults, injuries or slights• Perceives attacks on his or her character or reputation that are not apparent to others and is quick to react angrily or to counterattack
    46. 46. • Has recurrent suspicions, without justification, regarding fidelity of spouse or sexual partner• Does not occur exclusively during the course of schizophrenia, a mood disorder with psychotic disorder and is not due to the direct physiological effects of a general medical condition.
    47. 47. • May first become apparent in childhood and adolescence with solitariness, poor peer relationships, social anxiety, underachievement, hypersensitivity, peculiar thoughts and language, idiosyncratic fantasies.
    48. 48. Prevalence• 0.5%-2.5% general population• 10%-30% inpatient population• 2%-10% outpatient population
    49. 49. Familial Patterns• Increased prevalence of PPD in relatives of probands with chronic Schizophrenia• Familial realtionship with delusional Disorder, Persecutory Type
    50. 50. Course• Often lifelong problems living with and working with others• May be harbinger of schizophrenia• Paranoid traits may give way to reaction formation and appropriate concern with morality altruistic concerns.
    51. 51. Differential Diagnosis• Delusional Disorder• Borderline Personality Disorder• Antisocial Personality Disorder• Schizoid Personality Disorder
    52. 52. Course and Prognosis• No adequate systematic long-term studies• Some may be lifelong• Some may be precursor to schizophrenia.• In general lifelong problems orking and living with others.
    53. 53. Treatment• Psychotherapy• Therapist should be straightforward in all dealings• If accused of inconsistency: honesty/ apology• Professional and not overly warm style• Over-interpretation generates mistrust
    54. 54. Pharmacotherapy• Anxiolytics• Antipsychotics• Antidepressents
    55. 55. Schizoid Personality Disorder
    56. 56. • A pervasive pattern of detachment from social relationships and a restricted range of expression of emotions in interpersonal settings, beginning by early adulthood and present ina variety of contexts, as indicated by four or more of the following
    57. 57. • Neither desires nor enjoys close relationships, including being part of a family• Almost always chooses solitary activities• Has little, if any, interest in having sexual experiences with another person• Takes pleasure in few, if any, activities
    58. 58. • Lacks close friends or confidants other than first degree relatives• Appears indifferent to the praise or criticism of others• Shows emotional coldness, detachment or flattened affectivity
    59. 59. • Does not occur during the course of schizophrenia, a mood disorder with psychotic features, another psychotic disorder, or a pervasive developmental disorder, and is not due to the direct physical effects of a general medical condition.
    60. 60. Prevalence• Uncommon in clinical settings
    61. 61. Familial Pattern• May have increased prevalence in relatives of individuals with Schizophrenia or Schizotypal PD
    62. 62. Differential Diagnosis• Schizophrenia, delusional disorder, affective disorder with psychotic features• Paranoid Personality Disorder• Obsessive Compulsive Personality d/o• Shizotypal Personality Disorder• Avoidant Personality Disorder
    63. 63. Course and Prognosis• Usually begins in childhood• Long lasting, but not necessarily life long.• Proportion who incur schizophrenia not known
    64. 64. Treatment• Psychotherapy
    65. 65. Pharmacotherapy• Antipsychotics• Antidepressants• Psychostimulants• Serotonergic agents less sensitive to reject• Benzodiazepines for anxiety
    66. 66. Schizotypal Personality Disorder• Social and interpersonal deficits marked by acute discomfort with and reduced capacity for close relationships, as well as by cognitive or perceptual distortions and eccentricities of behavior, beginning by early adulthood in a variety of contexts marked by five or more
    67. 67. • Unusual ideas of reference (not delusions of ref)• Odd beliefs or magical thinking that influences behavior, and is not consistent with sub-cultural norms• Unusual perceptual experiences• Odd thinking and speech
    68. 68. • Suspiciousness or paranoid ideation• inappropriate or constricted affect• Behavior or appearance that is odd, eccentric or peculiar• Lack of close friends or relatives• Excessive social anxiety
    69. 69. Prevalence• 3% of general population• Relatively stable course, small proportion go on to develop Schizophrenia or other psychotic disorder
    70. 70. Familial Pattern• Aggregates in families• More common in relatives of individuals with Schizophrenia• May be modest increase in Schizophrenia and other psychotic disorders in relatives of probands with Schizotypal PD
    71. 71. Differential Diagnosis• Differentiate from schizoid or avoidant personality by presence of oddities, or by family history of schizophrenia• Differentiate from schizophrenia by absence of psychosis• Paranoid have suspiciousness but not oddities
    72. 72. Treatment• Psychotherapy (respectful of peculiarities such as cults, the occult, strange religious practices)• Pharmacotherapy: Antipsychotics and antidepressants
    73. 73. Cluster B
    74. 74. Borderline Personality Disorder• A pervasive pattern of instability of interpersonal relationships, self image, and affects, and marked impulsivity beginning by early adulthood and present in a variety of contexts, as indicated by five or more:
    75. 75. • Frantic efforts to avoid real or imagined abandonment• Pattern intense and unstable interpersonal relationships, characterized by alternating between extremes of idealization and devaluation• Identity disturbance: markedly and persistently unstable self image or sense of self
    76. 76. • Chronic feelings of emptiness• Inappropriate intense anger or difficulty controlling anger (frequent displays of temper, constant anger, recurrent physical fights)• Transient, stress related paranoid ideation or severe dissociative symptoms
    77. 77. • Impulsivity in at least two areas that are potentially self damaging (sex, spending, substance abuse, reckless driving, binge eating)• Recurrent suicidal behavior, gestures, or threats, or self mutilating behavior• Affective instability due to a marked reactivity of mood (intense episodic dysphoria, irritability, or anxiety)
    78. 78. Prevalence• 2% general population• 10% outpatient mental health• 20% inpatient mental health• 30%-60% among clinical populations with personality disorders
    79. 79. Familial Pattern• 5 times as common in first degree relatives• Increased familial risk for Substance Related Disorders, Antisocial PD, and Mood Disorders
    80. 80. Course• Most commonly chronic instability in early adulthood, serious affective and impulse control and high use of MH resources• Impairment and risk of suicide highest in young adult, wane advancing age• During 30s and 40s majority develop greater stability relationships/work
    81. 81. Differential Diagnosis• Differs from schizophrenia as borderline patient lacks prolonged psychotic episodes• Schizotypal patients have marked peculiarities thought, behavior• Paranoid personality show extreme suspiciousness• BPD self mutilate and manipulative SA
    82. 82. Differential Diagnosis• Histrionic PD attention seeking, manipulative, rapidly shifting emotions: BPD self-destructiveness, angry disruptions close relationships, emptiness, loneliness• Paranoid and Narcissistic can have angry reaction to minor stimuli: stability of self image, lack of self-destructive, impulsiveness, abandonment fears
    83. 83. Differential Diagnosis• Antisocial PD manipulative to gain profit, power, or some other material gratification, BPD gaining concern of caregivers• Dependent and BPD both fear of abandonment, BPD emotional emptiness, rage, demands, Dependent increased appeasement, submissiveness, other parnter
    84. 84. Treatment• DBT• Long term psychodynamic therapy with therapist specifically trained for BPD
    85. 85. Pharmacotherapy• Antipsychotics for anger, hostility, brief psychotic episodes• Antidepressants for depressed mood• MAOIs for impulse control???
    86. 86. Antisocial Personality Disorder
    87. 87. • Criteria A:• Pervasive pattern of disregard for and violation of the rights of others occurring since age 15 years, as indicated by three or more:
    88. 88. • Failure to conform to social norms with respect to lawful behaviors indicated by repeated acts that are grounds for arrest• Deceitfulness, indicated by lying, aliases, conning other for personal profit/pleasure• Impulsivity or failure to plan ahead• Irritability and aggressiveness, indicated by repeated fights or assaults
    89. 89. • Reckless disregard for safety of self or others• Consistent irresponsibility, as indicated y repeated failure to sustain consistent work behavior or honor financial obligations• Lack of remorse, indicated by indifference to or rationalizing having hurt, mistreated or stolen from others
    90. 90. • Criteria B: Individual is 18 year or older• Criteria C Evidence of Conduct Disorder with onset before 15 years• Criteria D: Antisocial behavior is not exclusively during course of Schizophrenia or Manic Episode
    91. 91. Prevalence• 3% males, 1% females general populaiton• 3%-30% depending on setting, or higher in substance abuse population or prison
    92. 92. Course• Chronic course• May be less evident by 4th decade of life• Remission may be most prominent in decrease crime, but likely also to be a decrease in full spectrum
    93. 93. Familial Pattern• More common in first degree relatives• Biological risk higher for females with disorder• Association with substance abuse d/o and somatization d/o (males/females)• Bio or adapted children of adults with ASPD are both at higher risk of each d/o
    94. 94. Differential Diagnosis• If antisocial behavior in context of substance abuse, do not dx with ASPD unless signs of ASPD were there before adulthood and carried into adulthood• If both substance abuse and ASPD sx there from childhood through adulthood, make both diagnoses, even if some antisocial behavior is due to substance use
    95. 95. Differential Diagnosis• Narcissistic PD and ASPD both tough- minded, glib, superficial, exploitative and un- empathic, but Narcissistic PD does not include impulsivity, aggression, deceit• Histrionic share impulsive, superficial, excitement seeking, reckless, seductive but not antisocial behaviors.• BPD manipulate for nurture not power
    96. 96. Treatment• Psychotherapy/Group therapy• Therapist has to frustrate the patient’s need to run from “honest human encounter”
    97. 97. Pharmacotherapy• Substance abuse makes more difficult• If ADHD, stimulants may be helpful• Antiepileptic drugs or beta blockers for impulsivity/aggression
    98. 98. Histrionic Personality Disorder
    99. 99. • A pervasive pattern of excessive emotionality and attention seeking beginning by early adulthood and present in a variety of contexts, indicated by five or more:
    100. 100. • Uncomfortable in situations in which he or she is not the center of attention• Interaction with others is often characterized by inappropriate sexually seductive or provocative behavior• Displays rapidly shifting and shallow expression of emotion
    101. 101. • Consistently uses physical appearance to draw attention to self• Style of speech that is excessively impressionistic and lacking in detail• Shows self-dramatization, theatricality, and exaggerated expression of emotio
    102. 102. • Is suggestible, easily influenced by others or circumstances• Considers relationships to be more intimate than they actually are
    103. 103. Prevalence• 2%-3% general population• Similar in men and women• 10%-15% in mental health settings
    104. 104. Differential Diagnosis• As before• Narcissistic PD also want praise, but for superiority, whereas Histrionic PD willing to be viewed as fragile or dependent if htis is instrumental in getting attention• Dependent PD want praise, guidance but w/o flamboyant, exaggerated emotional features
    105. 105. Treatment• Patients are not aware of their own feelings• Psychodynamic therapy best choice• Antidepressants for depression, antianxiety for anxiety, antipsychotics for derealization and illusions????
    106. 106. Narcissistic Personlity Disorder
    107. 107. • A pervasive pattern of grandiosity (in fantasy or behavior), need for admiration, and lack of empathy beginning by early adulthood and present in a variety of contexts as indicated by five or more:
    108. 108. • Grandiose sense of self-importance• Preoccupied with fantasies of unlimited success , power, brilliance, beauty, ideal love• Believes he or she is special, and unique,and can only be understood by, or should associate with other special or high-status people or institutions
    109. 109. • Requires excessive admiration• Sense of entitlement• Interpersonally exploitative, takes advantage of others to achieve ow ends• Lacks empathy
    110. 110. • Envious of other or believes that others are envious of him or her• Shows arrogant, haughty behaviors or attitudes
    111. 111. Prevalence• Less than 1% in general population• 2%-16% in clinical population• 50%-75% male
    112. 112. Differential Diagnosis• Histrionic, Antisocial, Borderline• Coquettish, callous, needy• GRANDIOSITY• relative lack of self-destructiveness, impulsivity, abandonment concerns (BPD)
    113. 113. Differential Diagnosis• Excessive pride in achievements, relative lack of emotional display, disdain for others’ sensitivities (Histrionic)• Obsessive Compulsive PD usually self critical, in addition to commitment to perfectionism and belief others can not do things as well
    114. 114. Treatment• Psychotherapy: Kernberg and Kohut advocate psychoanalytic approach
    115. 115. Pharmacotherapy• Lithium??? (mood swings)• Antidepressants (susceptible to depression due to poor tolerance of rejection)
    116. 116. Cluster C
    117. 117. Avoidant Personality Disorder
    118. 118. • A pervasive pattern of social inhibition, feelings of inadequacy, and hypersensitivity to negative evaluation, beginning by early adulthood and present in a variety of contexts, as indicated by 4 or more:
    119. 119. • Avoids occupational activities that involve significant interpersonal contact, b/c of fears of criticism, disapproval, rejection• Unwilling to get involved with people unless certain of being liked• Shows restraint within intimate relationships b/c of fear of being shamed or ridiculed
    120. 120. • Preoccupied with being criticized or rejected in social situations• Inhibited in new interpersonal situations because of feelings of inadequacy• Views self as socially inept, personally unappealing, or inferior to others• Unusually reluctant to take personal risk for fear of embarrassment
    121. 121. Prevalence• 0.5%-1% general population• 10% outpatient population
    122. 122. Course• Avoidant behaior often starts in infancy or childhood with shyness, isolation, and fear of strangers and new situations• Most individuals dissipates and does not become a PD• Avoidant PD individuals become more shy and avoidant in adolescence, early adulthood, may remit with age
    123. 123. Differential Diagnosis• Social Phobia (high overlap ? same)• Panic d/o with Agoraphobia (often co- ocurence)• Avoidant and Dependent both have feelings of inadequacy, hypersensitivity to criticism, need for reassurance: Avoid humiliation/ rejection vs focus on being taken care of
    124. 124. Differential Diagnosis• Avoidant Personality d/o and Dependent Personality d/o may be co-occurring• Schizoid or Schizotypal PD also tend to isolation, but Avoidant PD want to have relationships, and feel loneliness deeply, vs perhaps preferred isolation
    125. 125. Differential Diagnosis• Paranoid PD and Avoidant PD: Both reluctant to confide in others, but in Avoidant PD due to fear of being embarrassed or being found inadequate vs others’ malicious intent.
    126. 126. Course• Many may function in protected environment• Phobic avoidance is common• May develop social phobia
    127. 127. Treatment• Psychotherapy: Solidify alliance• Accepting attitude toward fears, especially fear of rejection• Eventual encouragement to take “great risk”• Care with “assignment” due to worsened low self esteem with “failure”
    128. 128. Psychopharmacology• Treat anxiety and depression• Consider beta blocker for autonomic nervous system hyperactivity which is common• SSRIs for rejection sensitivity• Dopamine agonists for “novelty seeking behavior” if psychologically prepared
    129. 129. Dependent Personality Disorder
    130. 130. • A pervasive and excessive need to be taken care of that leads to submissive and clinging behavior and fears of separation, beginning in early adulthood and present in a variety of contexts as indicated by five or more:
    131. 131. • Difficulty making everyday decisions w/o an excessive amount of advice and reassurance• Needs others to assume responsibility for most major areas of his or her life• Difficulty expressing disagreement with others b/c of fear of loss of support/ approval (do not include fears of realistic retribution)
    132. 132. • Difficulty initiating projects or doing things on his/her own (lack self confidence)• Goes to excessive lengths to obtain nurturance and support from others, to point of volunteer to do unpleasant things• Feels uncomfortable or helpless when alone b/c of exaggerated fears of being unable to care for slef
    133. 133. • Urgently seeks another relationship as a source of care and support when close relationship ends• Unrealistically preoccupied with fears of being left to take care of self
    134. 134. Prevalence• Among the most frequently encountered in mental health field• More common in women than men• One study stated 2.5% of all Pd• Children chronically ill susceptible
    135. 135. Differential Diagnosis• Distinguish from dependence secondary to Axis I or general medical condition’• BPD react with emotional emptiness, rage, whereas Dependent react with increasing appeasement and submissivenes• Histrionic: both need reassurance/approval but Dependent self-effacing/docile, vs gregarious flirtation/flamboyance
    136. 136. Differential Diagnosis• Avoidant Personality Disorder also feelings of inadequacy, hypersensitivity to criticism, need reassurance (like Dependent) but so fearful of humiliation and rejection they withdraw until certain of acceptance vs Dependent seek relationships
    137. 137. Course• May have impaired functioning as don’t act independently• Risk for physical or mental abuse as can not assert themselves• Risk of depression when loss of person on whom they depend
    138. 138. Treatment• Psychotherapy: Often successful• Insight oriented, CBT, Group have all been successful• Therapy is risked with pressure to leave a pathological relationship, patients feel torn• Must show great respect for feelings of attachment no matter how pathological
    139. 139. Pharmacotherapy• Antidepressants for Anxiety and Depression• Imipramine for panic or separation anxiety
    140. 140. Obsessive CompulsivePersonality Disorder
    141. 141. • Pervasive pattern of preoccupation with orderliness, perfectionism, and mental and interpersonal control, at the expense of flexibility, openness, and efficiency, beginning by early adulthood and present in a variety of contexts as indicated by 4 or more:
    142. 142. • Preoccupied with details, rules, lists, order, organization or schedules to extent that point of activity is lost• Shows perfectionism that interferes with task completion (unable to complete project b/c own overly strict standards not met)
    143. 143. • Excessively devoted to work and productivity to exclusion of leisure activities and friendships• Overconscientious, scrupulous, and inflexible about matters of morality, ethics or values• Unable to discard worn-out or worthless objects even when have no sentimental value
    144. 144. • Reluctant to delegate tasks or work w/ others unless they submit to exactly his or her way of doing things• Adopts a miserly spending style toward both self and others; money is to be hoarded for future catastrophes• Shows rigidity and stubornness
    145. 145. Prevalence• 1% general population• 3%-10% in mental health setting
    146. 146. Course• Highly variable• May flourish in positions demanding methodical, demanding, deductive work, vulnerable to unexpected changes• Personal life may be barren• High risk depression
    147. 147. Treatment• Often aware of suffering, seek treatment• Psychotherapy treatment long and complex, countertransference problems common• CBT and group therapy offer interrupting maladaptive behaviors
    148. 148. Pharmacotherapy• Consider clomipramine or fluoxetine or benzodiazepine clonazepam for severe obsessive compulsive symptoms
    149. 149. • Criteria Sets and Axes provided for further study• The DSM IV Task Force determined that there was insufficient information to warrant inclusion of these proposals as official categories or axes in DSM IV
    150. 150. • Pervasive pattern of depressive cognitions and behaviors beginning by early adulthood.....5 or more
    151. 151. • Usual mood dominated by defection, gloominess, cheerlessness, joylessness, unhappiness• Self-concept centers around beliefs of inadequacy, worthlessness, and low self esteem• Critical, blaming, derogatory toward self• Brooding and given to worry
    152. 152. • Negativistic, critical, and judgmental toward others• Pessimistic• Prone to feeling guilty or remorseful• Does not occur exclusively during Major Depressive Disorders and is not better accounted for by Dysthymic Disorder
    153. 153. Passive Aggressive PD• Passively resists fulfilling routine social and occ tasks•
    154. 154. Treatment

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