Adjustment, Personality Disorders

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  • What are the characteristics associated with an adjustment disorder? A person with adjustment disorder often experiences feelings of depression or anxiety or combined depression and anxiety. As a result, that person may act out behaviorally against the "rules and regulations" of family, work, or society. In some people, an adjustment disorder may manifest itself in such behaviors as skipping school, unexpected fighting, recklessness, or legal problems. Other people, however, instead of acting out, may tend to withdraw socially and isolate themselves during their adjustment problems. Still others may not experience behavioral disturbances, but will begin to suffer from physical illness. If someone is already suffering from a medical illness, that condition may worsen during the time of the adjustment disorder. People in the midst of adjustment disorders often do poorly in school or at work. Very commonly they begin to have more difficulty in their close, personal relationships.
  • Posttraumatic Stress Disorder, or PTSD, is a psychiatric disorder that can occur following the experience or witnessing of life-threatening events such as military combat, natural disasters, terrorist incidents, serious accidents, or violent personal assaults like rape. People who suffer from PTSD often relive the experience through nightmares and flashbacks, have difficulty sleeping, and feel detached or estranged, and these symptoms can be severe enough and last long enough to significantly impair the person's daily life.
  • Effect of personality disorders on the treatment outcome of axis I conditions: an update. Reich JH, Vasile RG. Department of Psychiatry, Brown University Medical School, Providence, Rhode Island. Consistent with previous investigations, recent studies continue to describe an adverse impact of personality pathology on the treatment outcome of a wide range of axis I disorders. The authors examine new studies that describe the effect of specific aspects of personality dysfunction on outcome measures of axis I disorders. New developments in this area include the predictive importance of both personality traits and disorders as well as possible specificity of traits in predicting outcome in some circumstances.
  • Identifying personality disorders: towards the development of a clinical screening instrument. Nurnberg HG, Martin GA, Somoza E, Coccaro EF, Skodol AE, Oldham JM, Andrews G, Mulder RT, Joyce PR. Department of Psychiatry at the University of New Mexico School of Medicine, Albuquerque, USA. The study objective was to identify a set of personality disorder (PD) criteria from the DSM PD diagnostic sets that can be used to detect subjects with an increased likelihood of having a PD diagnosis. In a series of outpatients evaluated systematically in two waves for every criteria item for 12 DSM-III-R PDs, stepwise logistic regression identified 45 criteria as discriminative for their specific PDs, which are selected for further analysis to assess their ability to discriminate for any PD. Receiver operating characteristic (ROC) analysis is used to evaluate their discriminative power in an independent conjoined sample (N = 1,342) from six centers that assessed every PD criteria item by structured instrument (Structured Clinical Interview for DSM-III-R PDs [SCID-II, Personality Disorder Examination [PDE], and Structured Interview for DSM-III-R PDs [SIDP-R]). The cutoff that maximizes information gain is used to determine the diagnostic threshold (DT). Initially, 15 of 45 criteria are identified. At the 0.43 PD prevalence, a DT of 2 or more of the 15 PD criteria across samples is optimal. The maximum information gain (MIG) is .42 bits, and the AUR is 0.94+/-.007. Other performance indices at this cutoff are .90 sensitivity, .84 specificity, .81 positive predictive power (PPP), .91 negative predictive power (NPP), and .86 hit rate (HR). Taken collectively, the 15 PD criteria selected by the data reduction techniques suggest a narrowed set to be assessed in screening for the presence or absence of any PD with comparable or better psychometric properties than other tests routinely used for diagnosing medical and psychiatric disorders. If specific PD categorization is needed, a second-step comprehensive assessment should follow.
  • 1. Personality traits are long-lasting patterns of perceiving, relating to, and thinking about the environment and oneself that are seen in a large number of social and personal contexts. 2. Only when the personality traits are inflexible and maladaptive and cause significant functional impairment or distress do they constitute a personality disorder.
  • In psychology, personality refers to the pattern of thoughts, feelings and behaviors, consistently exhibited by an individual over a long period of time, that strongly influences the way that individual perceives the world and himself/herself. Personality is a complex combination of traits and characteristics that determines our expectations, self-perceptions, values and attitudes, and predicts our reactions to people, problems and stress. Personality is not just who we are, it is also how we are. We all have personality traits and characteristics, although psychologists differ in the number of personality characteristics that appear to be distinct and unique. The degree to which we exhibit a specific personality trait varies from person to person. Some personality traits have biological roots, but all are influenced by our environment, especially our family relationships. Consequently, the millions of possible combinations of personality traits, in varying degrees, accounts for the unique individuality we all possess, but the relatively small number of different personality traits also explains why there are so many similarities between groups of people.  Possession of a personality trait found in a personality disorder does not mean that you have a personality disorder. We possess many traits in common with others, but we are all different. A personality disorder refers to a pattern of thoughts, feelings and behavior, consistently exhibited by an individual over a long period of time, that is maladaptive because it creates psychological distress and life coping problems , rather than assisting with life adjustment and problem solving.
  • Egosyntonic is behaving in ways you think is OK for you to behave. Egodystonic: behaving in ways that goes against your grain.
  • Paranoid: 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: suspects, without sufficient basis, that others are exploiting, harming, or deceiving him or her / is preoccupied with unjustified doubts about the loyalty or trustworthiness of friends or associates / is reluctant to confide in others because of unwarranted fear that the information will be used maliciously against him or her / 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 / has recurrent suspicions, without justification, regarding fidelity of spouse or sexual partner Schizoid: 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 in a variety of contexts. Essential Feature: A pattern of detachment from social relationships and a restricted range of emotional expression (DSM-IV™, 1994). The SPD Coming Into Treatment: No Cluster A personality disorder is particularly inclined to seek treatment. They are often forced into therapy by family or the legal system. These individuals are not psychologically resilient and will have severe difficulty in jail. SPDs are often the society's quiet misfits. Odd, distant, and unsocialized, they can spend a lifetime in single rooms in interpersonal isolation. Schizotypal: The essential feature of StPD is a "pervasive pattern of 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"; (DSM-IV™, 1994, p. 641). Schizotypal personality disorder encompasses a combination of peculiar behavior, speech, thought, and perception. Individuals with StPD are usually withdrawn and display eccentric beliefs, paranoid tendencies, idiosyncratic speech, perceptual illusion, unusual appearance, inappropriate affect, and social anxiety (Frances, 1995, p. 368).
  • Antisocial: Whether called black sheep, sociopaths, felons, con men, or misfits, some men break all the rules. They shirk everyday responsibilities, abuse drugs and alcohol, take up criminal careers, and lash out at family members. In the worst cases, they commit rape, murder, and other acts of extreme violence as though they lack a conscience. What makes these men--men we all know, whether as faces in the news or as people close to us--behave the way they do? Antisocial Personality Disorder results from desiring, needing, and delighting in challenge and adventure; and from fearing, and being distressed by, not getting or losing challenge and adventure. A person with a borderline personality disorder often experiences a repetitive pattern of disorganization and instability in self-image, mood, behavior and close personal relationships. This can cause significant distress or impairment in friendships and work. A person with this disorder can often be bright and intelligent, and appear warm, friendly and competent. They sometimes can maintain this appearance for a number of years until their defense structure crumbles, usually around a stressful situation like the breakup of a romantic relationship or the death of a parent. Diagnostic criteria which may identify Histrionic Personality Disorder would normally include the following. The accent would be on excessive, almost theatrical, emotional responsiveness. At the same time there may be a discernable shallowness to these emotions. For example, at the peak of a sudden burst of rage these people can answer the telephone in the calmest, mildest and friendliest tones. These people are invariably uncomfortable when not the center of attention. There is a style of speech that is excessively impressionistic if not downright theatrical. This may manifest as exaggeration in body gestures and almost always in words enlisted more for their emotional colouring than for their factual content. For these people the truth of any situation is less with the facts than with their hunches and gut feelings, as it were. This person may also behave in a manner which may be sexually provocative, but there would invariably be more style than content to this behavior. Narcissistic: The essential feature of the narcissistic personality disorder is a pervasive pattern of grandiosity, need for admiration, and lack of empathy (DSM-IV™, 1994, p. 658). Gunderson, et.al, (Livesly, ed., 1995, p. 208) notes that the grandiosity may not be overt or may involve arrogant and haughty behavior. Individuals with NPD may show little real ability outside of their fantasies. They can become self-destructive because their grandiosity and self-preoccupation impair their judgment and perspective. They can experience such inappropriate rage in response to someone diminishing their sense of superiority that they attack and attempt to destroy the source of criticism (Oldham, 1990, pp. 93-95). These individuals have a particularly difficult time with the limitations inherent in ageing; NPD has been associated with deterioration in midlife with the realization of mortality and loss of physical vitality (Wink, Costello, ed., p. 149).
  • Avoidant personality disorder (APD) ís considered to be an active-detached personality pattern, meaning that avoidants purposefully avoid people due to fears of humiliation & rejection. It ís thought to be a pathological syndromal extension of the “normal inhibited” personality, which ís characterized by a watchful behavioral appearance, shy interpersonal conduct, a preoccupied cognitive style, uneasy affective expression & a lonely self-perception ( Millon & Everly ). According to this view, the avoidant pattern seems to range ín varying degrees along a symptomological continuum from mild to extreme. In mild cases, a person may be said to be normally shy, whereas extreme cases indicate personality disorder. A pervasive and excessive need to be taken care of that leads to submissive and clinging behavior and fears of separation, beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following: (1) has difficulty making everyday decisions without an excessive amount of advice and reassurance from others (2) needs others to assume responsibility for most major areas of his or her life (3) has difficulty expressing disagreement with others because of fear of loss of support or approval. Note: Do not include realistic fears of retribution (4) has difficulty initiating projects 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) (5) goes to excessive lengths to obtain nurturance and support from others, to the point of volunteering to do things that are unpleasant (6) feels uncomfortable or helpless when alone because of exaggerated fears of being unable to care for himself or herself (7) urgently seeks another relationship as a source of care and support when a close relationship ends (8) is unrealistically preoccupied with fears of being left to take care of himself or herself (p. 668-9) Obsessive-Compulsive Personality Disorder is characterized by perfectionism and inflexibility. A person with a Obsessive-Compulsive Personality becomes preoccupied with uncontrollable patterns of thought and action. Symptoms may cause extreme distress and interfere with a person's occupational and social functioning.
  • Eyeore Tigger Rabbit Owl Pooh Piglet Christopher
  • GI-GERD; Peptic Ulcer; Ulcerative Colitis; Crohn’s Disease (Medications exacerbate psychological symptoms) Cardiovascular- Coronary Heart Disease; Valvular Heart Disease; CABG; Hypertension; Vasovagal Syncope; Respiratory System: Asthma; Hyperventilation Syndrome; Endocrine: Hyperthyroidism
  • Pathological Gambling is characterized by persistent and recurrent gambling that results in causing a detrimental effect on the person's life and family. Intermittent Explosive Disorder This disorder is characterized by frequent and often unpredictable episodes of extreme anger or physical outbursts. Between episodes, there is typically no evidence of violence or physical threat. Pyromania  Pyromania involves deliberate and purposeful fire setting on at least two occasions. There is typically tension or heightened arousal prior to the act and gratification or relief afterward. The fire setting is not done for monetary gain or an expression of anger, vengeance, personal gain, or psychosis. Kleptomania This disorder is characterized by episodes of stealing.  Usually with a build-up of tension before the act and a sense of relief after the act.  Most of the time the stolen objects are petty things that they can afford to buy. Trichotillomania This disorder is characterized by recurrent pulling out of one's hair from the head, eyebrows, eyelashes or other body parts; causing noticeable hair loss.  High levels of tension build up before the act and a sense of relief is experienced after the act.  There is a certain degree of obsessive-compulsive characteristics in this disorder.
  • Adjustment, Personality Disorders

    1. 1. Adjustment, Personality Disorders & Chronic Medical Conditions <ul><li>Jeff Baker, Ph.D. </li></ul><ul><ul><li>Chief Psychologist, Anesthesiology, Orthopaedics & Rehabilitation, Surgery </li></ul></ul><ul><ul><li>Director, SAHS Counseling & Student Services </li></ul></ul>
    2. 2. Objectives <ul><li>Identify psychological influences of personality. </li></ul><ul><li>Understand the influence of stress on personality. </li></ul><ul><li>Types of Stressors that influence patients’ rehabilitation. </li></ul><ul><li>Effective ways of managing patients with major psychosocial stressors </li></ul>
    3. 3. Personality Disorders & Stress <ul><li>Adjustment Reactions to Medical Conditions </li></ul><ul><li>PTSD </li></ul><ul><li>Long Term Effect </li></ul><ul><li>11 Personality Disorders (DSMIV TR) </li></ul><ul><li>Differentiation of Personality Disorders </li></ul><ul><li>Case Studies & Managing Psychosocial stress. </li></ul>
    4. 4. Adjustment Disorders <ul><li>Development of emotional or behavioral symptoms in response to an identifiable stressor(s) within 3 months of the onset of the stressor(s). </li></ul><ul><li>Evidenced by either of the following: </li></ul>
    5. 5. Adjustment Disorders <ul><li>1. Marked distress that is in excess of what would be expected. </li></ul><ul><li>2. Significant impairment in social or occupational functioning. </li></ul>
    6. 6. Adjustment Disorders <ul><li>The stress-related disturbance does not meet the criteria for another AXIS I or AXIS 2 disorder. </li></ul><ul><li>The symptoms do not represent bereavement. </li></ul><ul><li>Once the stressor has terminated, the symptoms do not persist for more than an additional 6 months. </li></ul>
    7. 7. Adjustment Disorders <ul><li>309.0 Adj Disorder with Depressed Mood </li></ul><ul><li>309.24 Adj Disorder with Anxiety </li></ul><ul><li>309.28 with mixed anxiety and depression </li></ul><ul><li>309.3 with disturbance in conduct </li></ul><ul><li>309.4 with disturb of emotions and conduct </li></ul><ul><li>309.9 Adj Disorder unspecified </li></ul>
    8. 8. Posttraumatic Stress Disorder <ul><li>The symptoms develop after a psychologically traumatizing event or events outside the range of normal human experience. May experience symptoms alone or in groups. The stressors contain a psychological component and frequently a concomitant physical component that may directly damage people's nervous systems. In adjustment disorder the precipitating stress event need not be severe or unusual. </li></ul>
    9. 9. Personality Disorders & Effect on the Individual Without Treatment Depression Phobias Elevated family violence Drug use Exacerbation of Existing Issues Inhibit Healing & Rehabilitation
    10. 10. Identifying Personality Disorders
    11. 11. 1. What are the characteristics of a person that would warrant a personality disorder diagnosis? 2. How would that effect my ability to provide treatment/therapy for the patient? 3. How is this going to effect the patient’s quality of life. Mini Self-Test
    12. 12. Definition of Personality Disorder <ul><li>It is pervasive and inflexible. </li></ul><ul><li>It has an onset in adolescence or early adulthood. </li></ul><ul><li>It is stable over time. </li></ul><ul><li>It leads to distrust or impairment. </li></ul><ul><li>P.D. Is thought to be an enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individual’s culture. </li></ul><ul><li>Coping or defense mechanisms, which are used to deal with high levels of stress that have been left untreated. </li></ul><ul><li>Coping with pain, loss of identity, mobility, and independence all may have profound effects on personality. </li></ul>
    13. 13. What are Personality Disorders Like? <ul><li>People with personality disorders typically have problems in many areas of their lives, including social skills, moods, and emotional states. People with these disorders have difficulty establishing normal, health relationships. </li></ul>
    14. 14. Personality Disorders <ul><li>In many of the disorders, sufferers lack the ability to have genuine emotions including empathy for others. </li></ul><ul><li>In some disorders, some have no desire to have social relationships or they want relationships, but are scared to reach out to people. </li></ul><ul><li>Personality disorder symptoms stem from basic personality traits that developed over time. A person does not “get” a personality disorder. </li></ul>
    15. 15. Personality Disorders <ul><li>Because personality disorder traits are deeply ingrained in the personality, there is no quick treatment. Treatment is typically based on psychotherapy which evaluates faulty thinking patterns and teaches new thinking and behavior patterns. </li></ul><ul><li>A problem in treating individuals with personality disorders is that many do not believe they have a problem. </li></ul>
    16. 16. Diagnosis Criteria 1) There are 10 personality disorders listed in the DSM-IV. 2) DSM-IV = Diagnostic and Statistical Manual of Mental Disorders-Fourth Edition, TR APA 2001 . 3) The criteria for each Personality Disorder is listed in the DSM-IV TR.
    17. 17. Differentiation of Personality Disorder and Disorder <ul><li>Personality Disorder tends to be EgoSyntonic </li></ul><ul><li>Disorder tends to be EgoDystonic </li></ul>
    18. 18. Types of Personality Disorders Cluster A: Odd or Eccentric 1. Paranoid Personality Disorder 2. Schizoid Personality Disorder 3. Schizotypal Personality Disorder
    19. 19. Cluster B: Dramatic, Emotional, or Erratic <ul><li>4. Antisocial Personality Disorder </li></ul><ul><li>5. Borderline Personality Disorder </li></ul><ul><li>6. Histrionic Personality Disorder </li></ul><ul><li>7. Narcissistic Personality Disorder </li></ul>
    20. 20. Cluster C: Anxious or Fearful <ul><li>8. Avoidant Personality Disorder </li></ul><ul><li>9. Dependent Personality Disorder </li></ul><ul><li>10. Obsessive-Compulsive Personality Disorder </li></ul><ul><li>Personality Disorder NOS </li></ul>
    21. 21. Diagnosis
    22. 22. Case Examples <ul><li>Patient who is verbally abusive and aggressive to staff and family. </li></ul><ul><li>Patient who is suspicious and questions your treatment methods. </li></ul><ul><li>Patient who wants to go have a cup of coffee with you and be your friend. </li></ul>
    23. 23. Case Examples <ul><li>Patient who is seductive and always seems dressed up and wearing lots of cologne when they come in for appointment. </li></ul><ul><li>Patient who cries and appears very sad about their future. </li></ul><ul><li>Patient who denies that their SCI will bring about any changes in their lifestyle. </li></ul>
    24. 24. Psychological Factors Affecting Medical Condition <ul><li>A general medical condition </li></ul><ul><ul><li>Neurotransmitter Response to Stress </li></ul></ul><ul><ul><li>Endocrine Response to Stress </li></ul></ul><ul><ul><li>Immune Response to Stress </li></ul></ul><ul><li>Psychological factors adversely affecting the medical condition </li></ul><ul><ul><li>Disorder; Psych symptoms; Personality traits; Maladaptive health behaviors; Stress related physiological response; Other (cultural; religious) </li></ul></ul>
    25. 25. Major Medical Issues <ul><li>Gastrointestinal System </li></ul><ul><li>Cardiovascular System </li></ul><ul><li>Respiratory System </li></ul><ul><li>Endocrine System </li></ul><ul><li>Skin Disorders </li></ul><ul><li>Musculoskeletal System </li></ul><ul><li>Headaches </li></ul><ul><li>Psycho-oncology </li></ul>
    26. 26. Example: Chronic Pain <ul><li>Explain the nature of the pain </li></ul><ul><li>Maximize placebo effect </li></ul><ul><li>Explain realistic expectations </li></ul><ul><ul><li>degree and course of pain </li></ul></ul><ul><ul><li>analgesic, reframe side effects </li></ul></ul>
    27. 27. Chronic Pain <ul><li>Chronic pain requires special arrangements: </li></ul><ul><ul><li>Eliminate doubts about the availability of meds. </li></ul></ul><ul><ul><li>No meds requiring proof of need (lost, stolen) </li></ul></ul><ul><ul><li>Focus on strengths, do not reinforce obsession with pain. </li></ul></ul><ul><ul><li>Do not make contact with cared system contingent on pain; remove that contingency. </li></ul></ul>
    28. 28. Clinical Use of the MMPI2 & Patients with Chronic Pain
    29. 29. Conclusions on PD <ul><li>Individuals Diagnosed with Personality Disorders vs Individuals with exacerbated Stressors </li></ul><ul><li>Difficult to Treat, Difficult to Manage </li></ul><ul><li>How Does it Affect Your Treatment of the Patient </li></ul>
    30. 30. Disorders of Impulse

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