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									Personality Disorders

     Duane E. Dede, Ph.D.
  Clinical Associate Professor
 Clinical & Health Psychology
Under stress…our
 personalities become
Sources of Information


   Behavioral      Test
   Observations   Results
       Personality Disorders
 Chronic behavioral disturbance with early
  and insidious onset that crystallize by late
  adolescence or early adulthood
 Behavior patterns are inflexible and
 Goal-discover how a pt’s personality
  interacts with the stress of illness or is
  manifested across situations
          PDO’s continued
 Because these behavior patterns are so
  ingrained, the PDO frequently only present
  when in Axis I crisis
 Quantitative difference-PDOs lead to
  impairment in occupational/interpersonal
  functioning (transcends the situation)
PDO’s General Tx Guidelines
 Goals should be realistic
 Goals should be relevant to the situation
 PDO’s are life-long patterns that will not
  change in short intervention.
    – Inpatient setting-”Play to strengths”
   Initial goals may only be some Sx
    improvement and increased awareness
              Cluster A PDOs
   “Odd & Eccentric Behavior”
   Paranoid PDO-a pattern of distrust &
    suspiciousness such that other’s motives are
    interpreted as malevolent.
   Schizoid PDO-a pattern of detachment from social
    relationships & a restricted range of emotional
   Schizotypal PDO- a pattern of acute discomfort in
    close relationships & restricted range of emotional
                    Paranoid PDO
   Derek worked in a large office as a computer programmer. When
    another programmer received a promotion, Derek felt that the
    supervisor "had it in for him" and would never recognize his worth. He
    was sure that his co-workers were subtly downgrading him. Often he
    watched as others took coffee breaks together and imagined they spent
    this time talking about him. If he saw a group of people laughing, he
    knew they were laughing at him. He spent so much time brooding
    about the mistreatment he received that his work suffered and his
    supervisor told him he must improve or receive a poor performance
    rating. This action reinforced all Derek's suspicions, and he looked for
    and found a position in another large company. After a few weeks on
    his new job, he began to feel that others in the office didn't like him,
    excluded him from all conversations, made fun of him behind his back,
    and eroded his position. Derek has changed jobs six times in the last
    seven years.
                 Paranoid PDO
   Excessive sensitivity to setbacks and rebuffs
   Bears long-term grudges (refuses to forgive)
   Suspiciousness and pervasive distrust by misconstruing the
    neutral or friendly actions of others as hostile
   Combative and tenacious sense of personal rights beyond
    what seems to be appropriate
   Recurrent suspiciousness, without justification about
    fidelity of spouse or sexual partner
   Excessive sense of self-importance
   Preoccupation with unsubstantiated conspiratorial
    explanations of event (personal or otherwise)
   “Geriatric Paranoia”
                  Schizoid PDO
   Few pleasurable activities (less desire than APDO)
   Emotionally cold and detached with flattened affect
   Limited capacity (or desire) to express warm, tender or
    angry feelings toward others
   Indifferent to praise or criticism
   Little interest in sexual relationship with other
   Consistent choice of solitary activities
   Excessive preoccupation with fantasy & introspection
   No desire for close relationships (“only one”)
   Insensitive to prevailing social norms & conventions
               Schizoid PDO Tx
   Medication & Psychotherapy
   Blackmon (94)
    – A schizoid young man made a methodical attempt at suicide. He
      revealed a paucity of object attachments leading to profound
      isolation. His early upbringing led him to extreme isolation of
      affect and a fear of fragmentation. His inner life was not safely
      reachable by conventional therapy. After he became involved in
      playing a fantasy game, dungeons and Dragons, the therapy was
      modified to use the game material as displaced, waking fantasy.
      This fantasy was used as a safe guide to help the patient learn to
      acknowledge and express his inner self in a safe and guided way.
      The patient ultimately matured and developed healthier object
      relations and a better life.
               Schizotypal PDO
   Ideas of reference (excluding delusions of reference)
   Odd beliefs or magical thinking that influence behavior
    and are inconsistent with sub-cultural norms
   Unusual perceptual experiences, including bodily illusions
   Odd thinking and speech (vague, metaphorical,
    overelaborate or stereotyped)
   Inappropriate or constricted affect
   Odd, eccentric or peculiar behavior or appearance
   Lack of close friends or confidants, other than relatives
   Excessive social anxiety that does not diminish with
    familiarity and tends to be associated with paranoid fears
    rather than negative self judgements
              Schizotypal PDO
   Strong genetic contribution
    – Consequently, late-onset schizophrenia is more
      frequent and more severe in women than in men.
    – The sex difference in age of onset is smaller in cases
      with a high genetic load and greater in cases with a low
      genetic load.
    – Type of onset and core symptoms do not differ between
      the sexes. The most pronounced sex difference is the
      socially negative illness behavior of young men.
    – Negative Schizophrenic Sx associated with ScPDO in
      family members
            Schizotypal PDO Tx
   ScPDO patients with prominent cognitive/perceptual
    distortion may respond to neuroleptic agents. The most
    salient example of this is the testing of serotonin-specific
    agents (e.g., fluoxetine) for potential antiaggressive
    efficacy in personality disordered subjects with prominent
    histories of impulsive aggressive behavior.
   Psychotherapy is difficult and may be cyclic around times
    of medication non-compliance. Focus is on stability,
    reality testing and improving coping mechanisms
                Case Example
   42 year-old African-American woman with
    chronic history of attention and concentration
    difficulties-presented for ADHD evaluation
   Presentation/Family History
   Results:
    – IQ, language and memory intact; mild executive
      dysfunction. Poor coping typified by isolation, anxiety,
      ruminative thinking and social introversion
              Cluster C PDO’s
   “Anxious and Fearful Behavior”
   Avoidant PDO-Social inhibition, inadequacy
    feelings, & hypersensitivity of negative evaluation
   Dependent PDO-Pervasive & excessive need to be
    taken care of that leads to submissive & clinging
    behavior and fears of separation
   Obsessive Compulsive PDO-Preoccupation with
    orderliness, perfectionism and mental &
    interpersonal control, at the expense of flexibility,
    openness, and efficiency.
                 Avoidant PDO’s
   Avoids activities with significant interpersonal contact,
    because of fears of criticism, disapproval or rejection
   Unwilling to become involved without “guarantees of
   Very restrained in intimate relationships due to fear of
    shame or ridicule
   Preoccupied with social criticism or rejection
   Inhibited in new interpersonal situations
   Views self as socially inept, personally unappealling or
    inferior to others
   Very reluctant to take personal risks
    Avoidant PDO continued
 Desire close relationships, but too shy and
  insecure to obtain (persevere) them
 Very frustrated by their inability to relate
 Will try to prevent rejection by ingratiating
  themselves to others
 Contrasted to Social Phobias, APDO fear all
  social situations
     Avoidant PDO Treatment
 Assertiveness training, group therapy (with
  care to limit confrontation early in tx.)
 Cognitive Behavior-focus on hierarchy and
  creating early success, normalize fears
 Risks
    – pushing too fast
    – too restrictive
             Dependent PDO
   Significant indecision without excessive advice or
    reassurance from others
   Needs others to be responsible for most major
    areas of his/her life
   Rarely disagrees due to fear of disapproval
   Rarely initiate projects or doing things alone due
    to poor self-confidence, instead of low motivation
   Goes to excessive length to obtain nurturance and
    support from others (volunteering for unpleasant
    Dependent PDO continued
   Feel uncomfortable or helpless when alone due to
    exaggerated fear of being unable ot care for self
   Urgently seeks another relationship as a source of care and
    support when a close relationship ends (most common
    reason for entering tx.)
   Unrealistically preoccupied with fears of being left to take
    care of himself or herself (“dreads autonomy”)
   Productive when supervised, otherwise see themselves as
    “inept or stupid”
   When pressed to name redeeming qualities, will reluctantly
    confess to being “good companion, loyal & kind”
    Other DPDO characteristics
 Freud-Oral characteristic-intense need to be
  fed or taken care of.
 Common in normal clinic situations, but
  very high in psychiatric patients
 Common with other PDO’s and Axis I D/Os
  such as Agoraphobia
 Gender?
           Dependent PDO Tx
   Short term-Group Therapy & Assertiveness
   Psychodynamic (Maxem)
    – origins of low self-esteem
    – fears of harming others by seeking autonomy (e.g.
      assigned to spend time alone)
    – dependency on the therapist
    – termination a key part of therapy
    – Countertransference-guilt and anger
    Obsessive Compulsive PDO
   How does it differ from OCD?
    – Some comorbidity, but OCPD rarely develops OCD
   Four or more of the following:
    – Preoccupied with details, rules, lists, order,
      organization and schedules
    – Perfectionism interferes with task completion
    – Excessively devoted to work and productivity
    – Overconscientious and inflexible about morals, ethics
      & values
      OCPD criteria continued
 Unable to discard worthless objects
 Aversive to delegating tasks
 “Miserly spending”-money is to be hoarded
  for catastrophes
 Stubborn and rigid traits
 Descriptors
    – Miss the forest for the trees; difficult seeing
      other’s perspectives; avoids “soft feelings”
   Prevalence (all existing cases @ one point in time)
     – 1% in community samples
     – Adult lifetime prevalence 2.5%
     – 3-10% in mental health clinics
   Gender differences
    – Males are twice as likely as females
   Freud’s (1908) Anal character
    – Orderly, obsessed with bodily cleanliness,
      conscientious to the utmost, obstinate
   Abraham (1921) expanded on this:
    – Discussed the pleasure of ordering things
 DSM-I & DSM-II highlighted orderliness
 DSM-III, III-R added some symptoms
 DSM-IV (TR) require 4 of 8
   Medications:
    – Contrary to OCD, very little consistent
      evidence of benefit from pharmacotherapy
   Psychotherapy-very effective
    – CBT targets maladaptive schemas,
      automatic/distorted thoughts, and impact of
      family background/expectations
   Consider the cultural background of client
              Cluster B PDOs
   Dramatic, emotional or erratic behavior
   Antisocial PDO-Pervasive disregard for &
    violation of the rights of others
   Borderline PDO-Pervasive instability of
    interpersonal relationships, self-image & affect
   Histrionic PDO-Excessive emotionality &
    attention seeking
   Narcissistic PDO-Pervasive grandiosity (fantasy &
    behavior), need for admiration & lack of empathy
              Antisocial PDO
   Pervasive pattern of disregard for and
    violation of rights of others, occurring since
    age 15, as indicated by 3 (or more) of:
    – Failure to conform to social norms with respect
      to lawful behaviors as indicated by repeated
    – Deceitfulness (repeated lying, use of aliases or
      conning others for personal profit or pleasure)
      Antisocial PDO continued
   Impulsivity or failure to plan ahead
   Irritability and aggressiveness, as indicated by repeated
    physical fights or assaults
   Reckless disregard for safety of self/others
   Consistent irresponsibility, as indicated by repeated failure
    to sustain consistent work behavior or honor financial
   Lack of remorse
   18 years of older; Evidence of a Conduct DO <15
   Antisocial behavior not exclusively during SCz of Mania
      Antisocial PDO continued
   Radar for people’s vulnerabilities; enjoy manipulating,
    exploiting and intimidating others.
   Crave stimulation (drugs, manipulation, sex) to medicate
    boredom or depression. Frontal lobe abnormalities*
   Sexual relationships are thrilling conquests and nothing
   Emotionally shallow, incapable of shame, guilt, loyalty,
    love and sincere emotion. Yet, quick to anger.
   30-80% are in prison; Only 2% remit by age 21
   3% of men & 1% of women in general population;
    3-15% in psychiatric populations
    Antisocial PDO Treatment
 Extremely difficulty to treat and often
  “ordered” into treatment by court*
 Prevention is most effective, therefore
  detection of AsPDO early is important
 Family therapy is critical for patient and
  especially the family
 Treat co-morbid substance abuse
                  Borderline PDO
   Intense fear of real/imagined abandonment
   Intense, unstable interpersonal relationships that alternate between
    idealization & devaluation
   Marked disturbance of identity/self-image
   Self-damaging impulsivity in at least 2 areas (sex, spending, substance
    abuse, reckless driving, binge eating)
   Recurrent suicidal behavior, gestures, threats or self-mutilating beh.
   Affective instability due to marked reactivity of mood
   Chronic feelings of “emptiness”
   Inappropriate, intense anger or difficulty modulating anger (frequent
    displays of temper, constant anger or physical fights)
   Transient, stress related paranoid ideation or severe dissociative Sx.
   Prevalence: Women: Men (2:1)
     Borderline PDO continued
   Label initially referred to straddling the border between
    neurosis and psychosis (“latent schizophrenia”)
   Identity confusion is often manifested as dissociation
   Often “present well” but turmoil very evident in
    interpersonal relationships
   Anything less than total love is hate; anything less than
    total commitment is rejection (rejection sensitivity)
   Expect & demand others to do what they can’t do for
   Chronically sad and demoralized which lead to
    presentation of neurotic Sx (anxiety, mood d/o &
    conversion Sx.) that become psychotic under stress
   Bizarre responses on structured & unstructured tests
     Borderline PDO Treatment
   Treatment is very difficult and marked by a series of goals
    from safety/stabilization to interpersonal consistency
   M. Linehan-Dilectical Behavior Therapy
   Therapy is long-term, demanding, marked by frequent
    hospitalizations and reality testing
   Strong contertransference reactions, which often benefit
    from consultation with peers
   Pharmacotherapy-MAOs, SSRIs (anger, impulsiveness)
    with Lithium/Dilantin used in severe cases
                 Histrionic PDO
   Uncomfortable if not center of attention
   Interactions are characterized by inappropriate sexually
    seductive or provocative behavior
   Rapidly shifting and shallow expression of emotions
   Consistently uses physical appearance to draw attention to
   Impressionistic style of speech, which lacks detail
   Self-dramatizing, overlytheatrical and exaggerated
    expression of emotions
   Suggestible & easily influenced by others/circumstances
   Considers relationships more intimate than they are
      Histrionic PDO continued
   Formerly known as Hysterical PDO
   Depicts worst stereotypes, Female-vain, vapid & vague
   Male stereotypes: Superficial, demanding, inconsiderate,
    self-indulgent, macho & preoccupied with their looks
   Suicidal threats are gestures and are frequently attempts to
    manipulate, rarely fatal unless by accident
   Actor/Actress- “always on stage” Difficult to know when
    they are actually upset since exaggeration is the norm
   Tend to think in impressions contrasted to OCPD which
    think in facts
      Histrionic PDO Treatment
   Increase awareness- Tend to be insecure & hypersensitive
    to rejection by others, therefore use manipulation,
    dependence or seduction in an attempt to obtain love,
    acceptance or reassurance.
   Countertransference-Seduced, overly involved or
    indifferent (which may be perceived as rejection)
   Behavioral Therapy-reward system where attention is
    contingent on appropriate behavior
   Groups-focus on learning how to share the spotlight
   Psychodynamic-focus on the relationship
                Narcissistic PDO
   Grandiose sense of self-importance, often unwarranted
   Preoccupied with fantasies of unlimited success, power,
    brilliance, beauty or ideal love
   Believes that s/he is “special” and can only be understood
    by other high-status people
   Requires excessive admiration
   Entitled sense and expects special treatment
   Interpersonally exploitative
   Lacks empathy; Unwilling to recognize others feelings
   Envious of others, believes others are envious of him/her
   Arrogant behaviors or attitudes
   Intolerant of criticism because of low self-esteem
   More prevalent in men
    Narcissistic PDO Treatment
   Difficult to enter treatment because it is often perceived as
    a sign of weakness (needing someone else)
   Frequently enter therapy after suffering a Narcissistic
    injury and are at risk for leaving treatment prematurely as
    the dust settles.
   Goal of treatment is to gain more realistic view of self
   Behavioral Therapy-expose patient to anxiety of feeling
    less than great (systematically)
   Cognitive Therapy-discuss the paradox, realizing that no
    achievement is enough
   Countertransference-work very hard to please the patient
    and therefore earn respect, leading to anger and battles

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