VIEWS: 6 PAGES: 43 POSTED ON: 10/24/2012
Personality Disorders Duane E. Dede, Ph.D. Clinical Associate Professor Clinical & Health Psychology Under stress…our personalities become emphasized Sources of Information History 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 maladaptive 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 expression Schizotypal PDO- a pattern of acute discomfort in close relationships & restricted range of emotional expression. 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 acceptance” 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 tasks) 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 Training 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” Epidemiology 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 History 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 Treatment 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 arrest. – 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 obligations 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 more. 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 themselves 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 him/herself 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 Questions?
Pages to are hidden for
"PD"Please download to view full document