PM Personality Disorders You ll be running laps soon if you

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					PMII-2            Personality Disorders
9/4/01

Michael B. First, M.D.     (lecturer)

Ben Donohue                (transcriber)
bfd6@
646-408-6142

reading= pp.149-165 (Psychiatry)


Lecture Summary


1. General Info

 Definition of Personality:    The way a person experiences the world. How he/she thinks, feels, acts.
  Definition of Trait:          An aspect or pattern of a person’s personality.

 Definition of Personality Disorder: A system of thinking, feeling, and acting that is inflexible and
                      maladaptive, leading to the impairment of social or occupational functioning.

 Trait vs. Disorder:      -distinction=blurred
                           -some traits are maladaptive on either end of continuum
                                ex. too much trust (gullible) or too little trust (paranoid)
                           -when a trait gets a person in trouble repeatedly (cramming for an
                                exam?) yet the person can not change  perhaps a disorder

 Personality formed by: 1. heredity/”temperment”/nature , 2. “character”/nurture
             -The latter can be changed, but only through much therapy. The character part of the
             personality is based on a person’s entire familial upbringing and many years of patterning. So
             disorders have often been building for a long period of time and cannot be easily undone.

 Effect of culture on diagnosis
             - personality that is seen as unusual in 1 culture might be considered as normal in another
             - ex. Southern Europeans tend to be histrionic and northern Europeans reserved so a
                  histrionic person might be viewed as normal in Italy but troubled in Norway. There is a
                  way to diagnose a disorder despite these differences. If a person switches cultures but
                  can’t adapt to the attitudes and mores of the new culture(“rigid, inflexible expression”),
                  he may have a disorder.
 Complicating Factors in Diagnosis
         1. ego-syntonic nature of patients (see page 4)
         2. reluctance to acknowledge unflattering traits
         3. denial or exaggeration may be characteristic of particular PD
         4. gender bias, clinician’s culture

2. Personality Disorder is an Axis II disorder (say what?)

 Review of DSM “multiaxial system” used to standardize diagnosis:

             Axis I:       Psychiatric diagnoses (depression, schizophrenia, anxiety disorder, etc.)
             Axis II:      Life-long psychiatric disorders (personality disorders, mental retardation)
             Axis III:     Nonpsychiatric medical conditions
             Axis IV:      Presence of contributing psychosocial stressors
             Axis V:        Patient’s highest level of social and occupational functioning in previous year
     - sometimes it is difficult to determine whether patient has Axis I or II disorder
                 ex. major depressive episode vs. avoidant or dependent personality disorder
                       social phobia vs avoidant personality disorder
     - many Axis I disorders are chronic with early onset

3. DSM-IV Criteria for Personality Disorder (PD)                         (this section borrows heavily from the lecture slides)

      6 criteria must be met to diagnose a PD
          A. An enduring pattern of inner experience and behavior that deviates markedly from the
               expectations of the individual’s culture, manifested in at least 2 of the following areas:
                   1. cognition (way of perceiving/interpreting self, others)
                   2. affectivity (range, intensity, lability, appropriateness of emotional response)
                   3. interpersonal functioning
                   4. impulse control
               “enduring” – occurs over years

           B. The enduring pattern is inflexible and pervasive across a broad range of personal and social
               situations. The person has problems in multiple contexts interacting with many different
               people (not just with a taskmaster boss or with a single family member).

           C. The enduring pattern leads to clinically significant distress or impairment in social,
               occupational, or other important areas of functioning. (If a person’s particular personality
               does not have negative ramifications in his current living conditions, it is difficult to classify
               him as having a PD)

           D. Personality pattern is stable and of long duration. Onset can be traced to at least early
              adulthood if not to adolescence.

           E. Pattern is not manifestation or consequence of another mental disorder. It should be shown to
                   be independent of Axis I illness.

           F.     Pattern is not due to effects of a substance (booze, medication, rec drugs, phenol) or a general
                  medical condition (head trauma)


5. 10 PDs in 3 clusters based on general patient appearance


                Cluster                               Phenotype                              PDs
                A (eccentric disorders)               odd-looking, withdrawn                 Paranoid, Schizoid,
                                                                                             Schizotypal,
                B (dramatic disorders)                dramatic                               Antisocial, Borderline,
                                                                                             Histrionic, Narcissistic
                C (anxious disorders)                 anxious                                Avoidant, Dependent,
                                                                                             Obsessive-Compulsive
(note: Psychiatry text contains DSM-IV diagnostic criteria for each of the 10 disorders.)



     Eccentric Disorders
         A. Paranoid
                   angry mistrust of other people
                   often, a self-fulfilling prophecy: mistrustful behavior causes others to act in an overly
                  cautious and even deceptive way
         B. Schizoid
                withdrawn, aloof, detached
                lack of concern about isolation
                inability to form personal relationships or respond to others emotionally
        C. Schizotypal
                appear quite odd
                magical thinking, idiosyncratic thought processes, unusual beliefs
                inappropriate affect, social anxiety

    Dramatic Disorders
       D. Antisocial
                 tend to attack trust and caring of other people
                 desire to manipulate, cheat, break law
                 lack of remorse for wrongdoing
                 very common with people in jail
       E. Borderline
                 emotional and interpersonal instability and impulsivity
                 abnormal feeling states, self-destructive behavior
                 fluctuating and extreme attitudes towards self and others
                 may experience transient psychotic breaks with crisis or substance use
       F. Histrionic
                 dramatic,highly emotional (though not as emotional as Borderline patients)
                 attention-seeking, self-dramatizing
                 excessively talkative, seductive, manipulative, exhibitionistic
                 shallow, vain, demanding
       G. Narcissistic
                 struggle with self-esteem; react with feelings of superiority, grandiosity, contempt
                towards other
                 egocentric, grandiose, feel “entitled”, manipulative
                 crave attention, praise and display symbols of power, wealth

    Anxious Disorders
       H. Avoidant
                 chronically anxious, timorous, unadventurous
                 low self-esteem, hypersensitive to rejection
       I. Dependent
                 attach themselves to others in an intense, desperate way
                 tendency to let other people make decisions, run their lives
                 live with parents into adulthood
       J. Obsessive-Compulsive
                 perfectionistic, emotionally constricted, excessively disciplined
                 driven, competitive, impatient
                 controlled, controlling personalities
                 rigidly repress all emotions except anger
                 typical P&S med student?


7. Dr. First then showed the class 3 clips from the 80s suspense film Fatal Attraction

    Clip 1        Michael Douglass’ character talks about his job and mentions “I have pull around this
                 restaurant.” He seems slightly ill at ease. He is possibly a narcissist.
                  Glen Close’s character seems a bit dramatic.
    Clip 2         GC’s character demands “I want to know where I stand.” This extreme attitude towards
                  a transient relationship is unusual. She is nervous the relationship will fail and laments,
                  “How come all the good men are married?”

    Clip 3         GC’s character attacks MD’s character and then she slits her wrists.

             Dr. First discussed GC character’s borderline PD. She has a problem with abandonment
             and alternates between overidealizing and degrading both herself, her partner, and their
             relationship. She engages in self-mutilation because of her distress and her self-hatred. She
             hopes MD’s character will care for her. The cuts snap her out of the disassociated state into
             which she had receded. MD’s character is likely narcissistic, as evidenced by his
             objectification of GC and lack of empathy for her. Does he have a PD? Could he be
             functional otherwise? Possible but not probable says Dr. First.

8. Random notes from text:
     prognosis depends on severity of PD
     some PDs respond better to Tx than others
     crucial yet difficult Pt interview requires open-ended questions
     PDs overlap
     general trait of “agreeableness” leads to better prognosis
     narcissist PD tends to present in middle age(exception to rule), while borderline PD tends to “burn
     out” by middle age
     PDs tend to be egosyntonic, meaning that patients regard their maladaptive patterns of behavior as
    part of themselves and not part of a disease process. Ergo the tendency to shield any problems from an
    interviewer. Other psychiatric disorders tend to be egodytonic, meaning that patients are aware of and
    complain about symptoms that they regard as forwign and separate from themselves.




Partially Related Piece of Interesting Information from Reading:

    “Heredity may account for about half of the variance of personality traits in each person.”

				
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