Adjustment Personality Disorders and Chronic Medical Conditions

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					Adjustment, Personality Disorders & Chronic Medical Conditions
• Jeff Baker, Ph.D.
• Chief Psychologist, Anesthesiology, Orthopaedics & Rehabilitation, Surgery • Director, SAHS Counseling & Student Services

• Identify psychological influences of personality. • Understand the influence of stress on personality. • Types of Stressors that influence patients’ rehabilitation. • Effective ways of managing patients with major psychosocial stressors

Adjustment Disorders
• Development of emotional or behavioral symptoms in response to an identifiable stressor(s) within 3 months of the onset of the stressor(s). • Evidenced by either of the following:

Adjustment Disorders
• 1. Marked distress that is in excess of what would be expected.
• 2. Significant impairment in social or occupational functioning.

Adjustment Disorders
• The stress-related disturbance does not meet the criteria for another AXIS I or AXIS 2 disorder. • The symptoms do not represent bereavement. • Once the stressor has terminated, the symptoms do not persist for more than an additional 6 months.

Adjustment Disorders
• 309.0 Adj Disorder with Depressed Mood
• 309.24 Adj Disorder with Anxiety • 309.28 with mixed anxiety and depression • 309.3 with disturbance in conduct • 309.4 with disturb of emotions and conduct

• 309.9 Adj Disorder unspecified

Posttraumatic Stress Disorder
• 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.

Personality Disorders & Effect on the Individual

Without Treatment Phobias

Elevated family violence
Drug use
Exacerbation of Existing Issues Inhibit Healing & Rehabilitation

Identifying Personality Disorders
1. Maladaptive behaviors 2. Pervasive

3. Pattern
4. Intensity

Definition of Personality Disorder

1. 2. 3. 4. 5. 6. 7.

It is pervasive and inflexible. It has an onset in adolescence or early adulthood. It is stable over time. It leads to distrust or impairment. Is thought to be an enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individual’s culture. Coping or defense mechanisms, which are used to deal with high levels of stress that have been left untreated. Coping with pain, loss of identity, mobility, and independence all may have profound effects on personality.

Mini Self-Test
1. What are the characteristics of a person that would warrant a personality disorder diagnosis? How would that effect my ability to provide treatment/therapy for the patient? How is this going to effect the patient’s quality of life. Results of careless diagnosis…. Video MC issues Debate…. What are pros and cons of diagnosing with PD?


3. 4. 5. 6.

What are Personality Disorders Like?
• Personality disorder symptoms stem from basic personality traits that developed over time. A person does not “get” a personality disorder. • 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, healthy relationships. • In some disorders, some have no desire to have social relationships or they want relationships, but are scared to reach out to people.

Personality Disorders & Emotion
• Some disorders involve restricted affect (schizoid, schizotypal) • Some disorders involve excess emotion (hystrionic) • And some disorders involve problems with emotion modulation (borderline)

Personality Disorders & Treatment
• 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. • A problem in treating individuals with personality disorders is that many do not believe they have a problem.

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.

Differentiation of Personality Disorder and Disorder
• Personality Disorder tends to be EgoSyntonic • Disorder tends to be EgoDystonic

Types of Personality Disorders

Cluster A: Odd or Eccentric 1. Paranoid Personality Disorder 2. Schizoid Personality Disorder 3. Schizotypal Personality Disorder

Paranoid PD
• Pervasive distrust and suspiciousness of others and interpret their motives as malevolent.

Schizoid PD
• Individuals with this disorder have a pervasive pattern of detachment from social relationships and a restricted range of expression of emotions in interpersonal settings.

Schizotypal PD
• Pervasive pattern of deficits marked by discomfort with, and reduced capacity for, close relationships, as well as cognitive or perceptual distortions and eccentricities of behavior.

Cluster B: Dramatic, Emotional, or Erratic

4. Antisocial Personality Disorder 5. Borderline Personality Disorder 6. Histrionic Personality Disorder 7. Narcissistic Personality Disorder

Antisocial PD
• At least 18 years of age, have evidence of Conduct Disorder occurring before age 15 years, and have a pervasive pattern of disregard for and violation of rights of others.

Borderline PD
• A pervasive pattern of instability in interpersonal relationships, self-images, affects, and control over impulses.
• Suicidal threats/attempts • Cutting behaviors

Histrionic PD
• A pervasive pattern of excessive emotionality and attention seeking.
• Somatic s/s common • May dress seductively or outrageously for attention.

Narcissistic PD
• Pervasive pattern of grandiosity (in fantasy or behavior, need for admiration, and lack of empathy.
• Self-centered • At the core are usually very insecure.

Cluster C: Anxious or Fearful
8. Avoidant Personality Disorder 9. Dependent Personality Disorder 10. Obsessive-Compulsive Personality Disorder

Personality Disorder NOS

Avoidant PD
• Pervasive pattern of social inhibition, feelings of inadequacy, and hypersensitivity to negative evaluation.

Dependent PD
• Pervasive and excessive need to be taken care of, leading to submissive and clinging behavior and fears of separation.

Obsessive-Compulsive PD
• Pervasive pattern of preoccupation with orderliness, perfectionism, and mental and interpersonal control, at the expense of flexibility, openness, and efficiency.
• Not like Axis I OCD because it does not include obsessions and compulsions.


Case Examples
• Patient who is verbally abusive and aggressive to staff and family. • Patient who is suspicious and questions your treatment methods. • Patient who wants to go have a cup of coffee with you and be your friend.

Case Examples
• Patient who is seductive and always seems dressed up and wearing lots of cologne when they come in for appointment. • Patient who denies that their SCI will bring about any changes in their lifestyle.

Psychological Factors Affecting Medical Condition
• A general medical condition
• Neurotransmitter Response to Stress • Endocrine Response to Stress • Immune Response to Stress

• Psychological factors adversely affecting the medical condition
• Disorder; Psych symptoms; Personality traits; Maladaptive health behaviors; Stress related physiological response; Other (cultural; religious)

Major Medical Issues
• • • • • • • • Gastrointestinal System Cardiovascular System Respiratory System Endocrine System Skin Disorders Musculoskeletal System Headaches Psycho-oncology

Conclusions on PD
• Individuals Diagnosed with Personality Disorders vs Individuals with exacerbated Stressors • Difficult to Treat, Difficult to Manage • How Does it Affect Your Treatment of the Patient

Disorders of Impulse