Personality Disorders Personality Disorders

Sean M. Blitzstein, M.D.

Learning Objectives
o Be able to recognize each of the 10 Personality Disorders when presented with a case
history
o Be able to predict how these patients commonly present in a primary care setting
o Be able to predict how these patients might commonly react to medical illnesses
o Be able to name a specific technique that may be employed by a physician to
successfully interact with a patient with each of the 10 Personality Disorders

Personality
o The totality of emotional and behavioral traits that characterize
the person in day-to-day living under ordinary conditions.
o Relatively stable and predictable.

Personality Disorders
o Deeply ingrained, inflexible, and maladaptive patterns of relating to and perceiving
both the environment and themselves.
o Influence cognition, affect, behavior and interpersonal style.
o Cause subjective distress or significant functional impairment.
o Symptoms are all plastic and ego-synchronic.
o 5-10% of the population.
o 60% of inpatient psychiatry patients.
o 12-100% of psychiatric outpatients with mood disorders.
o Having an understanding of personality disorders will improve the relationship,
enhance compliance, and reduce their stress.
o Axis II pathology affects the predisposition, presentation, course, and prognosis of Axis
I pathology.
o Genetic factors
o Temperamental factors
o Biological factors
o Psychodynamic factors: Internal object relations and Defense mechanisms.

Paranoid Personality Disorder

o 0.5-2.5% of the population.
o Men > Women.
o Higher incidence in relatives of schizophrenics.
o Higher among minorities, immigrants, and the deaf.
Paranoid Personality Disorder-Criteria
o Suspects, without sufficient basis, that others are exploiting, harming, or deceiving him
or her.
o Is preoccupied with unjustified doubts about the loyalty or trustworthiness of friends or
associates.
o Is reluctant to confide in others because of unwarranted fear that the information will be
used maliciously against him or her.
o Reads hidden demeaning or threatening meanings into benign remarks or events.

Paranoid Personality Disorder-Criteria

o Persistently bears grudges, i.e., is unforgiving of insults, injuries, or slights.
o Perceives attacks on his or her character or reputation that are not apparent to others
and is quick to react angrily or to counterattack.
o Has recurrent suspicions, without justification, regarding fidelity of spouse or sexual
partner.
o Does not occur exclusively during the course of a Psychotic Disorder and is not due to
a general medical condition.

Paranoid Personality Disorder-Interactions

o Acknowledge mistakes.
o Be open and honest.
o Have a professional and not overly warm style.
o Don confront.
o Set limits.
o Clearly explain procedures, medications and results.

Schizoid Personality Disorder

o 7.5% of the population.
o A 2-to-1 male-to-female ratio.

Schizorsoid Personality Disorder-Criteria

o Neither desires nor enjoys close relationships, including being part of a family.
o Almost always chooses solitary activities.
o Has little, if any, interest in having sexual experiences with another person.
o Takes pleasure in few, if any, activities.
o Lacks close friends or confidants other than first-degree relatives.

Schizoid Personality Disorder-Criteria

o Appears indifferent to the praise and criticism of others.
o Shows emotional coldness, detachment, or flattened affectivity.
o Does not occur exclusively during the course of a Psychotic Disorder, or a Pervasive
Developmental Disorder and is not due to a general medical condition.
Schizoid Personality Disorder-Interactions
o Understand their need for isolation.
o Minimize new contacts and intrusions.
o Maintain a quiet, reassuring, and considerate interest in them.
o Don insist on reciprocal responses.

Schizotypal Personality Disorder

o 3% of the population.
o Sex ratio is unknown.
o Greater association among biological relatives of schizophrenic patients.
o The premorbid personality of the schizophrenic patient.

Schizotypal Personality Disorder-Criteria

o Ideas of reference (excluding delusions of reference).
o Odd beliefs or magical thinking that influences behavior and is inconsistent with
subcultural norms (e.g., superstitiousness, belief in clairvoyance, telepathy, or sixth
sense?.
o Unusual perceptual experiences, including bodily illusions.
o Odd thinking and speech (e.g., vague, circumstantial, metaphorical, overelaborate, or
stereotyped).
o Suspiciousness or paranoid ideation.

Schizotypal Personality Disorder-Criteria

o Inappropriate or constricted affect.
o Behavior or appearance that is odd, eccentric. or peculiar.
o Lack of close friends or confidants other than first-degree relatives.
o Excessive social anxiety that does not diminish with familiarity and tends to be
associated with paranoid fears rather than negative judgments about self.
o Does not occur exclusively during the course of a Psychotic Disorder or a Pervasive
Developmental Disorder.

Schizotypal Personality Disorder-Interactions

o Similar to Schizoid PD.
o Misperceptions of physical symptoms and treatment.
o Do not ridicule or judge.
o Respect their need for privacy.

Antisocial Personality
DisorderDisorder
o 3% in men and 1% in women.
o Most common in poor urban areas.
o 75% in prison populations.
o Familial pattern present.
Antisocial Personality Disorder-Criteria
o Failure to conform to social norms with respect to lawful behaviors as indicated by
repeatedly performing acts that are grounds for arrest.
o Deceitfulness, as indicated by repeated lying, use of aliases, or conning others for
personal profit or pleasure.
o Impulsivity or failure to plan ahead.
o Irritability and aggressiveness, as indicated by repeated physical fights or assaults.
o Reckless disregard for safety of self or others.

Antisocial Personality Disorder-Criteria

o Consistent irresponsibility, as indicated by repeated failure to sustain consistent work
behavior or honor financial obligations.
o Lack of remorse, as indicated by being indifferent to or rationalizing having hurt,
mistreated, or stolen from another.
o The individual is at least age 18 years, and there is evidence of Conduct Disorder with
onset before age 15 years.
o The occurrence of antisocial behavior is not exclusively during the course of
Schizophrenia or
a Manic Episode.

Antisocial Personality Disorder-Interactions

o Set firm limits.
o Try not to be manipulated.
o Have high level of skepticism.
o Be careful not to prescribe excessive and/or unnecessary medications.

Borderline Personality Disorder

o 1-2% of the population.
o Twice as common in women as in men.
o Increased prevalence of Major Depressive Disorder, Alcohol Abuse/Dependence, and
Substance Abuse found in first-degree relatives.

Borderline Personality Disorder-Criteria

o Frantic efforts to avoid real or imagined abandonment.
o A pattern of unstable and intense interpersonal relationships characterized by
alternating between extremes of idealization and devaluation.
o Identity disturbance: markedly and persistently unstable self-image or sense of self.
o Impulsivity in at least two areas that are potentially self-damaging (e.g., spending, sex,
substance abuse, reckless driving, binge eating).
o Chronic feelings of emptiness.
Borderline Personality Disorder-Criteria
o Recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior.
o Affective instability due to a marked reactivity of mood (e.g., intense episodic
dysphoria, irritability,
or anxiety usually lasting a few hours and only rarely more than a few days).
o Inappropriate, intense anger or difficulty controlling anger (e.g., frequent displays of
temper, constant anger, recurrent physical fights).
o Transient, stress-related paranoid ideation or severe dissociative symptoms.

Borderline Personality Disorder-Interactions

o Be aware of and anticipate defenses.
o Often regress.
o Open and continuous communication with staff.
o Stable and calm reaction.
o Gently confront.
o Set fair and consistent limits on acting out.

Histrionic Personality Disorder

o 2-3%.
o Diagnosed more frequently in women than in men.
o Associated with Somatization Disorder and Alcohol abuse/Dependence.

Histrionic Personality Disorder-Criteria

o Is uncomfortable in situations in which he or she is not the center of attention.
o Interaction with others is often characterized by inappropriate sexually seductive or
provocative behavior.
o Displays rapidly shifting and shallow expression of emotions.
o Consistently uses physical appearance to draw attention to self.

Histrionic Personality Disorder-Criteria

o Has a style of speech that is excessively impressionistic and lacking in detail.
o Shows self-dramatization, theatricality, and exaggerated expression.
o Is suggestible, i.e., easily influenced by others or circumstances.
o Considers relationships to be more intimate that they actually are.

Histrionic Personality Disorder-Interactions

o Similar to Borderline PD.
o Medical illnesses threaten their sense of attractiveness and self-image.
Narcissistic Personality Disorder
o 2-16% in the clinical population.
o 1% in the general population.
o Number of cases increasing steadily.

Narcissistic Personality Disorder-Criteria

o Has a grandiose sense of self-importance (e.g., exaggerates achievements and talents,
expects to be recognized as superior without commensurate achievements).
o Is preoccupied with fantasies of unlimited success, power, brilliance, beauty, or ideal
love.
o Believes that he or she is special and unique and can only be understood by, or should
associate with, other special or high-status people (or institutions).
o Requires excessive admiration.

Narcissistic Personality Disorder-Criteria

o Has a sense of entitlement, i.e., unreasonable expectations of especially favorable
treatment or automatic compliance with his or her expectations.
o Is interpersonally exploitative, i.e., takes advantage of others to achieve his or her own
ends.
o Lacks empathy: is unwilling to recognize or identify with the feelings and needs of
others.
o Is often envious of others or believes that others are envious of him or her.
o Shows arrogant, haughty behavior or attitudes.

Narcissistic Personality Disorder-Interactions

o Handle criticism poorly.
o Become easily enraged.
o Medical illnesses can be a blow to their self-esteem.
o Reinforce that they are respected and appreciated.
o Set limits on demanding behavior.

Avoidant Personality Disorder

o 1-10% of the population.
o No information on sex ratio or familial pattern.
o Infants with a timid temperament may be more likely to develop Avoidant PD.
Avoidant Personality Disorder-Criteria
o Avoids occupational activities that involve significant interpersonal contact, because of
fears of criticism, disapproval, or rejection.
o Is unwilling to get involved with people unless certain of being liked.
o Shows restraint within intimate relationships because of the fear of being shamed or
ridiculed.

Avoidant Personality Disorder-Criteria

o Is preoccupied with being criticized or rejected in social situations.
o Is inhibited in new interpersonal situations because of feelings of inadequacy.
o Views self as socially inept, personally unappealing, or inferior to others.
o Is unusually reluctant to take personal risks or to engage in any new activities because
they may prove embarrassing.

Avoidant Personality Disorder-Interactions

o Have patience and understanding.
o Medical illnesses may be embarrassing.
o Minimize new and unfamiliar staff contacts.
o Respond with a calm and reassuring demeanor.
o Do not criticize them.

Dependent Personality Disorder

o Epidemiology is unknown.
o More common in women than men.
o Children with chronic physical illnesses may be more prone.

Dependent Personality Disorder-Criteria

o Has difficulty making everyday decisions without an excessive amount of advice and
reassurance from others.
o Needs others to assume responsibility for most major areas of his or her life.
o Has difficulty expressing disagreement with others because of fear of loss of support or
approval.
o 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).
Dependent Personality Disorder-Criteria
o Goes to excessive lengths to obtain nurturance and support from others, to the point of
volunteering to do things that are unpleasant.
o Feels uncomfortable or helpless when alone because of exaggerated fears of being
unable to care for himself or herself.
o Urgently seeks another relationship as a source of care and support when a close
relationship ends.
o Is unrealistically preoccupied with fears of being left to take care of himself or herself.

Dependent Personality Disorder-Interactions

o Respect their feelings of attachment.
o Be careful when encouraging a patient to change the dynamics of an abusive
relationship.
o When medically ill they may become frustrated that they are not being helped.
o Be active in the treatment planning.

Obsessive-Compulsive Personality Disorder

o Epidemiology unknown.
o More common in men than in women.
o Diagnosed more in oldest children.
o Often a history of harsh discipline as a child.

Obsessive-Compulsive PD-Criteria
o Is preoccupied with details, rules, lists, order, organization, or schedules to the extent
that the major point of the activity is lost.
o Shows perfectionism that interferes with task completion (e.g., is unable to complete a
project because his or her own overtly strict standards are not met).
o Is excessively devoted to work and productivity to the exclusion of leisure activities
and friendships.
o Is over conscientious, scrupulous, and inflexible about matters of morality, ethics, or
values.

Obsessive-Compulsive PD-Criteria
o Is unable to discard worn-out or worthless objects even when they have no sentimental
value.
o Is reluctant to delegate tasks or to work with others unless they submit to exactly his or
her way of doing things.
o Adopts a miserly spending style toward both self and others; money is viewed as
something to be hoarded for future catastrophes.
o Shows rigidity and stubbornness.
Obsessive-Compulsive PD-Interactions
o Give precise and rational explanations.
o Value efficiency and punctuality.
o Medical illnesses create a disruption in the patient work, orderly lifestyle, and sense
of control.
o Acknowledge the importance of work, but point out how avoiding treatment may have
harmful consequences.

Obsessive-Compulsive PD-Interactions
o Allow the patient to control his or her care as much as possible.
o Provide them with information.
o Avoid power struggles.
o Understand their need for order and control.

Personality Disorder Not Otherwise Specified

o Passive-Aggressive Personality Disorder.
o Depressive Personality Disorder.
o Specific traits or behaviors (sadism or masochism).
o Patient with features of more than one Personality Disorder.