Michelle Mathias, MA, MD, FRCPC April 3, 2013 B2B: Personality Disorders.
Transcript of Michelle Mathias, MA, MD, FRCPC April 3, 2013 B2B: Personality Disorders.
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Michelle Mathias, MA, MD, FRCPCApril 3, 2013
B2B: Personality Disorders
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Special thanks…
… to Dr. Deanna Mercer
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Objectives
General:Differentiate between PD and other mental illness, recognizing the high prevalence of co-morbidities
Formulate appropriate management plan
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Objectives
Specific:List & interpret critical clinical findings, inc:
Sufficient clinical info (e.g. MSE) to dx type of PDRisk factors associated with PDs (e.g. SI, substance)Any co-existing psych conditions (e.g. mood d/o)
Construct an effective initial management plan, inc:Proper management for pt needing immediate
intervention (e.g. suicide risk, risk to others)Judicious use of pharmacotherapy, with consideration
of risk for abuse or overdoseReferral for multi-disciplinary and/or specialized care,
if needed
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2-pass approach
Criteria/overview By objective/detailed
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B2B… PDs from the start
…definitions & diagnostic criteria!
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Definitions
Personality:Individual’s characteristic pattern of
response to his/her enviroIncludes: how one…
Thinks (cognitive)Feels (affective)Acts (behavioural)Relates to others (interpersonal)
Etiology: transactional modelTemperament (bio) + Environmental (social)
time
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Definitions (cont’d)
Personality Disorders:Clinically significant distress or impairment in
functioningEnduring pattern of inner experience and
behaviour that deviates markedly from expectations of individual’s culture
Impacts: 2 or more cognition, affectivity, interpersonal fxn & impulse control
Pattern:Inflexible & pervasive across broad range of personal and
social situationsNot better accounted for by other mental
disorder, GMC or substance
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Definitions (cont’d)
Personality Disorders:Ego-syntonic:
Individual experiences sig distress, but doesn’t feel their thoughts, emotions or behaviors are source of their problem
Locus of control: externalE.g. OCPD
VSEgo-dystonic:
Individual sees their disorder as arising from their own thoughts, emotions or behaviours
Locus of control: internalE.g. OCD
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Definitions (cont’d)
Personality Disorder Clusters: 3-4-3Cluster A: ODD
Schizoid, Schizotypal, ParanoidCluster B: Dramatic
Borderline, Histrionic, Narcissistic, Antisocial
Cluster C: AnxiousObsessive Compulsive, Dependent,
Avoidant
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Cluster A
Paranoid, Schizoid, Schizotypal
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Paranoid PDPervasive pattern of:
Distrust and suspiciousness of othersMotives of others are interpreted as
malevolent… beginning by early adulthood and present in various settings
Practically:Looks like delusional d/o (paranoid type),
butNo full blown delusionsMore pervasive suspiciousness
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Schizoid PDPervasive pattern of:
Detachment from social relationshipsRestricted range of expression of emotions in
interpersonal settings
… beginning by early adulthood and present in various settings
Practically:Mostly solitary activitiesFew friends other than first degreeCold & detachedLittle or no interest in relations; solitary lifestyleIndifferent to praise or criticism
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Schizotypal PDPervasive pattern of:
Social and interpersonal deficitsAcute discomfort with and reduced capacity for close
relationshipsCognitive or perceptual distortions or eccentricities
of behaviour… beginning by early adulthood and present in various settings
Practically:Eccentric behavioursOdd beliefs, unusual perceptions, suspiciousness,
paranoia, odd speechDiscomfort in close relationships - paranoia
(not b/c of fear of judgment)
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Flashback…
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Flashback…
Schizo ypal
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Flashback…
Schizo ypal
Devoid…Schizoid
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Cluster B
Antisocial, Borderline, Histrionic, Narcissistic
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Antisocial PDPervasive pattern of:
Disregard for and violation of rights of others… since age of 15 (must be at least 18yo)
Practically:Repeated lawbreakingDeceitfulnessImpulsivityIrritability and aggressivenessDisregard for safety of self or othersConsistent irresponsibilityLack of remorse
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Borderline PD
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Borderline PDPervasive pattern of:
Instability of interpersonal relationshipsInstability of self-image and affectsMarked impulsivity… beginning by early adulthood and present in various contexts
Practically:Efforts to self-harm or end lifeUnstable relationshipsMood lability
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Histrionic PDPervasive pattern of:
Excessive emotionalityAttention seeking… beginning by early adulthood and present in various settings
Practically:TheatricalIntense but shallow emotionsCraves being centre of
attention
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Narcissistic PDPervasive pattern of:
Grandiosity (in fantasy or behaviour)
Need for admirationLack of empathy… beginning by early adulthood and present in various contexts
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Cluster C
Avoidant, Dependent, Obsessive Compulsive
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Avoidant PD
Pervasive pattern ofSocial inhibitionFeelings of inadequacyHypersensitivity to negative evaluation
… beginning by early adult and present in various contexts
Practically:Similar to social phobia, but more
pervasive
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Dependent PDPervasive and excessive need to be taken care
of, leads to:Submissive and clinging behaviourFears of separation
… beginning by early adult and present in various contexts
Practically:Dependent on relationshipsDifficulty making everyday decisions without a lot of
advice, reassurance from othersUnable to disagree with others because fears loss of
supportWill do things that are unpleasant, degrading to
maintain support
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Obsessive Compulsive PDPervasive pattern of preoccupation with:
OrderlinessPerfectionismMental and interpersonal control
… at the expense of flexibility, openness and efficiency… beginning by early adult and present in various contexts
Practically:Controlling of others, inflexibleExcessively devoted to workReluctant to delegate tasksEmotionally constricted
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2-pass approach
Criteria/overview By objective/detailed
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Objectives
Specific:List & interpret critical clinical findings, inc:
Sufficient clinical info (e.g. MSE) to dx type of PDRisk factors associated with PDs (e.g. SI, substance)Any co-existing psych conditions (e.g. mood d/o)
Construct an effective initial management plan, inc:Proper management for pt needing immediate
intervention (e.g. suicide risk, risk to others)Judicious use of pharmacotherapy, with
consideration of risk for abuse or overdoseReferral for multi-disciplinary and/or specialized
care, if needed
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ObjectivesSpecific:
List & interpret critical clinical findings, inc:Criteria (done) & MSERisk factors associated with PDs (e.g. SI,
substance)Any co-existing psych conditions (e.g. mood d/o)
Construct an effective initial management plan, inc:Proper management for pt needing immediate
intervention (e.g. suicide risk, risk to others)Judicious use of pharmacotherapy, with
consideration of risk for abuse or overdoseReferral for multi-disciplinary and/or specialized
care, if needed
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ObjectivesSpecific:
List & interpret critical clinical findings, inc:MSERisk factors & prognosisAny co-existing psych conditions (e.g. mood d/o)
Construct an effective initial management plan, inc:Proper management for pt needing immediate
intervention (e.g. suicide risk, risk to others)Judicious use of pharmacotherapy, with
consideration of risk for abuse or overdoseReferral for multi-disciplinary and/or specialized
care, if needed
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ObjectivesSpecific:
List & interpret critical clinical findings, inc:MSERisk factors & prognosisComorbidities
Construct an effective initial management plan, inc:Proper management for pt needing immediate
intervention (e.g. suicide risk, risk to others)Judicious use of pharmacotherapy, with
consideration of risk for abuse or overdoseReferral for multi-disciplinary and/or specialized
care, if needed
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ObjectivesSpecific:
List & interpret critical clinical findings, inc:MSERisk factors & prognosisComorbidities
Construct an effective initial management plan, inc:Risk assessment & acute management (safety)Judicious use of pharmacotherapy, with
consideration of risk for abuse or overdoseReferral for multi-disciplinary and/or
specialized care, if needed
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ObjectivesSpecific:
List & interpret critical clinical findings, inc:MSERisk factors & prognosisComorbidities
Construct an effective initial management plan, inc:Risk assessment & acute management (safety)PharmacotherapyReferral for multi-disciplinary and/or
specialized care, if needed
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ObjectivesSpecific:
List & interpret critical clinical findings, inc:MSERisk factors & prognosisComorbidities
Construct an effective initial management plan, inc:Risk assessment & acute management
(safety)PharmacotherapyNon-pharm treatment
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Objectives
List & interpret critical clinical findings, inc:MSERisk factors & prognosisComorbidities
Construct an effective initial management plan, inc:Risk assessment & acute management
(safety)PharmacotherapyNon-pharm treatment
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General Word on Tx approach
Bio Psycho SocialAcute – safety(self & others)
Short-term(stabilizati
on)
Long-term (maintenan
ce)
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Cluster A
Paranoid, Schizoid, Schizotypal
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Paranoid PD(refresher… which one is this?)
MSE: evasive, minimal answers, suspicious,
paranoid thought content, serious, humourless affectively restricted, lack warmth
Risk factors & prognosis:Relatives often have SchizophreniaLifelong problem working & living with others
Comorbidities:Other cluster A PDs, mood disorder, substance
use, agoraphobia, OCD
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Paranoid PD(refresher… which one is this?)
Risk assessment & acute management (safety):Suicide attempters in ER: 9% with PPD
Pharmacotherapy:Antidepressants as indicatedLow dose antipsychotic for brief psychotic
episodes (increased stress)Non-pharm treatment:
Rarely seek help – insufficient trust to engage in process
CBT – address core beliefsGroup therapy – tend not to tolerate
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Schizoid PD(refresher… which one is this?)
MSE:Cold, constricted, aloof, difficulty gaining rapport, odd
metaphors, ill at ease, difficulty tolerating eye contact
Risk factors & prognosis:Parents – cold, neglectful, suggest
relationships not worth pursuingIntroversion Possible family link – schizophreniaChildhood onset, likely stable course
Comorbidities:other cluster A PDs, mood d/o, anxiety d/o
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Schizoid PD(refresher… which one is this?)
Risk assessment & acute management (safety):Low insight, low motivation… not usually self-
directed for txSuicide attempters in ER: 4%
Pharmacotherapy:Low-dose antipsychotic, antidepressants
Non-pharm treatment:PsychoeducationTherapeutic distance needed for pt to tolerate
relationshipSocial skills training
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Schizotypal PD(refresher… which one is this?)
MSE:Superstitious, difficulty identifying own feelings,
odd mannerisms and interests, prone to minimal responses (use open-ended questions), peculiar speech, appear unusual
Risk factors & prognosis:10% commit suicide; pre-morbid personality of
schizophrenia (or milder version of); 10-20% develop schizophrenia
14% have schizophrenia in familyComorbidities:
Other cluster A PDs, depression, possible Borderline PD traits (poor interpersonal relationships)
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Schizotypal PD(refresher… which one is this?)
Risk assessment & acute management (safety):SI assessment; intensity of delusion-like beliefs
Pharmacotherapy:Treat comorbiditiesMild-mod improvement with low-dose
antipsychoticsNon-pharm treatment:
Supportive psychotherapySocial skills trainingEncourage activity, but does not have to be
social
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Cluster B
Antisocial, Borderline, Histrionic, Narcissistic
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Antisocial PD(refresher… which one is this?)
MSE:Try to impress MD, good verbal intelligence; possibly
demandingAppear composed & credible (underneath = tension,
hostility… may need to push to discover)
Risk factors & prognosis:Px better if connected to some groupDecrease impulsivity & criminal behaviour, but continue
to be difficult people++ substance risk; ++ legal involvement
Comorbidities: Substance use disorders; other cluster B PDs, impulse
control disorders, ADHD
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Antisocial PD(refresher… which one is this?)
Risk assessment & acute management (safety):Harm to others!! Legal risk
Pharmacotherapy:Mood stabilizers for impulsivityStimulants for ADHDTx comorbid depression, anxiety
Non-pharm treatment:Firm limitsRational Emotive Therapy (CBT alternative)PsychoeducationProbation officers
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Borderline PD(refresher… which one is this?)
MSE:Manipulation, splitting, inconsistencies, avoiding,
deflecting, dramatic, poor problem solving, insight varies, poor judgment, thought process can vary and be significantly impaired in great distress
Risk factors & prognosis:Abusive upbringing, substance use disordersCan decrease over time, but less so than other PDs
Comorbidities:Other cluster B PDs, somatization disordersMood disorders (BPD vs Bipolar), anxiety disorders
(social anxiety)Brief psychotic episodesSubstance use disorders
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Borderline PD(refresher… which one is this?)
Risk assessment & acute management (safety):SAFETY!!! Self-harm, suicide attempts, aggressive acts
towards othersHospitalization if needed… try to avoidDBT support; ACT teams
Pharmacotherapy:Avoid TCAs (lethal in OD); SSRIs; mood stabilizersAntipsychotics for psychotic sx (derealization)
Non-pharm treatment:DBT (modified CBT); individual + groupPsychoeducation… give them the diagnosis!Psycho-analytic – NOT appropriateSocial skills trainingFamily & couples therapy
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Histrionic PD(refresher… which one is this?)
MSE:Dramatic, temper tantrums, superficial (nil
when go deeper), dramatic appearance (often sexual, esp clothing), eye contact varies
Risk factors & prognosis:As age, sx decreaseHistory of sexual abuseSubstance use
Comorbidities:Other cluster B PDs, brief psychotic episodes,
somatization, DID
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Histrionic PD(refresher… which one is this?)
Risk assessment & acute management (safety):Substance useSuicide attempts and ideationHeteroagressive ideation (“heat of passion”)
Pharmacotherapy:Treat comorbidities: antidepressants (depression,
anxiety, somatic complaints)Anti-psychotics: for derealization & illusions
Non-pharm treatment:Psychoanalysis is idealInsight-orientedPsychoeducationFamily & couples therapy
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Narcissistic PD(refresher… which one is this?)
MSE:Want their own way, no empathy, fake
sympathy, superficial rapport; vague answers or avoiding
Risk factors & prognosis:Substance useUpbringing with limited support and warmth
Comorbidities:Substance use, mood disorders, anxiety
disordersOther Cluster B PDs, sexual disorders
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Narcissistic PD(refresher… which one is this?)
Risk assessment & acute management (safety):Rejection, loss, occupational problems, interpersonal
problemsSubstance use
Pharmacotherapy:AntidepressantsTreat comorbidities (substance use disorders treatment)
Non-pharm treatment:Insight-oriented therapyProbation officersFamily & couples therapySocial skills training – learn how to develop empathic
response for others
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Cluster C
Avoidant, Dependent, Obsessive Compulsive
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Avoidant PD(refresher… which one is this?)
MSE:Timid, lack self-confidence, afraid to speak, ++
anxiety during interview, hypersensitive to disapproval or rejection
Do not express wishes, opinions, needsRisk factors & prognosis:
Genetic link with social phobiaParents – inconsistent, absent, abusive,
discouragingComorbidities:
Anxiety d/o (social phobia - generalized, agoraphobia)
Depression, dysthymia
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Avoidant PD(refresher… which one is this?)
Risk assessment & acute management (safety):Risk comes from associated anxiety and
depressionRisk of substance use – to cope with anxiety
Pharmacotherapy:Treat comorbidities: anti-depressantBeta adrenergic receptor antagonists (Atenolol):
decrease autonomic arousalNon-pharm treatment:
Assertiveness & social skillsCBT – core beliefsMindfulness
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Dependent PD(refresher… which one is this?)
MSE:Submissiveness; rapport is easy, but deeper exploration
is difficult; easy to interview… want you to like them… watch for boundary violations
Lack of self-confidence, pessimistic, helpless, childlike, ++ anxiety
Risk factors & prognosis:Pts with chronic physical illnessesCan’t fxn independently; limited social relationsSuicide risk: termination of Dependent relationship -
Comorbidities:Mood disorders (MDD, adjustment d/o), anxiety
disorders (social phobia, agoraphobia)BPD, histrionic PD, avoidant PD
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Dependent PD(refresher… which one is this?)
Risk assessment & acute management (safety):Suicide risk, safetyIsolation
Pharmacotherapy:Treat comorbidities: anti-depressants
Non-pharm treatment:Psychodynamic approachCBTSocial skills trainingFamily/ couples therapy
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OCPD(refresher… which one is this?)
MSE:Stiff, formal, rigid demeanor, lack spontaneity; stickler for
rulesDetailed answers; constricted affect; eager to please (esp
MD)Routine disturbed = anxiety; indecisive (fear of making
mistake)
Risk factors & prognosis:Parental control, perfectionism, shame, criticismPressures can lead to mood & anxiety d/o… suicide concern
Comorbidities:Other anxiety disorders Depressive disorders, dysthymiaVs OCPD (egodystonic): 30% OCPD have OCD (not same in
reverse)NPD, Schizoid, somatoform d/o
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OCPD(refresher… which one is this?)
Risk assessment & acute management (safety):Status of mood and anxietySubstance use – less prevalent (against rules; makes
more anxious)
Pharmacotherapy:AntidepressantsBenzos… bad for anxiety disorders; some use short-
term
Non-pharm treatment:CBT… careful for the perfect homework!PsychoeducationFamily & couples therapy
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Resources
“Brain Calipers”“Field Guide to Disordered
Personalities”
(David Robinson, Rapid Psychler Press)