Personality Disorders Michael McCloskey, Ph.D. Assistant Professor Clinical Neuroscience &...

Personality Disorders

Michael McCloskey, Ph.D.Assistant Professor

Clinical Neuroscience & Psychopharmacology Research Unit

The University of Chicago

What is a Personality Disorder?

A.A. A pattern of inner experience & A pattern of inner experience & behaviour that deviates markedly from behaviour that deviates markedly from expectations of the individual’s culture expectations of the individual’s culture in 2 or more of the following areas…in 2 or more of the following areas…

-cognition-cognition

-affect-affect

-interpersonal functioning-interpersonal functioning

-impulse control-impulse control

DSM-IV Personality Disorder General Criteria

DSM-IV Personality DisordersGeneral Criteria

B.B. The pattern is The pattern is inflexibleinflexible and and pervasivepervasive across across a broad range of personal and social a broad range of personal and social situations.situations.

C.C. Clinically significant distress or impairment Clinically significant distress or impairment (occupational, social).(occupational, social).

D.D. The pattern is stable and of long duration and The pattern is stable and of long duration and its onset can be traced back at least to its onset can be traced back at least to adolescence or early adulthood.adolescence or early adulthood.

Personality Disorders: Facts and Statistics

Prevalence of Personality DisordersPrevalence of Personality DisordersAbout 10% of the general populationAbout 10% of the general populationRates are higher in inpatient and outpatient Rates are higher in inpatient and outpatient

settingssettingsOrigins and Course of Personality Origins and Course of Personality

DisordersDisordersThought to begin in childhoodThought to begin in childhoodRun a chronic courseRun a chronic courseComorbidity rates are high Comorbidity rates are high

Specific DSM-IV Personality Disorders

A.A. Odd/EccentricOdd/EccentricA.A. SchizoidSchizoid

B.B. SchizotypalSchizotypal

C.C. ParanoidParanoid

B.B. Dramatic, Emotional, or ErraticDramatic, Emotional, or ErraticA.A. BorderlineBorderline

B.B. NarcissisticNarcissistic

C.C. AntisocialAntisocial

D.D. HistrionicHistrionic

C.C. Anxious or FearfulAnxious or FearfulA.A. AvoidantAvoidant

B.B. Obsessive-compulsiveObsessive-compulsive

C.C. DependentDependent

Cluster A: Odd or Eccentric Personality Disorders

1.1. Paranoid:Paranoid: Is characterized by a Is characterized by a pervasive tendency to be inappropriately pervasive tendency to be inappropriately suspicious of other people’s motives and suspicious of other people’s motives and behaviors. behaviors.

Mnemonic for Paranoid PD (4/7)

S - Spouse infidelity suspected S - Spouse infidelity suspected U - unforgiving (bears grudges) U - unforgiving (bears grudges) S - suspicious (of others) S - suspicious (of others) P - perceives attacks (and reacts quickly) P - perceives attacks (and reacts quickly) E - enemy in everyone - suspects associates, friends E - enemy in everyone - suspects associates, friends C - confiding in others feared C - confiding in others feared T - threats seen in very benign events T - threats seen in very benign events

Pinkofsky HB. Mnemonics for DSM-IV personality disorders. Psychiatr Serv. 1997 Sep;48(9):1197-8.

Paranoid PD Description SELF-VIEWSELF-VIEW: :

VulnerableVulnerable VIEW OF OTHERSVIEW OF OTHERS: :

AdversariesAdversaries BELIEFSBELIEFS: :

CoreCore beliefs: The world is threatening and I must protect myself beliefs: The world is threatening and I must protect myself I can only rely on myself, no one elseI can only rely on myself, no one else

THREATTHREAT: : EVERYONE!!!!!EVERYONE!!!!!

STRATEGYSTRATEGY: : Don’t trust anyone, social isolationDon’t trust anyone, social isolation

AFFECTAFFECT: : Hostile, anxious, dysphoricHostile, anxious, dysphoric

Paranoid PD

Associated Features:During high stress transient psychotic

symptoms may occur (Do not warrant additional diagnosis)

Predispose to Delusional Disorder and Schizophrenia, Paranoid Type

Substance Abuse, Depression common


2.2. Schizoid:Schizoid: A pattern of detachment from social A pattern of detachment from social relationships and a restricted range of affect.relationships and a restricted range of affect.

Mnemonic for Schizoid PD (4/7) D – Detached affectD – Detached affect I – Indifferent to praise or criticism I – Indifferent to praise or criticism S – Sexually uninterested S – Sexually uninterested T – Tasks done solitarily T – Tasks done solitarily A – Absence of close friends A – Absence of close friends N – Neither desire nor enjoys close relationship N – Neither desire nor enjoys close relationship T – Takes pleasure in few activities T – Takes pleasure in few activities

Schizoid PD Description

SELF-VIEWSELF-VIEW: : Different, EmptyDifferent, Empty

VIEW OF OTHERSVIEW OF OTHERS: : More trouble than worth, impediment to freedomMore trouble than worth, impediment to freedom

BELIEFSBELIEFS: : CoreCore beliefs are beliefs are ""Relationships are problematicRelationships are problematic ," "," "Life is Life is

less complicated without other peopleless complicated without other people ”” I need plenty of spaceI need plenty of space

THREATTHREAT: : Compliance, complications Compliance, complications

STRATEGYSTRATEGY: : IsoloationIsoloation

AFFECTAFFECT: : Flat (not to be confused with depressed)Flat (not to be confused with depressed)


3. Schizotypal: A pattern of acute discomfort in close relationships, cognitive or perceptual distortions, and eccentricities of behavior..

Mnemonic for Schizotypal PD (5/9)

M - magical thinking M - magical thinking E - eccentric behavior or appearanceE - eccentric behavior or appearance P - paranoid ideation P - paranoid ideation E - experiences unusual perceptions E - experiences unusual perceptions C - constricted (or inappropriate) affect C - constricted (or inappropriate) affect U - unusual thinking & speech U - unusual thinking & speech L - lacks friends L - lacks friends I - ideas of reference I - ideas of reference A - anxiety (socially) A - anxiety (socially) (R) - rule out psychosis & PDD (R) - rule out psychosis & PDD

Schizotypal PD Description SELF-VIEWSELF-VIEW: :

Outsider, defectiveOutsider, defective VIEW OF OTHERSVIEW OF OTHERS: :

Strange, scary, yet desire for social contactStrange, scary, yet desire for social contact BELIEFSBELIEFS: :

CoreCore beliefs: “I do not fit in”, “I must protect myself from beliefs: “I do not fit in”, “I must protect myself from threats”threats”

There are reasons for everything. Things don't happen by There are reasons for everything. Things don't happen by chancechance

THREATTHREAT: : World (don’t understand)World (don’t understand)

STRATEGYSTRATEGY: : Social isolationSocial isolation Retreat into delusional ideasRetreat into delusional ideas

AFFECTAFFECT: : Anxiety, DepressionAnxiety, Depression

Schizotypal PD

Associated Features:: Interpersonal relatedness impaired w/rare Interpersonal relatedness impaired w/rare

reciprocation of the expressions or gestures reciprocation of the expressions or gestures of othersof others

Few close friendsFew close friendsFeatures of Borderline Personality are often Features of Borderline Personality are often

present and may justify both diagnosespresent and may justify both diagnosesHistory of MDD common (> 50%)History of MDD common (> 50%)

Cluster B: Dramatic, Emotional, or Erratic Personality Disorders

1.1. Antisocial: Antisocial: A pattern of disregard for, A pattern of disregard for, and violation of, the rights of others.and violation of, the rights of others.

Mnemonic for Antisocial PD (3/7)

C - cannot follow law C - cannot follow law O - obligations ignored O - obligations ignored R - remorselessness R - remorselessness R – reckless disregard for safety R – reckless disregard for safety U – underhanded (deceitful) U – underhanded (deceitful) P - planning deficit (impulsive) P - planning deficit (impulsive) T - temper (irritable, aggressive)T - temper (irritable, aggressive) + Childhood conduct disorder+ Childhood conduct disorder

Antisocial PD Description

SELF-VIEWSELF-VIEW: : Superior, unconcernedSuperior, unconcerned

VIEW OF OTHERSVIEW OF OTHERS: : Suckers, inferior, means to an endSuckers, inferior, means to an end

BELIEFSBELIEFS: : CoreCore beliefs are “People are there to be taken," " beliefs are “People are there to be taken," "If I want something, I If I want something, I

should do whatever is necessary to get itshould do whatever is necessary to get it ”” If people can't take care of themselves, that's their problemIf people can't take care of themselves, that's their problem I can get away with things so I don't need to worry about bad I can get away with things so I don't need to worry about bad

consequencesconsequences THREATTHREAT: :

??? ??? STRATEGYSTRATEGY: :

Take what you want.Take what you want. AFFECTAFFECT: :

Irritability, anger when blocked from goals.Irritability, anger when blocked from goals.

Antisocial PD

Associated Features:Diminishes in midlifeDiminishes in midlifeSubstance abuse and early sex experiences Substance abuse and early sex experiences High levels of criminalityHigh levels of criminality


2.2. Borderline:Borderline: A pattern of instability in, A pattern of instability in, self-image, interpersonal relationships, self-image, interpersonal relationships, and affect, and marked impulsivity.and affect, and marked impulsivity.

Mnemonic for Borderline PD (5/9)

A - Abandonment fearsA - Abandonment fears M - Mood instabilityM - Mood instability S - Suicidal / self-injurious behavior S - Suicidal / self-injurious behavior U - Unstable, intense relationshipsU - Unstable, intense relationships I - Impulsivity I - Impulsivity C - Control of anger poor C - Control of anger poor I - Identity disturbanceI - Identity disturbance D - Dissociative / paranoid symptomsD - Dissociative / paranoid symptoms E - Emptiness E - Emptiness

Borderline PD Description

SELF-VIEWSELF-VIEW: : Unstable and fragmented, helpless, victimsUnstable and fragmented, helpless, victims

VIEW OF OTHERSVIEW OF OTHERS: : The cause of and answer to all life’s problemsThe cause of and answer to all life’s problems

BELIEFSBELIEFS: : CoreCore beliefs are “I am unlovable," " beliefs are “I am unlovable," "No one is ever there to meet No one is ever there to meet

my needs, to be strong for me, to care for memy needs, to be strong for me, to care for me ”” I can't cope on my own. I need someone to rely onI can't cope on my own. I need someone to rely on

THREATTHREAT: : AbandonmentAbandonment

STRATEGYSTRATEGY: : Demand love, test loveDemand love, test love

AFFECTAFFECT: : Anger, Depression, AnxietyAnger, Depression, Anxiety

Borderline PD

Associated Features: Up to 10% of persons with BPD eventually

die by their own handHigh co-morbidity with Mood DisordersMarked mood shifts, unpredictableUndermining one’s own successsome symptoms may improve by midlifeOver 50% report childhood maltreatment


3.3. Histrionic:Histrionic: A pattern of excessive A pattern of excessive emotionality and attention seeking.emotionality and attention seeking.

Mnemonic for Histrionic PD (5/8)

P - provocative (or seductive) behavior P - provocative (or seductive) behavior R - relationships, considered more intimate than they are R - relationships, considered more intimate than they are A - attention, must be at center of A - attention, must be at center of I - influenced easily I - influenced easily S - speech (style) - wants to impress, lacks detail S - speech (style) - wants to impress, lacks detail E - emotional lability, shallowness E - emotional lability, shallowness

M - made-up (physical appearance get attention) M - made-up (physical appearance get attention) E - exaggerated emotions (theatrical)E - exaggerated emotions (theatrical)

Histrionic PD Description

SELF-VIEWSELF-VIEW: : ??????

VIEW OF OTHERSVIEW OF OTHERS: : Objects to be won overObjects to be won over

BELIEFSBELIEFS: : CoreCore beliefs are “ beliefs are “In order to be happy I need other people to pay In order to be happy I need other people to pay

attention to meattention to me ," "," "Unless I entertain or impress people, I am Unless I entertain or impress people, I am nothingnothing ””

It is awful for people to ignore meIt is awful for people to ignore me THREATTHREAT: :

Being ignored, forgottenBeing ignored, forgotten STRATEGYSTRATEGY: :

Entertain, draw attention to selfEntertain, draw attention to self AFFECTAFFECT: :

Anxiety, depression when ignoredAnxiety, depression when ignored

Histrionic PD

Associated Features: Attempts to control other persons while

establishing dependent relationshipOften overly trustingComorbidity with somatization


4. 4. Narcissistic:Narcissistic: A pattern of grandiosity, need A pattern of grandiosity, need for admiration, and lack of empathy.for admiration, and lack of empathy.

Mnemonic for Narcissistic PD (5/9)

S – Special (believes they are) S – Special (believes they are) P – Preoccupied with fantasies of success, etc P – Preoccupied with fantasies of success, etc EE33 – Envious (of others), Entitled, Excessive admiration – Envious (of others), Entitled, Excessive admiration

needed needed C -- Conceited C -- Conceited I -- Interpersonally ExploitiveI -- Interpersonally Exploitive A -- Arrogant A -- Arrogant L -- Lacks EmpathyL -- Lacks Empathy

Narcissistic PD Description

SELF-VIEWSELF-VIEW: : Superior, specialSuperior, special

VIEW OF OTHERSVIEW OF OTHERS: : ““less equal”, servants, threatless equal”, servants, threat

BELIEFSBELIEFS: : CoreCore beliefs are “I am special and o beliefs are “I am special and other people should recognize ther people should recognize

how special I amhow special I am," "," "No one's needs should interfere with my No one's needs should interfere with my ownown ””

It's intolerable if I'm not accorded my due respect or don't get It's intolerable if I'm not accorded my due respect or don't get what I'm entitled towhat I'm entitled to

THREATTHREAT: : Being average (narcissistic facade?)Being average (narcissistic facade?)

STRATEGYSTRATEGY: : Demand special treatment, begrudge othersDemand special treatment, begrudge others

AFFECTAFFECT: : AngerAnger

Narcissistic PD

Associated Features: May attain significant achievement, but they

rarely accept them as “enough” or derive pleasure from them

Self-esteem, outwardly high, is actually quite fragile with a need for constant attention and admiration

Other PD are often commonAdjustment Disorders are common

Cluster C: Anxious or Fearful Personality Disorders

1. Avoidant: A pattern of social inhibition, feelings of inadequacy, and hypersensitivity to negative evaluation.

APD Mnemonic (4/7)

A – Avoids occupational activities V – Views self as socially inept O – Occupied with being criticized or rejected I – Inhibited in new interpersonal situations D – Declines to get involved with people E – Embarrassed by engaging in new activities R – Refrains from intimate relationships

Avoidant PD Description SELF-VIEWSELF-VIEW: :

Socially inept and incompetent in academic and/or work situations Socially inept and incompetent in academic and/or work situations VIEW OF OTHERSVIEW OF OTHERS: :

Potentially critical, uninterested, and demeaningPotentially critical, uninterested, and demeaning BELIEFSBELIEFS: :

CoreCore beliefs: I am no good...worthless...unlovable. I cannot tolerate beliefs: I am no good...worthless...unlovable. I cannot tolerate unpleasant feelings unpleasant feelings

If people got close, they would discover the 'real me' and reject me--that If people got close, they would discover the 'real me' and reject me--that would be intolerable . It is best to stay clear of risky involvement would be intolerable . It is best to stay clear of risky involvement

THREATTHREAT: : Rejection, demeaned, humiliation, “found out”Rejection, demeaned, humiliation, “found out”

STRATEGYSTRATEGY: : Avoid, Avoid, AvoidAvoid, Avoid, Avoid

AFFECTAFFECT: : Dysphoria – anxiety and sadnessDysphoria – anxiety and sadness

Avoidant PD

Associated Features:

PhobiasDepressionAnxiety


2. 2. Dependent:Dependent: A pattern of submissive and A pattern of submissive and clinging behavior related to an excessive clinging behavior related to an excessive need to be taken care of.need to be taken care of.

DPD Mnemonic (5/8) DD – Difficulty making everyday decisions – Difficulty making everyday decisions EE – Excessive lengths to obtain nurturance and support from others – Excessive lengths to obtain nurturance and support from others PP – Preoccupied with fears of being left to take care of self – Preoccupied with fears of being left to take care of self EE – Exaggerated fears of being unable to care for himself or herself – Exaggerated fears of being unable to care for himself or herself NN – Needs others to assume responsibility for his or her life – Needs others to assume responsibility for his or her life DD – Difficulty expressing disagreement with others – Difficulty expressing disagreement with others EE – End of a close relationship = beginning of another relationship – End of a close relationship = beginning of another relationship NN – Noticeable difficulties in initiating / doing things their own – Noticeable difficulties in initiating / doing things their own

(T)(T) – “Take care of me” is his or her motto – “Take care of me” is his or her motto

Dependent PD Description SELF-VIEWSELF-VIEW: :

Needy, weak, helpless and incompetent Needy, weak, helpless and incompetent VIEW OF OTHERSVIEW OF OTHERS: :

Caretakers, protectors, super-competentCaretakers, protectors, super-competent BELIEFSBELIEFS: :

CoreCore beliefs: I am helpless, I am all alone in the world beliefs: I am helpless, I am all alone in the world I need other people--specifically, a strong person--in order to survive I need other people--specifically, a strong person--in order to survive If I am not loved I cannot be happyIf I am not loved I cannot be happy

THREATTHREAT: : Rejection, abandonmentRejection, abandonment

STRATEGYSTRATEGY: : Cultivate relationship, subjugate own needs for “security”Cultivate relationship, subjugate own needs for “security”

AFFECTAFFECT: : Anxiety (relations strained), Depression (relation over), Euphoria Anxiety (relations strained), Depression (relation over), Euphoria

(relationship good)(relationship good)


3. 3. Obsessive-Compulsive:Obsessive-Compulsive: A pattern of A pattern of preoccupation with orderliness, preoccupation with orderliness, perfectionism, and control.perfectionism, and control.

OCPD Mnemonic (4/8) LL – Loses point of activity (preoccupation with detail) – Loses point of activity (preoccupation with detail) AA – Ability to complete tasks comprimized (perfectionism) – Ability to complete tasks comprimized (perfectionism) WW – Worthless objects (unable to discard) – Worthless objects (unable to discard)

FF – Friendships excluded (preoccupation with work) – Friendships excluded (preoccupation with work) II – Inflexible, overconscientious – Inflexible, overconscientious RR – Reluctant to delegate – Reluctant to delegate MM – Miserly (toward self and others) – Miserly (toward self and others) SS – Stubbornness (and rigidity) – Stubbornness (and rigidity)

Obsessive Compulsive PD Description

SELF-VIEWSELF-VIEW: : Responsible for themselves and others . Often core image of selves as Responsible for themselves and others . Often core image of selves as

inept / helplessinept / helpless VIEW OF OTHERSVIEW OF OTHERS: :

Too casual, often irresponsible, self-indulgent, or incompetentToo casual, often irresponsible, self-indulgent, or incompetent BELIEFSBELIEFS: :

CoreCore beliefs are "I could be overwhelmed," "I am basically disorganized beliefs are "I could be overwhelmed," "I am basically disorganized or disoriented”or disoriented”

If I don't have systems, everything will fall apart If I don't have systems, everything will fall apart If I fail in this, I am a failure as a personIf I fail in this, I am a failure as a person

THREATTHREAT: : Flaws, mistakes, disorganization, or imperfections –loss of controlFlaws, mistakes, disorganization, or imperfections –loss of control

STRATEGYSTRATEGY: : Be perfect, control everything.Be perfect, control everything.

AFFECTAFFECT: : Anxiety, irritability – and depression when “failure” occursAnxiety, irritability – and depression when “failure” occurs

Obsessive-Compulsive PD

Associated Features and Disorders:

Difficulty expressing tender feelingsDepressionType A -increased incidence of myocardial

infarction

Why is it important to assess for Personality Disorders?

Consequences of under-diagnosisConsequences of over-diagnosis

Consequences of under-diagnosis

Prevalence of PD = 10% + 2% PD Associated with

Increased suicide riskIncreased violence/criminality riskIncreased social /occupational difficultiesPoorer response to treatment for Axis I

disorders

Consequences of over-diagnosis

STIGMA, STIGMA, STIGMA Permanent RecordInfluences future diagnosesInfluences how mental health provider

interacts with patient

Personality Disorders Michael McCloskey, Ph.D. Assistant Professor Clinical Neuroscience &...

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