Personality Disorders Deanna Mercer MD FRCPC MSII Jan 2016 Schedule 1.Describe personality disorders: criteria, clusters and core symptoms 2.Understanding self injurious behaviour 3.Borderline Personality Disorder: diagnosis and treatment Objectives I 5296 Describe the general diagnostic criteria for a PD State the classification of PD in 3 clusters Describe the main enduring pattern of each PD type Describe the mental disorders associated with selfinjurious behaviours (SIB) 5301 List the biological, demographic, economic, social and developmental factors associated with SIB. Objectives II 5302 Describe the pertinent factors in the recognition of the potential of SIB List criteria for borderline personality disorder (BPD) Describe common psychiatric comorbidities associated with BPD Describe a treatment approach to BPD including use of hospitalization, outpatient care, pharmacological treatment and psychotherapy PERSONALITY? Definition of Personality Personality represents a complex set of attributes that mediate how each human being experiences his or her self and subsequently understands and interacts with the external world, especially the social world. Oldham, Skodol, Bender 2014 Personality NEO PI Neuroticism Extraversion Openness Agreeableness Conscientiousness NEO PI Neuroticism Extraversion Openness Agreeableness Conscientiousness Neuroticism: how prone an individual is to experiencing psychological distress Anxiety, angry hostility, depression, self consciousness, impulsiveness Extraversion: quantity, intensity of energy directed into the social world Warmth, Gregariousness, Assertiveness, Activity, Excitement Seeking, Positive Emotions Openness to Experience: active seeking and appreciation of experiences for their own sake Fantasy, Aesthetics, Feelings, Actions, Ideas, Values Agreeableness: the kinds of interactions an individual prefers from compassion to tough mindedness Trust, straightforwardness, altruism, compliance, modesty, tender mindedness Conscientiousness: degree of organization, persistence, control and motivation in goal directed behaviour Competence, order, dutifulness, achievement striving, self discipline, deliberation NEO-PI 5296 Describe the general diagnostic criteria for a PD Personality Disorder? Categorical Present or absent, like pregnancy DSM IV, DSM5 Section II Dimensional PD exists at the extreme of a dimension, ie extreme extroversion Like height Trait models DSM5 Section III Personality Disorder DSM 5 Section II A. Enduring pattern of inner experience and behaviour that deviates markedly from the expectations of the individuals culture. Manifested in two or more of the following: cognition, affectivity, interpersonal functioning, impulse control Cluster A: Schizoid, Schizotypal, Paranoid Cluster B: Histrionic, Narcissistic, Borderline, Antisocial Cluster C: Avoidant, Dependent, Obsessive Compulsive Personality change due to another medical condition Other/unspecified personality disorder DSM 5 Section III A.Moderate greater impairment in personality functioning (LPFS) B.One or more pathological personality traits Antisocial Borderline Schizotypal Avoidant Obsessive Compulsive Narcissistic OR PID5 Negative Affectivity Detachment Antagonism Disinhibition Psychoticism DSM 5 Section II General Criteria and criteria for one of 10 PDs #criteria required ParanoidPPD4/7 SchizoidSPD4/7 SchizotypalSTPD5/9 AntisocialASPD3/7 BorderlineBPD5/9 HistrionicHPD5/8 NarcissisticNPD5/9 AvoidantAPD4/7 DependentDPD5/8 Obsessive compulsiveOCPD4/8 Personality change due to another medical condition Other/Un specified Personality Disorder LPFS Moderate impairment in minimum of 2 of 4 areas Self Identity : sees self as unique; stability of self esteem, accuracy of self appraisal; experience and regulate emotions Self direction : Ability to set and pursue goals; prosocial internal standards of behaviours; can self reflect productively Interpersonal Empathy : understands others experiences and motivation; able to tolerate differing perspectives; understands effect of own behaviour on others Intimacy : Depth, duration, connection with others; desire and has capacity for closeness; behaviour reflects mutual regard in relationships American Psychiatric Association 2013 What is the impact of a personality disorder? Etiology Biology and Learning Genetic heritability of Personality Disorders similar to heritability of personality 0.3 0.5 Environment? Adverse Childhood Events Studychildhood-exp_7_b_ html What is an Adverse Childhood Experience / ACE? Growing up experiencing any of the following conditions in the household prior to age 18: 1. Recurrent physical abuse 2. Recurrent emotional abuse 3. Contact sexual abuse 4. An alcohol and/or drug abuser in the household 5. An incarcerated household member 6. Family member who is chronically depressed, mentally ill, institutionalized, or suicidal 7. Mother is treated violently 8. One or no parents 9. Physical neglect 10. Emotional neglect ACES health problems in adults The young brain is especially vulnerable to stress. prolonged stress in infancy and childhood causes increased release of the stress hormone cortisol stress hormones compromise normal brain development and the immature immune and nervous systems. Results in profound, lifelong impacts on the brain and body ACES impacts in adults Cardiovascular disease Cancer Heart attacks High blood pressure Stroke Diabetes Weight gain(especially abdominal fat) Exhaustion Reduced Growth Hormone Levels Compromised immune function Bone loss depression alcohol and substance abuse Epidemiology DSM 5 Any PD 9 15% Individual PDs 1-6 % Gender: ASPD more common in men Schizoid, schizotypal, narcissistic, obsessive compulsive diagnosed more commonly in men BPD, dependent diagnosed more commonly in women In clinical populations % PROGNOSIS Personality Disorder DSM 5 Section II Enduring pattern of inner experience and behaviour that deviates markedly from the expectations of the individuals culture. Manifested in two or more of the following: cognition, affectivity, interpersonal functioning, impulse control Enduring pattern that is inflexible, pervasive across a broad range of personal and social situations Leads to clinically significant distress or impairment in social, occupational or other important areas of functioning Is stable and of long duration, can be traced back to adolescence or early adulthood Not better explained by another mental disorder, substance or another medical condition DSM 5 Section III Moderate greater impairment in personality functioning One or more pathological personality traits Impairments are relatively inflexible and pervasive across a broad range of personal and social situations Impairments are relatively stable over time, can be traced back to at least to adolescence or early adulthood Not better explained by another mental disorder Not solely attributable to substance use or another medical condition Not better understood as normal for developmental stage or sociocultural environment Impact of PDs Functional Impairment more likely to be separated, divorced, never married than people with depression or no PD More unemployment, frequent job changes, on disability Borderline, schizotypal, avoidant most impaired Histrionic, Narcissistic, Obsessive Compulsive least or no functional impairment Increased treatment utilization Quality of Life PD more strongly related (negatively) to quality of life than other mental disorder, physical illness health, any other socio- economic, demographic or life situation variable Impact of Personality Disorder Prognosis gradual improvement over time, symptoms more than function BPD at 10 yr F/U: 85% remitted, 50% recovered Reduced life expectancy (early all cause mortality) years Suicide: increased for all personality disorders PD plus one psychiatric admission SMR (standardized mortality ratio) 32.8 women, 16.7 men Other mental disorders with PD More impaired, more chronicity Overall poorer response to treatment requiring more intensive and prolonged care Depression, anxiety, schizophrenia, alcohol and substance use disorders more frequent in people with PD Certain PDs (BPD, ASPD, Schizotypal PD) have specific treatments or are contraindications for certain treatments 5297 State the classification of PD in three clusters. Personality Disorders: Clusters Cluster A: odd Schizoid, schizotypal, paranoid Cluster B: dramatic Borderline, histrionic, narcissistic, antisocial Cluster C: anxious Obsessive compulsive, dependent, avoidant 5298 Describe the main enduring pattern of each PD type. Cluster A PD Schizoid Schizotypal Paranoid Cluster A PD All have genetic link to schizophrenia, schizotypal has strongest relationship. All have risk of brief psychotic episodes under stress Few relationships Schizoid, schizotypal: no close relationships except first degree relatives Paranoid PD: tends to associate with people who share similar beleifs Pictures of famous People with Schizoid Personality Disorder Pervasive pattern of: Detachment from social relationships Restricted range of expression of emotions in interpersonal settings beginning in early adulthood and present in a variety of contexts Schizoid PD Detachment from social relationships Prefer solitary pursuits Little interest in sexual experiences, rarely marry Observers, not participants asocial, not antisocial Restricted range of expression of emotions in interpersonal settings Bland, distant, lack social graces Symptoms resemble negative symptoms of schizophrenia, but psychotic symptoms not present or very brief (minutes to hours) psychotic symptoms under stress Negative symptoms schizophrenia 4 As: Flat Affect, Anhedonia lack of pleasure, Amotivation- lack of ability to begin, sustain activities, Alogia speaks little Schizotypal Personality Disorder Pervasive pattern of social and interpersonal deficits marked by: acute discomfort with, and reduced capacity for, close relationships cognitive or perceptual distortions eccentricities of behavior Schizotypal PD; clinical features acute discomfort with, and reduced capacity for, close relationships Excessive social anxiety that does not improve with familiarity. Due to paranoid fears/mistrust rather than negative judgments about self cognitive or perceptual distortions Odd beliefs: superstitious, clairvoyance, 6 th sense Unusual perceptions - bodily illusions my skin feels waxy and old Suspiciousness, paranoid ideation eccentricities of behavior Speech: vague, circumstantial Behaviour: odd dress and appearance Looks like positive symptoms of schizophrenia, but psychosis, if present, is brief 10 20% go on to have schizophrenia, less likely after age 30 Treatment: some evidence for low dose atypical antipsychotics Olanzapine 10 mg, Risperidone 2 mg Paranoid Personality Disorder Pervasive pattern of: distrust and suspiciousness of others Others motives are interpreted as malevolent Paranoid PD : Clinical features distrust and suspiciousness of others others motives are interpreted as malevolent Suspects others are exploiting him Unjustified doubts re: loyalty/trustworthiness of friends/associates Reads hidden meanings into benign remarks pathological jealousy Perceives attacks that are not apparent to others, quick to counterattack Looks like delusional disorder, paranoid type, but not psychotic (except briefly under stress) Inpatients 10-30% Outpatients 2-10% Increased in hearing impaired, new immigrants, minority groups CHALLENGE YOUR KNOWLEDGE Ms A Ms A is a 20 year woman referred for possible psychosis. She lives with her mother and has no friends. She reports that she has been feeling more paranoid lately and describes that she gets very restless around people and always has to be on her guard in case anyone takes advantage of me. Ms A has a number of unusual beliefs- including a belief in the occult, beliefs about the powers of various crystals which she prefers to medications, and ESP. Ms A was somewhat unkempt and dressed in bright clothing with heavy makeup. She keeps repeating that her fate lays with the stars and excusing herself to leave because you wont understand me. Ms A 1.What is your preferred diagnosis? 2.What types of psychotic disorder is Ms A at risk for? 3.What is Ms As prognosis? Mr H Mr H is a 40 yo man was referred for assessment of depression. He recently lost his job with a local call center. He was fired because he was not able to get along with other employees. He reports that he should have been promoted because everyone else he worked with were crooks, and he was the only one who was trustworthy. He said that he treated everyone else decently but added why bother since they all end up taking advantage of me. He would like to date, but has given up on this because women use me like a stepping stone. Mr H What is your preferred diagnosis How is the treatment of Mr Hs depression likely to be impacted by this diagnosis? What challenges do you anticipate will occur in the therapeutic relationship with Mr H? Ms M Ms M is a 72 year old woman who is referred to psychiatry by ER for assessment of capacity to make her own decisions about where she will live Ms M has a pneumonia and has been prescribed antibiotics. She plans to return to live on the street. The ER doc wants her to go to a shelter. She insists that she can handle herself and has lived on and off the streets her whole life. It is September. She plans to make her way back to Victoria once her pneumonia is better because the winters are milder and she doesnt mind the shelters in Victoria. Ms M denies any problems with depression, psychosis. She has family, but has not had contact with them, or anyone else, in years. She is soft spoken, makes little eye contact and seems unconcerned about her current situation. Ms M What is your preferred diagnosis? What are the possible reasons that Ms M avoids relationships with others? What are the likely causes of Ms Ms personality disorder? What is unusual about Ms Ms presentation? Cluster B Histrionic PD Antisocial PD Narcissistic PD Borderline PD Histrionic Personality Disorder Pervasive pattern of: excessive emotionality attention seeking HPD: clinical features excessive emotionality attention seeking Uncomfortable in situations in which they are not the centre of attention consistantly uses physical appearance to draw attention to self. More evident in opposite sex relationships Speech vague, lacking in detail theatrical: exaggerated, rapidly shifting, shallow expressions of emotion One of the least impairing of the PDs Antisocial Personality Disorder Pervasive pattern of: disregard for, and violation of, the rights of others occurring since age 15 years (conduct disorder) / must be at least age 18 years Antisocial PD disregard for, and violation of, the rights of others Repeated lawbreaking Deceitfulness Impulsivity Irritability and aggressiveness Reckless disregard for safety of self or others Consistent irresponsibility Lack of remorse occurring since age 15 years /at least age 18 years Conduct disorder: aggression towards people or animals, destruction of property, deceitfulness/theft, serious rule violations 25% of girls, 40% of boys with CD ASPD. Increased risk with early onset, more, severe behaviours and substance use disorder in adolescence ASPD: etiology Genetic and Environmental Genetic MAO-A low activity gene adult aggressive behaviour MAO-A high activity + childhood abuse OR 1.6 MAO-A low activity +childhood abuse OR 9.8 Congenital Smoking ppd OR 4.4 conduct disorder Severe starvation, first, second trimester OR 2.5 Poverty? Only for youth with aggressive behaviour Treatment Primary prevention National programs aimed at stopping physical punishment of children Early intervention programs for children of high risk moms Head Start. High risk moms teens, single, poverty, addictions, mental health, legal involvement Secondary Prevention Parenting education Positive Parenting for children who have aggression Tertiary Prevention Treatment alcohol and substance use disorders Maybe CBT for ASPD, not psychopathy atch?v=s5hEiANG4Uk Psychopathy Malignant form of ASPD 2 factors meanness Grandiose, deceptive, dominant, manipulative Shallow emotions, unable to form strong emotional bonds, lack empathy, guilt, remorse socially deviant lifestyle Irresponsible, impulsive, ignores social conventions and rules Robust risk factor for Recidivism, violence, poor treatment outcomes Narcissistic Personality Disorder A pervasive pattern of: Grandiosity - fantasy or behaviour need for admiration, lack of empathy Narcissus Greek mythological figure from poem Metamorphoses. Extremely handsome young man who scorned the love of others. A heartbroken young man/woman had their prayer answered by Nemesis: may he who loves not others love himself. While drinking water in a pond, Narcissus fell in love with his reflection and drowned/withered away NPD: Clinical Features need for Admiration Sense of entitlement Belief that he/she is special, should associate with other special people Easily injured self esteem leads to anger and resentment Grandiose sense of self importance Exaggerate own accomplishments (lying), begrudge successes of others, jealous/discredit those seen as competitors Preoccupied with fantasies of unlimited success, power, brilliance, beauty, love lacks Empathy interpersonally exploitative Normal developmental stage in teens, most grow out of this Despite being difficult to treat due to countertransference this PD is associated with minimal functional impairment Borderline Personality Disorder A pervasive pattern of: instability of interpersonal relationships, self-image affects, marked impulsivity CHALLENGE YOUR KNOWLEDGE Ms B Ms B is a 30 yo woman presents to ER following an overdose. She is extremely distressed because her boyfriend of 4 months broke up with her. She says it is all her fault because she kept fighting with him about his going out with his friends but refusing to take her. She said she loves to go out and hates being left behind. Ms B is fashionably made up and looks like she might be heading out to a dance club rather than spending a night alone at home. She explains she never goes out without her make-up because you never know who you will meet. She reports her mood as horribly depressed. Her mood in the interview varied between being animated and happy to being tearful. Ms B What is your preferred diagnosis? What is Ms Bs overall function level likely to be? What challenges do you anticipate in the clinical interview? Mr P Mr P is a 25 year man who presents for assessment of depression on his mothers urging. Mr P spends his days hanging around the house playing video games since he quit his job 3 weeks ago. He worked for a computer store and reports he was their best salesman. He quit because he was passed over for promotion to sales manager. He could not believe that an older person who had worked for the company longer got the job when clearly I am the one that they should be investing in. When asked if he had any other difficulties at work he admitted that he couldnt stand customers that asked stupid questions and had been given several warnings about this behaviour by his boss. Mr P has no plans to look for work just yet he is currently supported by his mother who he admits is loaning him money that she does not have He owes her 10,000 which he will pay back sometime. Mr P What is your preferred PD diagnosis? What is your emotional response to Mr P? What strategies can you use to manage your emotional response? What is Mr Ps likely outcome? Mr D Mr D is a 30 year old man who presents because CAS will not allow him to see his wife and son due to his frequent fights with his wife. He has never hit his wife I would never do that to a woman and is distraught that he cant see his son because I dont want to abandon him like my dad did to me. Mr D reports that he was bullied until high school, but when he grew bigger the tables were turned and no-one messed with me. He was kicked out of high school for fighting and frequent absences. He was involved in several break and enters in high school and also dealt THC. Mr D has had many jobs, but gets bored easily and quits. He is currently unemployed. He reports he has had a few fights, usually at the bar, when someone else takes the first swing and has done things he could be charged with from time to time but wont tell you what he has done. Mr D What is your preferred PD diagnosis? What is different about this diagnosis compared with the other PD diagnosis? Why is this criteria present? What is the likely outcome for Mr D? If Mr D was found to meet criteria for psychopathy, what would be the relevance of this information? Cluster C anxious Obsessive Compulsive Avoidant Dependent Obsessive Compulsive Personality Disorder A pervasive pattern of preoccupation with: Orderliness, perfectionism mental and interpersonal control, at the expense of flexibility, openness, and efficiency OCPD clinical features Orderliness: preoccupied with organization, lists, details to extent that point of the activity is lost perfectionism: to the degree that it interferes with task completion, excessive devotion to work to the exclusion of relationships Mental and interpersonal control overconscientous about morality, ethics, values, miserly spending style rigidity, stubbornness, reluctance to delegate Adolescents with strong OCPD traits often grow out of this Minimal or no impairment of quality of life, but significantly slower recovery from depression 30% also have OCD Avoidant Personality Disorder Pervasive pattern of: social inhibition feelings of inadequacy hypersensitivity to negative evaluation, Avoidant PD: clinical features social inhibition, feelings of inadequacy, hypersensitivity to negative evaluation unusually reluctant to take personal risks, engage in new activities because they may prove embarrassing, wont get involved with others unless they are certain of being liked avoids occupational activities that involve significant interpersonal contact because fears criticism, disapproval, or rejection Anxious attachment: wants to have close relationships and feels very vulnerable to potential punishment and neglect of others Shares genetics with social phobia, but environment is different One of the most impairing PDs Dependent Personality Disorder A pervasive and excessive need to be taken care of that leads to submissive and clinging behaviour and fears of separation Dependent PD Dependent on relationships Difficulty making everyday decisions without a lot of advice, reassurance unable to disagree with others because fears loss of support, will do things that are unpleasant, degrading to maintain support If persons fear of retribution realistic (abusive spouse) do not make diagnosis Urgently seeks another relationship (within days) when a relationship ends Unable to do things on their own Chronic physical illness, separation anxiety disorder in childhood risk for DPD CHALLENGE YOUR KNOWLEDGE Ms S Ms S is a 35 year old woman who presents with complaints of anxiety and problems sleeping. She works at a small library with people she has known for years. Her chronic difficulties with anxiety increased when she heard the library might be closed and her position moved to a larger library downtown where she will have to work with people she doesnt know. Ms S reports she has struggled all her life with fears of being evaluated and judged by others. She did many of her high school classes by correspondence because of this fear. Ms S has one friend and lives with her parents. She would like to have more friends but is never sure whether people really like her so is reluctant to try to make friends. Ms S What is your preferred PD diagnosis? If Ms S only had anxiety in performance situations, but felt comfortable with friends and can make new friends if she is able to take time to get to know them, would you still be able to make this diagnosis? Justify your answer. What is Ms Ss prognosis? Mr L Mr L is a 50 year old man who is referred by ER following a suicide attempt. He reports that he has struggled with depression over the past year since his mother passed away. His mother was everything to me. He lived at home with her and never lived on his own because I cant really care for myself. He has had several girlfriends but my mom takes care of me best my girlfriends wanted me to make too many decisions. Following the death of his mother, Mr L struggled to get in to work and eventually lost his job. He made his suicide attempt as a cry for help after his dad kicked him out of the house dad said I needed to stand on my own two feet and I cant. Mr L What is your preferred PD diagnosis? By what age does Mr L have to display symptoms to meet the criteria for a personality disorder diagnosis? What solution to his distress is Mr L likely pin his hopes on? Mr M Mr M is a 54 year old aeronautical engineer. He presents for treatment of depression following being laid off from work one year ago. He did receive a generous severance package, but has not looked for work because he believes he is unemployable. Mr M reports he was very good at his job because I was a detail person. However he had difficulty delegating tasks because he did not trust others to do the job properly which meant that he was chronically late for deadlines. Mr H was married, but his wife left because I worked too hard and because I was too hard to get along with. He is very lonely but wont invite people over because they might make a mess and it will take too long to clean up. Mr M What is your preferred PD diagnosis? In general what is the level of functioning for individuals with this diagnosis? What is the impact of this diagnosis on Mr Ms depression? Would you be able to make this diagnosis if Mr Ms symptoms were consistent with the expectations of his culture or subculture for example if everyone in his office worked long hours and neglected their families and partners? Borderline Personality Disorder BPD 5303 List criteria for borderline personality disorder (BPD) Describe common psychiatric comorbidities associated with BPD Describe a treatment approach to BPD including use of hospitalization, outpatient care, pharmacological treatment and psychotherapy BPD DSM 5 A pervasive pattern of instability of interpersonal relationships, self-image and affects, and marked impulsivity Affects emotional lability, problems with anger Behaviours suicide and self harm impulsive (sex, A&D, binge eating, driving fast, promiscuity) Relationships chaotic, idealizing/devaluing, fears of abandonment I hate you, dont leave me Cognitive: emptiness, unstable sense of self, mild psychotic symptoms under stress, dissociation Etiology Bio-Social Theory Emotionally Vulnerable Individual Intense emotions impulsive Invalidating Environment Linehan 1993 BPD: Comorbidity Mood disorders: 90% depression, dysthymia, bipolar disorder Eating Disorders(AN, BN, obesity) : 50% Anxiety Disorders: 90% Substance Use Disorders: 60% BPD Treatment Mainstay of treatment: outpatient care, psychotherapy. Teaching patients how to recognize, tolerate and regulate their emotional reactions, build healthy relationships. Hospitalization for crisis short term Medications for other mental disorders (depression and anxiety) and short term for sleep. BPD: prognosis With OPD treatment, psychotherapy 75% remitted after 6 years 75% have history of suicide and self harm attempts % die by suicide Best prognostic factor: GAF at time of diagnosis BPD: Hospitalization Admission indicated: After a serious suicide attempt Psychosis/severe disorganization May be indicated loss of significant social support Worsening depression, substance abuse Caution when Hospital has not been helpful or has made person worse SIB 5302 Describe the pertinent factors in the recognition of the potential of SIB Describe the mental disorders associated with selfinjurious behaviours (SIB) 5301 List the biological, demographic, economic, social and developmental factors associated with SIB. Self Harm / SIB Behaviours that inflict harm to ones body without the obvious intention of committing suicide Cutting, skin carving, burning, severe abrading, punching, hitting 1-4 % general population, may be increasing chronic/severe SH 1% Teens ~15 %, college age % Age of onset: 14 24 Social: Low SES, adverse events during childhood (abuse and trauma) Clinical Features majority (75%)