Personality Disorder Notes

Prevalance 10-20% of population… 50% of all patients with axis I also have axis II, personality disorders are all ego syntonic…

Paranoid personality;

  • Pervasive, distrust, suspicious of others
    • Suspects exploitation or deceit
    • Questions loyalty and fidelity
    • Reluctant to confide
    • Reads hidden demeaning messages
    • Unforgiving – grudge holder
    • Perceives attacks on character/reputation
  • Has to be without Schizophreia or other psychosis
  • Prevalance 0.5-2.5% of gen population
  • Increased risk in families who have schizophrenia
  • M>F
  • No direct family inheritence
  • Higher incidence in minorities, immigrants and deaf population
  • Affectively restricted, pride in being rational
  • Lack warmth and are impressed by power and rank
  • Psychotherapy is treatment of choice, requiring honest and straigtforward approaches, may need to use small doses of antipsychotics…

Schizoid personality

  •  Schizoids avoid
  • A pervasive pattern of detachment from social relatonships
  • A restricted range of emotional expression
  • Doesn’t desire or enjoy closeness with others
  • Chooses solitary activities, limited interests
  • Little interest in sex or friendships
  • Indifferent to opinions of others
  • Seems cold, detached, affect flattned
  • Rule out psychotic illness before diagnosing
  • May affect 7.5% of the general population
  • 2:1 M:F ratio
  • Choose solitary jobs with little to no contact with others
  • Not psycotic, and have good reality testing
  • Onset usually in early childhood
  • Psychotherapy treatment – single or group
  • Small doses of antipsychotics, antidepressants, stimulants

Schizotypal personality.

  • Atypical behaviour
  • Pervasive pattern of social and interpersonal deficits
  • Cognitive, perceptual distortions and eccentric behaviour
  • Ideas of reference, magical thinking, bodily illusions
  • Suspicious, odd, affect constricted
  • Lack of close friends, social anxiety that does not ease with familiarity, paranoid fears
  • Not explained by psychotic disorder
  • 3% of population… sex ratio unknown…
  • Increased in relatives of those with schizoprenia
  • ??? % commit ??? to tx ??? antipsychotics…

Antisocial personality

  • Pervasive pattern for and violation o basic rights of others since age 15
  • Failure to conform to social norms, unlawful behaviour
  • Deceitful, comfortable lying, conning others
  • Impulsive, does not plan ahead
  • Irritable, agressive, reckless disregard for safety
  • Irresponsible behaviour towards work or finances
  • Lack of remorse for actions
  • The person must be at least 18 years old for diagnosis
  • There must be evidence of conduct disorder onset prior to 15 years old
  • This behavour is not better explained by mania or schizophrenia
  • Many have a neurological or mental disorder that has been overlooked or undiagnosed
  • The height of antisocial behaviour is in late adolescence, improves as they age…
  • Many have somatisation disorder and multipe physical complaints
  • Co-morbidity common wit substance abuse and depression
  • When in hospital or prison, they become more open to change… when amongst peers, motification decreases.
  • Therapy – set firm limits, medications – mood stabilisers, beta blockers to reduce aggression
  • Prevalance 3% in men, 1% in women, 75% of prisoners
  • Family inheritance, 5 more in male’s 1st relatives.

Borderline personality

  • pervasive patterns of instability of interpersonal relationships, self-image and affects
  • Frantic efforts to avoid real or imagined abandomnent
  • Alternate between extremes of idealisaiton and devaluing others
  • Markedly disturbed self image or sense of self…
  • Impulsive in damaging ways – spending, sex, substance abuse, reckless driving, binge eating.
  • Recurrent suicidal behaviour, gestures, threats, self-mutilation
  • Affect unstable, marked reactivity of mood in hours
  • Chronic feelings of emptiness
  • inappropriate intense anger, difficulty controlling anger
  • Transient stress related paranoia or dissociation
  • “borderline” i.e. border of neurosis and psychosis…
  • 1-2% of population affected
  • M:F ratio – 1:2-3
  • Comorbidity with depression and substance abuse which is also found in first degree relatives
  • Dialectical behaviour therapy is treatment of choice
  • Medication; antidepressants, mood stabilisers and antipsycotics
  • Responds the best of all personality disorders to medication…

Histrionic personality

  •  Pervasive pattern of excessive emotionally and attention seeking, beginning by early adulthood
  • Uncomfortable when not center of attention
  • Sexually seductive, provocative interactions
  • Rapidly shifting and shallow emotions
  • Uses physical appearance to draw attention to oneself
  • Impressionistic speech – lacking in in details
  • Dramatic, theatrical, exaggerated emotions
  • Easily influenced by others, trusting, gullible
  • Considers relationships to be more intimate than they are
  • Prevalanece 2-3% in the population, 10-15% in mental health clinics and inpatient settings
  • F>M
  • Association with somatisation disorder and alcohol use…
  • Psychotherapy to connect them with their own feeling, psychoanalytic therapy is best…
  • Medication: antidepressants, antianxiety and antipsychotics…

Narcissistic Personality

  • Pervasive pattern of grandiosity, need for admiration and lack of empathy
  • Great sense of self importance, exaggerating achievements
  • Fantasies of success and adoration by others
  • Special and should only associate with high-ups.
  • Requires excessive admiration, arrogant attitude
  • Entitled and exploitative, envious of others
  • handles criticism poorly, relationshps are fragile
  • More vulnerable to midlife crisis
  • Group therapy is best.
  • medication; lithium and antidepressants…

Avoidant personality

  • Pervasive pattern of social inhibition
  • Avoids social contact fearing rejection
  • Needs assurance of being liked before risking interaction
  • Fear of shame or ridicule
  • Keeps connections superficial
  • Reluctant to try new things
  • Fears embarrassment
  • Views self as inept, or inadequate
  • Wanting companionship but having an inferiority complex…
  • Anxious upon interview – wanting approval
  • Function in a protective environment
  • Therapy; acceptance and trust are key… group therapy and assertiveness behavioral therapy are useful.
  • Medication; beta blockers, tx for anxiety and depression

Dependent Personality

  • Pervasive, excessive need to be taken care of with submissive, clinging behaviour
  • Trouble making decisions without advice and support
  • Difficulty disagreeing, doing things on their own.
  • Go to excessive lengths to obtain approval… e.g. doing unpleasant tasks
  • Unable to be alone, fears being unable to care for oneself…
  • Jumps from one relationship to another…
  • Fears of being left a big preoccupation
  • 2.5% of all personality disorders
  • Impaired occupational functioning
  • Therapy; insight oriented, group therapy
  • Medication for anxiety and depression, imipramine for panic attacks

Obsessive Compulsive personality (med students…)

  • Pervasive pattern of preoccupation with orderliness, perfectionism, control
  • Has rules, lists schedules which interfere with task completion
  • Excessive devotion to productivity at the expense of leisure
  • Over-moral, inflexible
  • Miserly, saves useless objects
  • Doesn’t delegate
  • Stubborn
  • Has few friends
  • Tx, group therapy and behavioural therapy
  • Unkown prevalance or family ineritence
  • Backgrounds of harsh discuplin
  • Medications; Clomipramine, Clonazepam, Fluoxetine…

 

 

 

 

 

 

 

 

Depressive Disorders

Major Depressive Disorder (MDD) is also known as clinical depression or unipolar depression and refers to distinct episodes of depression lasting >2 weeks and having a negative impact on everyday functioning. Criteria include;

  • Depressed mood for 2 weeks, with or without anhedonia… PLUS 4 of the following
    • Insomnia/Hypersomnia
    • Significant weight loss or gain
    • Fatigue
    • Poor concentration
    • Agitation or psychomotor retardation
    • Worthlessness or guilt
    • Recurrent thoughts of death, suicidal ideation, attempt or plan
    • Impairment or distress
  • Exclude or
  • Exclude medical or substance abuse rxns, must not be better accounted for by any other diagnosis…
  • Specifies:
    • W/ Anxious distress
    • W/ Mixed Features manic or hypomanic sx),
    • W/ Melancholic features
    • W/ Atypical features (eating excessively, seeping, a “leaden” feeling in the limbs, or being sensitive to rejection)
    • W/ Peripartum onset
    • W/ Seasonal pattern (occurs usually in winter… assoc w/ low levels of sunlight)

Screen for bipolar affective disorder  a low may have a high in the past and completely change the way we treat wit medications

Lifetime risk of M:F; 10-25%:5-12%,
nb1. men can develop symptoms prior to puberty, whereas women may develop symptoms from puberty til middle age…
nb2. 50+ the risk equilibrates M=F

Causes, onset and course of depression

– Depression is common, affecting ~20% of Australians over a lifetime… Depression is a word often used to describe feelings of sadness and grief that all people experience at times. However, for a person to be clinically diagnosed with a depressive disorder, his or her symptoms are usually much more intense and must have been present for at least 2 weeks… Depression is commonly accompanied by feelings o anxiety or agitation. Bereavement following death of a loved one is not considered a psychiatric illness  however one must carefully evaluation whether the symptoms have gone beyond grief and into a state of depression (which cannot co-exist with bereavement…
– Persistent complex bereavement disorder is not recognised as an illness yet but is being considered for further study… it consists of impaired functioning following a death of at least a year for adults and six months for children…
– People may experience depression as a result of any one or more of a range of factors including; Biochemistry, physical stress, chronic or sustained illness, seasonal influences, genetic predispositon, life stressors, personality factors…
– Depression may have acute or gradual onset and can be experienced at any time over the course of a person’s life…

 

Difficulties in diagnosis.

– Depression can be difficult to diagnose as people present complaining of physical problems that obscure psychiatric diagnosis. Depressive disorders often coexist with, and may be secondary to other medical disorders… particularly high rates of depression are found in people with alcohol related disorders, eating disorders, schozophrenia and somatoform disorders (vague physical complaints with no physical basis). Determining which disorder is primary and which is secondary is often a difficult task.

– Many of the people clinicians care for, both young and old are at risk of developing depression due to long standing physical illness and disability, further depression can present as early signs of dementia. It is important then for clinicans to remain alert to this possibility.

Goals for managing person’s experience of epression

  • Developing a relatonship based on empathy and trust
  • Promoting a person’s positive self regard
  • Promote positive health behavours… including medication compliance and healty lifestyle choices,
  • Promoting person’s engagement with social and support networks
  • Ensuring effective collaboration with other relevant service providers through effective working relationships and communication
  • Support and promotion of self care activities for families and carers of person with depression.

Frequently assess, document and manage risk for suicide and self har…

Associated disorders

  • Persistent depressive disorder (aka dysthymia), diagnosed when mood disturbance occurs for >2 years in adults…
  • Cyclothymic disorder: chronic disorder >2 years of alternating periods of low and high moods that are less severe than major depression or mania. It can be described as a mild form of bipolar…
  • Premenstrual Dysphoric Disorder – newly places in DSMV, at least 5 symptoms overall present before onset of menses, wit decrease or disappearance by onset of menses. At least one or more of the following: lability, irritability, depressed mood, anxiety/tension. at least one or more for the following as well: decreased interest, concentration difficulty, lethargy, change in appetite, sleeping too much or too little, overwhelmed, physical symptoms such as breast tenderness, bloating or weight gain.
  • Dysruptive mood dysregulation disorder: Diagnosis of children up to 12 y.o wo present with persistent irritability and frequent episodes of extreme behavioural dyscontrol…Children with this diagnosis often develop unipolar depression or anxiety disorders in adulthood, rather than bipolar conditions…
  • Substance/Medication induced depressive disorder…
  • Depressive disorder due to other medical condtitio

Adjustment Disorder vs Major Depressive Disorder

Med students are often asked to distinguish between Major Depressive Disorder (296.xx) and Adjustment Disorder with depressed mood (309.xx)… Both are characteristically different groups of conditions that although are categorically distinct, sometimes present with similar symptoms…

Adjustment disorder is a major depressive episode that occurs in response to a psychosocial stressor (e.g. losing a family member or loved one, major disaster, loss of job etc). Depression is distinguished fro adjustment disorder by the fact that the full criteria for MDD are not met in adjustment disorder…

As stated in the DSM V, MDD can be diagnosed based on criteria A-E.
Criteria A. Key Signs and Symptoms.
– >5 or more of the following during a 2 week period and represent a change from previous functioning; 1. Depressed mood, 2. Markedly diminished interest or pleasure in all or almost all activities most f the day, nearly every day, 3. Significant weight loss (not through intentional dieting/exercise), 4. Insomnia or hypersomnia nearly every day, 5. Psychomotor agitation or retardation nearly every day (observable by others, not merely subjective feelings of restlessness or being slowed down). 6. Fatigue or loss of energy, 7. Feelings of worthlessness or excessive or inappropriate guilt, 8. Diminished ability to think or concentrate, being indecisive, 9. Recurrent thought of death (not just fear of dying), recurring suicidal ideation without specific plan, or suicide attempt…
– AT LEAST ONE of the symptoms should be either 1. Depressed mood OR 2. Loss of interest in pleasure.

Criteria B; Significance
– the symptoms cause considerable distress or impairment in social, occupational or other important areas of functioning.

Criteria C; No attributes
– the episode cannot be attributed to substance use or any other medical condition.

Criteria D. No better explaination
– The occurrence of DD is not better explained by any other psychological condition (e.g. schizoaffective disorder, schizophrenia, schizopreniform, delusional disorder)

Criteria E; No previous manic episode..
– this is similar to criteria D as it may indicate bipolar disorder…

The above are better memorised with the mnemonic SADAFACES (Sleep Disturbance, Anhedonia, Depressed mood, Appetite loss, Fatigue, Aggitation, Concentration loss, Esteem loss, Suicidality)

It is important to note that MDD has many other differential diagnoses including…

– Manic episodes with irritable mood or mixed episodes
– Mood disorder due to another medical condition
– Substance/medication induced depression
– Bipolar disorder (I/II)
– Dysthymia
– ADHD (via manifestations of distractibility and low frustration tolerance)
– Plain ‘Sadness’ – the human experience

But the distinction should be somewhat more obvious..

An adjustment disorder with depressed mood may also present with clinically significant (i.e. marked distress, significant impairment) elements of low mood, tearfullness and feelings of hopelessness – but are frequently precipitated by an identifiabe stressor, within 3 months of the onset. This can be considered if a bereavement process is not seen to represent normal social/cultural practices or if symptoms persist an additional 6 months after that stressor has been terminated.

The key differential diagnoses for adjustment disorder include
– MDD
– PTSD
– Personality disorder
– Psychological factors from other medical conditions
– Normative stress reactions

ASD -a spectrum of disorders

Autistic Spectrum Disorder (ASD) is defined in the DSM V in section 299.00(F84.0)

The DSM stipulates that ASD is defined by criteria A-E…

Criteria A; Impairment of social interaction
– Persistent deficits in social communication and social interaction across multiple contexts, as manifested by the following, currently or by history (examples are illustrative, not exhaustive)… 1. Deficits in social emotional reciprocal, ranging for example, from abnormal social approach and failure of normal back-and-fourth conversation; to reduced sharing of interests, emotions or affect; to failure to initiate or respond to social interactions. 2. Deficits in nonverbal communicative behaviors used for social interaction, ranging for example, from poorly integrated verbal and nonverbal communication; to abnormalities in eye contact and body language or deficits in understanding and use of gestures; to a total lack of facial expressions and nonverbal communication. 3. Deficits in developing, maintaining and understanding relationships, ranging for example, from difficulties adjusting behavior to suit various social contexts; to difficulties in sharing imaginative play or in making friends; to absence of interest in peers.
– Specify current severity; severity is based on social communication impairments and restricted repetitive patterns of behavior…

Criteria B; Restricted repetitive patterns of behaviour, interests or activities
Restricted, repetitive patterns of behaviour, interests or activities, as manifested by at least two of the following, currently or by history (examples are illustrative, not exhaustive)… 1. Stereotyped or repetitive motor movements, use of objects or speech (e.g. simple motor stereotypes, lining up toys or flipping objects, ecolalia, idiosyncratic phrases). 2. Insistence on sameness, inflexible adherence to routines or ritualized patterns of verbal or non-verbal behaviour e.g. extreme distress at small changes, difficulties with transitions, rigid thinking patterns, greeting rituals, need to take same rout or eat same food every day). 3. Highly restricted, fixated interests that are abnormal in intensity or focus (e.g. strong attachment to or preoccupation with unusual objects, excessively circumscribed or perseverative interests). 4. Hyper- or hyporeactivity to sensory input or unusual interest in sensory aspects of the environment e.g. apparent indifference to pain/temperature, adverse response to specific sounds or textures, excessive smelling or touching of objects, visual fascination with lights or movement).

C. Symptoms must be present in the early develipmental period

D. Symptoms cause clinically significant impairment in social, occupationl, or other important areas of current functioning.

E. These disturbances are not better explained by intellectual dissability.

Nb. Individuals with well-established DSM IV diagnosis of autistic disorder, aspergers disorder, or pervasive developmental disorder not otherwise specified should be given the diagnosis of autism spectrum disorder. Individuals who have marked effects in social communication, but whose symptoms do not otherwise meet criteria for autism spectrum disorder, should be evaluated for social (pragmatic) communication disorder.