Evaluation and Treatment of Patients with Personality Disorders

in Primary Care

Scott S. Meit, PsyD, MBA, FAACPScott S. Meit, PsyD, MBA, FAACP

Vice Chair for PsychologyVice Chair for Psychology

Department of Psychiatry and PsychologyDepartment of Psychiatry and Psychology

The Cleveland ClinicThe Cleveland Clinic

Objectives

Keys to Dx and Diagnostic Differential Options for initial management Referral, Consultation, & Coordination of

Care

Buy one get one free?

Personality Transplant?

Abusive Leader needs a personality transplant

Dear Joan,

A group of us are so irate that we had to write to get your reaction to this situation. Our branch (we work in a financial institution) recently had an all company training meeting at the branch, which was led by our branch manager. We were all required to attend.

During the meeting, the branch manager…

excerpt From Joan Lloyd at Work 11/06/2002

                                                                                                                                                        

 

Somebody get this guy a personality transplant                                                                                                               

January 13, 2005

Somebody get this guy a personality transplant. What to make of Jay Farrar? I've endured three interviews with this human fungus over the year…

From the Pressbox

Canadiens need a personality transplant

Tuesday, February 13, 2007 | 10:35 AM ET

It isn’t easy to make hockey history in Montreal, but the Canadiens did it last weekend.

Following their 5-3 loss to Ottawa, the players held a 29-minute meeting – no coaches, just themselves…

CBC's Elliotte Friedman puts the world of sports under a microscope

What is Personality?

per – son – al – i – ty 3. a) habitual patterns and qualities of behavior of any individual as expressed by physical and mental activities and attitudes; distinctive individual qualities of a person, considered collectively.

Webster’s New World Dcitionary, 2nd Edition

According to the Experts…

“ …a pattern of deeply embedded and broadly exhibited cognitive, affective, and overt behavioral traits that persist over extended periods of time.”

“These traits emerge from a complicated matrix of biological dispositions and experiential learning.”

- Theodore Millon & George S. Everly, Jr.

As such…

Few clinicians are eager to Dx a personality disorder on a 1st visit

Most clinicians are quite reluctant to assign such Dxs to those who have not yet reached adulthood…

Critical Caveats

There are a lot of normal variants of personality

A psychiatric diagnosis (of any kind) requires there be “clinically significant distress or impairment in social, occupational, or other important areas of functioning”

DSM-IV-TR general criteria for a personality disorder An enduring pattern of inner experience and behavior

that deviates markedly from the expectations of the individual's culture

The pattern is inflexible and pervasive across a broad range of personal and social situations

Significant distress/impairment in social and/or occupational…

Pattern is stable and of long duration – traceable back to late adolescence/early adulthood

Enduring pattern not better accounted for by another mental disorder

Enduring pattern is not due to physiological effects of a substance or a medical condition

The Clusters

A (odd & eccentric): Paranoid, Schizoid, & Schizotypal

B (emotionality, drama, & erratic): Borderline, Histrionic, & Narcissistic

C (fearful & anxious): Avoidant, Dependent, & Obsessive-Compulsive

* While useful toward conceptualization and, perhaps, research & education the clustering system has not been consistently validated; it cannot be considered evidenced-based

Paranoid Personality Disorder

Pervasive distrust and suspiciousness (and 4 or more)

Suspect of others’ motives Questions the “fidelity” of friends & associates Suspect of the FIDELITY of spouse or partner Reluctant to confide in others Reads hidden meanings into remarks or

events Bears grudges Thin skinned/vigilant to “attacks” upon their

character or reputation

Differentials

Delusional Disorder, Persecutory type

Non-bizarre delusions (involving situations that could occur in real life; e.g. having one’s phone tapped, being poisoned)

• If + for hallucinations, R/O Schizophrenia, Paranoid type (referral for psychiatric eval)

Schizoid Personality Disorder

A pervasive pattern of social detachment and restricted range of emotion (and 4 or more)

Neither desires nor enjoys social relations (incl. family involvements)

Solitary activities dominate Little interest in sexuality Few, if any, pleasurable activities Lacks close friends or confidents Appears indifferent to praise or criticism Emotionally cool, detached, aloof, flat affect

Differentials

Schizotypal can also be socially distant with constricted range of affect BUT looks a lot “crazier”

Avoidant Personality Disorder, at 1st glance, can be just as solitary and socially disconnected as Schizoid BUT this is out of fear of social rejection and NOT for lack of want of social interaction

Schizotypal Personality Disorder

Pervasive pattern of social/interpersonal deficits accompanied by cognitive & perceptual distortions and eccentricities of behavior (and 5 or more)

Beliefs that causal events have a particular significance or specific connection to them (ideas of reference)

Magical Thinking (e.g. “6th sense”, clairvoyance) Unusual perceptual experiences (incl. bodily) Odd thinking & speech Suspiciousness/paranoia Inappropriate or constricted affect Odd/eccentric/peculiar behavior Lack of close friends or confidents Excessive social anxiety associated with paranoid fears

Wide Differential…

R/O Schizoid Personality Disorder If + for hallucinations and/or if ideas of ref

reach delusional intensity, R/O Schizophrenia R/O Delusional Disorder, Somatic type if

bodily perceptions/illusions reach delusional intensity (also consider somatoform disorders if this is predominant feature of Pt presentation)

R/O Paranoid Personality Disorder

Antisocial Personality

A pervasive pattern of disregard for & violation of the rights of others (and 3 or more)

Repeated acts that are grounds for arrest Deceitful behaviors (e.g. lying, cons, swindles) Impulsivity/failure to plan Aggressiveness, fights, assaults Recklessness (with own and/or others’ safety) Irresponsibility – evidenced by repeated failure to keep

a job and/or meet financial obligations Lack of remorse

Evidence of Conduct Disorder by Hx Pt. must be at least 18 Behavior not better accounted for by Manic

Episode/Bi-polar or Schizophrenia

Risk of catastrophic injury and/or pre-mature violent death. Alcohol/Drug abuse common.

Borderline Personality

Pervasive pattern of instability of interpersonal relations, self-image, & affects – with markedimpulsivity (and 5 or more)

Frantic efforts to avoid abandonment Pattern of unstable, intense “love/hate” relationships Identity disturbance/unstable self-image Impulsivity in at least 2 areas: e.g. spending, sex,

etoh/substance abuse, reckless driving, binge eating (behavioral dysregulation)

Recurrent suicidal and/or self-mutilation behavior

BPD cont.

Affective instability/marked reactivity of mood (emotional dysregulation)

Chronic feelings of emptiness Inappropriate intense expression of anger

which may include physically acting out Transient stress induced paranoid ideation

and/or dissociative Sxs (cognitive dysregulation)

Marsha Linehan, PhD conceptualizes BPD as a disorder of cognitive, emotional, & behavioral dysregulation

The Beasts of Chaos

Identity Disorder can be a precursor to BPD:Uncertainty regarding multiple issues relating to self includingFriendship patterns, long-term goals, career, sexual orientation& behavior, moral values, group loyalties…

BPD Differential & Tx

Most clinicians recognize BPD when in its presence… There are no medications with specific indications for Tx

of personality disorders. However, Tx of associated Sxs can prove helpful. In case of BPD, SSRIs, mood stabilizers, and even antipsychotics have been used depending upon the prominent Sxs being targeted. Psychiatric consultation is recommended.

Behaviorally, DBT provided in a specialized group practice is fast becoming the Tx of choice (Laurelwood & SW General have programs)

Link Wikipedia description of DBT: http://mentalhelp.net/poc/view_doc.php?type=doc&id=8140&cn=91

Histrionic Personality

A pervasive pattern of excessive emotionality & attention seek (and 5 or more)

Uncomfortable when not center of attention Interactions are often sexualized or otherwise

provocative Rapidly shifting & shallow expressions of

emotion Uses physical appearance to draw attention Style of speech is impressionistic & lacking in

detail

HPD criteria cont.

Dramatic, theatrical, & exaggerated displays Is very suggestible/easily influenced Considers relationships to be more intimate

than they are

Pretty simple Differential

R/O other Cluster Bs- Borderline PD- Narcissistic PD

Narcissistic Personality

A pervasive pattern of grandiosity, need of admiration, and lack of empathy (and 5 or more)

Grandiose sense of self-importance, exaggerates achievements

Preoccupied with fantasies of unlimited success, power, brilliance, or ideal love

Belief that one is “special” or unique and should only associate with other high status persons or institutions

Requires excessive admiration Sense of Entitlement Interpersonally Exploitative Lacks empathy Often envious of others and/or believes

others to be envious of them Displays arrogant, haughty behaviors &

attitudes

Narcissistic Personality Continued

Narcissus

Differential

R/O Antisocial PD based upon overlap of exploitation of others & lack of empathy/remorse (but pretty easy R/O)

Grandiosity and acceleration of goal directed activities are also hallmark to manic and hypo-manic episodes. Consider bi-polar spectrum of disorders & consultation to assist diagnostic clarification.

Avoidant Personality

A pervasive pattern of socialinhibition, feelings of inadequacy, &hypersensitivity to negative evaluation (and 4 or more) Avoids occupations that involve significant

interpersonal contact Unwilling to interact with others unless certain of

being liked Restraint in intimate relationships Pre-occupied with fears of being criticized or rejected

socially

Avoidant Personality continued…

Inhibited in new interpersonal situations due to feelings of inadequacy

Views self as socially inept, unappealing, inferior

Usually unwilling to take social risks or engage in new activities which may prove embarassing

Differentials & Co-morbidities

Schizoid and Avoidant PDs can look similar at a glance as individuals may be seen or even self-describe as “loners”. However, the Schizoid has no “use” for people; the Avoidant would be the 1st at the party if guaranteed acceptance and approval.

Social Phobia is a common co-morbidity with Avoidant PD.

Treatments…

Social Skills training and CBT are proven therapies

Some physicians make use of beta blockers to assist with select “high stakes” events (e.g. a major presentation or … talks like this!)

Dependent Personality

A pervasive and excessive need to be taken care of that leads to submissive and clinging behavior (and 5 or more)

Difficulty making everyday decisions w/o excessive reassurance and advise

Needs others to assume responsibilites for most major areas of his/her life

Difficulty expressing disagreements due to fear of loss of support/approval

Dependent Personality continued…

Difficulty initiating projects or doing things on their own

Goes to excessive lengths to obtain nurturance/approval

Feels uncomfortable or helpless when alone due to exaggerated fears of not being able to take care of themselves

Urgently seeks a “replacement” relationship when another one ends (“rebound”)

Pre-occupied with fears of being left to take care of themselves

Differential & Treatment

Some similar features exist in Borderline, but differential generally is not too difficult

CBT, social skills, and interpersonal therapies

Obsessive-Compulsive Personality

A pervasive pattern of preoccupation

with orderliness, perfectionism, and

mental & interpersonal control at the

expense of flexibility, openness, and

efficiency

OCPD continued… 4 or more

Preoccupied with details, rules, lists, order, organization, schedules

A level of perfectionism that interferes with task completion

Excessively devoted to work to exclusion of leisure activities and friendships

Morally overbearing, scrupulous, & inflexible Unable to discard old worn out objects of no

sentimental value

OCPD continued…

Reluctant to delegate tasks w/o assurances that others will do things exactly their way

A miserly lifestyle – money is hoarded as a hedge against future catastrophe

Rigidity and stubbornness

Differential (& models to consider)

One or the other or both…

continuumOCPD OCD

BehavioralLearningEnvironment

Biological Bases

OCPD

OCD

parallel or co-morbid

Personality Disorder NOS

Formerly “Mixed Personality Disorder” Features of multiple PDs where criteria are

not fully met for any specific personality disorder

Can be used if PDs under consideration (e.g. Depressive Personality Disorder, Passive-Aggressive PD) are judged to be present

Note: You can Dx more than one PD if full criteria for more than one exist

Diagnoses under consideration (DSM-IV, Appendix B)

Depressive Personality Disorder

Passive-Aggressive Personality Disorder

Depressive Personality Disorder vs. Dysthymia

DPD Dysthymia Usual mood is dominated by

dejection, gloominess, cheerlessness,..

Self-concept centers around beliefs of inadequacy, worthlessness, low self-esteem

Self-blame, self-deprecating, self-critical

Brooding, worry Negativistic, critical of others Pessimistic Prone to feeling

guilty/remorseful

Depressed mood (more days than not) for at least 2 years

(2 or more): low self-esteem, feelings of hopelessness, low energy/fatigue, appetite and/or sleep disruptions

* Criteria of DPD tend to focus more upon cognitive, interpersonal, & intrapersonal traits

Passive-Aggressive Personality(Scott’s experimental criteria – adapted from an

internet source)

Statement I think I’ll just read a book for

a while Don’t worry, I already have

CDs in the car Oh, I thought we were

having steak tonight Well, I guess we’ll just have

to agree to disagree You remember when we

used to _____? Man that was great.

Translation How I loathe you – get away

from me I detest every piece of music

you own Where’s my blankity blank

steak! Your stupidity is really quite

shocking! We’re stuck in a bottomless

downward spiral.

Passive-Aggressive Personality(Negativistic Personality Disorder)

A pervasive pattern of negativistic attitudes and passive resistance to demands for adequate performance (4 or more)

Passively resists fulfilling routine social & occupational tasks Complains of being misunderstood and unappreciated Is sullen and argumentative Expresses envy & resentment toward those who appear more

fortunate Exaggerated and persistent complaints of misfortune Alternates between hostile defiance and contrition

* Not occuring exclusively during MDD and is not better accounted for by Dysthymic Disorder.

General Treatment Considerations

By definition, Personality is long established and enduring

Few Pts will develop a presenting problem (and solicit help) around “I need to change my personality”.

You will likely never have someone present for Tx of their narcissistic personality problems

Persons who do seek Tx for their antisocial difficulties (e.g. “I need ‘anger management’ training”) are often compelled to Tx – legally or otherwise

True Personality Disorders are managed; not cured

Managing PDs in Primary Care

Some Dxs have better prognosis – avoidant, dependent, even histrionic can respond well to social skills and CBT interventions

Be flexible - adjusting your Dr-Pt style in relation to the challenges which accompany each PD; do not allow yourself to be “sucked in”.

Bridging techniques can be time efficient and effective – i.e. assisting Pts to see a connection (a relationship) between their standard ways of interpreting & processing life events and consequent Sxs/stress. Listen for Language (10 Common Thought Distortions)

10 Common Thought Distortions

1. All-or-Nothing Thinking2. Overgeneralization 3. Mental Filter 4. Disqualifying the Positive 5. Jumping to Conclusions 6. Magnification and Minimization 7. Emotional Reasoning 8. Should Statements 9. Labeling and Mislabeling 10. Personalization

* http://depression.about.com/cs/psychotherapy/a/cognitive.htm

Craft your Comfort in Referral for Psychological or Psychiatric consultation

It’s easier to write an Rx. It is not always optimal – esp. for PDs. Social skills, interpersonal, CBT, & DBT are effective therapies (and again there are no scripts with specific indication to Tx personality disorder)

Assure your Pt that your are not “exiling” them from your practice, but are referring for consultation and coordination of care - just as you might to an endocrinologist, dermatologist, or cardiologist where a complex diabetes, skin, or cardiac condition would warrant specialty input.

Assure that you will remain their doctor and coordinate with the behavioral health specialist to the degree they (your Pt.) wish.

Pharmacotherapy Basics for Personality Disorders

Sxs such as paranoid ideation (such as that which may be present with cluster A disorders) may improve with low dose antipsychotics (e.g. haloperidol, risperidone, olanzapine). Where overt psychotic Sxs are suspect, consult with a psychiatrist

Cluster B disorders should be evaluated for prominent mood Sxs. If present, SSRIs may assist

Prominent mood fluctuation and instability may be addressed with mood stabilizers (e.g. valproate, lithium). Again, psychiatric consultation may be advisable.

For Cluster C disorders, prominent fear & anxiety may also be assisted with SSRI and/or brief course of benzodiazipine.

• From Behavioral Medicine in Primary Care: A Practical Guide © 2003

Cases and Q&A

Primary Care Cases Some of my cases:

1. Mr. “So What” (Looking for Mr. “write” Rx)

2. Ms. “In my stocking feet”

3. Mr. “I know no one” (but my wife is very outgoing)

Your cases…