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INTRODUCTION TO MEDCINE IIINTRODUCTION TO MEDCINE II

PSYCHIATRYPSYCHIATRY

PERSONALITY DISORDERS

INSTRUCTOR: JIMMY SANTANA, P.A. - C

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PDs Characteristics PDs Characteristics

Presence of long-standing, rigid, unsuitable pattern of relating to others

Presence of personality characteristics that cause social and occupational impairment

Lack of insight Failure to seek psychological help unless

compelled by others Absence of frank psychosis

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Personality Disorder ClustersPersonality Disorder Clusters

There are three clusters

1. Cluster A: Patient is eccentric and/or fears social

relationships Includes:

– Paranoid personality disorder

– Schizoid personality disorder

– Schizotypal personality disorder

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2. Cluster B Patient is emotional, erratic, and/or dramatic Includes:

– Histrionic personality disorder– Narcissistic personality disorder– Antisocial personality disorder– Borderline personality disorder

3. Cluster C Patient is fearful and/or anxious Includes:

– Avoidant personality disorder– Obsessive-compulsive personality disorder– Dependent personality disorder

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EpidemiologyEpidemiology Personality disorder is prevalent in @ 1% of

population Schizoid personality disorder may be less

common More common (slightly) are

– Dependent personality disorder

– Schizotypal personality disorder

– Histrionic personality disorder

Symptoms must be present by early adulthood for diagnosis

Antisocial personality disorder can notcan not diagnosed until 18 years of age

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Relatives of patients with personality disorders may have other psychiatric disorders:

1. Schizoid, Schizotypal and Parannoid – schizophrenia

2. Paranoid - delusional disorder (persecutory type)

3. Antisocial – substance abuse and somatization disorders

4. Borderline -- Mood disorders, substance abuse and antisocial personality disorder

5. Avoidant -- anxiety disorder

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The patients with PDs have excessive use of maladaptive or inappropriate defense mechanisms

Prognosis for these patients is that the disease is chronic and lifelong

Medication for these patients are not useful except in borderline personality disorder

Medication is usually for symptoms associated with depression and anxiety

It is important to remember that PD patients have a high potential for addiction THEREFORE--- BE CAUTIOUS WHEN PRESCRIBING MEDICATIONS

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PARANOID PERSONALITY PARANOID PERSONALITY DISORDERDISORDER

PATIENT WITH THIS DISORDER ARE:– SUSPICIOUS

– MISTRUSTFUL

– LITIGIOUS

– ATTRIBUTES RESPONSIBILTY FOR PROBLEMS TO OTHERS

DEFENSE MECHANISM USED ARE– PROJECTION

– DENIAL

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TYPICAL PATIENT PRESENTATION

50 YEAR-OLD OFFICE WORKER TELLS YOU THAT HE HAS NEVER BEEN PROMOTED BECAUSE HIS CO-WORKERS FREQUENTLY CLAIM HIS IDEAS AS THEIR OWN. WHEN HE IS FIRED FOR POOR PERFORMANCE, HE FILES A LAWSUIT AGAINST THE COMPANY

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Schizoid Personality DisorderSchizoid Personality Disorder

These patients have a life long pattern of voluntary social withdrawal

Similar to delusional disorder and schizophrenia but without frank psychotic symptoms

In the young can be mistaken for mild autistic disorder

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TYPICAL PATIENT PRESENTATION

48 YEAR-OLD MAN IS CONTENT LIVING ALONE IN AN ISOLATED CABIN, GROWING HIS OWN FOOD, AND RARELY HAVING CONTACT WITH OTHERS

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SCHIZOTYPAL PERSONALITY SCHIZOTYPAL PERSONALITY DISORDERDISORDER

THESE PATIENTS HAVE:– PECULIAR APPEARANCE– MAGICAL THINKING– ODD THOUGHT PATTERNS AND

BEHAVIOR WITHOUT PSYCHOSIS– MAJOR DEPRESSION COULD BE FOUND

(CO-MORBIDEDLY) IN THESE PATIENTS

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DENIAL AND PROJECTION ARE USED AS DEFENSE MECHANISMS

DDX:– DELUSIONAL DISORDER– SCHIZOPHRENIA– MOOD DISORDER WITH PSYCHOSIS

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TYPICAL PATIENT PRESENTATION

35 YEAR-OLD MALE PATIENT TELLS YOU THAT HE NEVER STEPS ON CRACKS IN THE SIDEWALK TO AVOID “BREAKING HIS MOTHER’S BACK”(MAGICAL THINKING). HE SEEMS ODD, SAYS THAT HE OFTEN FEELS UNCOMFORTABLE IN SOCIAL SITUATIONS AND HAS FEW FRIENDS

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HISTRIONIC PERSONALITY HISTRIONIC PERSONALITY DISORDERDISORDER

THESE PATIENTS ARE:

– EXTROVERTED– EMOTIONAL– DRAMATIC– SEXUALITY PROVOCATIVE (LIFE OF THE

PARTY)– INABILITY TO MAINTAIN INTIMATE

RELATIONSHIPS– “DON JUAN” BEHAVIOR IN MEN

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DEFENSE MECHANISM:– REPRESSION– REGRESSION– SOMATIZATION

DDX:1. BORDERLINE PD: SHOULD INCLUDE CHRONIC

FEELINGS OF BOREDOM, EMPTINESS AND SUICIDAL BEHAVIORAL

2. NARCISSISTIC PD: SHOULD INCLUDE FEELINGS OF SUPERIOITY

3. DEPENDENT PD: NO FLAMBOYANCE OR AN OVERLY EMOTIONAL STATE

4. HYPOMANIC EPISODE IN BIPOLAR II OR CYCLOTHYMIC DISORDER: SYMPTOMS REMIT WHEN THE EPISODE ENDS

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TYPICAL PATIENT PRESENTATION

25 YEAR-OLD FEMALE PATIENT COMES TO YOUR OFFICE DRESSED IN A LOW – CUT BLOUSE AND VERY SHORT SKIRT AND BRINGS A GIFT FOR YOU. SHE FISHES FOR COMPLIMENTS FROM THE OFFICE STAFF AND TELLS YOU THAT YESTERDAY SHE “ALMOST BLED TO DEATH” WHEN SHE CUT HER FINGER.

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Narcissistic Personality Narcissistic Personality DisorderDisorder

These patients are:– Grandiose– Envious– Has sense of special entitlement– Lack empathy

Defense Mechanism:– Denial– Displacement– Poor ego functioning

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DDX:

– Histrionic PD and Borderline PD [ include emotionality and instability]

– Obsessive – Compulsive PD [includes feelings of imperfection]

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TYPICAL PATIENT PRESENTATION

40 YEAR – OLD MALE PATIENT TELLS YOU THAT BECAUSE YOU ARE A DOCTOR, YOU CAN UNDERSTAND THAT HE IS “ BETTER THAN MOST PEOPLE.” HE THEN ASKS TO BE REFERRED TO A PHYSICIAN WHO GRADUATED FROM AN IVY LEAGUE SCHOOL.

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ANTISOCIAL PERSONALITY ANTISOCIAL PERSONALITY DISORDERDISORDER

THESE PATIENTS ARE:– ALSO KNOWN AS SOCIOPATHS OR

PSYCHOPATH– UNWILLING TO CONFORM TO SOCIAL

NORMS– FAIL TO LEARN FROM EXPERIENCES– ASSOCIATED WITH CONDUCT

DISORDER IN CHILDHOOD– CRIMINALITY IN ADULTHOOD

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DEFENSE MECHANISM:– INADEQUATE SUPEREGO FUNCTIONING

DDX:– SUBSTANCE ABUSE– CRIMINAL BEHAVIOR– NARCISSISTIC PD– PARANOID PD– HYPOMANIC EPISODE IN BIPOLAR II OR

CYCLOTHYMIC DISORDERS

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TYPICAL PATIENT PRESENTATION

A 29 YEAR- OLD MAN TELLS YOU THAT HE HAS STOLEN VALUABLE ITEMS FROM FRIENDS AND FAMILY ON MANY OCCASSIONS WITH NO INTENTION OF RETURNING THEM AND WITHOUT CONCERN FOR THE PEOPLE HE STOLE FROM. HE HAS BEEN UNEMPLOYED ON AND OFF FOR MANY YEARS AND HAS BEEN ARRESTED ON A VARIETY OF MINOR CHARGES.

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BORDERLINE PERSONALITY BORDERLINE PERSONALITY DISORDERDISORDER

THESE PATIENTS ARE:– UNSTABLE BEHAVIOR AND MOOD– BOREDOM, EMPTINESS – FEELINGS OF ALONENESS– IMPULSIVENESS– SUICIDE ATTEMPTS– BRIEF PERIOD OF LOSS OF CONTACT

WITH REALITY (MINI – PSYCHOTIC EPISODES)

– OFTEN COMORBID WITH MOOD DISORDER

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DEFENSE MECHANISM:– DENIAL– DISPLACEMENT– SPLITTING– POOR EGO FUNCTIONING

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TYPICAL PATIENT PRESENTATION

A 39 – YEAR – OLD FEMALE PATIENT TELLS YOU ON HER SECOND VISIT THAT SHE IS IN LOVE WITH YOU. WHEN YOU REFER HER TO ANOTHER PRACTITIONER, SHE ATTEMPTS SUICIDE

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AVOIDANT PERSONALITY AVOIDANT PERSONALITY DISORDERDISORDER

THESE PATIENTS ARE:– SHY– SENITIVE TO REJECTION– SOCIALLY WITHDRAWN– HAS INFERIORITY COMPLEX

DEFENSE MECHANISM:– AVOIDANCE– REGRESSION

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DDX:

– SOCIAL PHOBIA– DEPENDENT PD– SCHIZOID PD

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TYPICAL PATIENT PRESENTATION

A 40 YEAR – OLD WOMAN WHO LIVES ALONE SEEMS TENSE AND FEARFUL. SHE TELLS YOU THAT SHE WOULD LIKE TO HAVE FRIENDS BUT IS AFRAID THAT PEOPLE WILL NOT LIKE HER.

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OBSESSIVE – COMPULSIVE OBSESSIVE – COMPULSIVE PERSONALITY DISORDERPERSONALITY DISORDER

THESE PATIENTS ARE:– PERFECTIONISTIC

– ORDERLY

– STUBBORN

– INDECISIVE

DEFENSE MECHANISM– ISOLATION OF AFFECT

– RATIONALIZATION

– INTELLECTUALIZATION

– UNDOING

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DDX:– OBSESSIVE – COMPULSIVE DISORDER

TYPICAL PATIENT PRESENTATION

A 32 YEAR – OLD MALE PATIENT TELLS YOU THAT HIS FOURTH ROOMMATE HAS JUST MOVED OUT BECAUSE THE PATIENT MAKES UNREASONABLE RULES AND SCHEDULE CONCERNING THE CARE OF THE APARTMENT

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DEPENDENT PERSONALITY DEPENDENT PERSONALITY DISORDERDISORDER

THESE PATIENTS ARE:– LACKS SELF – CONFIDENCE– LETS OTHERS ASSUME THEIR

RESPONSIBILITIES

DEFENSE MECHANISM– REGRESSION– AVOIDANCE

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DDX:– DEPRESSION

TYPICAL PATIENT PRESENTATION

A 30 YEAR – OLD FEMALE PATIENT CALLS YOUR OFFICE FREQUENTLY TO ASK YOUR ADVICE ABOUT OBVIOUS, MINOR MEDICAL PROBLEMS

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PASSIVE – AGGRESSIVE PASSIVE – AGGRESSIVE PERSONALITY DISORDERPERSONALITY DISORDER

THESE PATIENTS ARE:– STUBBORN– INEFFICIENT– PROCASTINATES– SEEMS COMPIANT BUT ARE DEFIANT– NO LONGER A DSM IV DIAGNOSIS

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TYPICAL PATIENT PRESENTATION

TWO WEEKS AFTER YOUR 40 YEAR – OLD MALE PATIENT AGREES THAT HE NEEDS TO LOSE 10 POUNDS AND YOU SPEND TIME DESCRIBING AN APPROPRIATE DIET, HE HAS GAINED 2 POUNDS AND TELLS YOU THAT HE DID NOT YET “GET A CHANCE” TO BUY THE NECESSARY DIET.