1. Personality Disorders in the Primary Care Setting
Presented by: Jonathan Betlinski, MD
Date: 02/02/2017 1 1

2. Learning Objectives: Disclosures and Learning Objectives
Know what percentage of Primary Care Patients have a Personality Disorder
Be familiar with the common diagnostic features of Personality Disorders
Know the names and clusters of all ten Personality Disorders
Be able to name at least three strategies for success with each Disorder Cluster
Disclosures: Dr. Jonathan Betlinski has nothing to disclose. 2 2

3. Review the epidemiology of Personality Disorders
Personality Disorders in Primary Care
Review the epidemiology of Personality Disorders
Review the diagnostic criteria for Personality Disorders
Discuss the impact of Personality Disorders in Primary Care
Discuss strategies for working with those who have Personality Disorders 3 3

4. Personality Disorders: Epidemiology
Personality Disorders are quite common
9% currently have a Personality Disorder
10-13% lifetime prevalence
Up to 30% of Primary Care patients
Individuals with Personality Disorders have
Poorer health status
Poorer treatment outcomes
Higher rates of healthcare use
Higher overall healthcare costs

5. Prevalence of Personality Disorders
Total – 10.6%
Paranoid – 5.1%
Schizoid – 1.7%
Schizotypal – 1.1%
Antisocial – 1.2%
Borderline – 3.9%
Histrionic – 0.9%
Narcissistic – 2.2%
Avoidant – 6.4%
Dependent – 0.8%
OCPD – 4.7%
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Total – 13.4%
Paranoid – 2.4%
Schizoid – 1.7%
Schizotypal – 0.6%
Antisocial – 0.7%
Borderline – 0.7%
Histrionic – 2.0%
Narcissistic – 0.8%
Avoidant – 5.0%
Dependent 1.5%
OCPD – 2.0%

6. Personality Disorders: Diagnosis
An enduring pattern of inner experience and behavior that deviates markedly from the expectations of an individual’s culture. The pattern is manifested in two (or more) of the following ways
Cognition
Affectivity
Interpersonal Function
Impulse Control
_tr_personalidad_psicosis/material/dsm.pdf

7. Personality Disorders: Diagnosis
B. The enduring pattern is inflexible and pervasive across a broad range of personal and social situations
C. The enduring pattern leads to clinically significant distress or impairment in social, occupational or other important areas of functioning
D. The pattern is stable and of long duration, and its onset can be traced back at least to adolescence or early adulthood
rsonalidad_psicosis/material/dsm.pdf

8. Personality Disorders: Diagnosis
Problematic Personality Patterns Pervasive Persistent Present early

9. Cluster A: Odd or Eccentric Behaviors
Cluster A Personality Disorders
Paranoid
Schizoid
Schizotypal
Management strategies
Adopt a respectful, professional stance
Provide clear expectations
Avoid over-involvement in personal and social issues

10. Paranoid Personality Disorder
Mistrust and Suspiciousness of others (4/7)
Suspects, without sufficient basis, that others are exploiting, harming or deceiving him or her
Is preoccupied with unjustified doubts about the loyalty or trustworthiness of friends or associates
Is reluctant to confide in others because of unwarranted fear that the information will be used maliciously against him or her
Reads hidden demeaning or threatening meanings into benign remarks or events
Persistently bears grudges, i.e. is unforgiving of insults, injuries or slights
Perceives attacks on his or her character or reputation that are not apparent to others and is quick to react angrily or to counterattack
Has recurrent suspicions, without justification, regarding fidelity of spouse or sexual partner
alidad_psicosis/material/dsm.pdf

11. Paranoid Personality Disorder: Management
Challenges
Fear physician may harm
Arguments and other conflict
Strategies for Success
Adopt a professional stance
Provide clear explanations
Be empathetic to fears
Avoid directly challenging paranoia

12. Schizoid Personality Disorder
Restricted Range of Emotional Expression &
Detachment from Social Relationships (4/7)
Neither desires nor enjoys close relationships, including being part of a family
Almost always chooses solitary activities
Has little, if any, interest in having sexual experiences with another person
Takes pleasure in few, if any, activities
Lacks close friends or confidants other than first-degree relatives
Appears indifferent to the praise or criticism of others
Shows emotional coldness, detachment, or flattened affectivity
rsonalidad_psicosis/material/dsm.pdf

13. Schizoid Personality Disorder: Management
Challenges
Delay in seeking care
Appear unappreciative
Strategies for Success
Adopt a professional stance
Provide clear explanations
Avoid over-involvement in personal and social issues

14. Schizotypal Personality Disorder
Cognitive, Behavioral, Perceptual Oddities &
Discomfort with Close Relationships (4/8)
Ideas of reference
Odd beliefs or magical thinking that influences behavior and is inconsistent with subcultural norms
Unusual perceptual experiences, including bodily illusions
Odd thinking and speech (vague, circumstantial, metaphorical, etc)
Suspiciousness or Paranoid Ideation
Inappropriate or constricted affect
Behavior or appearance that is odd, eccentric, or peculiar
Lack of close friends or confidants other than first-degree relatives
rsonalidad_psicosis/material/dsm.pdf

15. Schizotypal Personality Disorder: Management
Challenges
Delay in seeking care
Odd beliefs and behaviors
Strategies for Success
Adopt a professional stance
Provide clear explanations
Tolerate odd beliefs and behaviors
Avoid directly challenging paranoia

16. Cluster B: Dramatic or Erratic Behaviors
Cluster B Personality Disorders
Antisocial
Borderline
Histrionic
Narcissistic
Management Strategies
Set Clear Limits
Avoid Excessive Familiarity
Provide clear, non-technical explanations
population.shtml

17. Antisocial Personality Disorder
Disregard for and Violation of Others’ Rights by age 15 (3/7)
Failure to conform to social norms with respect to lawful behaviors as indicated by repeatedly performing acts that are grounds for arrest
Deceitfulness, as indicated by repeated lying, use of aliases, or conning others for personal profit or pleasure
Impulsivity or failure to plan ahead
Irritability and aggressiveness, as indicated by repeated physical fights or assaults
Reckless disregard for safety of self and others
Consistent irresponsibility, as indicated by repeated failure to sustain consistent work behavior or honor financial obligations
Lack of remorse, as indicated by being indifferent to or rationalizing having hurt, mistreated or stolen from another
psicosis/material/dsm.pdf

18. Antisocial Personality Disorder: Management
Challenging Behaviors
Anger
Deceit
Impulsive or manipulative behavior
Strategies
Carefully investigate concerns and motives
Communicate clearly and non-punitively
Set clear limits

19. Borderline Personality Disorder
Instability of Interpersonal Relationships, Self- Image and Affects (5/9)
Frantic efforts to avoid real or imagined abandonment
A pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation
Identity disturbance: markedly and persistently unstable self-image or sense of self
Impulsivity in at least two areas that are potentially self-damaging
Recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior
Affective instability due to a marked reactivity of mood
Inappropriate, intense anger or difficulty controlling anger
Transient, stress-related paranoid ideation or severe dissociative symptoms
Chronic feelings of emptiness
sicosis/material/dsm.pdf

20. Borderline Personality Disorder: Management
Challenging Behaviors
Fear of rejection and abandonment
Self-destructive acts
Idealization/devaluation of PCP
Strategies
Avoid excessive familiarity
Use Relationship Management Techniques
Refer for Dialectic Behavioral Therapy

21. Histrionic Personality Disorder
Excessive Emotion & Attention-Seeking (5/8)
Is uncomfortable in situations in which he or she is not the center of attention
Interaction with others is often characterized by inappropriate sexually seductive or provocative behavior
Displays rapidly shifting and shallow expression of emotions
Consistently uses physical appearance to draw attention to self
Has a style of speech that is excessively impressionistic and lacking in detail
Shows self-dramatization, theatricality, and exaggerated expression of emotion
Is suggestible, i.e., easily influenced by others or circumstances
Considers relationships to be more intimate than they actually are
onalidad_psicosis/material/dsm.pdf

22. Histrionic Personality Disorder: Management
Challenging Behaviors
Overly dramatic, attention-seeking behavior
Inability to focus on facts and details
Somatization
Strategies
Avoid excessive familiarity
Show professional concern for feelings
Emphasize objective issues

23. Narcissistic Personality Disorder
Grandiosity, Need for Admiration, and Lack of Empathy (5/9)
Has a grandiose sense of self importance
Is preoccupied with fantasies of unlimited success, power, brilliance, beauty or ideal love
Believes that he or she is “special” and unique and can only be understood by, or should associate with, other special or high-status people
Requires excessive admiration
Has a sense of entitlement (expects especially favorable treatment)
Is interpersonally exploitative (takes advantage of others for own ends)
Lacks empathy (unwilling to recognize feelings and needs of others)
Is often envious of others or believes that others are envious
Shows arrogant, haughty behaviors or attitudes
rsonalidad_psicosis/material/dsm.pdf

24. Narcissistic Personality Disorder: Management
Challenging Behaviors
Frequently demanding
Denial of illness
Alternating praise and devaluation of PCP
Strategies for Success
Channel patient’s skills into dealing with illness
Validate concerns
Give attentive and factual responses

25. Cluster C: Anxious or Fearful Behaviors
Cluster C Personality Disorders
Avoidant
Dependent
Obsessive-Compulsive
Management Strategies
Provide reassurance
Provide thorough explanations
Encourage patient participation in treatment

26. Avoidant Personality Disorder
Social Inhibition, Feelings of Inadequacy, Hypersensitivity to Negative Eval (4/7)
Avoids occupational activities that involve significant interpersonal contact, because of fears of criticism, disapproval or rejection
Is unwilling to get involved with people unless certain of being liked
Shows restraint within intimate relationships because of the fear of being shamed or ridiculed
Is preoccupied with being criticized or rejected in social situations
Is inhibited in new interpersonal situations because of feelings of inadequacy
Views self as socially inept, personally unappealing or inferior to others
Is unusually reluctant to take personal risks or to engage in any new activities because they may prove embarrassing
rsonalidad_psicosis/material/dsm.pdf

27. Avoidant Personality Disorder: Management
Challenging Behaviors
Withholds information
Avoids questioning or disagreeing with providers
Strategies for Success
Provide reassurance and validate concerns
Encourage reporting of symptoms and concerns
Consider referral for Behavioral Therapy

28. Dependent Personality Disorder
Excessive need to be taken care of, Submissive/Clinging Behaviors (5/8)
Has difficulty making everyday decisions without an excessive amount of advice and reassurance from others
Needs others to assume responsibility for most major areas of his or her life
Has difficulty expressing disagreement with others because of fear of loss of support or approval
Has difficulty initiating projects or doing things on his or her own
Goes to excessive lengths to obtain nurturance and support from others
Feels uncomfortable or helpless when alone because of exaggerated fears of being unable to care for himself or herself
Urgently seeks another relationship as a source of care and support when a close relationship ends
Is unrealistically preoccupied with fears of being left to take care of himself or herself
nalidad_psicosis/material/dsm.pdf

29. Dependent Personality Disorder: Management
Challenging Behaviors
Urgent demands for attention
Prolongation of illness to obtain care and other attention
Strategies for Success
Provide reassurance; avoid rejection
Schedule regular check-ups
Set realistic limits on availability
Enlist others to support patient personality.pdf

30. Obsessive-Compulsive Personality Disorder
Need for Orderliness, Perfection, Control (4/8)
Is preoccupied with details, rules, lists, order, organization or schedules to the extent that the major point of the activity is lost
Shows perfectionism that interferes with task completion
Is excessively devoted to work and productivity to the exclusion of leisure activities and friendships
Is overconscientious, scrupulous, and inflexible about matters of morality, ethics or values
Is unable to discard worn-out or worthless objects even when they have no sentimental value
Is reluctant to delegate tasks or to work with others unless they submit to exactly his or her way of doing things
Adopts a miserly spending style toward both self and others
Shows rigidity and stubbornness
personalidad_psicosis/material/dsm.pdf

31. Obsessive-Compulsive Personality Disorder: Management
Challenging Behaviors
Fear of relinquishing control
Excessive questions and attention to details
Anger about disruption of routines
Strategies for Success
Thorough histories, exams and explanations
Encourage patient participation in treatment
Do not overemphasize uncertainty

32. Personality Disorders: Pharmacology
Lithium may be helpful for aggression
AEDs may help mood instability, irritability and impulsivity
Antipsychotics may help psychotic symptoms, especially in Schizotypal PD
SSRIs may help BPD
SSRIs may help with Cluster C anxiety

33. Summary Personality Disorders are very common in Primary Care settings
Remembering the basic features of each cluster (and disorder) will help you remember the best style of interaction
Pharmacology is less likely to be helpful for Personality Disorders
When in doubt, refer for an assessment and therapy 33 33

34. Assessing Borderline Personality Disorder
The End!
Assessing Borderline Personality Disorder
02/09/17 34 34