1. Personality Disorders Mark Kimsey, M.D. March 8, 2014

2. Objectives Understanding personality disorders using criteria from DSM-5. Learn approaches for separating personality disorders from other major illnesses. Review non-pharmacologic treatment approaches.

3. General Information Data from 2001-2002 National Epidemiological Survey on Alcohol and Related Conditions suggest that 15% of U.S adults have at least one personality disorder. People frequently have more than one co- occurring personality disorder It is extremely common for people with other psychiatric problems to also have personality disorders

4. DSM-5 Recent update of the Diagnostic and Statistical Manual of Mental Disorders Personality disorders discussed in 2 sections. – Section II- Diagnostic criteria and Codes Same diagnoses and criteria as DSM-IV Categorical model that sees personality disorders as distinct clinical syndromes – Section III- Emerging Measures and Models Dimensional model- personality disorders vary and merge into each other and into normality.

5. General Personality Disorder Enduring pattern of inner experience and behavior that deviates markedly from expectations of the individual’s culture. Manifested in 2 or more of 4 areas: – Cognition- (ways of perceiving and interpreting self, others, and events). – Affectivity- (range, intensity, lability, and appropriateness of emotional response). – Interpersonal Functioning – Impulse Control

6. General Personality Disorder (cont’d) Enduring pattern is inflexible and pervasive across a broad range of personal/social situations. Enduring pattern leads to significant distress or impairment in social, occupational, or other important areas of functioning. Stable and of long duration, beginning in at least adolescence or early adulthood.

7. General Personality Disorder (cont’d) Enduring pattern not better explained by another mental disorder. Enduring pattern not attributable to effects of a substance or medical condition.

8. DSM-5 Organization No longer coded as 5 Axis system. May code more than one diagnosis if fits criteria. Broken down into 3 clusters – Cluster A-Paranoid, Schizoid, Schizotypal – Cluster B- Antisocial, Borderline, Histrionic, Narcissistic – Cluster C- Avoidant, Dependent, Obsessive- Compulsive Also- Other, unspecified, due to another medical condition

9. Cluster A- Odd/Eccentric Paranoid P.D. (2.3-4.4%) Pattern of distrust and suspiciousness. Sees others as malevolent. Schizoid P.D. (3.1-4.9%) Detachment from social relationships and a restricted range of emotional expression. Schizotypal P.D.(3.9-4.6%) Eccentric behaviors, discomfort in close relationships, ideas of reference, odd beliefs.

10. Cluster B- Dramatic Antisocial P.D. (0.2-3.3%) Conduct disorder before age 15 yrs. Pervasive pattern of disregard and violation of rights of others. Criminal, lying, impulsivity, aggression, disregard for safety of self/others, irresponsible, lack of remorse.

11. Cluster B- Dramatic Borderline P.D.(1.6-5.9%) Severe, pervasive pattern of instability in several areas. Fear of abandonment, unstable/intense interpersonal relationships, identity disturbance, impulsivity, suicidal ‘gestures’, intense affective instability, feelings of emptiness, transient paranoia or dissociative sx’s. (Prevalence 6% in primary care settings, 10% in outpatient MH, 20% Inpatient psych)

12. Cluster B- Dramatic Histrionic P.D. (1.84%) Center of attention, provocative, shallow, dramatic, considers relationships to be more intimate than they really are. Narcissistic P.D. (0-6.2%) Grandiose self importance, preoccupation with fantasies of unlimited success, etc., ‘special’, Requires excessive admiration, entitled, exploitative, no empathy, envious.

13. Cluster C- Anxious/Avoidant Avoidant P.D. (2.4%) Severe social inhibition, poor self esteem/image. Dependent P.D. (0.49-0.6%) Sees themselves as needing others, to point of submission, clinging, and fears of separation. Obsessive-Compulsive P.D. (2.1-7.9%) Differentiate from OCD. Other Personality D/O’s

14. Differential Diagnosis Separating and merging different personality disorders, shortcomings of current system Going beyond the chief complaint(s) Longitudinal versus cross-sectional viewpoint Traits versus Personality Disorders Effects of stress, substance abuse, other primary diagnoses, and general medical problems

15. Differential Diagnosis In general, there’s no rush to make a personality disorder diagnosis. May have suspicions on the initial contact, but keep an open mind about other issues/dx’s. Personality Disorders are often ‘cured’ with the appropriate medication. Cutting is not synonymous with Borderline PD.

16. Treatment Approaches Pharmacologic – No FDA approved medications for “Personality Disorders”. – Often based on symptom management. – ‘Kitchen sink’ approach. Throw whatever medications into the mix that seem to reduce symptoms. – “Medicine is the art of entertaining the patient while the body heals itself.”- Voltaire

17. Non-pharmacologic Treatments Most emphasis has been placed on Borderline Personality Disorder. Many challenges to treatment – Insurance limitations- ‘Axis II’. – Who’s distressed? – Dropout from treatment. (lack of motivation, too painful) – Lack of consistency from one therapist to the next. Dialectical behavior therapy (DBT) and Cognitive therapy (CT). Analytically oriented psychotherapy. Interpersonal psychotherapy. Group therapy

18. Dialectical behavior therapy (DBT) Weekly one-on-one counseling sessions and group therapy. Development of skills. – Improved distress tolerance. – Increased interpersonal effectiveness. – Improved regulation of emotions – Mindfulness skills. Has shown significant reduction of self harm and lower rate of dropout than ‘therapy as usual’.

19. Cognitive therapy (CT) Targets dysfunctional core beliefs about the self, others and the world. Usually weekly sessions with therapist. Workbooks, homework assignments, worksheets. Related to Cognitive Behavioral Therapy (CBT). CBT aimed at a wide variety of mood, anxiety, and personality disorders.

20. Alternative DSM-5 Model New approach that was proposed to address numerous shortcomings in prior model. PD’s are characterized by impairments in personality functioning and pathological personality traits. Fewer PD’s – Antisocial, avoidant, borderline, narcissistic, obsessive-compulsive, and scizotypal. – Also PD-TS- personality d/o- trait specified.

21. Alternative DSM-5 Model General Criteria – Moderate or greater impairment in personality (self/interpersonal) functioning – Impairments are pervasive and inflexible – Stable over time – Exclusionary criteria Elements of personality functioning – Self- Identity, self-direction – Interpersonal- Empathy, intimacy

22. Alternative DSM-5 Model Personality traits divided into 5 broad domains – Negative affectivity – Detachment – Antagonism – Disinhibition – Psychoticism Further divided into 25 specific trait facets

23. Negative Affectivity (vs. emotional stability) Emotional labilityPerseveration AnxiousnessDepressivity (also under Detachment) Separation InsecuritySuspiciousness (also under Detachment) SubmissivenessRestricted Affectivity Hostility

24. Detachment (vs. Extraversion) WithdrawalSuspiciousness Intimacy Avoidance Anhedonia Depressivity Restricted Affectivity

25. Antagonism (vs. Agreeableness) Manipulativeness Deceitfulness Grandiosity Attention Seeking Callousness Hostility

26. Disinhibition (vs. Conscientiousness) Irresponsibility Impulsivity Distractibility Risk taking Rigid perfectionism (also lack of)

27. Psychoticism Unusual beliefs and experiences Eccentricity Cognitive and perceptual dysregulation

28. Example- Antisocial PD Personality Functioning- – Identity- Egocentrism – Self- direction- failure to conform to law/culture – Empathy- lack of empathy/remorse – Intmacy- exploitative, dominance Pathological Traits – Antagonism- manipulativeness, callousness, deceitfulness, hostility – Disinhibition- Risk taking, impulsivity, irresponsibility

29. Example- Narcissistic PD Personality functioning – Identity- Needs others for self-definition and self- esteem regulation, extremes – Self-direction- goal setting based on gaining approval, personal standards too high or low – Empathy- severly impaired – Intimacy- Superficial relationships, need for personal gain Personality traits- Antagonism- grandiosity, attention seeking

30. Questions?