B2B: Personality Disorders
Michelle Mathias, MA, MD, FRCPC
April 3, 2013
Special thanks…
… to Dr. Deanna Mercer
Objectives
 General:
 Differentiate between PD and other mental
illness, recognizing the high prevalence of comorbidities
 Formulate appropriate management plan
Objectives
 Specific:
 List & interpret critical clinical findings, inc:
 Sufficient clinical info (e.g. MSE) to dx type of PD
 Risk factors associated with PDs (e.g. SI, substance)
 Any co-existing psych conditions (e.g. mood d/o)
 Construct an effective initial management plan, inc:
 Proper management for pt needing immediate intervention
(e.g. suicide risk, risk to others)
 Judicious use of pharmacotherapy, with consideration of risk
for abuse or overdose
 Referral for multi-disciplinary and/or specialized care, if
needed
2-pass approach
Criteria/overview
objective/detailed
By
B2B… PDs from the start
…definitions & diagnostic criteria!
Definitions
 Personality:
 Individual’s characteristic pattern of response to
his/her enviro
 Includes: how one…
 Thinks (cognitive)
 Feels (affective)
 Acts (behavioural)
 Relates to others (interpersonal)
 Etiology: transactional model
 Temperament (bio) + Environmental (social)
time
Definitions (cont’d)
 Personality Disorders:
 Clinically significant distress or impairment in functioning
 Enduring pattern of inner experience and behaviour that
deviates markedly from expectations of individual’s culture
 Impacts: 2 or more
 cognition, affectivity, interpersonal fxn & impulse control
 Pattern:
 Inflexible & pervasive across broad range of personal and social situations
 Not better accounted for by other mental disorder, GMC or
substance
Definitions (cont’d)
 Personality Disorders:
 Ego-syntonic:
 Individual experiences sig distress, but doesn’t feel their thoughts,
emotions or behaviors are source of their problem
 Locus of control: external
 E.g. OCPD
VS
 Ego-dystonic:
 Individual sees their disorder as arising from their own thoughts,
emotions or behaviours
 Locus of control: internal
 E.g. OCD
Definitions (cont’d)
 Personality Disorder Clusters: 3-4-3
 Cluster A: ODD
 Schizoid, Schizotypal, Paranoid
 Cluster B: Dramatic
 Borderline, Histrionic, Narcissistic, Antisocial
 Cluster C: Anxious
 Obsessive Compulsive, Dependent, Avoidant
Cluster A
Paranoid, Schizoid, Schizotypal
Paranoid PD
 Pervasive pattern of:
 Distrust and suspiciousness of others
 Motives of others are interpreted as malevolent
… beginning by early adulthood and present in various
settings
 Practically:
 Looks like delusional d/o (paranoid type), but
 No full blown delusions
 More pervasive suspiciousness
Schizoid PD
 Pervasive pattern of:
 Detachment from social relationships
 Restricted range of expression of emotions in interpersonal settings
… beginning by early adulthood and present in various settings
 Practically:
 Mostly solitary activities
 Few friends other than first degree
 Cold & detached
 Little or no interest in relations; solitary lifestyle
 Indifferent to praise or criticism
Schizotypal PD
 Pervasive pattern of:
 Social and interpersonal deficits
 Acute discomfort with and reduced capacity for close relationships
 Cognitive or perceptual distortions or eccentricities of behaviour
… beginning by early adulthood and present in various settings
 Practically:
 Eccentric behaviours
 Odd beliefs, unusual perceptions, suspiciousness, paranoia, odd
speech
 Discomfort in close relationships - paranoia
 (not b/c of fear of judgment)
Flashback…
(-) sx
Cog
sx
(+)
sx
Schizophrenia
Flashback…
(-) sx
Cog
sx
(+)
sx
Schizo
Schizophrenia
ypal
Flashback…
(-) sx
Devoid…
Schizoid
Cog
sx
(+)
sx
Schizo
Schizophrenia
ypal
Cluster B
Antisocial, Borderline, Histrionic, Narcissistic
Antisocial PD
 Pervasive pattern of:
 Disregard for and violation of rights of others
… since age of 15 (must be at least 18yo)
 Practically:
 Repeated lawbreaking
 Deceitfulness
 Impulsivity
 Irritability and aggressiveness
 Disregard for safety of self or others
 Consistent irresponsibility
 Lack of remorse
Borderline PD
Borderline PD
 Pervasive pattern of:
 Instability of interpersonal relationships
 Instability of self-image and affects
 Marked impulsivity
… beginning by early adulthood and present in various
contexts
 Practically:
 Efforts to self-harm or end life
 Unstable relationships
 Mood lability
Histrionic PD
 Pervasive pattern of:
 Excessive emotionality
 Attention seeking
… beginning by early adulthood and
present in various settings
 Practically:
 Theatrical
 Intense but shallow emotions
 Craves being centre of attention
Narcissistic PD
 Pervasive pattern of:
 Grandiosity (in fantasy or
behaviour)
 Need for admiration
 Lack of empathy
… beginning by early
adulthood and present in
various contexts
Cluster C
Avoidant, Dependent, Obsessive Compulsive
Avoidant PD
 Pervasive pattern of
 Social inhibition
 Feelings of inadequacy
 Hypersensitivity to negative evaluation
… beginning by early adult and present in various contexts
 Practically:
 Similar to social phobia, but more pervasive
Dependent PD
 Pervasive and excessive need to be taken care of, leads to:
 Submissive and clinging behaviour
 Fears of separation
… beginning by early adult and present in various contexts
 Practically:
 Dependent on relationships
 Difficulty making everyday decisions without a lot of advice,
reassurance from others
 Unable to disagree with others because fears loss of support
 Will do things that are unpleasant, degrading to maintain support
Obsessive Compulsive PD
 Pervasive pattern of preoccupation with:
 Orderliness
 Perfectionism
 Mental and interpersonal control
… at the expense of flexibility, openness and efficiency
… beginning by early adult and present in various contexts
 Practically:
 Controlling of others, inflexible
 Excessively devoted to work
 Reluctant to delegate tasks
 Emotionally constricted
2-pass approach
Criteria/overview
objective/detailed
By
Objectives
 Specific:
 List & interpret critical clinical findings, inc:
 Sufficient clinical info (e.g. MSE) to dx type of PD
 Risk factors associated with PDs (e.g. SI, substance)
 Any co-existing psych conditions (e.g. mood d/o)
 Construct an effective initial management plan, inc:
 Proper management for pt needing immediate intervention (e.g. suicide
risk, risk to others)
 Judicious use of pharmacotherapy, with consideration of risk for abuse or
overdose
 Referral for multi-disciplinary and/or specialized care, if needed
Objectives
 Specific:
 List & interpret critical clinical findings, inc:
 Criteria (done) & MSE
 Risk factors associated with PDs (e.g. SI, substance)
 Any co-existing psych conditions (e.g. mood d/o)
 Construct an effective initial management plan, inc:
 Proper management for pt needing immediate intervention (e.g.
suicide risk, risk to others)
 Judicious use of pharmacotherapy, with consideration of risk for
abuse or overdose
 Referral for multi-disciplinary and/or specialized care, if needed
Objectives
 Specific:
 List & interpret critical clinical findings, inc:
 MSE
 Risk factors & prognosis
 Any co-existing psych conditions (e.g. mood d/o)
 Construct an effective initial management plan, inc:
 Proper management for pt needing immediate intervention (e.g.
suicide risk, risk to others)
 Judicious use of pharmacotherapy, with consideration of risk for
abuse or overdose
 Referral for multi-disciplinary and/or specialized care, if needed
Objectives
 Specific:
 List & interpret critical clinical findings, inc:
 MSE
 Risk factors & prognosis
 Comorbidities
 Construct an effective initial management plan, inc:
 Proper management for pt needing immediate intervention (e.g.
suicide risk, risk to others)
 Judicious use of pharmacotherapy, with consideration of risk for
abuse or overdose
 Referral for multi-disciplinary and/or specialized care, if needed
Objectives
 Specific:
 List & interpret critical clinical findings, inc:
 MSE
 Risk factors & prognosis
 Comorbidities
 Construct an effective initial management plan, inc:
 Risk assessment & acute management (safety)
 Judicious use of pharmacotherapy, with consideration of risk for
abuse or overdose
 Referral for multi-disciplinary and/or specialized care, if needed
Objectives
 Specific:
 List & interpret critical clinical findings, inc:
 MSE
 Risk factors & prognosis
 Comorbidities
 Construct an effective initial management plan, inc:
 Risk assessment & acute management (safety)
 Pharmacotherapy
 Referral for multi-disciplinary and/or specialized care, if needed
Objectives
 Specific:
 List & interpret critical clinical findings, inc:
 MSE
 Risk factors & prognosis
 Comorbidities
 Construct an effective initial management plan, inc:
 Risk assessment & acute management (safety)
 Pharmacotherapy
 Non-pharm treatment
Objectives
 List & interpret critical clinical findings, inc:
 MSE
 Risk factors & prognosis
 Comorbidities
 Construct an effective initial management plan, inc:
 Risk assessment & acute management (safety)
 Pharmacotherapy
 Non-pharm treatment
General Word on Tx approach
Bio
Acute – safety
(self & others)
Short-term
(stabilization)
Long-term
(maintenance)
Psycho
Social
Cluster A
Paranoid, Schizoid, Schizotypal
Paranoid PD
(refresher… which one is this?)
 MSE:
 evasive, minimal answers, suspicious, paranoid thought content,
serious, humourless affectively restricted, lack warmth
 Risk factors & prognosis:
 Relatives often have Schizophrenia
 Lifelong problem working & living with others
 Comorbidities:
 Other cluster A PDs, mood disorder, substance use, agoraphobia,
OCD
Paranoid PD
(refresher… which one is this?)
 Risk assessment & acute management (safety):
 Suicide attempters in ER: 9% with PPD
 Pharmacotherapy:
 Antidepressants as indicated
 Low dose antipsychotic for brief psychotic episodes (increased
stress)
 Non-pharm treatment:
 Rarely seek help – insufficient trust to engage in process
 CBT – address core beliefs
 Group therapy – tend not to tolerate
Schizoid PD
(refresher… which one is this?)
 MSE:
 Cold, constricted, aloof, difficulty gaining rapport, odd metaphors, ill at ease,
difficulty tolerating eye contact
 Risk factors & prognosis:
 Parents – cold, neglectful, suggest relationships not worth
pursuing
 Introversion
 Possible family link – schizophrenia
 Childhood onset, likely stable course
 Comorbidities:
 other cluster A PDs, mood d/o, anxiety d/o
Schizoid PD
(refresher… which one is this?)
 Risk assessment & acute management (safety):
 Low insight, low motivation… not usually self-directed for tx
 Suicide attempters in ER: 4%
 Pharmacotherapy:
 Low-dose antipsychotic, antidepressants
 Non-pharm treatment:
 Psychoeducation
 Therapeutic distance needed for pt to tolerate relationship
 Social skills training
Schizotypal PD
(refresher… which one is this?)
 MSE:
 Superstitious, difficulty identifying own feelings, odd mannerisms
and interests, prone to minimal responses (use open-ended
questions), peculiar speech, appear unusual
 Risk factors & prognosis:
 10% commit suicide; pre-morbid personality of schizophrenia (or
milder version of); 10-20% develop schizophrenia
 14% have schizophrenia in family
 Comorbidities:
 Other cluster A PDs, depression, possible Borderline PD traits
(poor interpersonal relationships)
Schizotypal PD
(refresher… which one is this?)
 Risk assessment & acute management (safety):
 SI assessment; intensity of delusion-like beliefs
 Pharmacotherapy:
 Treat comorbidities
 Mild-mod improvement with low-dose antipsychotics
 Non-pharm treatment:
 Supportive psychotherapy
 Social skills training
 Encourage activity, but does not have to be social
Cluster B
Antisocial, Borderline, Histrionic, Narcissistic
Antisocial PD
(refresher… which one is this?)
 MSE:
 Try to impress MD, good verbal intelligence; possibly demanding
 Appear composed & credible (underneath = tension, hostility… may need to
push to discover)
 Risk factors & prognosis:
 Px better if connected to some group
 Decrease impulsivity & criminal behaviour, but continue to be difficult people
 ++ substance risk; ++ legal involvement
 Comorbidities:
 Substance use disorders; other cluster B PDs, impulse control disorders,
ADHD
Antisocial PD
(refresher… which one is this?)
 Risk assessment & acute management (safety):
 Harm to others!! Legal risk
 Pharmacotherapy:
 Mood stabilizers for impulsivity
 Stimulants for ADHD
 Tx comorbid depression, anxiety
 Non-pharm treatment:
 Firm limits
 Rational Emotive Therapy (CBT alternative)
 Psychoeducation
 Probation officers
Borderline PD
(refresher… which one is this?)
 MSE:
 Manipulation, splitting, inconsistencies, avoiding, deflecting, dramatic, poor
problem solving, insight varies, poor judgment, thought process can vary and
be significantly impaired in great distress
 Risk factors & prognosis:
 Abusive upbringing, substance use disorders
 Can decrease over time, but less so than other PDs
 Comorbidities:
 Other cluster B PDs, somatization disorders
 Mood disorders (BPD vs Bipolar), anxiety disorders (social anxiety)
 Brief psychotic episodes
 Substance use disorders
Borderline PD
(refresher… which one is this?)
 Risk assessment & acute management (safety):
 SAFETY!!! Self-harm, suicide attempts, aggressive acts towards others
 Hospitalization if needed… try to avoid
 DBT support; ACT teams
 Pharmacotherapy:
 Avoid TCAs (lethal in OD); SSRIs; mood stabilizers
 Antipsychotics for psychotic sx (derealization)
 Non-pharm treatment:
 DBT (modified CBT); individual + group
 Psychoeducation… give them the diagnosis!
 Psycho-analytic – NOT appropriate
 Social skills training
 Family & couples therapy
Histrionic PD
(refresher… which one is this?)
 MSE:
 Dramatic, temper tantrums, superficial (nil when go deeper),
dramatic appearance (often sexual, esp clothing), eye contact
varies
 Risk factors & prognosis:
 As age, sx decrease
 History of sexual abuse
 Substance use
 Comorbidities:
 Other cluster B PDs, brief psychotic episodes, somatization, DID
Histrionic PD
(refresher… which one is this?)
 Risk assessment & acute management (safety):
 Substance use
 Suicide attempts and ideation
 Heteroagressive ideation (“heat of passion”)
 Pharmacotherapy:
 Treat comorbidities: antidepressants (depression, anxiety, somatic complaints)
 Anti-psychotics: for derealization & illusions
 Non-pharm treatment:
 Psychoanalysis is ideal
 Insight-oriented
 Psychoeducation
 Family & couples therapy
Narcissistic PD
(refresher… which one is this?)
 MSE:
 Want their own way, no empathy, fake sympathy, superficial
rapport; vague answers or avoiding
 Risk factors & prognosis:
 Substance use
 Upbringing with limited support and warmth
 Comorbidities:
 Substance use, mood disorders, anxiety disorders
 Other Cluster B PDs, sexual disorders
Narcissistic PD
(refresher… which one is this?)
 Risk assessment & acute management (safety):
 Rejection, loss, occupational problems, interpersonal problems
 Substance use
 Pharmacotherapy:
 Antidepressants
 Treat comorbidities (substance use disorders treatment)
 Non-pharm treatment:
 Insight-oriented therapy
 Probation officers
 Family & couples therapy
 Social skills training – learn how to develop empathic response for others
Cluster C
Avoidant, Dependent, Obsessive Compulsive
Avoidant PD
(refresher… which one is this?)
 MSE:
 Timid, lack self-confidence, afraid to speak, ++ anxiety during
interview, hypersensitive to disapproval or rejection
 Do not express wishes, opinions, needs
 Risk factors & prognosis:
 Genetic link with social phobia
 Parents – inconsistent, absent, abusive, discouraging
 Comorbidities:
 Anxiety d/o (social phobia - generalized, agoraphobia)
 Depression, dysthymia
Avoidant PD
(refresher… which one is this?)
 Risk assessment & acute management (safety):
 Risk comes from associated anxiety and depression
 Risk of substance use – to cope with anxiety
 Pharmacotherapy:
 Treat comorbidities: anti-depressant
 Beta adrenergic receptor antagonists (Atenolol): decrease
autonomic arousal
 Non-pharm treatment:
 Assertiveness & social skills
 CBT – core beliefs
 Mindfulness
Dependent PD
(refresher… which one is this?)
 MSE:
 Submissiveness; rapport is easy, but deeper exploration is difficult; easy to
interview… want you to like them… watch for boundary violations
 Lack of self-confidence, pessimistic, helpless, childlike, ++ anxiety
 Risk factors & prognosis:
 Pts with chronic physical illnesses
 Can’t fxn independently; limited social relations
 Suicide risk: termination of Dependent relationship -
 Comorbidities:
 Mood disorders (MDD, adjustment d/o), anxiety disorders (social phobia,
agoraphobia)
 BPD, histrionic PD, avoidant PD
Dependent PD
(refresher… which one is this?)
 Risk assessment & acute management (safety):
 Suicide risk, safety
 Isolation
 Pharmacotherapy:
 Treat comorbidities: anti-depressants
 Non-pharm treatment:
 Psychodynamic approach
 CBT
 Social skills training
 Family/ couples therapy
OCPD
(refresher… which one is this?)
 MSE:
 Stiff, formal, rigid demeanor, lack spontaneity; stickler for rules
 Detailed answers; constricted affect; eager to please (esp MD)
 Routine disturbed = anxiety; indecisive (fear of making mistake)
 Risk factors & prognosis:
 Parental control, perfectionism, shame, criticism
 Pressures can lead to mood & anxiety d/o… suicide concern
 Comorbidities:
 Other anxiety disorders
 Depressive disorders, dysthymia
 Vs OCPD (egodystonic): 30% OCPD have OCD (not same in reverse)
 NPD, Schizoid, somatoform d/o
OCPD
(refresher… which one is this?)
 Risk assessment & acute management (safety):
 Status of mood and anxiety
 Substance use – less prevalent (against rules; makes more anxious)
 Pharmacotherapy:
 Antidepressants
 Benzos… bad for anxiety disorders; some use short-term
 Non-pharm treatment:
 CBT… careful for the perfect homework!
 Psychoeducation
 Family & couples therapy
Resources
“Brain Calipers”
“Field Guide to Disordered Personalities”
(David Robinson, Rapid Psychler Press)
Thank You
… questions? comments?
Michelle Mathias
mmath051@uottawa.ca