Personality Disorders
in the Primary Care Setting
Presented by: Jonathan Betlinski, MD
Date: 02/05/2015
Disclosures and Learning Objectives
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
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
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
http://apt.rcpsych.org/content/8/1/1.full.pdf+html; http://www.aafp.org/afp/2004/1015/p1505.pdf
Prevalence of Personality Disorders
Total – 13.4%
Total – 14.8%
Paranoid – 2.4%
Paranoid – 4.4%
Schizoid – 1.7%
Schizoid – 3.1%
Schizotypal – 0.6%
Schizotypal – (1-5%)
Antisocial – 0.7%
Antisocial – 3.6%
Borderline – 0.7%
Borderline – (1-4%)
Histrionic – 2.0%
Histrionic – 1.8%
Narcissistic – 0.8%
Narcissistic – (0-6%)
Avoidant – 5.0%
Avoidant – 2.4%
Dependent 1.5%
Dependent – 0.5%
OCPD – 2.0%
OCPD – 7.9%
http://www.ncbi.nlm.nih.gov/pubmed/1138
http://www.nih.gov/news/pr/aug2004/niaaa-
Personality Disorders: Diagnosis
A. 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
http://www.psi.uba.ar/academica/carrerasdegrado/psicologia/sitios_catedras/practicas_profesionales/820_clinica
_tr_personalidad_psicosis/material/dsm.pdf
http://www.dsm5.org/Documents/Personality%20Disorders%20Fact%20Sheet.pdf
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
http://www.psi.uba.ar/academica/carrerasdegrado/psicologia/sitios_catedras/practicas_profesionales/820_clinica_tr_pe
rsonalidad_psicosis/material/dsm.pdf
Personality Disorders: Diagnosis
Problematic Personality
Patterns
Pervasive
Persistent
Present early
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
https://www.harvardpilgrim.org/portal/page?_pageid=253,840018&_dad=portal&_schema=PORTAL
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
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 paranoid
ideation http://www.aafp.org/afp/2004/1015/p1505.pdf; http://cdn.hivguidelines.org/wp-
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
http://www.psi.uba.ar/academica/carrerasdegrado/psicologia/sitios_catedras/practicas_profesionales/820_clinica_tr_pe
rsonalidad_psicosis/material/dsm.pdf
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
http://www.aafp.org/afp/2004/1015/p1505.pdf; http://cdn.hivguidelines.org/wp-content/uploads/2009/06/mpersonality.pdf
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
http://www.psi.uba.ar/academica/carrerasdegrado/psicologia/sitios_catedras/practicas_profesionales/820_clinica_tr_pe
rsonalidad_psicosis/material/dsm.pdf
Paranoid 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 paranoid
ideation http://www.aafp.org/afp/2004/1015/p1505.pdf; http://cdn.hivguidelines.org/wp-
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
https://www.harvardpilgrim.org/portal/page?_pageid=253,840018&_dad=portal&_schema=PORTAL
http://www.nimh.nih.gov/news/science-news/2007/national-survey-tracks-prevalence-of-personality-disorders-in-us-
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
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
http://www.aafp.org/afp/2004/1015/p1505.pdf; http://cdn.hivguidelines.org/wp-content/uploads/2009/06/m-
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
•
Chronic feelings of emptiness
•
Inappropriate, intense anger or difficulty controlling anger
•
Transient, stress-related paranoid ideation or severe dissociative
symptoms
Borderline Personality Disorder:
Management
Challenging Behaviors
• Fear of rejection and abandonment
• Self-destructive acts
• Idealization and devaluation of PCP
Strategies
• Avoid excessive familiarity
• Use Relationship Management Techniques
• Refer for Dialectic Behavioral Therapy
http://www.aafp.org/afp/2004/1015/p1505.pdf;
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2379842/pdf/canfamphys00110-0101.pdf
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 ot 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
http://www.psi.uba.ar/academica/carrerasdegrado/psicologia/sitios_catedras/practicas_profesionales/820_clinica_tr_pers
onalidad_psicosis/material/dsm.pdf
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
http://www.aafp.org/afp/2004/1015/p1505.pdf; http://cdn.hivguidelines.org/wp-content/uploads/2009/06/mpersonality.pdf
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
Narcissistic Personality Disorder:
Management
Challenging Behaviors
• Frequently demanding
• Denial of illness
• Alternating praise and devaluation of PCP
Strategies for Success
• Validate concerns
• Give attentive and factual responses
• Channel patient’s skills into dealing with
illness http://www.aafp.org/afp/2004/1015/p1505.pdf; http://cdn.hivguidelines.org/wp-
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
https://www.harvardpilgrim.org/portal/page?_pageid=253,840018&_dad=portal&_schema=PORTAL
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
http://www.psi.uba.ar/academica/carrerasdegrado/psicologia/sitios_catedras/practicas_profesionales/820_clinica_tr_pe
Avoidant Personality Disorder: Management
Challenging Behaviors
• Withholds information
• Avoids questioning providers
• Avoids disagreeing with providers
Strategies for Success
• Provide reassurance and validate concerns
• Consider referral for Behavioral Therapy
• Encourage reporting of symptoms and
concerns http://www.aafp.org/afp/2004/1015/p1505.pdf; http://cdn.hivguidelines.org/wp-
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
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
http://www.aafp.org/afp/2004/1015/p1505.pdf; http://cdn.hivguidelines.org/wp-content/uploads/2009/06/m-
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
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
http://www.aafp.org/afp/2004/1015/p1505.pdf; http://cdn.hivguidelines.org/wp-content/uploads/2009/06/mpersonality.pdf
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
http://apt.rcpsych.org/content/8/1/1.full.pdf+html
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
http://cdn.hivguidelines.org/wp-content/uploads/2009/06/m-personality.pdf
The End!
ObsessiveCompulsive
Disorder
02/12/15
http://proof.nationalgeographic.com/2014/12/08/photo-of-the-day-best-of-november-2/?source=photosite