Personality Disorders
Mark Kimsey, M.D.
March 8, 2014
Objectives
• Understanding personality disorders using
criteria from DSM-5.
• Learn approaches for separating personality
disorders from other major illnesses.
• Review non-pharmacologic treatment
approaches.
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 cooccurring personality disorder
• It is extremely common for people with other
psychiatric problems to also have personality
disorders
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.
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
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.
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.
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, ObsessiveCompulsive
• Also- Other, unspecified, due to another medical
condition
Cluster A- Odd/Eccentric
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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.
Cluster B- Dramatic
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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.
Cluster B- Dramatic
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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)
Cluster B- Dramatic
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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.
Cluster C- Anxious/Avoidant
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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
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
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.
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
Non-pharmacologic Treatments
• Most emphasis has been placed on Borderline Personality
Disorder.
• Many challenges to treatment
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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
Dialectical behavior therapy (DBT)
• Weekly one-on-one counseling sessions and
group therapy.
• Development of skills.
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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’.
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.
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.
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
Alternative DSM-5 Model
• Personality traits divided into 5 broad domains
– Negative affectivity
– Detachment
– Antagonism
– Disinhibition
– Psychoticism
• Further divided into 25 specific trait facets
Negative Affectivity (vs. emotional
stability)
Emotional lability
Perseveration
Anxiousness
Depressivity (also under
Detachment)
Separation Insecurity
Suspiciousness (also under
Detachment)
Submissiveness
Restricted Affectivity
Hostility
Detachment (vs. Extraversion)
Withdrawal
Intimacy Avoidance
Anhedonia
Depressivity
Restricted Affectivity
Suspiciousness
Antagonism (vs. Agreeableness)
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Manipulativeness
Deceitfulness
Grandiosity
Attention Seeking
Callousness
Hostility
Disinhibition (vs. Conscientiousness)
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Irresponsibility
Impulsivity
Distractibility
Risk taking
Rigid perfectionism (also lack of)
Psychoticism
• Unusual beliefs and experiences
• Eccentricity
• Cognitive and perceptual dysregulation
Example- Antisocial PD
• Personality Functioning–
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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
Example- Narcissistic PD
• Personality functioning
– Identity- Needs others for self-definition and selfesteem 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
Questions?