Personality Disorders
Dr. Mark Johnston, MD, FRCPC
Friday, 2 October, 2015
CFPC CoI Templates: Slide 1
Faculty/Presenter Disclosure
• Faculty: Dr. Mark Johnston
• Relationships with commercial interests:
– Grants/Research Support: Otsuka, Roche, Merck, Lundbeck, Forum, Pfizer
– Speakers Bureau/Honoraria: Pfizer, Lundbeck, Purdue, J&J, BMS
– Consulting Fees: None.
CFPC CoI Templates: Slide 2
Disclosure of Commercial Support
•
This program has received financial support from Lundbeck in the form of logistical support and
educational grant.
• Potential for conflict(s) of interest:
– Dr. Mark Johnston has received NSCFP funding from Lundbeck
CFPC CoI Templates: Slide 3
Mitigating Potential Bias
• Medications are not approved for the treatment of PD’s
• Some might be used off-label, but efficacy is limited
AD Research
Specific Personality Disorders
CLUSTER A :
Odd, Bizarre,
Eccentric
CLUSTER B :
CLUSTER C :
- Paranoid PD
Dramatic,
Emotional,
Erratic
- Antisocial PD
Anxious, Fearful
- Avoidant PD
- Schizoid PD
- Borderline PD
- Dependent PD
- Schizotypal PD
- Histrionic PD
- Obsessivecompulsive PD
- Narcissistic PD
Personality Disorders affect an average 10% of
people
Cluster A
Paranoid




Pervasive distrust of others, including friends, family, and
partner
Guarded and suspicious, constantly on the lookout for clues or
suggestions to validate fears
Strong sense of personal rights
Withdraw from others and struggles with building close
relationships
Cluster A
Schizoid

Detached and aloof

Prone to introspection and fantasy

No desire for social or sexual relationships



Indifferent to others and to social norms and conventions, and lacks
emotional response
Highly sensitive with a rich inner life
Rarely present to medical attention (well functioning, untroubled by
oddness)
Cluster A
Schizotypal





Oddities of appearance, behavior, speech, and unusual
perceptual experiences
Anomalies of thinking similar to those seen in schizophrenia
Odd beliefs, magical thinking, suspiciousness, obsessive
rumination
Fear social interaction; think others are harmful
Ideas of reference (beliefs or intuitions that events and
happenings are somehow related to them)
Cluster B
Antisocial

More common in men than women

Callous unconcern for the feelings or others

Disregards social rules and obligations



Irritable and aggressive, acts impulsively, lacks guilt, and fails to learn
from experience
No trouble finding relationships, but they are usually fiery, turbulent, and
short lived
Correlated with crime (criminal record, history of being in and out of
prison)
Cluster B
Borderline




Lacks sense of self, therefore experiences feelings of emptiness
and fears of abandonment
Pattern of intense, but unstable relationships, emotional
instability, outbursts of anger and violence, and impulsive
behavior
Suicidal threats and acts of self harm (frequently seek medical
attention)
Sometimes results from childhood sexual abuse (more common
in women)
Cluster B
Histrionic
Lack a sense of self-worth; depend for their wellbeing on attracting
the attention and approval of others

Dramatizing (“playing a part”)

May take great care of appearance and behave in a manner that is
overly charming or seductive

Crave excitement and act on impulse of suggestion

Sensitive to criticism and rejection, and react badly to loss or failure

Cluster B
Narcissistic

Extreme feeling of self-importance, entitlement, and need to be
admired

Envious of others and expects to be envied

Lacks empathy and readily exploits others to achieve their aims


To others, they may seem self-absorbed, controlling, intolerant,
selfish, or insensitive
If felt obstructed or ridiculed, they can fly into a fit of anger and
revenge or rage
Cluster C
Avoidant

Believe they are socially inept, unappealing, or inferior

Constantly fear being embarrassed, criticized, or rejected

Avoid meeting others, and restrained even in intimate relationships

Experience anxiety


May be associated with actual or felt rejection by parents or peers in
childhood
Excessively monitor internal reactions, both their own and those of
others
Cluster C
Dependent

Lack of self-confidence and excessive need to be looked after

Needs help making everyday life decisions


Fears abandonment; goes through considerable lengths to secure and
maintain relationships
See oneself as inadequate and helpless; submits to one or more protective
others

Naive and child-like perspective; limited insight into themselves and others

Vulnerable to abuse and exploitation
Cluster C
Obsessive-compulsive

Excessive preoccupation with details, rules, lists, order, organization, or schedules

Perfectionism so extreme, it prevents a task from being completed

Doubting and cautious, rigid and controlling, humorless, and miserly



Underlying anxiety arises from lack of control over a world that eludes his
understanding
Little tolerance for complexity or nuance; sees things black and white (either all
good or all bad)
Relationships strained by unreasonable and inflexible demands that they make
upon them
Causes
•
Childhood abuse
Causes
•
Social environment
Causes
•
Problems in brain functioning
Borderline
5 of the following 9 symptoms must be present:
1) Frantic efforts to avoid real or imagined abandonment
2) A pattern of unstable and intense interpersonal
relationships characterized by altering between extremes of
idealization and devaluation
3) Identity disturbance: Markedly and persistently unstable
self image or sense of self
4) Impulsivity in at least two areas that are potentially selfdamaging (spending, sex, substance abuse, reckless driving,
binge eating)
Borderline Cont’d
5) Recurrent suicidal behavior, gestures, or threats, or selfmutilating behavior
6) Affective instability due to marked reactivity of mood (intense
episodic dysphoria, irritability, or anxiety usually lasting a few
hours and only rarely more than a few days)
7) Chronic feelings of emptiness
8) Inappropriate, intense anger or difficulty controlling anger
9) Transient, stress-related paranoid ideation or severe
dissociative symptoms
The Brain
It has been show that brain regions that process negative emotions (for
example, anger and sadness) are overactive in people with BPD, while
brain regions that would normally help damp down negative emotions
are underactive
“I hate you, but don’t leave me”
• People with BPD need to
develop more comfort with their
own emotions
• They have so much anxiety they
start to use projection:
Form of defense
Unwanted feelings or impulses
are displaced onto another
person (usually the counselor
in this case)
Denying their existence in
themselves, while attributing
them to others
• Example: A person who is
rude may constantly accuse
others of being rude
Continued
As the Counselor :
•Remain neutral
•Constantly re-assuring them against their own fears is BAD
•Ask them to judge whether there’s really anything to worry about
•Offer emotional support, understanding, patience, and
encouragement — change can be difficult and frightening to
people with borderline personality disorder, but it is possible for
them to get better over time
Case Study
Molly is a 21 year old unemployed women. She has
currently dropped out of University where she was studying
Biology, stating that “life is just too hard right now” and
that she just can’t make things work. Molly has been
treated previously for Anorexia Nervosa and non-suicidal
self-injuring behaviors with little success. She has always
been a worrier and stressed over small things. Her mood
fluctuates often and she has difficulty controlling her anger.
Case Study Cont’d
Molly’s roommate has been very supportive of her, but
the recent increase of starving, purging, cutting, and burning
behaviors have had a very negative effect on her. As a result,
she has asked Molly to move out. Molly has recently broken
up with her boyfriend, so she can’t live with him. She
described their relationship as “intense”. Her only other
option is to move back home with her parents who Molly
describes as cold and controlling.
Molly presents herself as a pleasant, friendly women who
is happy to chat about mundane things, but becomes guarded
to speaking about her health and relationships.
Options of Coping
1) Counseling
Cognitive Behavioral Therapy (CBT), Dialectical
Behavioral Therapy (DBT), Schema-focused Therapy
2) Remain neutral
Don’t get sucked in! Remember, people with Borderline
Personality Disorder tend to have major difficulties
with relationships
3) Medication
No medications have been approved by the U.S. Food
and Drug Administration to treat BPD; but there are
some to help with symptoms such as anxiety,
depression, or aggression
Dialectical Behavioral Therapy
Modified form of Cognitive Behavioral Therapy; adapted to
meet particular needs of people who experience emotions
very intensely, such as people with Borderline Personality
Originally created for treatment of BPD, but is now used in
a variety of treatment settings
DBT is a therapy designed to help people change patterns
of behavior that are not helpful, such as self-harm, suicidal
thinking, and substance abuse
Uses group work (skills training), individual therapy, and
self-monitoring to change target behaviors
DBT
The main focus is on increasing the persons emotional and
cognitive regulation by learning about the triggers that lead
to reactive states
Also focuses on accepting who you are at the same time as
acknowledging that they need to change in order to reach
their goals
Places particular importance on the relationship between
the person and their therapist; this relationship is used to
actively motivate the person to change
DBT Cont’d
Skills taught in DBT:
Mindfulness, distress tolerance, interpersonal
effectiveness, emotion regulation
Medication
•
Antidepressants
•
Atypical Antipsychotics
Comorbidity
•
Someone with a PD is likely to have a co-occurring
major mental disorder, including:

Anxiety disorders

Mood disorders

Impulse control disorders

Substance abuse or dependence
Conclusion

A personality disorder is a type of mental illness in which you have trouble
perceiving and relating to situation and to people – including yourself

Therapy is the best form of treatment for personality disorders; use
medication only as a last resort

Families play a crucial role in supporting their affected family member’s
recovery, but families also need support and nurturing to recover from the
impact of their family member’s illness