DSM-IV-TR Personality
Disorders: Recognition and
Treatment
Presentation to Guam AIMFT Association September 2006
By Archana G. Leon-Guerrero, MD
General and Addiction Psychiatry
Diplomate, American Board of Psychiatry and Neurology
Member, American Society of Addiction Medicine
671-646-2908
Overview of Personality Disorders:
Why is it important to know about them?
 Very prevalent in clinical practice, particularly in
couples/family and other interpersonal problem
presentations, and in those with depression/anxiety
disorders on Axis I
 Almost never is the presenting complaint “I have a
personality disorder”. You must learn to recognize it.
 If not recognized, will likely lead to treatment
dropout/failure.
 High rate of bad outcomes such as suicide, violence,
substance abuse, legal problems. These bad
outcomes may be lessened by proper
recognition/treatment. Downward drift in
socioeconomic status may also be prevented if
caught early.
Overview of Personality Disorders:
What is a Personality Disorder?
 DSM: “An enduring pattern of inner
experience and behavior that deviates
markedly from the expectations of the
individual’s culture, is pervasive and
inflexible, has an onset in adolescence or
early adulthood, is stable over time, and
leads to distress* or impairment.”
 *note that, depending on which personality
disorder we are talking about, the distress is
often felt by others more than the person with
the d/o
Overview of Personality Disorders:
How are these different than Axis I Clinical
Syndromes?
 Axis I: Clinical Syndromes
 Temporary State vs.
 Axis II: Personality DO
 Ongoing Trait vs. Temporary
Ongoing Trait
Something I “have” rather
than I “am”
Easier to Recognize
Easier to Treat
Better insight
State
Something I “am” rather
than I “have”
Harder to recognize
Harder to treat
Little insight, see others as
the problem
Can lead to Axis I
depression, anxiety,
substance abuse
Can be a “mild case” of Axis
I disorders
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Personality D/O: Assessment
 Source of info: client PLUS COLLATERALS
 Look for patterns:
 Trouble getting along with people prior to
presenting incident.
 Blaming others.
 Trouble maintaining jobs/relationships prior
to presenting incident.
 If see these patterns, ask questions more
specific to PD you suspect OR about
substance abuse.
Overview of Personality Disorders:
Matching Game: Match the Personality Disorder with the
Related Axis I Syndrome that it is on a spectrum with
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Paranoid PD
Borderline PD
Avoidant PD
Histrionic PD
Schizotypal PD
Obsessive/Compulsive PD
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Obsessive/Compulsive D/O
Cyclothymic D/O
Schizophrenia
Delusional D/O
Social Phobia
Somatization D/O
Note: there may be more than
one right match to any PD
listed
Classification of Personality Disorders
DSM classification is based on similarities in
presentations
Cluster A: Odd/Eccentric
Paranoid, Schizoid, Schizotypal
Cluster B: Dramatic/Emotional/Erratic
Antisocial, Borderline, Histrionic, Narcissistic
Cluster C: Anxious/Fearful
Avoidant, Dependent, Obsessive-Compulsive
Not Otherwise Specified
Mixed, Codependent, Passive-Aggressive
Cluster A:Eccentric: Paranoid PD
 Pattern of distrust and suspiciousness of people in general (doubting
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loyalty, reading in hidden meanings, misinterpret compliments, bear
grudges, easily angry/jealous, contolling in relationships to avoid
betrayal). Often present for couple’s issues.
Strong biological relationship in family studies to delusional disorder
and schizophrenia. False beliefs less fixed. Less bizarre behavior. No
hallucinations.(Danish adoption study)
Treatment:
Courtesy, honesty, respect: ie honestly apologize for being late.
No group or confrontive therapy, including confronting the false belief.
Empathy: “if that is true, you must be very upset about it”
Low dose antipsychotic medication: “I know that your problems are due
to how others treat you. Medication will help you deal with the stress of
that.”
Discuss the possibility that belief may have been false only AFTER
medication has softened it up.
Cluster A: Eccentric: Schizoid PD
 Pattern of detachment from social
relationships, restricted emotions
 Lack of desire for intimacy: loners, cold, aloof
 Strong biological relationship in family studies
to Schizophrenia.
 Treatment: Rarely needed because these
individuals are not distressed, nor do they
enter into interpersonal relationships so don’t
distress anyone else. They choose
occupations in which they can be loners.
Cluster A: Eccentric: Schizotypal PD
 Pattern of interpersonal deficits marked by discomfort
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with close relationships and cognitive/perceptual
distortions as well as behavioral eccentricities.
Ideas of reference, magical thinking, superstitious,
sensory illusions (not hallucinations).
Loners not by choice as in Schizoid, but due to mild
paranoia which causes anxiety.
Strong biological relationship in family studies to
Schizophrenia.
Treatment: Psychoeduction. Social Skills Training,
Case Management, Antipsychotic Medication.
Cluster B: Erratic: Antisocial
 Pattern of disregard for rights of others.
 Can’t be dx under age 18, likely because of frequent legal
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involvement: BUT must have had some aspects of conduct
disorder before age 15.
Illegal actions, conning, lying, frequent fighting, recklessness,
irresponsibility, lack of remorse, promiscuity without pleasure in
women, STD’s, frequent unwanted pregnancies.
Much higher in men than women.
Can be charming at times, mostly to get their way.
Treatment: usually only successful with court
mandates/consequences. Group therapy/involvement in
therapeutic communities, religious groups, self-help groups
much more helpful than individual therapy.
Cluster B: Erratic: Borderline PD
 Pattern of unstable relationships, self-image and
affects, together with impulsivity in many contexts.
 Fear of abandonment, alternating between idealizing
and devaluing others, impulsive in self-damaging
ways (sex, driving, substance abuse, binge eating,
spending), recurrent suicidality or self-mutilation,
marked mood lability rective to environment, empty
feelings, intense anger, stress-related paranoia or
dissociation.
 Biological relationship in family studies to depression,
bipolar, substance abuse: NOT schizophrenia.
 Most have a marked trauma history
Cluster B: Borderline PD (continued)
 Treatment:
 Far better than the rest: Dialectical Behavior Therapy,
a form of cognitive/behavioral therapy focusing on
teaching techniques to self-regulate affect. More info
at www.brtc.psych.washington.edu
 Also very good: Eye Movement Desensitization and
Reprocessing—an innovative technique applying a
neurologic procedure to cognitive/behavioral therapy.
More info at www.emdr.com. I am trained in this.
 Medications may be helpful for the short-term,
targeted to the problem symptom at the time
(depression, impulsivity, anxiety)
Cluster B: Erratic: Histrionic PD
 Pattern of excess emotionality and attention-seeking
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behavior
Seductiveness, concern with physical appearance,
exaggerated emotional expression, self-centered,
naïve.
Associated with somatization disorder.
Becoming more recognized as a mild variant of
Bipolar Disorder, hypomanic type without the
tendency to depression.
Treatment: Insight-oriented psychotherapy, moodstabilizing medication.
Cluster B: Erratic: Narcisstic PD
 Pattern of grandiosity, need for admiration, lack of empathy.
 Fantasies of unlimited success, sense of entitlement, exploits
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others, arrogant.
Fragile self-esteem, subject to “injury” from criticism. They often
feel humiliated and react with rage.
May be a variant of Bipolar Hypomanic, although this needs
further research.
Treatment: Almost impossible. They almost always “fire” the
therapist. If proves to be a type of Bipolar DO, then moodstabilizing meds may help.
Education of family can help them cope, which indirectly helps
the client. Be careful about confidentiality when doing this.
Cluster C: Anxious: Avoidant PD
 Pattern of social inhibition and feelings of inadequacy
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due to hypersensitivity to negative evaluation.
Loners, but WANT relationships.
Won’t get involved with people or activities due to
fear of being ridiculed, rejected.
May actually be a natural byproduct of social phobia.
Current research is being done, and this PD
diagnosis may be eliminated soon.
Treatment: assertiveness training, anxiety
medication, behavioral therapy teaching techniques
to regulate anxiety (relaxation, deep breathing,
imagery)
Cluster C: Anxious: Dependent PD
 Pattern of execcive need to be taken cafre of
that leads to submissive and clingy behavior.
 Trouble making decisions without advice,
won’t express disagreement, lacks initiative,
fear of being alone, urgently seeks another
relationship when one ends.
 Often tolerate abuse.
 Often have a history of being abused.
 Treatment: Assertiveness training, Safety
plan, EMDR for prior and current trauma.
Cluster C: Anxious: ObsessiveCompulsive PD
 Preoccupation with orderliness, perfectionism, and
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control, at the expense of flexibility, openness and
efficiency.
Can’t “see the forest for the trees”, too detailed,
works too much, rigid moral values, “my way or no
way”, hoards money and objects, stubborn.
Not in touch with feelings, sense that they are
missing something, less likely to blame others than
other PD’s.
Some overlap with Obsessive-Compulsive Disorder
Treatment: psychodynamic therapy focusing on
insight into feelings, Behavioral therapy (preferably
group) teaching social skills.
Closing
 Personality Disorders are very prevalent in clinical
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populations, jails, social service settings etc.
ie….where we all work!
People with Personality Disorders are hard to deal
with. The very things that make them hard to deal
with are the things they need help with!
Rarely do they tell us “I have a personality disorder”.
It is incumbent upon us to recognize it.
Once we recognize it, treatment can help with most
of the disorders.
Good luck!