Course:PostgradFamilyPractice/ExamPrep/99 Priority Topics/Personality Disorder

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Personality Disorder - Key Features

1. Clearly establish and maintain limits in dealing with patients with identified personality disorders. For example, set limits for:
- appointment length.
- drug prescribing.
- accessibility.

2. In a patient with a personality disorder, look for medical and psychiatric diagnoses when the patient presents for assessment of new or changed symptoms. (Patients with personality disorders develop medical and psychiatric conditions, too.)

3. Look for and attempt to limit the impact of your personal feelings (e.g., anger, frustration) when dealing with patients with personality disorders (e.g.,stay focused, do not ignore the patient’s complaint).

4. In a patient with a personality disorder, limit the use of benzodiazepines but use them judiciously when necessary.

5. When seeing a patient whom others have previously identified as having a personality disorder, evaluate the person yourself because the diagnosis may be wrong and the label has significant repercussions.

DSM-IV-TR Definition
o An enduring pattern of inner experience and behaviour that deviates markedly from the expectations of the individuals culture. Manifested in 2 or more of the following areas:

• Cognition
• Affectivity
• Interpersonal functioning
• Impulse control

o Enduring pattern is inflexible across a broad range of personal and social situations
o Leads to clinically significant distress or impairment in social, occupational or other important areas of functioning
o Pattern is stable and of long duration and can be traced back at least to adolescence or early adulthood
o Not better accounted for by another mental disorder, general medical condition or substance effect.
Coded on Axis II.
Patients often lack insight regarding the connection between their behaviors and interpersonal difficulties
More common in males, the young, poorly educated, and unemployed
Highly comorbid with Axis I disorders

Personality disorders are divided into 3 clusters
o Cluster A: Appears odd and eccentric – “mad”

• Paranoid
• Suspects others are exploiting, harming or deceiving them, doubts trustworthiness of others, interprets benign remarks as demeaning, bears grudge, concerned of partners fidelity
• Treatment - psychotherapy
• Schizoid
• Neither desires nor enjoys close relationships, isolated, chooses solitary activities; indifferent to praise or criticism, emotional detachment
• Treatment - psychotherapy
• Schizotypal
• Odd beliefs/thinking/speech pattern, eccentric behavior, unusual perceptual experience
• Treatment - psychotherapy, social skills training, low-dose anti-psychotics


o Cluster B: Dramatic, emotional, and erratic – “bad”

• Borderline
• Frantic efforts to avoid abandonment, unstable relationships, impulsivity, affective and emotional instability, self-harm/suicidal behaviour, chronic feelings of emptiness
• Use of Splitting as defense mechanism
• Treatment - psychotherapy, group psychotherapy, CB, dialectical behavioural therapy, low dose anti-psychotics/anti-depressants
• Antisocial
• Criminal, aggressive, irresponsible behavior, lack of remorse, symptoms of conduct disorder before age 15
• Treatment – Support groups, behaviour control, control of substance abuse
• Narcissistic
• Exaggerated sense of self-importance, believes they are special, preoccupied with fantasies of unlimited success, power, beauty, love
• Treatment - psychotherapy
• Histrionic
• Not comfortable unless center of attention, dramatic/exaggerated expression of emotions, inappropriately sexually seductive
• Treatment - psychotherapy


o Cluster C: Anxiety, fearfulness, constricted affect – “sad”

• Avoidant
• Avoids activities and interpersonal contact due to fear of criticism or rejection, views self as inferior.
• Treatment – psychotherapy, CBT, systematic desensitization, assertiveness training
• Dependent
• Needs others to assume responsibility for most areas of life and decision-making
• Treatment – psychotherapy, CBT, group therapy, assertiveness training, social skills training
• Obsessive-Compulsive
• Perfectionism interferes with task completion, pre-occupied with details, inflexible morals, reluctant to delegate, excessively devoted to work.
o In OCPD symptoms are ego-syntonic (person is unaware of abnormal traits and consistent with their way of thinking.
o In OCD symptoms are ego-dystonic (realizes the obsessions are not-reasonable).
• Treatment – psychotherapy, group therapy, CBT


General Management for PD
o Develop a treatment plan early on
o Treatment may involve combination of:

• Individual therapy
• Group therapy
• Self-education
• Substance abuse treatment
• Medication
• Hospitalization at times of crisis

o Compliance with treatment plans is often an issue
o Clearly establish and set limits in dealing with patients with identified personality disorder eg.

• Appointment length
• Drug prescribing
• Accessibility

o Look for medical and psychiatric diagnoses when the patient presents for assessment of new or changed symptoms (patients with PD develop medical and psychiatric conditions too).
o Limit the use of benzodiazepines, but use them judiciously when necessary.
o When seeing a patient whom others have previously identified as having PD, evaluate the person yourself because the diagnosis may be wrong and the label has significant repercussions.
o Be aware of counter-transference in doctor-patient relationship

Study Guide

Personality Disorder

Resources

DSM-IV-TR
Uptodate
Toronto Notes 2007