Lecture 3 Personality Disorders 1

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INTRODUCTION TO MEDCINE IIINTRODUCTION TO MEDCINE II
PSYCHIATRYPSYCHIATRY
PERSONALITY DISORDERS
INSTRUCTOR: JIMMY SANTANA, P.A. - C

2. 2
PDs Characteristics PDs Characteristics
lPresence of long-standing, rigid, unsuitable
pattern of relating to others
lPresence of personality characteristics that
cause social and occupational impairment
lLack of insight
lFailure to seek psychological help unless
compelled by others
lAbsence of frank psychosis

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Personality Disorder ClustersPersonality Disorder Clusters
lThere are three clusters
3.Cluster A:
lPatient is eccentric and/or fears social
relationships
lIncludes:
–Paranoid personality disorder
–Schizoid personality disorder
–Schizotypal personality disorder

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1.Cluster B
lPatient is emotional, erratic, and/or dramatic
lIncludes:
–Histrionic personality disorder
–Narcissistic personality disorder
–Antisocial personality disorder
–Borderline personality disorder
2.Cluster C
lPatient is fearful and/or anxious
lIncludes:
–Avoidant personality disorder
–Obsessive-compulsive personality disorder
–Dependent personality disorder

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EpidemiologyEpidemiology
lPersonality disorder is prevalent in @ 1% of
population
lSchizoid personality disorder may be less
common
lMore common (slightly) are
–Dependent personality disorder
–Schizotypal personality disorder
–Histrionic personality disorder
lSymptoms must be present by early adulthood for
diagnosis
lAntisocial personality disorder can notcan not diagnosed
until 18 years of age

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lRelatives of patients with personality disorders
may have other psychiatric disorders:
1.Schizoid, Schizotypal and Parannoid – schizophrenia
2.Paranoid - delusional disorder (persecutory type)
3.Antisocial – substance abuse and somatization
disorders
4.Borderline -- Mood disorders, substance abuse and
antisocial personality disorder
5.Avoidant -- anxiety disorder

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lThe patients with PDs have excessive use of maladaptive
or inappropriate defense mechanisms
lPrognosis for these patients is that the disease is chronic
and lifelong
lMedication for these patients are not useful except in
borderline personality disorder
lMedication is usually for symptoms associated with
depression and anxiety
lIt is important to remember that PD patients have a high
potential for addiction THEREFORE--- BE CAUTIOUS
WHEN PRESCRIBING MEDICATIONS

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PARANOID PERSONALITY PARANOID PERSONALITY
DISORDERDISORDER
lPATIENT WITH THIS DISORDER ARE:
–SUSPICIOUS
–MISTRUSTFUL
–LITIGIOUS
–ATTRIBUTES RESPONSIBILTY FOR PROBLEMS
TO OTHERS
lDEFENSE MECHANISM USED ARE
–PROJECTION
–DENIAL

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TYPICAL PATIENT PRESENTATION
50 YEAR-OLD OFFICE WORKER TELLS YOU
THAT HE HAS NEVER BEEN PROMOTED
BECAUSE HIS CO-WORKERS FREQUENTLY
CLAIM HIS IDEAS AS THEIR OWN. WHEN
HE IS FIRED FOR POOR PERFORMANCE, HE
FILES A LAWSUIT AGAINST THE
COMPANY

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Schizoid Personality DisorderSchizoid Personality Disorder
lThese patients have a life long pattern of
voluntary social withdrawal
lSimilar to delusional disorder and
schizophrenia but without frank psychotic
symptoms
lIn the young can be mistaken for mild
autistic disorder

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TYPICAL PATIENT PRESENTATION
48 YEAR-OLD MAN IS CONTENT
LIVING ALONE IN AN ISOLATED
CABIN, GROWING HIS OWN FOOD,
AND RARELY HAVING CONTACT
WITH OTHERS

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SCHIZOTYPAL PERSONALITY SCHIZOTYPAL PERSONALITY
DISORDERDISORDER
lTHESE PATIENTS HAVE:
–PECULIAR APPEARANCE
–MAGICAL THINKING
–ODD THOUGHT PATTERNS AND
BEHAVIOR WITHOUT PSYCHOSIS
–MAJOR DEPRESSION COULD BE FOUND
(CO-MORBIDEDLY) IN THESE PATIENTS

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lDENIAL AND PROJECTION ARE USED
AS DEFENSE MECHANISMS
lDDX:
–DELUSIONAL DISORDER
–SCHIZOPHRENIA
–MOOD DISORDER WITH PSYCHOSIS

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TYPICAL PATIENT PRESENTATION
35 YEAR-OLD MALE PATIENT TELLS
YOU THAT HE NEVER STEPS ON
CRACKS IN THE SIDEWALK TO
AVOID “BREAKING HIS MOTHER’S
BACK”(MAGICAL THINKING). HE
SEEMS ODD, SAYS THAT HE OFTEN
FEELS UNCOMFORTABLE IN SOCIAL
SITUATIONS AND HAS FEW FRIENDS

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HISTRIONIC PERSONALITY HISTRIONIC PERSONALITY
DISORDERDISORDER
lTHESE PATIENTS ARE:
–EXTROVERTED
–EMOTIONAL
–DRAMATIC
–SEXUALITY PROVOCATIVE (LIFE OF THE
PARTY)
–INABILITY TO MAINTAIN INTIMATE
RELATIONSHIPS
–“DON JUAN” BEHAVIOR IN MEN

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lDEFENSE MECHANISM:
–REPRESSION
–REGRESSION
–SOMATIZATION
lDDX:
lBORDERLINE PD: SHOULD INCLUDE CHRONIC
FEELINGS OF BOREDOM, EMPTINESS AND
SUICIDAL BEHAVIORAL
lNARCISSISTIC PD: SHOULD INCLUDE FEELINGS
OF SUPERIOITY
lDEPENDENT PD: NO FLAMBOYANCE OR AN
OVERLY EMOTIONAL STATE
lHYPOMANIC EPISODE IN BIPOLAR II OR
CYCLOTHYMIC DISORDER: SYMPTOMS REMIT
WHEN THE EPISODE ENDS

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TYPICAL PATIENT PRESENTATION
25 YEAR-OLD FEMALE PATIENT COMES TO
YOUR OFFICE DRESSED IN A LOW – CUT
BLOUSE AND VERY SHORT SKIRT AND
BRINGS A GIFT FOR YOU. SHE FISHES FOR
COMPLIMENTS FROM THE OFFICE STAFF
AND TELLS YOU THAT YESTERDAY SHE
“ALMOST BLED TO DEATH” WHEN SHE
CUT HER FINGER.

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Narcissistic Personality Narcissistic Personality
DisorderDisorder
lThese patients are:
–Grandiose
–Envious
–Has sense of special entitlement
–Lack empathy
lDefense Mechanism:
–Denial
–Displacement
–Poor ego functioning

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lDDX:
–Histrionic PD and Borderline PD [ include
emotionality and instability]
–Obsessive – Compulsive PD [includes feelings
of imperfection]

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TYPICAL PATIENT PRESENTATION
40 YEAR – OLD MALE PATIENT TELLS
YOU THAT BECAUSE YOU ARE A
DOCTOR, YOU CAN UNDERSTAND
THAT HE IS “ BETTER THAN MOST
PEOPLE.” HE THEN ASKS TO BE
REFERRED TO A PHYSICIAN WHO
GRADUATED FROM AN IVY LEAGUE
SCHOOL.

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ANTISOCIAL PERSONALITY ANTISOCIAL PERSONALITY
DISORDERDISORDER
lTHESE PATIENTS ARE:
–ALSO KNOWN AS SOCIOPATHS OR
PSYCHOPATH
–UNWILLING TO CONFORM TO SOCIAL
NORMS
–FAIL TO LEARN FROM EXPERIENCES
–ASSOCIATED WITH CONDUCT
DISORDER IN CHILDHOOD
–CRIMINALITY IN ADULTHOOD

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lDEFENSE MECHANISM:
–INADEQUATE SUPEREGO FUNCTIONING
lDDX:
–SUBSTANCE ABUSE
–CRIMINAL BEHAVIOR
–NARCISSISTIC PD
–PARANOID PD
–HYPOMANIC EPISODE IN BIPOLAR II OR
CYCLOTHYMIC DISORDERS

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TYPICAL PATIENT PRESENTATION
A 29 YEAR- OLD MAN TELLS YOU THAT HE
HAS STOLEN VALUABLE ITEMS FROM
FRIENDS AND FAMILY ON MANY
OCCASSIONS WITH NO INTENTION OF
RETURNING THEM AND WITHOUT
CONCERN FOR THE PEOPLE HE STOLE
FROM. HE HAS BEEN UNEMPLOYED ON
AND OFF FOR MANY YEARS AND HAS
BEEN ARRESTED ON A VARIETY OF
MINOR CHARGES.

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BORDERLINE PERSONALITY BORDERLINE PERSONALITY
DISORDERDISORDER
lTHESE PATIENTS ARE:
–UNSTABLE BEHAVIOR AND MOOD
–BOREDOM, EMPTINESS
–FEELINGS OF ALONENESS
–IMPULSIVENESS
–SUICIDE ATTEMPTS
–BRIEF PERIOD OF LOSS OF CONTACT
WITH REALITY (MINI – PSYCHOTIC
EPISODES)
–OFTEN COMORBID WITH MOOD
DISORDER

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lDEFENSE MECHANISM:
–DENIAL
–DISPLACEMENT
–SPLITTING
–POOR EGO FUNCTIONING

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TYPICAL PATIENT PRESENTATION
A 39 – YEAR – OLD FEMALE PATIENT
TELLS YOU ON HER SECOND VISIT
THAT SHE IS IN LOVE WITH YOU.
WHEN YOU REFER HER TO ANOTHER
PRACTITIONER, SHE ATTEMPTS
SUICIDE

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AVOIDANT PERSONALITY AVOIDANT PERSONALITY
DISORDERDISORDER
lTHESE PATIENTS ARE:
–SHY
–SENITIVE TO REJECTION
–SOCIALLY WITHDRAWN
–HAS INFERIORITY COMPLEX
lDEFENSE MECHANISM:
–AVOIDANCE
–REGRESSION

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lDDX:
–SOCIAL PHOBIA
–DEPENDENT PD
–SCHIZOID PD

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TYPICAL PATIENT PRESENTATION
A 40 YEAR – OLD WOMAN WHO
LIVES ALONE SEEMS TENSE AND
FEARFUL. SHE TELLS YOU THAT
SHE WOULD LIKE TO HAVE FRIENDS
BUT IS AFRAID THAT PEOPLE WILL
NOT LIKE HER.

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OBSESSIVE – COMPULSIVE OBSESSIVE – COMPULSIVE
PERSONALITY DISORDERPERSONALITY DISORDER
lTHESE PATIENTS ARE:
–PERFECTIONISTIC
–ORDERLY
–STUBBORN
–INDECISIVE
lDEFENSE MECHANISM
–ISOLATION OF AFFECT
–RATIONALIZATION
–INTELLECTUALIZATION
–UNDOING

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lDDX:
–OBSESSIVE – COMPULSIVE DISORDER
TYPICAL PATIENT PRESENTATION
A 32 YEAR – OLD MALE PATIENT TELLS
YOU THAT HIS FOURTH ROOMMATE HAS
JUST MOVED OUT BECAUSE THE PATIENT
MAKES UNREASONABLE RULES AND
SCHEDULE CONCERNING THE CARE OF
THE APARTMENT

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DEPENDENT PERSONALITY DEPENDENT PERSONALITY
DISORDERDISORDER
lTHESE PATIENTS ARE:
–LACKS SELF – CONFIDENCE
–LETS OTHERS ASSUME THEIR
RESPONSIBILITIES
lDEFENSE MECHANISM
–REGRESSION
–AVOIDANCE

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lDDX:
–DEPRESSION
TYPICAL PATIENT PRESENTATION
A 30 YEAR – OLD FEMALE PATIENT
CALLS YOUR OFFICE FREQUENTLY TO
ASK YOUR ADVICE ABOUT OBVIOUS,
MINOR MEDICAL PROBLEMS

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PASSIVE – AGGRESSIVE PASSIVE – AGGRESSIVE
PERSONALITY DISORDERPERSONALITY DISORDER
lTHESE PATIENTS ARE:
– STUBBORN
–INEFFICIENT
–PROCASTINATES
–SEEMS COMPIANT BUT ARE DEFIANT
–NO LONGER A DSM IV DIAGNOSIS

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TYPICAL PATIENT PRESENTATION
TWO WEEKS AFTER YOUR 40 YEAR –
OLD MALE PATIENT AGREES THAT
HE NEEDS TO LOSE 10 POUNDS AND
YOU SPEND TIME DESCRIBING AN
APPROPRIATE DIET, HE HAS GAINED
2 POUNDS AND TELLS YOU THAT HE
DID NOT YET “GET A CHANCE” TO
BUY THE NECESSARY DIET.