Personality Disorders: PHA 535

• Personality Disorders
• Human Behavior and Psychiatry
• Dr. Natalie Foucauld, DMSC, MCMSC, PA-C
• PHA 535
• Spring 2025

Instructional Objectives

• Distinguish between the ten Personality Disorders according to their diagnostic criteria:
• Paranoid, Schizoid, Schizotypal, Antisocial, Borderline, Histrionic, Narcissistic, Avoidant, Dependent, and Obsessive-Compulsive.
• Recognize the difference between an obsessive-compulsive personality disorder and obsessive-compulsive disorder (OCD)
• Differentiate between avoidant and schizoid PDs
• Differentiate between histrionic and borderline PDs
• Know the treatment strategies for personality disorders

Personality

• Combination of thoughts, emotions, and behaviors that make one unique
• How one views, understands, and relates to the outside world, and oneself (inner world)

Personality Development

• Forms during childhood and shaped via interaction of two factors:
• Inherited tendencies/temperament from genetics:
• Shyness, optimism, miserliness, arrogance, independence.
• This is the "nature" part.
• Environment: surroundings, events, and relationships with family/community.
• Includes parenting (ex: loving or abusive). -The nurture part

Personality Disorders

• Characteristic patterns of thinking, feeling, and interpersonal behavior that are relatively inflexible
• Causes significant functional impairment or subjective distress for the individual
• Not caused by substance abuse or a general medical condition
• Statistics:
• 11% worldwide
• 9-15% in US

DSM 5 Personality Disorders (PDS) Defined

• Enduring pattern of inner experience and behavior: inflexible, maladaptive, (persistent) and pervasive
• "Defense mechanisms become established into a personality disorder"
• Impairs and causes distress in two or more areas:
• Cognition (thinking/ perception)
• Affectivity (emotions and their expression)
• Interpersonal functioning (social)
• Impulse control (ability to say "no" and/ or wait)

Challenges with Addressing PDS

• Patients are often regarded as "difficult patients"
• Challenges in eliciting an accurate symptom history, explaining the assessment, reaching agreement over a treatment plan, and motivating behavior changes.
• Associated with worse outcomes and higher hospitalization rates than those without PDs.

PD: Culture-Related Diagnostic Issues

• Takes into account the individual's ethnic, cultural, and social background
• Should not be confused with acculturation following immigration, habits, customs, or religious and political values of their culture of origin
• Ideally, obtain additional information from others who are familiar with the person's cultural background
• Being culturally sensitive allows us to consider other forms of expression that may be misrepresented as a personality disorder

Manifestations of PD

• Physical injury from fights and accidents due to impulsive and reckless behavior
• Suicide attempts
• Unplanned pregnancy and high-risk sexual behavior
• Comorbid anxiety, mood, and/or substance use disorder
• Are difficult to treat and may be misdiagnosed as/ or concurrent with depression, anxiety disorder, or substance use disorder
• Comorbid physical disorders, including cardiovascular disease, arthritis, diabetes, and gastrointestinal conditions
• Reduced life expectancy

PDS Associated with Violence: Duty to Warn

• If a patient threatens someone else with injury, the provider has a duty to warn the intended victim, either directly or through legal authorities, under the Tarasoff ruling

PD Diagnosis Hierarchy

• PD disorder is not better explained by another psychiatric condition

Personality Disorders Divided into 3 General Characteristic Clusters

• Cluster A (Odd-Eccentric): Paranoid, schizoid, schizotypal
• Cluster B (Dramatic-Emotional): Antisocial, borderline, histrionic, narcissistic
• Cluster C (Anxious-Fearful): Avoidant, dependent, obsessive-compulsive

Cluster A: Odd/Eccentric

• Express only a limited range of emotion in social interactions and form few if any close relationships with others
• Patients are viewed as "strange” or “peculiar”
• Can be associated with psychotic features

Cluster A Odd/Eccentric Types

• Paranoid
• Schizoid
• Schizotypal

Paranoid PD

• Pervasive distrust and suspiciousness of others
• Motives are interpreted as malevolent, beginning by early adulthood

Paranoid traits

• Assumes others will disappoint, manipulate, or talk behind their back.
• Needs to ensure loyalty of family & friends.
• Generally distrustful and suspicious, suspecting partner infidelity.
• Reacts severely if feels they've been lied to or slighted.

Paranoid Personality Disorder summarized with GET FACT

• Grudges are held for long periods.
• Exploitation is expected (without sufficient basis).
• Trustworthiness of others is doubted.
• Fidelity of sexual partner is questioned.
• Attacks on character are perceived.
• Confides in others rarely, if at all.
• Threatening meanings are read into events.

Schizoid PD

• Detachment from social relationships
• Restricted range of expression of emotions in interpersonal settings
• Rich inner life, imagination, and creativity

Schizoid Personality Disorder summarized with SIR SAFE

• Solitary lifestyle.
• Indifferent to praise or criticism.
• Relationships of no interest.
• Sexual experiences are not of interest.
• Activities not enjoyed.
• Friends lacking.
• Emotionally cold and detached.

Schizotypal Personality Disorder

• Have little capacity for close relationships, but would like to: "socially awkward"
• Eccentric in their behaviors, perceptions, and thinking
• Believe in superstition, "mind reading", special powers ("I can communicate with animals")
• Could be delusional

Signs of Schizotypal Personality Disorder

• Difficulty making friends
• Serious social anxiety
• Social awkwardness
• Vague, odd speech
• Eccentric clothing
• Magical beliefs
• Paranoia
• Odd perceptions
• Odd emotions
• Ideas of reference

Schizotypal Personality Disorder summarized with UFO AIDER

• Unusual perceptions
• Friendless except for family
• Odd beliefs, thinking, and speech
• Affect - inappropriate, constricted.
• Ideas of reference.
• Doubts others - suspicious.
• Eccentric appearance/behavior.
• Reluctant in social situations, anxious.

Cluster A PDS Treatment

• Rarely seek treatment
• Therapies: psychoanalytic, CBT
• Pharmaceutical management: low-dose anti-psychotic drugs have shown efficacy
• Be respectful and honest and explain diagnosis clearly

Cluster B: Dramatic/Emotional

• Regularly disregard and violate the rights of others
• Behaviors aggressive or destructive and may involve breaking laws or rules, deceit or theft
• Emotional and inconsistent
• Associated with mood disorders

Cluster B: Dramatic/Emotional Types

• Antisocial
• Borderline
• Histrionic
• Narcissistic

Antisocial Personality Disorder summarized with CALLOUS MAN

• Conduct disorder before age 15.
• Current age at least 18.
• Antisocial acts; commits acts that are grounds for arrest.
• Lies frequently; lacks guilt.
• Lacks a superego.
• Obligations are not honored.
• Unstable; can't plan ahead.
• Safety of self and others is ignored.
• Money problems; spouse and children are not supported.
• Aggressive, assaultive (impulsive "hot tempered").
• Not occurring exclusively during schizophrenia or mania.

Antisocial PD

• Pattern of disregard for and violation of the rights of others
• May present themselves in a superficially grandiose manner, and may also initially appear charismatic

Antisocial PD Treatment

• Provider needs to be "street wise,” set boundaries
• Mood stabilizers as in Bipolar Disorder
• Antipsychotics
• Group, CBT
• Poor outcomes

Borderline PD

• Impulsive, highly reactive, emotionally dysregulated
• Unstable relationships, self-image, and emotions
• Can present like bipolar disorder; may have both

I DESPAIRR: Borderline Personality

• Identity: have trouble knowing who one is
• Disordered affect: Are you a moody person?
• Empty feeling: Do you often feel empty inside?
• Suicidal behavior: Do you ever do something to hurt yourself, like cutting yourself or overdosing?
• Paranoia or dissociative symptoms: Do you feel like you lose touch with your environment or people are ganging up against you?
• Abandonment terror: When someone abandons you or rejects you, how do you react?
• Impulsivity: Do you ever get really impulsive and do crazy things?
• Rage: Do you hold it inside or let loose with it?
• Relationship instability: Do your relationships tend to be calm and stable or stormy and with lots of ups and downs?

Borderline Intense Emotional Shifts:

• Experiences splitting:
  • Important things may be seen as all good or all bad.
• May shift between intense joy to rage.
• May have intense relationships.
• Fear of abandonment.

Characteristics Borderline PD shares with Bipolar disorder:

• Affective lability
• Disproportionate anger
• Suicidality
• Risky behaviors
• Impulsivity
• Delusions

Unique Characteristics to Borderline PD:

• Fear of abandonment
• Unstable self-image
• Unstable relationships
• Feelings of emptiness
• Mood often shaped by interpersonal conflicts
• Sudden and short-lived mood shifts

Unique Characteristics to Bipolar Disorder:

• Sleep Disturbance
• Distinct euphoric and depressive states
• Mood often stable between episodes
• Sustained mood shifts lasting days/weeks

Dialectical Behavioral Therapy (DBT)

• Developed to curb the self-destructive impulses of chronic suicidal patients
• Treatment of choice for borderline personality disorder, emotion dysregulation, and associated psychiatric conditions
• Focuses on teaching individuals skills to effectively manage their emotions, improve interpersonal relationships, tolerate distress, and change harmful behavior
• Acknowledges the need for change in the context of acceptance of situations and recognizes the constant flux of feelings–many of them contradictory–without having to get caught up in them
• Help patients understand and accept that thought an inherently messy process

Four Skills of DBT

• Mindfulness:
• Being fully aware of the mind and body in the present moment
• Acceptance, noting the fleeting nature of emotions, which diminishes the power of emotions to direct their actions
• Distress tolerance:
• Ability to tolerate painful emotions in difficult situations rather than needing to escape from it or acting in ways that make difficult situations worse
• Emotion regulation:
• Strategies to manage and change intense emotions that are causing problems in their life
• Interpersonal effectiveness:
• Communicating needs and wants effectively while maintaining respect for oneself and others which strengthens relationships
• Learning how to ask directly for what one wants, which diminishes resentment and hurt feelings and clarifies realistic expectations

DBT Treatment Modes

• Individual therapy (1 hr/week)
• Group skills training (2.5 hr/week)
• Therapist consultation team (1-1.5 hr/week)
• Phone coaching (as needed)
• 3-4 hours/week for 6 months to year

Borderline PD Treatment

• Concentrating upon the patient's life outside of therapy by establishing long-term goals and focusing on the best ways to achieve them. "Creating a life worth living."
• The therapist's role is that of a real person who is active, responsive, and validating

Clinical Concerns: Patient with Borderline PD

• Often angry, manipulative, demanding, or defensive
• A history of doctor shopping, legal suits, suicide attempts, and several brief marriages or intimate relationships
• Idealization of you as a "wonderful PA," especially if the patient compares you with disappointing caregivers of the past
• Excessive interest in your personal life, leading to invitations to socialize = a boundary violation
• tries to "cement" relationship, allaying ever-present fear of abandonment

Borderline PD Treatment: Transference in Therapy

• Exploration, confrontation, and transference interpretations of emotionally charged issues in the relationship between the patient and therapist
• Goal is to correct the patient's tendency to perceive significant others in a distorted manner

Borderline PD Treatment: Medication

• Used in conjunction with therapy
• Mood stabilizers: Lithium, Lamotrigene , Carbamazepine
• Antipsychotics
• SSRis
• Omega-3 fatty acids: eicosapentaenoic (EPA) 700-1000 mg/ day (or fish)
• Improves affect dysregulation and impulsive behavior

Histrionic PD

• Dramatic with excess emotionality
• Characterized by a long-standing pattern of attention-seeking behavior
• Includes extreme emotionality
• Discomfort when one is not the center of attention
• Difficulty when people are not exclusively focused on them
• "Dramatic" "Theatrical"

Histrionic Personality Disorder summarized with I CRAVE SIN

• Inappropriate behavior (seductive or provocative)
• Center of attention
• Relationships are seen as closer than they really are
• Appearance is most important
• Vulnerable to others' suggestions
• Emotional expression is exaggerated
• Shifting emotions (shallow)
• Impressionistic manner of speaking (lacks detail)
• Novelty is craved

Histrionic PD Treatment

• Provide emotional support to the patient but resist a close, interpersonal relationship
• Psychotherapy, CBT

Narcissistic PD

• Grandiosity (in fantasy or behavior), need for admiration, and lack of empathy, beginning by early adulthood

Narcissistic PD Traits

• Believing that you're better than others.
• Fantasizing about power, success, and attractiveness.
• Exaggerating your achievements or talents.
• Expecting constant praise and admiration.
• Believing that you're special and acting accordingly.
• Failing to recognize other people's emotions and feelings.
• Expecting others to go along with your ideas and plans.

Narcissistic Personality Disorder summarized with A FAME GAME

• Admiration required in excessive amounts.
• Fantasizes about unlimited success, brilliance, etc.
• Arrogant.
• Manipulative.
• Envious of others.
• Grandiose sense of importance.
• Associates with special people.
• Me first attitude.
• Empathy lacking for others.

Narcissistic PD Treatment

• Provider must deal with emotional transitions by the patient, from over idealizing to devaluing
• Avoid being defensive about mistakes
• Include patient in decision-making

Narcissistic PD Treatment: Therapy

• Drop out rates as high as 64%
• Same as Borderline PD
• Medication same as Borderline PD

Cluster C: Anxious/Fearful

• Sacrifice openness, spontaneity, and flexibility for orderliness, control, and perfectionism
• Fearful/ anxious
• Associated with anxiety disorders

Cluster C personality disorders:

• Avoidant
• Dependent
• Obsessive-compulsive

Avoidant PD

• Social inhibition, feelings of inadequacy, and hypersensitivity to negative evaluation/ rejection.
• "clammed up", "wall flower"

Avoidant Personality Disorder summarized with "RIDICULE"

• Restrained within relationships.
• Inhibited in interpersonal situations.
• Disapproval expected at work.
• Inadequate (view of self).
• Criticism is expected in social situations.
• Unwilling to get involved.
• Longs for attachment to others.
• Embarrassment is the feared emotion.

Avoidant PD Treatment

• Avoid criticism
• Establish the provider-patient relationship
• Refer for therapy
• SSRIs for anxiety

Dependent PD

• Excessive need to be taken care of, leading to submissive and clinging behavior and fears of separation

Dependent Personality Disorder summarized with "DARN HURT"

• Disagreement is difficult to express.
• Advice - needs excessive input.
• Responsibility delegated to others.
• Nurturance is sought by others.
• Helpless when alone.
• Unrealistic with being left to care for self.
• Relationships are desperately sought when one ends.
• Tasks - has difficultly initiating projects; lacks self-confidence.

Dependent PD Treatment

• Set limits with the patient
• Refer to therapy
• SSRIs

Obsessive-Compulsive PD

• Preoccupation with orderliness, "perfectionism," and mental and interpersonal control, at the expense of flexibility, openness, and efficiency
• Preoccupied with details, rules, lists, organization, or schedules to the extent that the main goal is lost
• Reluctant to delegate tasks or to work with others unless they submit to exactly their way of doing things

Obsessive-Compulsive Personality summarized with "LOW MIRTH"

• Leisure activity minimal
• Organizational focus
• Work and productivity predominate
• No friends, no fun
• Miserly spending habits
• Inflexible around morals, values, etc.
• Rigidity and stubbornness
• Task completion is impaired (by perfectionism)
• Hoards items

Obsessive-Compulsive PD Treatment

• Share control of treatment with the patient, allowing the individual to actively participate in decisions regarding their care
• Avoid being defensive and authoritarian with the patient
• SSRIs

OCD VS OCPD

• Obsessive Compulsive Disorder:
• Characterized by disturbing persistent or repetitive unwanted thoughts (obsessions) or behaviors (compulsions)
• Hand washing, stove checking
• More likely to seek treatment
• Ego dystonic = tormented!
• Interferes with functioning and causes distress
• Obsessive Compulsive PD:
• Patients feel that their thoughts are valid or wanted
• Preoccupied with perfectionism and rigid control
• Less likely to seek treatment since they fail to see their condition as a problem
• May be a positive or negative trait

Personality Change Due to a Medical Condition Example

• Usually fairly sudden in older patient
• Patient with a brain injury to the frontal lobe that may yield symptoms such as a lack of judgment, disinhibition, and euphoria
• Patients with strokes invoking rages of outbursts
• Patients are viewed by others as "not himself or herself"

Individuals Sabotage Success

• Individuals sabotage their own success or pleasure in relationships, opportunities for pleasure/ advancement, and accomplishment

Personality Disorder Checklist

• Cluster A (odd, eccentric):
  • Paranoid (suspicious, hypersensitive, secretive)
  • Schizoid (seclusive, indifferent, passive)
  • Schizotypal (odd in thinking, bizaare fantasy, peculiar language)
• Cluster B (dramatic or emotional):
  • Histrionic (attention-seeker, flamboyant, provocative)
  • Narcissistic (excessive self-admiration, egocentric, sense of grandiose)
  • Borderline (impulsive, self-mutilative, manipulative)
  • Antisocial (rule breaker, aggressive, abusive)
• Cluster C (anxious or fearful):
  • Avoidant (fears criticism, overly serious, withdrawn)
  • Dependent (clingy, indecisive, submissive)
  • Obsessive-Compulsive (perfectionist, passive-aggressive, rigid)