Personality Disorders (Fall 2023) - PDF

Personality Disorders Advanced Psychopathology Fall 2023 Dr. Fahey Review from last week… • • • • • • • • Oppositional Defiant Disorder Intermittent Explosive Disorder Conduct Disorder Antisocial Personality Disorder [briefly] Pyromania Kleptomania Implications of these diagnoses Cultural conside...

Personality Disorders Advanced Psychopathology Fall 2023 Dr. Fahey Review from last week… • • • • • • • • Oppositional Defiant Disorder Intermittent Explosive Disorder Conduct Disorder Antisocial Personality Disorder [briefly] Pyromania Kleptomania Implications of these diagnoses Cultural considerations How can you differentiate between ODD and ADHD? W h a t a re th e differenc es between CD and ASPD? Why do yo pyrom u think klept ania and o in thi mania are s diag n group ostic ? Following Up • #5 on test: • Correct answer is false • Both ICD-11 and DSM-5-TR are considered to be category based • Slides from week 2 • Can you have bipolar 1 with psychotic features or schizophrenia but not schizoaffective? • Yes! • Bipolar 1 – At least 1 manic episode (at least 1 week) • Schizophrenia – at least 2 of delusions, hallucinations, and/or disorganized speech (most of 1 month) • Schizoaffective – mood symptoms same time as psychosis symptoms (2 or more weeks) • Page 125 • Questions to ask: • Are there mood symptoms? • Yes: Bipolar 1/MDD with psychotic features or schizoaffective • No: Schizophrenia • Are delusions and/or hallucinations present even when no mood symptoms? • Yes: Schizoaffective • No: Depressive/bipolar disorder with psychotic features • Need to understand “proportion of mood to psychotic symptoms over time and concurrence” • Collateral info and documents may be required DSM-5-TR: Definition of Personality “Personality traits are enduring patterns of perceiving, relating to, and thinking about the environment and oneself that are exhibited in a wide range of social and personal contexts.” • Enduring pattern of inner experience and behavior that deviates markedly from norms and expectations of individual’s culture DSM-5-TR: Definition of Personality Disorder • Manifested in at least 2 areas: • Cognition • Affectivity • Interpersonal functioning • Impulse control • Pervasive and inflexible • Maladaptive • Stable and of long duration • Leads to subjective distress or impairment • Onset in adolescence or early adulthood • Not due to another mental disorder, substance, or medical condition DSM-5-TR Personality Disorders Paranoid personality disorder Schizoid personality disorder Schizotypal personality disorder Antisocial personality disorder Borderline personality disorder Histrionic personality disorder Narcissistic personality disorder Avoidant personality disorder Dependent personality disorder Obsessivecompulsive personality disorder Personality change due to another medical condition Other specified personality disorder and unspecified personality disorder Prevalence of Personality Disorders Overall prevalence Sex-specific prevalence • Cluster A: 5.7% • Cluster B: 1.5% • Cluster C: 6.0% • Data suggest 9-15% of U.S. adults have a personality disorder • ASPD more commonly diagnosed in males • Borderline, histrionic, dependent PDs more commonly diagnosed in females • Why do you think that is? Development & Age Considerations for PDs • Typically emerge in adolescence or early adulthood • Usually anything seen in childhood will not persist into adulthood • May not be noticed until later in adulthood though, depending on person’s lifestyle + cultural expectations • Symptoms of some of the PDs typically become less prominent with age (but not all PDs) • Can be exacerbated by a triggering event (ex. job loss or death of support person) • To diagnose someone under the age of 18 with a PD, the features must have been present for 1 year • However, antisocial personality disorder specifically CANNOT be diagnosed in individuals under the age of 18 Differentials for PDs What do you think are some important differentials to consider? • Psychotic disorders • Paranoid, schizoid, and schizotypal PD • Substance use • Anxiety • Depression • Neurocognitive disorders • ASD vs. schizoid PD • Bipolar disorders • PTSD • Personality changes are commonly seen • Personality change due to medical condition Personality Disorders: Cluster A ~Focus on distrust, detachment, discomfort with relationships~ • Paranoid Personality Disorder (F60.0) • Schizoid Personality Disorder (F60.1) • Schizotypal Personality Disorder (F21) Paranoid Personality Disorder (F60.0) • Pervasive pattern of distrust and suspiciousness of others, without sufficient basis • What other disorders could this look like? • delusional disorder, schizophrenia with paranoid thinking, mood disorders with psychotic features, influence of substance use/intoxication, actual threats • Consider role of culture and systemic injustices Diagnostic Criteria: DSM-5-TR pg. 737 Schizoid Personality Disorder (F60.1) • Pervasive pattern of detachment from social relationships and restricted range of expression of emotions; does not desire or enjoy close relationships • What other disorders could this look like? • Schizophrenia, mood disorder with psychotic features, autism spectrum disorder, substance use/intoxication, social anxiety, agoraphobia Diagnostic Criteria: DSM-5-TR pg. 741 Schizotypal Personality Disorder (F21) • Pervasive pattern of social and interpersonal deficits; discomfort with and reduced capacity for close relationships; eccentric behavior • What other disorders could this look like? • Schizophrenia, mood disorder with psychotic features, autism spectrum disorder, social anxiety, delusional disorder • Consider cultural differences Diagnostic Criteria: DSM-5-TR pg. 744 Personality Disorders: Cluster B ~Relationships with others are marked by focus on self, own needs, objectification of others, emotional instability~ • • • • Antisocial Personality Disorder (F60.2) Borderline Personality Disorder (F60.3) Histrionic Personality Disorder (F60.4) Narcissistic Personality Disorder (F60.81) Antisocial Personality Disorder (F60.2) • Pervasive pattern of disregard for and violation of rights of others; deceitful, impulsive, often aggressive, failure to conform to social norms, lack of regard for authority, rules, & law • Symptoms occurring since 15 years old • Individual is at least 18 years old • What other diagnoses could this look like? • Schizophrenia, mood disorder, substance use, other PDs, especially Narcissistic P.D. Diagnostic Criteria: DSM-5-TR pg. 748 Borderline Personality Disorder (F60.3) • Pervasive pattern of unstable and intense relationships, mood, self-image and marked impulsivity • Significantly elevated suicide risk associated with this diagnosis • Clinically: feels like a yo-yo • Read: I Hate You, Don’t Leave Me • What other diagnoses could this look like? • Mood disorders, substance use, other PDs • Treatment: Dialectical Behavior Therapy (DBT) • Video: BPD and co-occurring diagnoses Diagnostic Criteria: DSM-5-TR pg. 663 Histrionic Personality Disorder (F60.4) • Pervasive pattern of emotionality and attention seeking behavior • Uncomfortable unless center of attention; shallow, rapidly shifting expression of emotions • What other diagnoses could this look like? • Other P.D.s; anything else? Diagnostic Criteria: DSM-5-TR pg. 757 Narcissistic Personality Disorder (F60.81) • Pervasive pattern of grandiosity, need for admiration, lack of empathy • Often arrogant, haughty behavior and/or attitude • Many say that at the heart of a narcissist is a brittle ego AKA very low self-esteem • What other diagnoses could this look like? • Mania or hypomania, substance use/intoxication, other P.D. such as ASPD Diagnostic Criteria: DSM-5-TR pg. 760 Class Discussion • How might some of the PDs we have discussed so far vary based on cultural norms? • Recall the Disruptive, Impulse-Control, and Conduct Disorders from last class… • What are some similarities between those and the Cluster B personality disorders that we just discussed? • What are some differences? Personality Disorders: Cluster C ~Marked by intrapsychic anxiety, inhibition, and anxiety-reducing behaviors~ • Avoidant Personality Disorder (F60.6) • Dependent Personality Disorder (F60.7) • Obsessive-Compulsive Personality Disorder (F60.5) Avoidant Personality Disorder (F60.6) • Pervasive pattern of social inhibition, feelings of inadequacy, hypersensitivity to evaluation often leading to avoidance of situations that may involve vulnerability • What other diagnoses could this look like? • Social anxiety disorder and other anxiety disorders Diagnostic Criteria: DSM-5-TR pg. 764 Dependent Personality Disorder (F60.7) • Pervasive and excessive need to be taken care of • Submissive, clingy behavior • Fear of separation • What other diagnoses could this look like? • Other PDs, especially Borderline P.D.; rule out situational factors such as recent exposure to trauma, abusive relationship, etc. Diagnostic Criteria: DSM-5-TR pg. 768 Pop Quiz! you How might te differentia PD and between D anxiety? separation Obsessive-Compulsive Personality Disorder (F60.5) • Pervasive pattern of preoccupation with orderliness, perfectionism, and mental and interpersonal control • Painstaking attention to rules, details, lists, & procedures • Work-a-holic • Makes significant sacrifices such as leisure time, openness, and relationships due to rigidity • What other diagnoses could this look like? • Diagnostic Criteria: DSM-5-TR pg. 771 OCD, other PDs, trauma-related disorder Pop quiz Can you d ! iagnose something with both OCD and OCPD? Check In How do you feel like it might be to work with someone with a personality disorder? Is there any particular one you have a strong reaction to? Clinical, semi-structured, or structured interview Observation Assessment for Personality Disorders Collateral reports Self-report measures •Personality Assessment Inventory (PAI) •Millon Clinical Multiaxial Inventory (MCMI-IV–revised for DSM-5) •Minnesota Multiphasic Personality Inventory (MMPI-3) Projective measures •Rorschach •Thematic Apperception Test (TAT) •Projective drawings Treatment for Personality Disorders (PDs) Not very much… Remember that PDS are enduring, pervasive, and inflexible – that’s pretty hard to treat! • Most research on treatment of PDs focuses on Borderline Personality Disorder (BPD) specifically • Some EBPs for PDs (not necessarily found to be effective for every PD): • Dialectical Behavior Therapy (DBT) • Schema-focused therapy • Mentalization-based therapy (MBT) • Systems training for emotional predictability and problem-solving (STEPPS) • Transference-focused psychotherapy (TFP) AKA psychodynamic psychotherapy • Forming a healthy, stable therapeutic relationship • Skills training • Medication management Small Groups 1. 6 groups of 3 or 4 2. I will give each group a PD and you have to write a vignette to present to the class. 3. Assign a scribe to create a Word doc of this vignette. Use DSM information about etiology, associated behaviors, and psychosocial factors, etc. to round out your vignette. 1. Make it tricky! 4. Include the following: 1) client’s demographics & history, 2) relevant components of the MSE, 3) presenting concerns, 4) symptoms of the diagnosis 5. Present your case to class and we will try to figure out which it is. 6. Email me the vignette after you present. Done for today! • Questions? • Next week: • Substance Use Disorders