Personality Disorders

Overview

Personality disorders are inflexible and maladaptive patterns of behavior, typically causing impairment in social or occupational functioning. They lie on a spectrum between personality traits and "full-blown" psychiatric pathologies (such as schizophrenia, mania, etc.).

Personality disorders are typically ego-syntonic, such that the patient denies or does not realize they have a problem.

Personality disorders differ from personality traits in that personality traits typically cause no social or occupational impairments. Personality disorders do cause impairments.

Personality traits are not a pathology. As in many things in psychiatry, a person's psychological presentation may be quite extreme, but until it causes social or occupational impairment, it is not pathological.

Personality disorders differ from "full-blown" psychiatric pathology in that patients do not meet criteria for any other psychiatric diagnosis.

For example, a schizotypal patient may have very eccentric behaviors causing significant social impairment, but exhibit clear logical thinking, not experience any hallucinations, etc. Therefore psychosis cannot be diagnosed.

The treatment for personality disorders typically includes psychotherapy and symptomatic pharmacotherapy.

Cluster A

Mnemonic:

• Cluster A personality disorders are "Weird"

• Cluster B are "Wild"

• Cluster C are "Worried".

United by a theme of eccentric or odd behavior with fear of social relationships. The three disorders in this cluster are:

• Paranoid

• Schizoid

• Schizotypal.,

• Or Cluster A are "Accusatory, Aloof, and Awkward", respectively.

Paranoid

Paranoid personality disorder exhibits suspicious, mistrustful behavior. Patients typically attribute responsibility of problems to others and are accusatory without evidence.

Patients with paranoid personality disorder frequently use the defense mechanism of projection.

Example: A patient divorces his wife after repeated accusations of her infidelity. He later refuses to speak with friends who try and help him patch things up with his wife, and accuses them of siding with her.

Schizoid

Schizoid personality disorder exhibits a lifelong pattern of voluntary social withdrawal. Patients are content with social isolation and prefer to be alone.

Example: An intelligent businessman is repeatedly fired from jobs due to inability to work cooperatively in social settings.

Schizoid personality disorder differs from avoidant personality disorder because schizoid patients shun social contact.

In contrast, patients with avoidant personality disorder desire social relationships but cannot achieve them.

Schizotypal

Schizotypal personality disorder exhibits magical thinking, peculiar appearance, and eccentric thought patterns. These patients may be obsessed with the occult, incorporating such beliefs and practices into their lifestyle.

Example: A mystic card reader alienates her friends and family due to spending the majority of her time studying her trade. She states that her loved ones "don't understand the magnitude of her work."

Cluster B

Exhibit emotional, dramatic, or erratic behavior. The 4 disorders in this cluster are:

• Antisocial

• Borderline

• Histrionic

• Narcissistic.,

Or Cluster B are "Bad to the Bone" since they are most likely to harm others, physically or emotionally.

Histrionic

Displays dramatic, extroverted behavior. Patients are attention-seeking, in ways including but not limited to sexual provocativeness.,

Patients with histrionic personality disorder classically utilize the defense mechanism of regression. They regress to child-like behavior in order to gain the attention of others.

Example: A scantily-clad woman presents with a fever of 99.1 F and states she is "burning up" and "needs your wisdom and expertise to nurse me back to health."

Borderline

Borderline personality disorder displays unstable mood, emptiness, and poorly defined identity. They are dramatic, but in a way that is more emotional than the flamboyant, theatrical drama of histrionic PD. Classically, they exhibit splitting, where they perceive issues and social interactions in black/white, with no gray area.

Patients with borderline personality disorder can be treated with dialectical behavioral therapy (DBT).

DBT is a modified form of cognitive behavioral therapy that focuses on preventing self-injury and encouraging patients to be more adaptive to stressors and change.

Example: A 24-year-old woman presents to the ER with multiple lacerations on her forearms after breaking up with her boyfriend of 2 weeks who didn't call her when he said he would. When you interview her compassionately, she tells you you're the best doctor she's ever met.

Narcissistic

Narcissistic personality disorder exhibits grandiosity, inflated ego, and a sense of entitlement. They have fragile self-esteem that requires constant inflation and re-assurance through criticism of others.

Example: A businessman cancels his appointment with your colleague after learning she did not attend an ivy league medical school. He shows up late to his next appointment because he says he "had more important things to attend to."

Antisocial

Antisocial personality disorder displays inability to conform to social norms, and a disregard for the rights of others. They typically have a criminal history and may be described as "sociopaths" or "psychopaths". Antisocial personality disorder is considered conduct disorder in patients under 18 years old.

Example: A 25-year-old with an extensive history of theft and destruction of property is charged with the murder of his girlfriend of 2 years. His remorse over the crime appears limited to the inconvenience associated with being arrested and held.

Cluster C

United by a pattern of fearful or anxious behavior. The three disorders included in Cluster C are:

• Avoidant

• Dependent

• Obsessive-Compulsive.,

Or Cluster C are "Cowardly, Clingy, and Compulsive", respectively.

Avoidant and dependent personality disorders may present similarly with shyness and clinginess to relationships. Patients with avoidant personality disorder are slow to enter and grow relationships, while patients with dependent personality disorder actively and aggressively search for new relationships.

Avoidant

Avoidant personality disorder (sometimes referred to as anxious personality disorder) displays feelings of inadequacy that lead to social withdrawal and shyness. Importantly, these patients desire relationships with others, as opposed to schizoid personality disorder.

Example: A 43-year-old male lies about conflicting plans to avoid going to a bar with coworkers, because he is too afraid of "being awkward."

OCD

Obsessive-compulsive personality disorder is characterized by stubborn perfectionism, particularly regarding cleanliness and order. Patients often are ultimately ineffective at tasks due to their inability to sacrifice procedure for product.

Note that the name of this personality disorder is a misnomer; the disorder simply is reminiscent of OCD, but there are no obsessions nor compulsions.

Example: A medical student times herself studying and clocks in 72.5 hours/week of studying on average. She struggles to get C's in her classes because of her ritualistic study habits which include making 3 different outlines of the material, 2 sets of flashcards, and a highlighter system composing of 7 colors.

Dependent

Dependent personality disorder is characterized by a lack of self-confidence and an excessive need to be taken care of. Patients experience anxiety and helplessness when forced to take care of themselves, make decisions, or assume responsibility.

Example: A 37-year-old man misses a week of work after his girlfriend, who used to pack his lunch and bring him to work, breaks up with him. He experiences a panic attack in the interim period before finding another girlfriend.

• both: fear of abandonment

• Dependent lack the impulsivity, uncontrolled anger, and history of unstable, intense relationships seen in BPD. They react to fears of rejection with increasing submissiveness rather than emptiness and rage.

Defense

Mature

Mature defense mechanisms are healthy, adaptive ways of reconciling conflicts of the ego (e.g. guilt, grief, inadequacy) in a way that is acceptable or admirable to society. They include suppression, altruism, sublimation, and humor.

Suppression is the conscious decision to ignore a conflict.

• Example: A man prevents himself from thinking about his recently deceased wife while at work, so that he may properly mourn at home.

Altruism is the performance of acts that benefit others. It may be in the spirit of "penitence" or vicarious experience.

• Example: A woman who struggled with caring for her child as he developed a rare disease raises public awareness of the disease and helps other families cope.

Sublimation is the channeling of an ego conflict into a productive or socially acceptable form.

• Example: A man with OCD characterized by intrusive thoughts of violence enters the military.

Humor is the deflection of ego conflicts in the form of lighthearted or casual banter.

• Example: A man with a debilitating medical illness makes jokes about some of his symptoms.

Immature

Immature defense mechanisms are less sophisticated methods of resolving ego conflict that may include all other defense mechanisms besides the four mature ones.

Acting out is the act of causing trouble or being disobedient to avoid the anxiety of properly dealing with a stressor.

• Example: A man "forgets" a deadline of starting a project at work to avoid the anxiety associated with beginning it.

Denial is the rejection of a distressing reality.

• Example: A woman insists her doctor made a mistake in her new terminal diagnosis.

Displacement is the release of ego conflicts brought upon by someone else onto a new person.

• Example: A woman who is reprimanded by her boss at work is hypercritical to her children when they come home from school.

Identification is the act of modeling one's behavior after a more influential or powerful person.

• Example: A freed hostage defends the motives of his/her captor ("Stockholm Syndrome").

Isolation of affect refers to a flat affect (e.g. monotonality, limited facial expression or emotion, etc.) in the midst of an emotionally distressing process.

• Example: A patient surviving from a graphic automobile accident flatly recalls the scene of the event.

Projection is the act of casting of one's ego conflict onto another, then acting accordingly.

• Example: A man who has cheated in his relationships in the past is a very controlling boyfriend in all new relationships.

Rationalization is the insertion of logic to reconcile an ego conflict, when the distressing conflict actually occurred for another reason.

• Example: A woman who is fired from her job explains to her friends that she was overqualified for the position and was looking for a way out of the company.

Reaction formation is an action taken in direct opposition to unconscious ideas or feelings in an attempt to remedy them.

• Example: A man whose financial difficulties are causing him to be evicted spends lavishly on holiday gifts and harshly criticizes homeless people for being "lazy".

Regression is the return of a patient to a more immature developmental level in the face of a stressor.

• Example: A child who was once potty trained begins to wet the bed after a move across the country.

Fixation is the act of partially remaining at a childish level of development. Sticking to a certain way of reacting, even if ineffective.

• Example: A middle-aged man is consistently distressed by doctor's visits and buys himself a lollipop every visit. He recalls a particularly distressing doctor's visit early in childhood that "scarred" him.

• e.g. choosing same type of SO even though didn't work out before.

Splitting is the separation of interactions with people into black/white categories due to an intolerance of ambiguity.

• Example: A patient with borderline personality disorder brags incessantly about her lawyer until he loses her case; the lawyer then becomes "the most deceitful, incompetent person she has ever met".

Questions

case: A 58-year-old woman brings her elderly father to the office. He has multiple medical problems, including diabetes, chronic pulmonary disease, and mild cognitive impairment. He recently moved in with the daughter as he could no longer live independently. The daughter reluctantly quit her job to stay home full-time and resents having to care for him. She has been angry and upset with her siblings, who have not offered to help. The father was mostly absent during the daughter's childhood due to business travel, and he divorced the mother when the daughter was 13. During the visit, the daughter is extremely attentive to her father, repeatedly asking if he is comfortable and offering to get him water and tissues. She tells the physician, "It's great having Dad live with me. I feel that we can catch up on lost time." Which of the following defense mechanisms best explains this woman's behavior toward her father?

• Altruism: This service provides gratification, unlike in reaction formation, in which a true sense of internal pleasure is lacking. Eg, this woman developing a support group for caregivers

• Reaction formation: complete opposite behavior. Her negative feelings are transformed into over-solicitous behavior during the office visit. Individuals are usually not aware that they are exhibiting this defense mechanism despite it being readily apparent to others.

• Sublimation is a mature defense mechanism in which a person channels unacceptable thoughts or impulses into socially acceptable behavior (eg, this woman channeling her anger into athletic pursuits). In sublimation, the behavior is similar to the original thought/impulse; in reaction formation, it is the opposite.