Personality Disorders - Public Health and Psychology - Lecture Slides, Slides of Public Health

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Personality Disorders Docsity.com • Under stress…our personalities become emphasized Docsity.com PDO’s continued • Because these behavior patterns are so ingrained, the PDO frequently only present when in Axis I crisis • Quantitative difference-PDOs lead to impairment in occupational/interpersonal functioning (transcends the situation) Docsity.com PDO’s General Tx Guidelines • Goals should be realistic • Goals should be relevant to the situation • PDO’s are life-long patterns that will not change in short intervention. – Inpatient setting-”Play to strengths” • Initial goals may only be some Sx improvement and increased awareness Docsity.com Cluster A PDOs • “Odd & Eccentric Behavior” • Paranoid PDO-a pattern of distrust & suspiciousness such that other’s motives are interpreted as malevolent. • Schizoid PDO-a pattern of detachment from social relationships & a restricted range of emotional expression • Schizotypal PDO- a pattern of acute discomfort in close relationships & restricted range of emotional expression. Docsity.com Schizoid PDO • Few pleasurable activities (less desire than APDO) • Emotionally cold and detached with flattened affect • Limited capacity (or desire) to express warm, tender or angry feelings toward others • Indifferent to praise or criticism • Little interest in sexual relationship with other • Consistent choice of solitary activities • Excessive preoccupation with fantasy & introspection • No desire for close relationships (“only one”) • Insensitive to prevailing social norms & conventions Docsity.com Schizoid PDO Tx • Medication & Psychotherapy • Blackmon (94) – A schizoid young man made a methodical attempt at suicide. He revealed a paucity of object attachments leading to profound isolation. His early upbringing led him to extreme isolation of affect and a fear of fragmentation. His inner life was not safely reachable by conventional therapy. After he became involved in playing a fantasy game, dungeons and Dragons, the therapy was modified to use the game material as displaced, waking fantasy. This fantasy was used as a safe guide to help the patient learn to acknowledge and express his inner self in a safe and guided way. The patient ultimately matured and developed healthier object relations and a better life. Docsity.com Schizotypal PDO • Ideas of reference (excluding delusions of reference) • Odd beliefs or magical thinking that influence behavior and are inconsistent with sub-cultural norms • Unusual perceptual experiences, including bodily illusions • Odd thinking and speech (vague, metaphorical, overelaborate or stereotyped) • Inappropriate or constricted affect • Odd, eccentric or peculiar behavior or appearance • Lack of close friends or confidants, other than relatives • Excessive social anxiety that does not diminish with familiarity and tends to be associated with paranoid fears rather than negative self judgements Docsity.com Case Example • 42 year-old African-American woman with chronic history of attention and concentration difficulties- presented for ADHD evaluation • Presentation/Family History • Results: – IQ, language and memory intact; mild executive dysfunction. Poor coping typified by isolation, anxiety, ruminative thinking and social introversion Docsity.com Cluster C PDO’s • “Anxious and Fearful Behavior” • Avoidant PDO-Social inhibition, inadequacy feelings, & hypersensitivity of negative evaluation • Dependent PDO-Pervasive & excessive need to be taken care of that leads to submissive & clinging behavior and fears of separation • Obsessive Compulsive PDO-Preoccupation with orderliness, perfectionism and mental & interpersonal control, at the expense of flexibility, openness, and efficiency. Docsity.com Avoidant PDO’s • Avoids activities with significant interpersonal contact, because of fears of criticism, disapproval or rejection • Unwilling to become involved without “guarantees of acceptance” • Very restrained in intimate relationships due to fear of shame or ridicule • Preoccupied with social criticism or rejection • Inhibited in new interpersonal situations • Views self as socially inept, personally unappealling or inferior to others • Very reluctant to take personal risks Docsity.com Dependent PDO • Significant indecision without excessive advice or reassurance from others • Needs others to be responsible for most major areas of his/her life • Rarely disagrees due to fear of disapproval • Rarely initiate projects or doing things alone due to poor self-confidence, instead of low motivation • Goes to excessive length to obtain nurturance and support from others (volunteering for unpleasant tasks) Docsity.com Dependent PDO continued • Feel uncomfortable or helpless when alone due to exaggerated fear of being unable ot care for self • Urgently seeks another relationship as a source of care and support when a close relationship ends (most common reason for entering tx.) • Unrealistically preoccupied with fears of being left to take care of himself or herself (“dreads autonomy”) • Productive when supervised, otherwise see themselves as “inept or stupid” • When pressed to name redeeming qualities, will reluctantly confess to being “good companion, loyal & kind” Docsity.com Other DPDO characteristics • Freud-Oral characteristic-intense need to be fed or taken care of. • Common in normal clinic situations, but very high in psychiatric patients • Common with other PDO’s and Axis I D/Os such as Agoraphobia • Gender? Docsity.com OCPD criteria continued • Unable to discard worthless objects • Aversive to delegating tasks • “Miserly spending”-money is to be hoarded for catastrophes • Stubborn and rigid traits • Descriptors – Miss the forest for the trees; difficult seeing other’s perspectives; avoids “soft feelings” Docsity.com Epidemiology • Prevalence (all existing cases @ one point in time) – 1% in community samples – Adult lifetime prevalence 2.5% – 3-10% in mental health clinics • Gender differences – Males are twice as likely as females Docsity.com History • Freud’s (1908) Anal character – Orderly, obsessed with bodily cleanliness, conscientious to the utmost, obstinate • Abraham (1921) expanded on this: – Discussed the pleasure of ordering things • DSM-I & DSM-II highlighted orderliness • DSM-III, III-R added some symptoms • DSM-IV (TR) require 4 of 8 Docsity.com Antisocial PDO • Pervasive pattern of disregard for and violation of rights of others, occurring since age 15, as indicated by 3 (or more) of: – Failure to conform to social norms with respect to lawful behaviors as indicated by repeated arrest. – Deceitfulness (repeated lying, use of aliases or conning others for personal profit or pleasure) Docsity.com Antisocial PDO continued • Impulsivity or failure to plan ahead • Irritability and aggressiveness, as indicated by repeated physical fights or assaults • Reckless disregard for safety of self/others • Consistent irresponsibility, as indicated by repeated failure to sustain consistent work behavior or honor financial obligations • Lack of remorse • 18 years of older; Evidence of a Conduct DO <15 • Antisocial behavior not exclusively during SCz of Mania Docsity.com Antisocial PDO continued • Radar for people’s vulnerabilities; enjoy manipulating, exploiting and intimidating others. • Crave stimulation (drugs, manipulation, sex) to medicate boredom or depression. Frontal lobe abnormalities* • Sexual relationships are thrilling conquests and nothing more. • Emotionally shallow, incapable of shame, guilt, loyalty, love and sincere emotion. Yet, quick to anger. • 30-80% are in prison; Only 2% remit by age 21 • 3% of men & 1% of women in general population; 3- 15% in psychiatric populations Docsity.com Borderline PDO continued • Label initially referred to straddling the border between neurosis and psychosis (“latent schizophrenia”) • Identity confusion is often manifested as dissociation • Often “present well” but turmoil very evident in interpersonal relationships • Anything less than total love is hate; anything less than total commitment is rejection (rejection sensitivity) • Expect & demand others to do what they can’t do for themselves • Chronically sad and demoralized which lead to presentation of neurotic Sx (anxiety, mood d/o & conversion Sx.) that become psychotic under stress • Bizarre responses on structured & unstructured tests Docsity.com Borderline PDO Treatment • Treatment is very difficult and marked by a series of goals from safety/stabilization to interpersonal consistency • M. Linehan-Dilectical Behavior Therapy • Therapy is long-term, demanding, marked by frequent hospitalizations and reality testing • Strong contertransference reactions, which often benefit from consultation with peers • Pharmacotherapy-MAOs, SSRIs (anger, impulsiveness) with Lithium/Dilantin used in severe cases Docsity.com Histrionic PDO • Uncomfortable if not center of attention • Interactions are characterized by inappropriate sexually seductive or provocative behavior • Rapidly shifting and shallow expression of emotions • Consistently uses physical appearance to draw attention to him/herself • Impressionistic style of speech, which lacks detail • Self-dramatizing, overlytheatrical and exaggerated expression of emotions • Suggestible & easily influenced by others/circumstances • Considers relationships more intimate than they are Docsity.com Narcissistic PDO • Grandiose sense of self-importance, often unwarranted • Preoccupied with fantasies of unlimited success, power, brilliance, beauty or ideal love • Believes that s/he is “special” and can only be understood by other high-status people • Requires excessive admiration • Entitled sense and expects special treatment • Interpersonally exploitative • Lacks empathy; Unwilling to recognize others feelings • Envious of others, believes others are envious of him/her • Arrogant behaviors or attitudes • Intolerant of criticism because of low self-esteem • More prevalent in men Docsity.com Narcissistic PDO Treatment • Difficult to enter treatment because it is often perceived as a sign of weakness (needing someone else) • Frequently enter therapy after suffering a Narcissistic injury and are at risk for leaving treatment prematurely as the dust settles. • Goal of treatment is to gain more realistic view of self • Behavioral Therapy-expose patient to anxiety of feeling less than great (systematically) • Cognitive Therapy-discuss the paradox, realizing that no achievement is enough • Countertransference-work very hard to please the patient and therefore earn respect, leading to anger and battles Docsity.com