1. Personality Disorders Derek S. Mongold MD Assistant Professor WVU 2012

2. Objectives. Learn how to differentiate between the three major categories of personality disorders. Identify specific personality disorders within each category. Learn specific treatments for each personality disorder.

3. Overview. Definition. Cluster A disorders. Cluster B disorders. Cluster C disorders.

4. Definition 1. An enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individual’s culture in at least 2 of the following areas. Cognition (i.e., ways of perceiving and interpreting self, others, and events). Affectivity (range, intensity, labiality, and appropriateness of emotional response). Interpersonal functioning. Impulse control.

5. Definition 1. The pattern is enduring, inflexible, and pervasive across a broad range of situations. Leads to clinically significant distress or impairment in social, occupational, or other important areas of functioning. Stable, of long duration, and its onset can be traced back at least to adolescence or early adulthood. Not substance induced or due to another mental, physical, or medical disorder.

6. The Clusters. Cluster A. Cluster B. Cluster C.

7. Cluster A Disorders. Paranoid. Schizoid. Schizotypal.

8. Cluster B Disorders. Antisocial. Borderline. Histrionic. Narcissistic.

9. Cluster C Disorders. Avoidant. Dependent. Obsessive-compulsive.

10. Mnemonic. Weird. Wild. Worried.

11. Cluster A.

12. Paranoid 1. Pervasive distrust and suspiciousness of others such that their motives are interpreted as malevolent, beginning by early adulthood and present in a variety of contexts, as indicated by 4 or more of the following: Suspects, without sufficient basis, that others are exploiting, harming, or deceiving them. Is preoccupied with unjustified doubts about the loyalty or trustworthiness of friends or associates. Is reluctant to confide in others because of unwarranted fear that the information will be used maliciously against them. Reads hidden demeaning or threatening meanings into benign remarks or events. Persistently bears grudges (i.e., is unforgiving of insults, injuries, or slights). Perceives attacks on his or her character or reputation that are not apparent to others and is quick to react angrily or to counterattack. Has recurrent suspicions, without justification, regarding fidelity of spouse or sexual partner. Does not due to something else. If criteria are met prior to Schizophrenia add “premorbid”.

13. Schizoid 1. A pervasive pattern of detachment from social relationships and a restricted range of expression of emotions in interpersonal settings, beginning by early adulthood and present in a variety of contexts, as indicated by 4 or more of the following: Neither desires nor enjoys close relationships, including being part of a family. Almost always chooses solitary activities. Has little, if any, interest in having sexual experiences with another person. Takes pleasure in few, if any, activities. Lacks close friends or confidants other than first-degree relatives. Appears indifferent to the praise or criticism of others. Shows emotional coldness, detachment, or flattened affectivity. Not due to something else. If criteria are met prior to Schizophrenia add “premorbid”.

14. Schizotypal 1. A pervasive pattern of social and interpersonal deficits marked by acute discomfort with, and reduced capacity for close relationships as well as by cognitive or perceptual distortions and eccentricities of behavior, beginning by early adulthood and present in a variety of contexts, as indicated by 5 or more of the following. Ideas of reference (excluding delusions of reference). Odd beliefs or magical thinking that influences behavior and is inconsistent with subcultural norms (e.g. superstitiousness, belief in clairvoyance, telepathy, or “sixth sense”, in children and adolescents, bizarre fantasies or preoccupations). Unusual perceptual experiences, including bodily illusions. Odd thinking and speech (e.g., vague, circumstantial, metaphorical, overelaborate, or stereotyped). Suspiciousness or paranoid ideation. Inappropriate or constricted affect. Behavior or appearance that is odd, eccentric, or peculiar. Lack of close friends or confidants other than first-degree relatives. Excessive social anxiety that does not diminish with familiarity and tends to be associated with paranoid fears rather than negative judgments about self. Not due to something else. If criteria are met prior to Schizophrenia add “premorbid”.

15. Cluster B.

16. Antisocial 1. There is a pervasive pattern of disregard for and violation of the rights of others occurring since age 15 years, as indicated by 3 or more of the following: Failure to conform to social norms with respect to lawful behaviors as indicated by repeatedly performing acts that are grounds for arrest. Deceitfulness, as indicated by repeated lying, use of aliases, or conning others for personal profit or pleasure. Impulsivity or failure to plan ahead. Irritability and aggressiveness, as indicated by repeated physical fights or assaults. Reckless disregard for safety of self or others. Consistent irresponsibility, as indicated by repeated failure to sustain consistent work behavior or honor financial obligations. Lack of remorse, as indicated by being indifferent to or rationalizing having hurt, mistreated, or stolen from another. At least 18 years old. Evidence of Conduct Disorder with onset before age 15. Does not happen exclusively during a course of Schizophrenia or Manic Episode.

17. Borderline Personality Disorder 1. A pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following. Frantic efforts to avoid real or imagined abandonment. A pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation. Identity disturbance: markedly and persistently unstable self image or sense of self. Impulsivity in at least two areas that are potentially self damaging (e.g., spending, sex, substance abuse, reckless driving, binge eating). Not suicidal or self-mutilating behavior. Recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior. Affective instability due to a marked reactivity of mood (e.g., intense episodic dysphoria, irritability, or anxiety usually lasting a few hours and only rarely more than a few days). Chronic feelings of emptiness. Inappropriate, intense anger or difficulty controlling anger (e.g., frequent displays of temper, constant anger, recurrent physical fights). Transient, stress-related paranoid ideation or severe dissociative symptoms.

18. Histrionic Personality Disorder 1. A pervasive pattern of excessive emotionality and attention seeking, beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following: Is uncomfortable in situations in which he or she is not the center of attention. Interaction with others is often characterized by inappropriate sexually seductive or provocative behavior. Displays rapidly shifting and shallow expression of emotions. Consistently uses physical appearance to draw attention to self. Has a style of speech that is excessively impressionistic and lacking in detail. Shows self-dramatization, theatricality, and exaggerated expressions of emotion. Is suggestible, I.e., easily influenced by others or circumstances. Considers relationships to be more intimate than they actually are.

19. Narcissistic Personality Disorder 1. A pervasive pattern of grandiosity (in fantasy or behavior), need for admiration, and lack of empathy, beginning by early adulthood and present in a variety of contexts, as indicated by 5 (or more) of the following: Has a grandiose sense of self-importance (e.g., exaggerates achievements and talents, expects to be recognized as superior without commensurate achievements). Is preoccupied with fantasies of unlimited success, power, brilliance, beauty, or ideal love). Believes that he or she is “special” and unique and can only be understood by, or should associate with, other special or high-status people (or institutions). Requires excessive admiration. Has a sense of entitlement, i.e., unreasonable expectations of especially favorable treatment or automatic compliance with his or her expectations. Is interpersonally exploitative, i.e., takes advantage of others to achieve his or her own ends. Lacks empathy: Is unwilling to recognize or identify with the feelings and needs of others. Is often envious of others or believes that others are envious of him or her. Shows arrogant, haughty behaviors or attitudes.

20. Cluster C.

21. Avoidant Personality Disorder 1. A pervasive pattern of social inhibition, feelings or inadequacy, and hypersensitivity to negative evaluation, beginning by early adulthood and present in a variety of contexts, as indicated by 4 (or more) of the following: Avoids occupational activities that involve significant interpersonal contact, because of fears of criticism, disapproval, or rejection. Is unwilling to get involved with people unless certain of being liked. Shows restraint within intimate relationships because of the fear of being shamed or ridiculed. Is preoccupied with being criticized or rejected in social situations. Is inhibited in new interpersonal situations because of feelings of inadequacy Views self as socially inept, personally unappealing, or inferior to others. Is unusually reluctant to take personal risks to to engage in any new activities because they may prove embarrassing.

22. Dependent Personality Disorder 1. A pervasive and excessive need to be taken care of that leads to submissive and clinging behavior and fears of separation, beginning by early adulthood and present in a variety of contexts, as indicated by 5 (or more) of the following: Has difficulty making everyday decisions without an excessive amount of advice and reassurance from others. Needs others to assume responsibility for most major areas of his or her life. Has difficulty expressing disagreement with others because of unrealistic fears of loss of support or approval. Has difficulty initiating projects or doing things on his or her own (because of a lack of self-confidence in judgment or abilities rather than a lack of motivation or energy). Goes to excessive lengths to obtain nurturance and support from others, to the point of volunteering to do things that are unpleasant. Feels uncomfortable or helpless when alone because of exaggerated fears of being unable to care for himself or herself. Urgently seeks another relationship as a source of care and support when a close relationship ends. Is unrealistically preoccupied with fears of being left to take care of himself or herself.

23. Obsessive-Compulsive Personality Disorder 1. A pervasive pattern of preoccupation with orderliness, perfectionism, and mental and interpersonal control, at the expense of flexibility, openness, and efficiency, beginning by early adulthood and present in a variety of contexts, as indicated by 4 (or more) of the following: Is preoccupied with details, rules, lists, order, organization, or schedules to the extent that the major point of the activity is lost. Shows perfectionism that interferes with task completion (e.g., is unable to complete a project because his or her own overly strict standards are not met). Is excessively devoted to work and productivity to the exclusion of leisure activities and friendships (not accounted for by obvious economic necessity). Is overconscientious, scrupulous, and inflexible about matters of morality, ethics, or values (not accounted for by cultural or religious identification). Is unable to discard worn-out or worthless objects even when they have no sentimental value. Is reluctant to delegate tasks or to work with others unless they submit to exactly his or her way of doing things. Adopts a miserly spending style toward both self and others; money is viewed as something to be hoarded for future catastrophes. Shows rigidity and stubbornness.

24. Personality Disorder NOS 1. Meets the general diagnostic criteria for a Personality Disorder, but does not meet criteria for any specific Personality Disorder.

25. Cluster A.

26. Paranoid Personality Disorder.

27. Paranoid Personality Disorder 2. Overview. Long-standing suspiciousness and mistrust of persons in general. Often hostile, irritable, and angry. Often develop into: Bigots. Injustice collectors. Pathologically jealous spouses. Litigious cranks.

28. Paranoid Personality Disorder 1. Pervasive distrust and suspiciousness of others such that their motives are interpreted as malevolent, beginning by early adulthood and present in a variety of contexts, as indicated by 4 or more of the following: Suspects, without sufficient basis, that others are exploiting, harming, or deceiving them. Is preoccupied with unjustified doubts about the loyalty or trustworthiness of friends or associates. Is reluctant to confide in others because of unwarranted fear that the information will be used maliciously against them. Reads hidden demeaning or threatening meanings into benign remarks or events. Persistently bears grudges (i.e., is unforgiving of insults, injuries, or slights). Perceives attacks on his or her character or reputation that are not apparent to others and is quick to react angrily or to counterattack. Has recurrent suspicions, without justification, regarding fidelity of spouse or sexual partner. Does not due to something else. If criteria are met prior to Schizophrenia add “premorbid”.

29. Paranoid Personality Disorder 2. Epidemiology. 0.5-2.5% of the general population. Relatives of patients with schizophrenia show a higher incidence of paranoid personality disorder than controls. More common in men than women. Thought to be higher among minority groups, immigrants, and persons who are deaf.

30. Paranoid Personality Disorder 2. Interview. Formal in manner. Act baffled about having to seek psychiatric help. Humorless and serious. Scan the environment. Have muscular tension. Are unable to relax.

31. Paranoid Personality Disorder 2. Interview. Thought content shows: Projection. Prejudice. Occasional ideas of reference.

32. Paranoid Personality Disorder 2. Clinical features. Long-standing suspiciousness and mistrust of others. Interpret actions of others as deliberately demeaning, malevolent, threatening, exploiting, or deceiving and expect to be harmed by them. Express disdain for those they see as weak, sickly, impaired, or defective and are impressed with, and pay close attention to, power and rank. They are often hostile, irritable, angry and show pathological jealousy, but can often pull themselves together and appear undistressed during an interview.

33. Paranoid Personality Disorder 2. Differential Diagnosis. Unlike in delusional disorder, there are no fixed delusions. Unlike in Schizophrenia, there are no hallucinations or formal thought disorder. Unlike borderline personality disorder, patents are not in overly close relationships. No extensive history of antisocial behavior. Patients with schizoid personality disorder are also withdrawn, but do not have paranoid ideation.

34. Paranoid Personality Disorder 2. Course and Prognosis. No adequate, systematic long-term studies exist. In general, patients have lifelong problems working and living with others and occupational and marital problems are common. Some patients go on to develop Schizophrenia.

35. Paranoid Personality Disorder 2. Treatment. Psychotherapy. Treatment of choice. Therapists need to be straightforward and professional (not overly warm) with honesty and an apology preferable to a defensive explanation for the mistakes patients will often point out. Since patients may behave threateningly and with delusional accusations, limit setting and dealing with accusations must be done realistically (but gently).

36. Paranoid Personality Disorder 2. Treatment. Psychotherapy. Therapists should never offer to take control unless they are willing and able to do so since patients are profoundly frightened when they feel those that are helping them are weak. Patients do not do well in group psychotherapy. Many cannot tolerate the intrusiveness of behavior therapy (but it is often used for social skills training).

37. Paranoid Personality Disorder 2. Treatment. Pharmacotherapy. Benzodiazepines may help with anxiety. Antipsychotics may be needed in small dosages for brief periods of time. Some evidence that pimozide (Orap) may be helpful.

38. Schizoid Personality Disorder.

39. Schizoid Personality Disorder 2. Overview. Lifelong pattern of social withdrawal. Discomfort with human interaction, introverted, bland and constricted affect. Seen by others as: Eccentric. Isolated. Lonely.

40. Schizoid Personality Disorder 1. A pervasive pattern of detachment from social relationships and a restricted range of expression of emotions in interpersonal settings, beginning by early adulthood and present in a variety of contexts, as indicated by 4 or more of the following: Neither desires nor enjoys close relationships, including being part of a family. Almost always chooses solitary activities. Has little, if any, interest in having sexual experiences with another person. Takes pleasure in few, if any, activities. Lacks close friends or confidants other than first-degree relatives. Appears indifferent to the praise or criticism of others. Shows emotional coldness, detachment, or flattened affectivity. Not due to something else. If criteria are met prior to Schizophrenia add “premorbid”.

41. Schizoid Personality Disorder 2. Epidemiology. Prevalence is unknown but may affect 7.5% of the population. Sex ratio is unknown but may be 2:1, Male:Female.

42. Schizoid Personality Disorder 2. Interview. Patients appear ill at ease. Rarely tolerate eye contact. Seem eager for the interview to end. Affect may be constricted, aloof, or inappropriately serious, but fear may be recognized underneath. Difficult to be lighthearted and their humor may seen adolescent and off the mark.

43. Schizoid Personality Disorder 2. Interview. Give short answers, avoid spontaneous conversation and may occasionally use unusual figures of speech such as odd metaphors. May be fascinated with inanimate objects or metaphysical constructs. May think they have a sense of intimacy with personas they do not know well. Sensorium is intact, memory functions well, and proverb interpretations are abstract.

44. Schizoid Personality Disorder 2. Clinical Features. Seem cold, aloof, quiet, distant, seclusive, unsociable. Have solitary, lonely jobs that involve little or no contact with others (often night shifts). Show no involvement with everyday events and concerns of others. Last to be aware of fashion changes.

45. Schizoid Personality Disorder 2. Clinical Features. Sexual lives are postponed and may only exist in fantasy. Have a normal capacity to recognize reality, have a lifelong inability to express anger directly and respond to threats with fantasized omnipotence or resignation.

46. Schizoid Personality Disorder 2. Differential Diagnosis. No positive psychotic symptoms as there is in schizophrenia, delusional disorder, and affective disorders with psychotic features. Patients with paranoid personality disorder show more social engagement, aggressive verbal behavior, and a greater tendency to project their feelings onto others.

47. Schizoid Personality Disorder 2. Differential Diagnosis. Patients with obsessive-compulsive and avoidant personality disorders experience loneliness as dysphoric and possess a richer history of past object relations. Closely resembles Schizotypal personality disorder, but with less positive schizophrenia like symptoms.

48. Schizoid Personality Disorder 2. Course and Prognosis. Occurs in early childhood. Long lasting but not necessarily lifelong. The proportion of patients who develop schizophrenia is unknown.

49. Schizoid Personality Disorder 2. Treatment. Psychotherapy. Treated similarly to paranoid personality disorder. Since they tend toward introspection, they may become devoted, but distant patients. After trust develops, fantasies, imaginary friends, fears of unbearable dependence, even merging with the therapist may be revealed.

50. Schizoid Personality Disorder 2. Treatment. Psychotherapy. In group therapy, patients may be silent for long periods and should be protected against aggressive group members, but eventually become involved. Other group members become important to the patient and may provide the only social contact they receive.

51. Schizoid Personality Disorder 2. Treatment. Pharmacotherapy. Small doses of antipsychotics, antidepressants, and psychostimulants have benefitted some patients. Serotonergic agents may make patients less sensitive to rejection. Benzodiazepines may help diminish interpersonal anxiety.

52. Schizotypal Personality Disorder.

53. Schizotypal Personality Disorder 2. Overview. Strikingly odd or strange, even to laypersons. Characterized by: Magical thinking. Peculiar notions. Ideas of reference. Illusions. Derealization.

54. Schizotypal Personality Disorder 1. A pervasive pattern of social and interpersonal deficits marked by acute discomfort with, and reduced capacity for close relationships as well as by cognitive or perceptual distortions and eccentricities of behavior, beginning by early adulthood and present in a variety of contexts, as indicated by 5 or more of the following. Ideas of reference (excluding delusions of reference). Odd beliefs or magical thinking that influences behavior and is inconsistent with subcultural norms (e.g. superstitiousness, belief in clairvoyance, telepathy, or “sixth sense”, in children and adolescents, bizarre fantasies or preoccupations). Unusual perceptual experiences, including bodily illusions. Odd thinking and speech (e.g., vague, circumstantial, metaphorical, overelaborate, or stereotyped). Suspiciousness or paranoid ideation. Inappropriate or constricted affect. Behavior or appearance that is odd, eccentric, or peculiar. Lack of close friends or confidants other than first-degree relatives. Excessive social anxiety that does not diminish with familiarity and tends to be associated with paranoid fears rather than negative judgments about self. Not due to something else. If criteria are met prior to Schizophrenia add “premorbid”.

55. Schizotypal Personality Disorder 2. Epidemiology. 3% of the population. Sex ratio is unknown. Associated with biological relatives that have schizophrenia. Monozygotic:dizygotic twin ratio is 33:4.

56. Schizotypal Personality Disorder 2. Interview. History taking may be difficult because of the patients’ unusual way of communicating. Diagnosis is made based on peculiarities of thinking, behavior, and appearance.

57. Schizotypal Personality Disorder 2. Clinical features. Disturbed thinking and communication, but no frank thought disorder. May not know their own feelings but are exquisitely sensitive to others (especially negative) feelings. Superstitious, and think they have special powers such as clairvoyance. May have vivid imaginary relationships and child-like fears and fantasies.

58. Schizotypal Personality Disorder 2. Clinical features. May have perceptual illusions and, brief, psychosis when stressed. Have few friends because they are so strange. May show features of borderline personality disorder. Severe cases show anhedonia and severe depression.

59. Schizotypal Personality Disorder 2. Differential diagnosis. Distinguished from schizoid and avoidant personality disorders by the oddities in their behavior, thinking, perception, and communication (and family history of schizophrenia). Unlike schizophrenia, they have brief, if any, periods of psychosis. Patients with paranoid personality disorder are suspicious, but lack the odd behavior of patients with schizotypal personality disorder.

60. Schizotypal Personality Disorder 2. Course and Prognosis. 10% of patients eventually commit suicide. Since it is considered the premorbid personality of Schizophrenia, many patients develop that disease. Some patients maintain a stable schizotypal personality throughout their lives and may marry and work despite their oddities.

61. Schizotypal Personality Disorder 2. Treatment. Psychotherapy. Same as treatment of schizoid personality disorders, but clinicians must be more sensitive. Many patients are involved in cults, strange religious practices, and the occult. Therefore clinicians must be nonjudgmental and not ridicule these activities.

62. Schizotypal Personality Disorder 2. Treatment. Pharmacotherapy. Antipsychotics may help with ideas of reference, illusions, and other symptoms. Antidepressants are useful there there is a depressive component.

63. Antisocial Personality Disorder.

64. Antisocial Personality Disorder 2. Overview. Inability to conform to the social norms that ordinarily govern many aspects of a person’s adolescent and adult behavior Is called dissocial personality disorder in ICD-10.

65. Antisocial Personality Disorder 1. There is a pervasive pattern of disregard for and violation of the rights of others occurring since age 15 years, as indicated by 3 or more of the following: Failure to conform to social norms with respect to lawful behaviors as indicated by repeatedly performing acts that are grounds for arrest. Deceitfulness, as indicated by repeated lying, use of aliases, or conning others for personal profit or pleasure. Impulsivity or failure to plan ahead. Irritability and aggressiveness, as indicated by repeated physical fights or assaults. Reckless disregard for safety of self or others. Consistent irresponsibility, as indicated by repeated failure to sustain consistent work behavior or honor financial obligations. Lack of remorse, as indicated by being indifferent to or rationalizing having hurt, mistreated, or stolen from another. At least 18 years old. Evidence of Conduct Disorder with onset before age 15. Does not happen exclusively during a course of Schizophrenia or Manic Episode.

66. Antisocial Personality Disorder 2. Epidemiology. 3% in men. 1% in women. Most common in poor urban areas. Boys come from larger families than girls. Onset is before age 15.

67. Antisocial Personality Disorder 2. Epidemiology. Girls usually have symptoms before puberty, and boys even earlier. Prevalence may be 75% in prisons. 5 X more common among first-degree relatives of men with the disorder than among controls.

68. Antisocial Personality Disorder 2. Interview. Even experienced clinicians may be fooled. Patient’s appear composed and credible, but underneath the veneer is tension, hostility, irritability, and rage. A “stress interview”, in which patients are vigorously confronted with inconsistencies may be necessary to reveal the pathology.

69. Antisocial Personality Disorder 2. Clinical features. Seem normal, harming and ingratiating, especially to opposite-sex clinicians (but same-sex clinicians may think they are manipulative and demanding). Histories often include lying, truancy, running away from home, thefts, fights, substance abuse, and other illegal activities that begin in childhood. Later engage in promiscuity, spousal abuse, child abuse, and drunk driving.

70. Antisocial Personality Disorder 2. Clinical features. Extremely manipulative “con men”. Have a striking lack of remorse or conscience. No anxiety, depression, delusions, or other irrational thinking. May threaten suicide and have somatic preoccupations.

71. Antisocial Personality Disorder 2. Differential diagnosis. Distinguished from illegal behavior because it involves many areas of a person’s life. Difficult to differentiate from substance abuse and both diagnoses should be given unless the illegal behavior is clearly secondary to substance use.

72. Antisocial Personality Disorder 2. Differential diagnosis. Clinicians must adjust for socioeconomic status, cultural background, and sex. The diagnosis should not be given if the criminal behavior is secondary to mental retardation, schizophrenia, or mania.

73. Antisocial Personality Disorder 2. Course and Prognosis. Usually lifelong. Some reports show that symptoms decrease as a person grows older. Height of antisocial behavior is in late adolescence. Many patients have Somatization Disorder and multiple physical complaints.

74. Antisocial Personality Disorder 2. Treatment. A diagnostic workup should include a thorough neurological examination since patients often show abnormal EEG results and soft neurological signs suggesting minimal brain damage in childhood.

75. Antisocial Personality Disorder 2. Treatment. Psychotherapy. If patients are “immobilized” (placed in hospitals), they become amenable to psychotherapy. Since patients do better when among peers, self-help groups have been very helpful. Firm limits are essential. Self-destructive behavior and fear of intimacy salient clinical challenges. Therapists face the challenge of separating control from punishment and of separating help and confrontation from social isolation and retribution.

76. Antisocial Personality Disorder 2. Treatment. Pharmacotherapy. Must be used judiciously since patients are often substance abusers. Psychostimulants may help if ADHD is present. Antiepileptics may help control impulsive behavior, especially if abnormal waveforms are noted on EEG. B-Adrenergic receptor antagonists may help reduce aggression.

77. Borderline Personality Disorder.

78. Borderline Personality Disorder 2. Overview. Patients stand at the borderline between neurosis and psychosis. Extraordinarily unstable affect, mood, behavior, object relations, and self-image. Chronic feelings of emptiness. Short-lived psychotic episodes Impulsive acts. Demand extraordinary relationships. May mutilate themselves and make manipulative suicide attempts.

79. Borderline Personality Disorder 2. Other names: Ambulatory Schizophrenia. As-if personality. Pseudoneurotic schizophrenia. Psychotic character disorder. ICD-10: Emotionally unstable personality disorder.

80. Borderline Personality Disorder 1. A pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following. Frantic efforts to avoid real or imagined abandonment. A pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation. Identity disturbance: markedly and persistently unstable self image or sense of self. Impulsivity in at least two areas that are potentially self damaging (e.g., spending, sex, substance abuse, reckless driving, binge eating). Not suicidal or self-mutilating behavior. Recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior. Affective instability due to a marked reactivity of mood (e.g., intense episodic dysphoria, irritability, or anxiety usually lasting a few hours and only rarely more than a few days). Chronic feelings of emptiness. Inappropriate, intense anger or difficulty controlling anger (e.g., frequent displays of temper, constant anger, recurrent physical fights). Transient, stress-related paranoid ideation or severe dissociative symptoms.

81. Borderline Personality Disorder 2. Epidemiology. 1-2% of the population. Female:male 2:1. An increased prevalence of major depressive disorder, alcohol use disorders, and substance abuse is found in first-degree relatives of persons with borderline personality disorder.

82. Borderline Personality Disorder 2. Clinical features. Almost always appear to be in a state of crisis. Mood swings are common. Can have short-lived psychotic episodes that are almost always circumscribed, fleeting, or doubtful. Behavior is highly unpredictable with repetitive self- destructive acts such as self-mutilations. Relationships are tumultuous with dependency, but enormous anger toward intimate friends.

83. Borderline Personality Disorder 2. Clinical features. Cannot tolerate being alone and will accept a stranger as a friend or behave promiscuously so they don’t have to be alone. Show splitting (identifying people as all good or all bad). They often complain of depression, chronic feelings of emptiness, boredom, and a lack of a consistent sense of identity.

84. Borderline Personality Disorder 2. Clinical features. Use the immature defense mechanism of projective identification in which intolerable aspects of the self are projected into another, the other person is induced to play the projected role, and the two persons act in unison. Show ordinary reasoning abilities on structured tests (IQ testing), but show deviant processes on unstructured projective tests (Rorschach test).

85. Borderline Personality Disorder 2. Differential diagnosis. Distinguished from schizophrenia by a lack of prolonged psychotic episodes, thought disorder, and other classic schizophrenic signs.

86. Borderline Personality Disorder 2. Course and Prognosis. Patients change little over time. The diagnosis is usually made before 40, when patients are attempting to make occupational, marital, and other choices found in the normal stages of the life cycle. There is no progression toward schizophrenia. There is a high incidence of major depressive episodes.

87. Borderline Personality Disorder 2. Treatment. Psychotherapy. Patients do well in the hospital setting where they: Receive intensive psychotherapy. Are given limits on behaviors. Ideally patients stay until they show marked improvement (up to 1 year). Patients can then be discharged to special support systems such as day hospitals, night hospitals, and halfway houses.

88. Borderline Personality Disorder 2. Treatment. Psychotherapy. Common features of psychotherapy for BPD. 1.Therapy is not expected to be brief. 2.A strong helping relationship develops between patient and therapist. 3.Clear roles and responsibilities of patient and therapist are established. 4.Therapist is active and directive, not a passive listener. 5.Patient and therapist mutually develop a hierarchy of priorities. 6.Therapist conveys empathic validation plus the need for patient to control his/her behavior. 7.Flexibility is needed as new circumstances, including stresses, develop. 8.Limit setting, preferably mutually agreed upon, is used. 9.Concomitant individual and group approaches are used.

89. Borderline Personality Disorder 2. Treatment. Psychotherapy. Difficult for patient and therapist alike. Patients regress easily, act out their impulses, and show labile or fixed negative or positive transferences, which are difficult to analyze. Projective identification may cause countertransference problems (especially when the therapists are unaware that the patients are trying to coerce them to act out a particular behavior).

90. Borderline Personality Disorder 2. Treatment. Psychotherapy. Splitting causes patients to alternately love and hate the therapist. A reality-oriented approach is more effective than in-depth interpretations of the unconscious.

91. Borderline Personality Disorder 2. Treatment. Psychotherapy Behavior therapy: Helps control patients’ impulses and angry outbursts and to reduce their sensitivity to criticism and rejection. Social Skills Training: Helps enable patients to see how their actions affect others and improve their interpersonal behavior (especially when videotape playback is used).

92. Borderline Personality Disorder 2. Treatment. Psychotherapy DBT: Treatment of choice for Borderline Personality Disorder.

93. Borderline Personality Disorder 2. DBT. Developed by Marsha Linehan, Ph.D. Originally developed for BPD patients with chronically self-injurious patients with parasuicidal behavior. Eclectic and draws on: Therapy techniques such as supportive, cognitive, and behavioral therapy. Eastern philosophy such as Zen.

94. Borderline Personality Disorder 2. DBT. Patients are seen weekly with two main goals in mind: Decrease self-destructive behavior. Improve interpersonal skills.

95. Borderline Personality Disorder 2. DBT. These goals are accomplished by providing 5 essential Functions: Enhance and expand skillful behavioral patterns. Improve motivation to change by reducing reinforcement of maladaptive behavior, including dysfunctional cognition and emotion. Ensure new behavioral patterns generalize from therapy to the home environment. Structure the environment so that effective behaviors are reinforced. Enhance motivation and capabilities of the therapists so that effective treatment is rendered.

96. Borderline Personality Disorder 2. DBT. The five essential functions are accomplished by providing 4 modes of treatment. Group skills training. Individual therapy. Phone Consultations. Consultation team.

97. Borderline Personality Disorder 2. DBT. Group Skills training. A didactic approach is used to teach behavioral, emotional, cognitive, and interpersonal skills geared at control of emotional dysregulation and inpulsive behavior. Individual Therapy. Weekly 50-60 minute sessions are used to reskills learned during group training and life events of the previous week. Patients also keep diary cards which are analyzed in the session.

98. Borderline Personality Disorder 2. DBT. Telephone consultation. Therapists are available 24 hours per day for brief (~10 min) phone calls. Patients are encouraged to call if they feel themselves heading toward a crisis. Consultation team. Therapists meet weekly to provide support for each other, maintain motivation in their work, and compare techniques.

99. Borderline Personality Disorder 2. DBT. Results of studies show: Low dropout rate. Decrease in parasuicidal behaviors. Decrease in self reported angry affect. Improved social adjustment. Improved work performance.

100. Borderline Personality Disorder 2. Treatment. Pharmacotherapy. Antipsychotics: Control anger, hostility, and brief psychotic episodes. Antidepressants: improve depressed mood. SSRI’s: have been helpful in some cases. MAOI’s: Have successfully modulated impulsive behavior in some patients. Benzodiazepines: (especially Xanax), help anxiety and depression, but some patients show disinhibition. Anticonvulsants: May improve global functioning for some patients.

102. Histrionic Personality Disorder.

103. Histrionic Personality Disorder 2. Overview. Patients are excitable and emotional. They behave in colorful, dramatic, extroverted, flamboyant fashion. However, they have an inability to maintain deep, long-lasting attachments.

104. Histrionic Personality Disorder 1. A pervasive pattern of excessive emotionality and attention seeking, beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following: Is uncomfortable in situations in which he or she is not the center of attention. Interaction with others is often characterized by inappropriate sexually seductive or provocative behavior. Displays rapidly shifting and shallow expression of emotions. Consistently uses physical appearance to draw attention to self. Has a style of speech that is excessively impressionistic and lacking in detail. Shows self-dramatization, theatricality, and exaggerated expressions of emotion. Is suggestible, I.e., easily influenced by others or circumstances. Considers relationships to be more intimate than they actually are.

105. Histrionic Personality Disorder 2. Interview. Cooperative and eager to give a detailed history. Gestures and dramatic punctuation in their conversations are common. Make frequent slips of the tongue. Language is colorful. Affective display is common. However, when pressed to acknowledge certain feelings, they may respond with surprise, indignation, or denial. Although MSE is grossly normal, they seem to forget affect- laden material.

106. Histrionic Personality Disorder 2. Clinical features. Patients show a high degree of attention-seeking. Exaggerate their thoughts and feelings. Make everything sound more important than it really is. Display temper tantrums, tears, and accusations when they are not the center of attention or receiving praise or approval. Have an endless need for reassurance.

107. Histrionic Personality Disorder 2. Clinical features. Seductive behavior is common in both sexes. Sexual fantasies are common, but patients are inconsistent about verbalizing these fantasies and may be coy or flirtatious rather than sexually aggressive. May have psychosexual dysfunction with anorgasmia in women and impotence in men.

108. Histrionic Personality Disorder 2. Clinical features. May act on their sexual impulses to reassure themselves that they are attractive. Relationships tend to be superficial and they can be vain, self-absorbed, and fickle. Their strong dependence needs make they overly trusting and gullible.

109. Histrionic Personality Disorder 2. Differential Diagnosis. May be difficult to distinguish from borderline personality disorder. However, in borderline personality disorder, the following are more likely: Suicide attempts. Identity diffusion. Brief psychotic episodes.

110. Histrionic Personality Disorder 2. Differential Diagnosis. Somatization disorder may occur in conjunction with histrionic personality disorder. Patients with brief psychotic disorder and dissociative disorders may warrant a coexisting diagnosis of histrionic personality disorder.

111. Histrionic Personality Disorder 2. Course and Prognosis. With age, patients show fewer symptoms. Patients are sensation seekers and may: Get into trouble with the law. Abuse substances. Be promiscuous.

112. Histrionic Personality Disorder 2. Treatment. Psychotherapy. Since patients are unaware of their own real feelings, clarification of inner feelings is an important therapeutic process. Psychoanalytically oriented psychotherapy is probably the treatment of choice.

113. Histrionic Personality Disorder 2. Treatment. Pharmacotherapy. No standard medications are recommended but symptoms may be targeted in a rational manner (e.g. antidepressants for depression).

114. Narcissistic Personality Disorder.

115. Narcissistic Personality Disorder 2. Overview. Patients have a heightened sense of self-importance and grandiose feelings of uniqueness.

116. Narcissistic Personality Disorder 1. A pervasive pattern of grandiosity (in fantasy or behavior), need for admiration, and lack of empathy, beginning by early adulthood and present in a variety of contexts, as indicated by 5 (or more) of the following: Has a grandiose sense of self-importance (e.g., exaggerates achievements and talents, expects to be recognized as superior without commensurate achievements). Is preoccupied with fantasies of unlimited success, power, brilliance, beauty, or ideal love). Believes that he or she is “special” and unique and can only be understood by, or should associate with, other special or high-status people (or institutions). Requires excessive admiration. Has a sense of entitlement, i.e., unreasonable expectations of especially favorable treatment or automatic compliance with his or her expectations. Is interpersonally exploitative, i.e., takes advantage of others to achieve his or her own ends. Lacks empathy: Is unwilling to recognize or identify with the feelings and needs of others. Is often envious of others or believes that others are envious of him or her. Shows arrogant, haughty behaviors or attitudes.

117. Narcissistic Personality Disorder 2. Epidemiology. <1% in the general population. 2-16% in the clinical population. Since these patients impart an unrealistic sense of omnipotence, grandiosity, beauty, and talent to their children, their offspring may have a higher than usual risk for developing the disorder themselves. The number of cases reported is increasing steadily.

118. Narcissistic Personality Disorder 2. Clinical features. Grandiose sense of self-importance. Self entitled. Expect special treatment. Handle criticism poorly. When someone dares to criticize them they either become enraged or may appear completely indifferent to criticism. Want their own way and are frequently ambitious to achieve fame and fortune.

119. Narcissistic Personality Disorder 2. Clinical features. Relationships are fragile. Can make others furious by their refusal to obey conventional rules of behavior. Interpersonal exploitiveness is commonplace. Cannot show empathy and feign sympathy only to achieve their own selfish ends.

120. Narcissistic Personality Disorder 2. Clinical features. However, they have a fragile self-esteem. Are susceptible to depression. The stresses they are least able to handle are also the ones they teen to cause and include: Interpersonal difficulties. Occupational problems. Rejection. Loss.

121. Narcissistic Personality Disorder 2. Differential Diagnosis. Borderline, histrionic, and antisocial personality disorders often accompany narcissistic personality disorder and are hard to tease out. Compared with borderlines, narcissists have less anxiety, tend to lead less chaotic lives, and are less likely to attempt suicide. Compared with antisocials, narcissists have less impulsive behavior, alcohol or substance abuse, and less trouble with the law. However, histrionics show exhibitionism and interpersonal manipulativeness that resembles narcissists.

122. Narcissistic Personality Disorder 2. Course and Prognosis. Chronic and difficult to treat. Patients must constantly deal with blows to their narcissism. Aging is handled poorly since patients value beauty, strength, and youthfulness. May be more vulnerable to a midlife crisis.

123. Narcissistic Personality Disorder 2. Treatment. Psychotherapy. Treatment is difficult since patients must renounce their narcissism to make progress. Psychoanalytic approaches and group therapy are advocated, but much more research is needed.

124. Narcissistic Personality Disorder 2. Treatment. Pharmacotherapy. Lithium has been used when mood swings are present. Antidepressants may be helpful since patients tolerate rejection so poorly.

125. Avoidant Personality Disorder.

126. Avoidant Personality Disorder 2. Overview. Extreme sensitivity to rejection. Socially withdrawn life. Appear shy, but have a great desire for companionship. Need unusually strong guarantees of uncritical acceptance. Described as having an inferiority complex.

127. Avoidant Personality Disorder 1. A pervasive pattern of social inhibition, feelings or inadequacy, and hypersensitivity to negative evaluation, beginning by early adulthood and present in a variety of contexts, as indicated by 4 (or more) of the following: Avoids occupational activities that involve significant interpersonal contact, because of fears of criticism, disapproval, or rejection. Is unwilling to get involved with people unless certain of being liked. Shows restraint within intimate relationships because of the fear of being shamed or ridiculed. Is preoccupied with being criticized or rejected in social situations. Is inhibited in new interpersonal situations because of feelings of inadequacy Views self as socially inept, personally unappealing, or inferior to others. Is unusually reluctant to take personal risks to to engage in any new activities because they may prove embarrassing.

128. Avoidant Personality Disorder 2. Epidemiology. 1-10% of the general population. No data is available on sex ratio or familial pattern. Infants with a timid temperament may be more susceptible to the disorder.

129. Avoidant Personality Disorder 2. Interview. Patients have anxiety about talking with the interviewer. Their nervous and tense manner appears to wax and wane with how much they think the interviewer likes them. Vulnerable to the interviewer’s comments and suggestions. May regard a clarification or interpretation as a criticism.

130. Avoidant Personality Disorder 2. Clinical Features. Show hypersensitivity to rejection by others. Appear timid, shy, and eager to please. Afraid to speak up in public or make requests of others. When talking to someone they: Express uncertainty Show a lack of self confidence. May speak in a self-effacing manner.

131. Avoidant Personality Disorder 2. Clinical Features. Desire companionship, but have no close friends. Justify their avoidance of relationships with their fear of rejection. Misinterpret others comments as derogatory or ridiculing. If any of their requests are refused, they withdraw and feel hurt. Rarely attain much personal advancement or exercise much authority.

132. Avoidant Personality Disorder 2. Course and prognosis. Able to function in a protected environment. Some marry and have children. May live their lives surrounded only by family members. Have a high likelihood of social phobia.

133. Avoidant Personality Disorder 2. Treatment. Psychotherapy. Treatment depends on solidifying an alliance with patients. Therapist must convey an accepting attitude toward the patient’s fears, especially of rejection. Therapist may eventually encourage patient to take more social risks. However, failure can reinforce the patients’ low self-esteem. Troup therapy may help patients understand how their sensitivity to rejection affects them and others. Assertiveness training may help with poor self-esteem.

134. Avoidant Personality Disorder 2. Treatment. Pharmacotherapy. B-blockers may help with autonomic hyperactivity. Serotonergic agents may help with rejection sensitivity. Theoretically, dopaminergic drugs might encourage novelty-seeking behavior.

135. Dependent Personality Disorder.

136. Dependent Personality Disorder 2. Overview. Patients subordinate their own needs to those of others. Get others to assume responsibility for major areas of their lives. Lack self-confidence. May experience intense discomfort when alone for more than a brief period. Has been called passive-dependent personality.

137. Dependent Personality Disorder 2. Freud described “oral-dependent personality” characterized by: Dependence. Pessimism. Fear of sexuality. Self-doubt. Passivity. Suggestibility. Lack of perseverance.

138. Dependent Personality Disorder 1. A pervasive and excessive need to be taken care of that leads to submissive and clinging behavior and fears of separation, beginning by early adulthood and present in a variety of contexts, as indicated by 5 (or more) of the following: Has difficulty making everyday decisions without an excessive amount of advice and reassurance from others. Needs others to assume responsibility for most major areas of his or her life. Has difficulty expressing disagreement with others because of unrealistic fears of loss of support or approval. Has difficulty initiating projects or doing things on his or her own (because of a lack of self-confidence in judgment or abilities rather than a lack of motivation or energy). Goes to excessive lengths to obtain nurturance and support from others, to the point of volunteering to do things that are unpleasant. Feels uncomfortable or helpless when alone because of exaggerated fears of being unable to care for himself or herself. Urgently seeks another relationship as a source of care and support when a close relationship ends. Is unrealistically preoccupied with fears of being left to take care of himself or herself.

139. Dependent Personality Disorder 2. Interview. Try to cooperate. Compliant. Welcome specific questions. Look for guidance.

140. Dependent Personality Disorder 2. Clinical features. Pervasive pattern of dependent and submissive behavior. Cannot make decisions without an excessive amount of advice and reassurance from others. Avoid positions of responsibility and become anxious if asked to assume leadership roles. Can easily perform tasks for someone else, but can not do the same tasks on their own.

141. Dependent Personality Disorder 2. Clinical features. Prefer to be submissive and will often tolerate an abusive, unfaithful, or alcoholic spouse. These patients often experience: Pessimism. Self-doubt. Passivity. Fear of expressing sexual feelings. Fear of expressing aggressive feelings.

142. Dependent Personality Disorder 2. Differential Diagnosis. Very difficult since dependent traits are found in many psychiatric disorders. Unlike histrionic and borderline personalities, patients usually have a long-term relationship with ONE person, rather than a series of people. Dependents are not overtly manipulative. Dependence can occur in agoraphobia, but these patients have a higher level of anxiety and panic.

143. Dependent Personality Disorder 2. Course and Prognosis. Little is known about long-term outcome. Occupational functioning tends to be impaired. Social relationships are limited. Patients may suffer physical or mental abuse. Major depressive disorder can develop if patients loose the person they depend on. However, with treatment, prognosis is favorable.

144. Dependent Personality Disorder 2. Treatment. Psychotherapy. Treatment is often successful. Therapists mush show great respect for the patients feelings of attachment, even if they are pathological. One pitfall of treatment is when therapists ask patients to change the dynamics of a pathological relationship. At that point, patients may feel torn between complying with the therapist and losing a pathological external relationship.

145. Dependent Personality Disorder 2. Treatment. Psychotherapy. Insight-oriented therapies help patients understand the antecedents of their behaviors. Other helpful therapies include: Behavioral therapy. Assertiveness training. Family therapy. Group therapy.

146. Dependent Personality Disorder 2. Treatment. Pharmacotherapy. Some evidence that imipramine (Tofranil) helps patients with panic attacks or high levels of separation anxiety. SSRI’s and Benzodiazepines may also help anxiety. Some patients depression and withdrawal symptoms respond to psychostimulants.

147. Obsessive-Compulsive Personality Disorder.

148. Obsessive-Compulsive Personality Disorder 2. Overview. Pervasive pattern of perfectionism and inflexibility. Patients show: Emotional constriction. Orderliness. Perseverance. Stubbornness. Indecisiveness. ICD-10: Anancastic personality disorder.

149. Obsessive-Compulsive Personality Disorder 1. A pervasive pattern of preoccupation with orderliness, perfectionism, and mental and interpersonal control, at the expense of flexibility, openness, and efficiency, beginning by early adulthood and present in a variety of contexts, as indicated by 4 (or more) of the following: Is preoccupied with details, rules, lists, order, organization, or schedules to the extent that the major point of the activity is lost. Shows perfectionism that interferes with task completion (e.g., is unable to complete a project because his or her own overly strict standards are not met). Is excessively devoted to work and productivity to the exclusion of leisure activities and friendships (not accounted for by obvious economic necessity). Is overconscientious, scrupulous, and inflexible about matters of morality, ethics, or values (not accounted for by cultural or religious identification). Is unable to discard worn-out or worthless objects even when they have no sentimental value. Is reluctant to delegate tasks or to work with others unless they submit to exactly his or her way of doing things. Adopts a miserly spending style toward both self and others; money is viewed as something to be hoarded for future catastrophes. Shows rigidity and stubbornness.

150. Obsessive-Compulsive Personality Disorder 2. Epidemiology. Prevalence is unknown. More common in men than women. Diagnoses is most often in the eldest child. More common in first-degree relatives. Patients often have backgrounds of harsh discipline. Freud thought it was associated with difficulties in the anal stage (2 year olds), but various studies have failed to validate this.

151. Obsessive-Compulsive Personality Disorder 2. Interview. Patients are stiff, formal, and rigid. Mood is serious. Lack spontaneity. May be anxious about not being in control. Answers are unusually detailed. Affect is constricted, but not blunted or flat.

152. Obsessive-Compulsive Personality Disorder 2. Interview. Defense mechanisms include: Rationalization. Isolation. Intellectualization. Reaction formation. Undoing.

153. Obsessive-Compulsive Personality Disorder 2. Clinical features. Preoccupied with: Rules. Regulations. Orderliness. Neatness. Details. Achievement of perfection.

154. Obsessive-Compulsive Personality Disorder 2. Clinical features. Insist that rules be followed rigidly an cannot tolerate infractions. Lack flexibility. Capable of prolonged work if it is routinized and does not require changes.

155. Obsessive-Compulsive Personality Disorder 2. Clinical features. Have limited interpersonal skills and few friends. Alienate people. Are unable to compromise. Insist others submit to their needs. Eager to please those more powerful than them and carry out their wishes in an authoritarian manner.

156. Obsessive-Compulsive Personality Disorder 2. Clinical features. Formal and serious. Lack a sense of humor. Indecisive and ruminate about making decisions. Anything that can upset their “stability” causes anxiety. Usually keep their anxiety “bound up” in their rituals.

157. Obsessive-Compulsive Personality Disorder 2. Differential diagnosis. Unlike OCPD, which is pervasive throughout a patient’s life, OCD involves specific obsessions and compulsions. An axis I diagnosis of OCD can also be comorbid. A diagnosis of personality disorder should only be given if the symptoms cause significant impairments in their occupational or social effectiveness. Delusional disorder is sometimes comorbid and should also be diagnosed.

158. Obsessive-Compulsive Personality Disorder 2. Course and prognosis. Variable and unpredictable. Patients may develop obsessions or compulsions. Adolescents often go either of two ways: 1.Evolve into warm, open, and loving adults. 2.Develop Schizophrenia or (decades later) MDD.

159. Obsessive-Compulsive Personality Disorder 2. Course and prognosis. Patients may flourish in positions demanding methodical, deductive, or detailed work. Are vulnerable to unexpected changes. Personal lives may remain barren. Depressive disorders are common (especially late onset ones).

160. Obsessive-Compulsive Personality Disorder 2. Treatment. Psychotherapy. Patients are often aware of their problems and seek treatment. Patients value free association and no-directive therapy highly. Treatment is often long and complex. Countertransference problems are common.

161. Obsessive-Compulsive Personality Disorder 2. Treatment. Psychotherapy. Group and behavior therapy occasionally offer certain advantages. Maladaptive interactions or explanations can be easily interrupted. Preventing completion of habitual behavior raises the patients anxiety and leaves them susceptible to learning new coping strategies. Direct rewards for change can be given in group therapy.

162. Obsessive-Compulsive Personality Disorder 2. Treatment. Pharmacotherapy. Klonopin has reduced symptoms in severe OCD, but it is unknown if it is helpful in OCPD. Antidepressants [specifically clomipramine (Anafranil), fluoxetine, and nefazodone (Serzone)] have benefitted some people.

163. References. 1. (2000). Diagnostic and statistical manual of mental disorders, dsm-iv-tr.. (IV ed.). Washington, DC.: Amer Psychiatric Pub Inc. 2. Sadock, B. J., H. I. Kaplan, and V. A. Sadock. Kaplan & sadock\'s synopsis of psychiatry, behavioral sciences/clinical psychiatry. 10. Lippincott Williams & Wilkins, 2007. Print.