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Personality Disorders in a Hospital Setting. Personality The totality of emotional and behavioral traits characterizing a person’s day-to- day living.

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Presentation on theme: "Personality Disorders in a Hospital Setting. Personality The totality of emotional and behavioral traits characterizing a person’s day-to- day living."— Presentation transcript:

1 Personality Disorders in a Hospital Setting

2 Personality The totality of emotional and behavioral traits characterizing a person’s day-to- day living. Relatively stable and predictable under ordinary conditions

3 Personality Disorders Inflexible, maladaptive, exaggerated traits Pattern of behavior deeply ingrained and maladaptive in perceiving self, others, environment

4 DSM-IV-TR Axis I Major mental disorder Axis II Personality disorders Cluster A, B, C

5 Cluster A Paranoid Schizoid Schizotypal

6 Cluster B Antisocial Borderline Histrionic Narcissistic

7 Cluster C Avoidant Dependent Obsessive-compulsive Not Otherwise Specified (NOS)

8 Personality Disorder Classification Controversial, Problematic Diagnostic unreliability Preferential personality (co-existing conditions?) Shared characteristics (excessive number of PDs) Heterogeneity Inconsistent, unstable, arbitrary boundaries Inadequate literature coverage Too frequent use of NOS category

9 Proposal 1 Dimensional profile: narrative description of case, not only diagnostic classification, identifying fundamental maladaptive personality traits underlying its functioning

10 Proposal 2 Integrate the various personality disorders into Axis I diagnostic classification: e.g., depressive personality disorder will change to dysthymia, early onset.

11 Factors in behavior Genetic, temperamental, biological, psychological factors determine reaction of an individual towards others and environment throughout life and help form a pattern of behaviors typical for the individual.

12 Defense Mechanisms Unconscious mental processes that the ego (self) employs to free itself from conscious anxiety generated during interactions with others, its own instincts, reality, conscience Used to avoid an increase in conscious anxiety and/or depression

13 Defense Mechanism Types Fantasy Dissociation Denial Isolation Projection Splitting Passive-Aggressive Acting out Projective identification

14 Fantasy Fear of intimacy Schizoid behavior Aloofness Loneliness Creating imaginary life, companions Fears should be recognized in a reassuring, non-confrontational, not insistent manner.

15 Denial - Dissociation Unconscious covers-up for anxiety/other unpleasant emotions (e.g., fear) via exhibiting histrionic superficiality. Makes little of problems. May not remember important events of life and medical history. Caution to not make them more defensive Caution in not accepting histrionics at face value Allow to ventilate feelings and anxiety

16 Isolation Obsessive-compulsive Orderly Relates well Tells unnecessary details about self in cool collected manner Responds well to precise, systematic, rational information. Wants punctuality. Demands interest from physician, others. Often intelligent, able to control own care.

17 Projection Attribution of own feelings to others Fault-finding Prejudicial Hyper-vigilant Distrustful Avoid confrontation. Normal but concerned approach. May be useful to establish alliance and expose him/her to interpretations of other reasons for suspiciousness.

18 Splitting Divides people into good and bad Some staff members may be idealized Some staff members disparaged Disruptive behavior Gentle confrontation – no one is totally good or bad.

19 Passive-Aggression Anger turned against self (masochism) Shows as self-demeaning or self- destructive behavior (wrist-cutting) Hostility may be part of provocative behavior Often viewed as sadistic Allow ventilation of anger.

20 Acting Out (I) Tantrums Expression of ambivalent feelings conscious or unconscious Assaults without motivation, at times sudden Different types of abuse (physical, sexual, adults, children) At times no apparent guilt feelings Homicide may take place in uncontrolled aggression

21 Acting Out (II) Interviewer must be calm, good listener. Realize patient lost control and is agitated. How can I help if you keep screaming or being so upset?

22 Projective Identification Mainly present in Borderline Personality Disorder Aspect of self projected onto other. Coercion of the other to identify with the projected aspect. Projector and recipient feel some kind of union.

23 Paranoid Personality Disorder (I) Frequency – 0.5-2.5% Referrals from spouse, family, employer More frequent in men Higher in immigrants Higher in deaf Appears serious, humorless, suspicious Speech logical but with false premises Prejudice, projection, ideas of reference

24 Paranoid Personality Disorder (II) Fear of exploitation Jealous Disdains weak and impaired Businesslike, efficient Questions trustworthiness of friends A chronic condition that poses difficulty in living with spouse, friends, co-workers.

25 Schizoid Personality Disorder (I) About 7.5% of population Social withdrawal Discomfort in relating to people Introversion Constricted affect Isolated Lonely Prefers solitary job, also at night

26 Schizoid Personality Disorder (II) Avoids eye contact Fearful Short answers Minimal spontaneous speech Flattened affect Unable to relate Lives in fantasy world Repressed intimacy and sexuality

27 Schizoid Personality Disorder (III) Unable to express anger Pseudo-philosophizes Excessive day-dreaming Good patients in hospital who, absorbed in self, need protection from other patients (dyscontrolled or paranoid). If staff is able to establish rapport, they will uncover a plethora of day-dreaming.

28 Schizotypal Personality Disorder 3% of general population Odd, strange magical thinking Ideas of reference Illusions Peculiarity of thinking, behavior, appearance 10% commit suicide

29 Antisocial Personality Disorder (I) 3% male – 1 % female Nonconforming Antisocial Criminal behavior Callous Remorseless Prone to lying, irritability, rage Conduct disorder in childhood

30 Antisocial Personality Disorder (II) May have a veneer of normality, seductiveness Must be dealt with firmness and by establishing clear staff-patient rapport.

31 Borderline Personality Disorder (I) Previously called Ambulatory Schizophrenia, Psychotic Character, or Pseudoneurotic Schizophrenia 1-2% of general population More common in women Unable to establish lasting relationships Love-hate tendencies Fluctuation of mood

32 Borderline Personality Disorder (II) Proclivity to move into psychosis under intense stress Always in a state of crisis Argumentative, depressed No feelings Micropsychotic episodes Unpredictable Behavior

33 Borderline Personality Disorder (III) Repetitive self-destructive acts Self-mutilation- expresses anger Do well in hospital setting because of attention received, avoiding intrafamilial problems. Limits posed to behavior (self- destructive acts) in a supervised protected environment. Suicide attempts frequent.

34 Histrionic Personality Disorder (I) 2-3% of general population More frequent in women Found especially in mental institutional settings Colorful Extroverted Dramatic behavior Excitable Flamboyant

35 Histrionic Personality Disorder (II) Attention-seeking Frequently somatize Use drugs/alcohol Gesturing Eager to express and communicate in colorful way Some tangentiality and forgetfulness Magnify importance of events

36 Histrionic Personality Disorder (III) Mood swings and tears to make point Seductive, flirtatious, inconsistent Sensation seeking May get into trouble with law

37 Narcissistic Personality Disorder (I) 1% of general population Larger number in clinical setting Exaggerated sense of self-importance Enraged by criticism or completely ignores it Ambitious Continuous search for recognition Needs reassurance

38 Narcissistic Personality Disorder (II) Superficial relationships No empathy Cunning and exploitative Fragile self-esteem May become depressed Often rejected because of behavior Need structured firmness, clear understanding of procedures.

39 Avoidant Personality Disorder (I) 1-2% of general population Sensitive to rejection Lonely Very timid Inferiority feelings Anxious/tense Need acceptance Vulnerable to comments about self

40 Avoidant Personality Disorder (II) Misperceives interviewing statements Needs and wants companionship May express fears of rejection Phobic avoidance Should be approached with friendly acceptance, made to feel wanted and appreciated.

41 Dependent Personality Disorder (I) Lack of self-confidence Relies on others Does not assume responsibility Passive, pessimistic, suggestible Lack emotional endurance Submissive Fear of expressing sexual/aggressive feelings

42 Dependent Personality Disorder (II) Unable to make decisions on their own Subject to abuse by others Patient should be told what has to be done. Should undergo behavior and assertiveness therapy/training.

43 Obsessive-Compulsive Personality Disorder (I) Perfectionist Obsessed with orderliness Obsessive thoughts Affect constricted Stiff, formal, rigid, stubborn Anal stage of development Want to be in control Detailed answers when interviewed

44 Obsessive-Compulsive Personality Disorder (II) Rationalization Intellectualizations Doing-undoing/ritualistic behavior Should be dealt with in matter-of-fact, rigid routine and a formal relationship.

45 Personality Disorder NOS Passive-aggressive Depressive Sado-masochistic Sadistic

46 Personality Changes due to a General Medical Condition Significant changes of habitual pattern of premorbid behavior ICD-10 Personality and Behavioral Disease due to: Brain disease Brain damage Brain dysfunction Post-encephalopathy Syndrome Post-concussion Syndrome

47 Personality Changes due to a Medical Condition ( I) Head trauma Cerebrovascular disease Cerebral tumor Epilepsy (partial complex epilepsy) Huntington’s Disease Multiple Sclerosis Endocrine disorders

48 Personality Changes due to a Medical Condition ( II) Heavy metal poisoning (manganese, mercury) Neurosyphillis Acquired Immune Deficiency Syndrome (AIDS)

49 Organic Personality Disorder Diagnostic Criteria (I) Alteration of habitual pattern of behavior Emotions, impulses and needs are affected Defective cognitive function consequences of actions/planning

50 Organic Personality Disorder Diagnostic Criteria (II) Perseverance in goal-directed activity reduced Unable to postpone gratification Emotional lability Euphoria, inappropriate jocularity Sudden shift from cheerfulness to irritability Outbursts of anger and aggression

51 Organic Personality Disorder Diagnostic Criteria (III) Apathy Impulsive actions w/ caring for consequences (stealing, sexual exposure/ advances, etc.) Suspiciousness Paranoid ideation, preoccupation (extreme) with religious or abstract themes Circumstantiality, viscosity

52 Organic Personality Disorder Diagnostic Criteria (IV) Alters sexual behavior Possibly violent behaviors, especially if intoxicated

53 Anabolic steroids (used to maximize muscle strength) may cause a persistent alteration of personality and behavior.

54 In dementia there is a global deterioration in intellectual and behavioral capacities. Personality changes in brain tumor, multiple sclerosis, Huntington’s Disease may evolve into dementia.

55 In general medical conditions personality changes show with: Cognitive disorder with significant memory loss, confusion, at times eventuating in dementia. Changes persist if cause persists. Trauma followed by coma. Delirium due to vascular accident

56 Personality changes in chronic intoxication, medical illness, drug therapy (levodopa for Parkinson’s Disease) may be reversed if cause is eliminated. Some patients need custodial care. Caution! Behavioral Dyscontrol

57 Neuroimaging Studies

58 From: Book


60 Neuroimaging Studies MRI CT scans PET-SPECT Minimal cortical atrophy, dilatation of lateral ventricles, hypermetabolism of basal ganglia

61 Schizotypal Personality Disorder Cluster A Larger ventricles (lateral) Smaller caudate and left hippocampus Larger hippocampus (R) Reduced prefrontal regions Decrease perfusion basal ganglia and thalamus

62 Borderline Personality Disorder (BPD) Cluster B Disinhibited aggression and affective instability associated with deficient top-down control of negative emotions

63 BPD: Impulsive aggression due to high level of anger ASPD: Aggressive behavior associated with less anger-stimulation and/or gain

64 Emotional Modulation Circuit (I) ACC (anterior cingulate cortex) OFC (orbital frontal cortex) VMC (ventromedial prefrontal cortex) DLPFC (dorso-lateral prefrontal cortex)

65 Emotional Modulation Circuit (II) OFC (orbital frontal cortex) ACC ( anterior cingulate cortex) OFC and ACC interact to modulate response of amygdala

66 BPD Structural and Functional Studies Smaller total frontal lobe volumes Reduction in gray matter volume Reduction in neural density (reduction of acetylaspartate in DLPFC [dorsolateral prefrontal cortex]) Questionable volume reduction of amygdala Decrease in volume of ACC and hippocampus Hyperactive amygdala? 5-HT diminished in aggressive impulsivityy

67 ASPD 20% may be psychopaths Frontal regions in emotional tasks may function insufficiently (relatively speaking), even though there is increased activation Questionable volume of amygdala Affective memory tasks slow Decreased activity in amygdala, hippocampus, parahippocampus, ventral striatum, anterior-posterior cingulate gyrus

68 Fear-Anxiety Cluster C Top-down control of subcortical network responding to fear and connected with memory Larger ACC ↔ higher score of Harm- Avoidance (HC)

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