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personality disorder 2

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Terms

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What is a personality?
The sum total of an individual’s ENDURING PATTERNS of perception, cognition, and action in the interpersonal world. A habitual and predictable style of thinking, feeling, and acting, arising from the integration of constitution, early life experience, development, and interpersonal, social, and cultural influences.”
Temperament:
the inborn mood state
Character:
individual’s personal qualities that reflect his/her attitude and level of adherence to social and moral values
Social Construction
how the person relates to the world, which is CULTURE DEPENDENT & interactive between the individual & environment
What is a personality disorder?
“A CHRONICALLY MALADAPTIVE PATTERN OF INTERPERSONAL FUNCTIONING; habitual patterns of thought, feeling, and action that repeatedly result in significant social impairment and/or personal distress.”
personality disorder course
Personality disorders usually begin developing in early childhood and persist, often to a large extent, THROUGHOUT LIFE. They are PERVASIVE, and usually impact most or all aspects of a person’s life.
personality disorder treatment
Due to their persistent and insidious nature, personality disorders typically require LONG TERM PSYCHOTHERAPY to help restructure the personality. They are difficult to treat. Some have had limited success with medications.
A personality disorder can be conceptualized as a personality ORDER OR ORGANIZATION. It is an ADAPTIVE RESPONSE to early events in which the individual does not yet have adequate internal resourses or coping skills
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ID
Basic Want
Pleasure Principle
Ego
Mediates between internal and external worlds
Creative ways of getting needs met
Superego
Social values/morals
Defense Mechanisms
Repression – forget it protend it didn’t happen

Denial

Projection

Reaction Formation-kid annoys you so you love them to death

Displacement – kick the dog when mad at your boss

Rationalization – talk themselves into or out of things

Regression – go back to child-like state

Sublimation – take more aggressive impulse or primative and turn it into something positive
Melanie Klein – splitting
Primitive way to organize experience
Good/bad; male/female – need to see that there is shades of grey.
Psych-Social Development
Trust
Autonomy
Initiative
Industry
Identity
Intimacy
Generativity
Ego Integrity
Stages of Separation-Individuation
Margaret Mahler
Normal Infant Autism
Symbiosis
Separation-Individuation
-Hatching
-Practicing/Ambitendency
-Rapproachment
On the Road to Object Constancy
Percent of pop. w/ diagnosable personality disorder
10-13%
Axis?
personality disorders are coded on Axis II. They can also have traits that are on Axis II as well
Patient Presentation of patient with personality disorder
Effective functioning is limited by the disordered personality and the resulting PERCEPTUAL DISTURBANCE and IMPARED JUDGEMENT; responses to the environment tend to be chronically inadequate, leading to perpetual difficulties

Patients will likely have a series of interpersonal failures socially, and possibly occupationally
Odd/ Eccentric cluster of personality disorders
Schizoid

Paranoid

Schizotypal
Dramatic/Erratic cluster of personality disorders
Histrionic

Antisocial

Borderline

Narcissistic
Anxious/Fearful cluster of personality disorders
Avoidant

Dependent

Obsessive-Compulsive
Schizoid Personality
Withdraws from emotional interactions due to lack of desire to relate; socially isolative; few relationships
Flat/constricted affect; a sense of coldness or aloofness; indifferent
Bright; smart, intelligent
Lacks motivation
Seems to have little energy
Slow/monotonous speech
More common in men
Possible link to schizophrenia or OCD (can be repetitive); may be at risk for schizophrenia
Treatment Implications of Schizoid Personality
Patient may be out of touch with his/her body
Information provided during H&P may be limited & lack important details
May need to use structured interviewing; open-endedness or empathy may not yield results
Paranoid Personality
Doesn’t trust/always on guard; hyper-vigilant; believes people are out to get him/her; constant environmental scanning (The best defense is a good offense)
Distance themselves by perceiving or misinterpreting others as hostile
Fearful of being controlled, dominated, indebted to anyone, so tends to be a loner
Intelligent, but perceptions are distorted
Can be viewed as a type of self-centeredness or grandiosity; therefore low self-esteem/inferiority likely to be core issues
Schizotypal Personality
Typically considered by others to be “odd” or “strange”; on the “eccentric” side
Ideas of reference - suspicious thinking; desire for relationships, but anxious and mistrustful
Some odd beliefs/loose associations; magical thinking (“this is a sign”); inhibits social functioning
Dress may be peculiar; Speech may be different
May have odd “collections”
Possible link to schizophrenia (at risk)
Treatment Implications of Schizotypal Personality
Information gathered in the medical interview may be unreliable

More easy-going than the schizoid, cares more about relating; therefore, they may be more receptive if doctor is perceived as warm and caring
Histrionic Personality
Presentation is dramatic, flamboyant, theatrical; driven by a need for attention; seeks approval by providing entertainment
More common in females
Exaggerate emotions; poor impulse control
Easily taken advantage of because they don’t think things through
Little or no insight into their needs or behavior; focus is putting on the next show
Seductive in their presentation; manipulative
Treatment Implications of Histrionic Personality
Style is designed to distract from the facts; medical interviewer needs to set boundaries and consistently redirect
Will provide a colorful picture with lots of irrelevant or non-factual information; resist getting “sucked in” to the drama
Help ground them in what they need and how to go about getting it
Anti-Social Personality
Also known as “sociopath” or “criminal personality”
Conduct disorder by age 15; typically male
Chronic conscious exploitative behavior with no guilt/regret (only getting caught); chronic lying/disregard for others’ rights or consequences
Core belief that people are to be used; lack of ability to form interpersonal bonds
Core feels empty, which fills him/her with hostility & shame; getting away with things gives a high and relieves the stress
Typically grandiose/narcissistic; lacks impulse control
Lacks internal boundaries, so no self-control; typically do well in prison due to the structure
Treatment Implications of Anti-Social Personality
Typical reasons for help-seeking are court referral, detoxification, desire for medication, need to use doctor in some way (ie., note to get out of work, avoid military service, etc.) – don’t be “used”

Best treatment is early intervention for conduct disorder
Borderline Personality
Most extreme & impaired personality – “borderline” refers to bordering on psychotic functioning
Marked by extreme instability in mood, impulses, thought processes - history/pattern of intense, short-lived & unstable relationships
Core issue is fear of rejection/abandonment; any perception of this leads to rage
Feels misunderstood and has a list of complaints as to how they have been wronged
Typically female
Does not have a cohesive sense of self, what their needs are, or how to get their needs met; therefore, they expect an unrealistic level of attunement and everything is a crisis; others have a sense of “always walking on eggshells”
Uses “splitting” or “all or nothing” thinking
Treatment Implications of Borderline Personality
Will have a history of help-seeking in attempts to draw people in

Black and white thinking will make you either the best or worst physician (idealization vs. devaluation)

Interviewer must set boundaries & encourage them to help themselves; may get lots of crisis calls – important to document

Watch danger to self/other issues
Narcissistic Personality
Marked by excessive grandiosity and entitlement; great need for admiration, recognition & attention
Self-absorbed because empathy is missing from the personality; only their needs are important
Isolated & conflicted – wants to be seen, but doesn’t want you to see that they feel totally inadequate and ashamed
Will rationalize any perceived failure or weakness
Happy in relationship as long as they are being idealized; otherwise will completely devalue others, especially those that see them for what they are
Everything s/he does is designed to avoid pain by supporting his/her own inflated self-image
Typically male; often have borderline partners
Avoidant Personality
Unlike the Schizoid who is not motivated to relate, the Avoidant actively avoids relationships despite wanting them - a very painful conflict
Social anxieties/fears of rejection are overpowering - they must create distance to feel safe
Extremely shy, self-conscious, sensitive to criticism
Very low self-esteem is at the core
Unclear whether this is the same thing as Social Anxiety Disorder
Treatment Implications of Avoidant Personality
May avoid treatment due to discomfort or embarrassment
Will likely be very uncomfortable in the doctor-patient relationship - Doctor will have to work very hard to have empathy, and create an accepting, safe relationship or patient could filter important information in order to avoid possible rejection
Dependent Personality
Incapable of making even simple decisions without input from another
Tremendous fear of abandonment leading to excessive need to please and be reassured
Extreme desperation and neediness tends to push people away or attract abusive partners
More likely female; may have Anti-Social partner
Makes bad decisions in order to please others, puts self in harms’ way
Obsessive-Compulsive Personality
Overly concerned with perfectionism to maintain sense of control; painful issues such as inadequacy, powerlessness, and dependency are avoided by focusing on order
Rigid/inflexible thinking; black & white thinking (“If I’m not perfect, I’m a total failure”)
Prefers structure; things must be done “right”
Extremely detail-oriented; misses the forest for the trees
Very work-oriented, but doesn’t accomplish much due to perfectionism & focus on detail; hard to follow through on their commitments
Treatment Implications of Obsessive-Compulsive Personality
In the interview, they are opposite of the Histrionic, presenting with little or controlled emotion, and lots of facts and rationalizations

Interviewer must provide structure and guide/redirect interview to stay on track
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