Pharmacological and other

Somatic Management of
Personality Disorders
 Personality Disorders

• A personality disorder is an enduring pattern of inner experience and behavior

that deviates markedly from the expectations of the individual's culture, is
pervasive and inflexible, has an onset in adolescence or early adulthood, is
stable over time, and leads to distress or impairment…………….(DSM 5)

2
 Personality Disorders

 A personality disorder typically becomes recognizable in adolescence or

early adulthood and symptoms last for years
 Among the most difficult psychological disorders to treat
 Many sufferers are not even aware of their personality disorder
Prevalence estimates for the different clusters suggest 5.7% for
disorders in Cluster A, 1.5% for disorders in Cluster B, 6.0% for
disorders in Cluster C, and 9.1% for any personality disorder,
indicating frequent co-occurrence of disorders from different
clusters. 3
 How Common Is It?

• 5-10% of general adult population

(zimmerman and coryell, 1990)
• 35% + of those in Psychiatric Hospital
• 50% of female prisoners
• 60-80% of male prisoners
 Personality Disorders
• High comorbidity
• complicates a person’s chances for a successful recovery from
other psychological problems

5
General Personality Disorder
Criteria
A. An enduring pattern of inner experience and behavior that deviates markedly from the
expectations of the individual’s culture. This pattern is manifested in two (or more) of the following areas:
1. Cognition (i.e., ways of perceiving and interpreting self, other people, and events).
2. Affectivity (i.e., the range, intensity, lability, and appropriateness of emotional response).
3. Interpersonal functioning.
4. Impulse control.
B. The enduring pattern is inflexible and pervasive across a broad range of personal and
social situations.
C. The enduring pattern leads to clinically significant distress or impairment in social, occupational,
or other important areas of functioning.
D. The pattern is stable and cf long duration, and Its onset can be traced back at least to
adolescence or early adulthood.
E. The enduring pattern is not better explained as a manifestation or consequence of another
mental disorder.
F. The enduring pattern is not attributable to the physiological effects of a substance (e.g.,
a drug of abuse, a medication) or another medical condition (e.g., head trauma).
 Classifying Personality Disorders

 The DSM-5 identifies ten personality disorders and separates these into
three groups or “clusters”:
 Odd or eccentric behavior
 Paranoid, schizoid, and schizotypal
 Dramatic, emotional, or erratic behavior
 Antisocial, borderline, histrionic, and narcissistic
 Anxious or fearful behavior
 Avoidant, dependent, and obsessive-compulsive
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 Psychiatric Classifications

ICD-10 Categories
CLUSTER 1
(similar to DSM-IV)
•PARANOID
•SCHIZOID
•SCHIZOTYPAL

CLUSTER 2 CLUSTER 3
•DISSOCIAL •ANXIOUS/ AVOIDANT
•DEPENDENT
•BORDERLINE
•ANANKASTIC

•HISTRIONIC
 Classifying Personality Disorders

 This DSM listing is called a categorical approach

 It assumes that:
 Problematic personality traits are either present or absent
 A personality disorder is either displayed or not
 A person who suffers from a personality disorder is not
markedly troubled by personality traits outside of that
disorder
 It turns out, however, that these assumptions are frequently 9

contradicted in clinical practice

• New ICD – 11 due 2015
Likely to move to Dimensions (how badly affected is the
person) rather than Categories (what type)
 What may facilitate diagnosis?

• Psychological Testing
• WAIS
• MMPI
• Bender-Gestalt
• Rorschach ink blot
 Classifying Personality Disorders

 In fact, the symptom of the personality disorders overlap each other so

much that it can be difficult to distinguish one from another
 In addition, diagnosticians sometimes determine that particular individuals have more
than one personality disorder
 This lack of agreement has raised concerns about the validity (accuracy) and
reliability (consistency) of these categories

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Classifying Personality Disorders

Odd or eccentric
Extreme suspiciousness,
social withdrawal, and
peculiar ways of thinking
and perceiving things
Paranoid Personality Disorder
• Includes four or more of the following:
• Suspiciousness of others
• Unjustified doubts about disloyalty
• Reluctance to confide in others
• Reading threatening meanings into benign events
• Persistent tendency to bear grudges
• Tendency to feel attacked and counterattack
• Unjustified suspiciousness about infidelity of partner
 Treatments for
Paranoid Personality Disorder

 People with paranoid personality disorder do not typically see themselves as

needing help
 Few come to treatment willingly
 Those who are in treatment often distrust and rebel against their therapists
 As a result, therapy for this disorder, as for most of the other personality
disorders, has limited effect and moves slowly

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• Schizoid Personality Disorder
• Include four or more of the following:
• Neither desires nor enjoys close relationships
• Almost always chooses solitude
• Little if any interest in sexual relationships
• Takes pleasure in few activities
• Lacks close friends
• Indifferent to praise or criticism
• Emotional coldness, detachment or flatness
• Schizotypal Personality Disorder
Five or more of the following:
Ideas of reference
Odd beliefs or magical thinking
Unusual perceptual experiences
Odd thinking and speech
Suspiciousness or paranoid ideas
Inappropriate or constricted affect
Odd, eccentric or peculiar behavior or appearance
Lack of close friends
Excessive social anxiety
 How Do Theorists Explain
Schizotypal Personality Disorder?

 Because the symptoms of schizotypal personality disorder so often

resemble those of schizophrenia, researchers have hypothesized that
similar factors are at work in both disorders
 Schizotypal symptoms are often linked to family conflicts and to psychological
disorders in parents
 Researchers have also begun to link schizotypal personality disorder to some of the
same biological factors found in schizophrenia, such as high dopamine activity
 The disorder has also been linked to mood disorders, especially depression
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 Treatments for
Schizotypal Personality Disorder
 Therapy is as difficult in cases of schizotypal personality disorder, as in cases
of paranoid and schizoid personality disorders
 Most therapists agree on the need to help clients “reconnect” and recognize
the limits of their thinking and powers
 Cognitive-behavioral therapists further try to teach clients to objectively evaluate their
thoughts and perceptions and provide speech lessons and social skills training
 Antipsychotic drugs appear to be somewhat helpful in reducing certain
thought problems
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 “Dramatic” Personality Disorders

 Behaviors so dramatic, emotional, or erratic that it is almost impossible for

them to have relationships that are truly giving and satisfying
 More commonly diagnosed than the others
 Only antisocial and borderline personality disorders have received much study
 Causes of the disorders not well understood
 Treatments range from ineffective to moderately effective
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Antisocial Personality Disorder
Includes three or more of the following:
• Failure to conform to lawful behavior
• Deceitfulness
• Impulsivity
• Irritability or aggressiveness
• Reckless disregard for safety of self and
others
• Consistent irresponsibility
• Lack of remorse
 Antisocial Personality Disorder

 Aside from substance use disorders, this is the disorder most linked to adult
criminal behavior
 The DSM-5 requires that a person be at least 18 years of age to receive this
diagnosis
 Most people with an antisocial personality disorder displayed some patterns of
misbehavior before they were 15 years old (conduct disorder).

22
 Antisocial Personality Disorder
4 times more common in men than women
Often arrested, therefore researchers frequently
look at prison populations
Higher rates of alcoholism/substance use
disorders

23
 How Do Theorists Explain
Antisocial Personality Disorder?

• Psychodynamic theorists propose that this disorder begins with an absence

of parental love, leading to a lack of basic trust; Lack of superego
• Many behaviorists have suggested that antisocial symptoms may be
learned through modeling or unintentional reinforcement

24
 How Do Theorists Explain
Antisocial Personality Disorder?

 Cognitive view says that people with the disorder hold attitudes that
trivialize the importance of other people’s needs
 Biological factors may play a role:
 Lower levels of serotonin, impacting impulsivity and aggression
 Deficient functioning in the frontal lobes of the brain
 Lower levels of anxiety and arousal, leading them to be more likely than others to take
risks and seek thrills

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 Treatments for
Antisocial Personality Disorder

 Treatments are typically ineffective

 A major obstacle is the individual’s lack of conscience or desire to change
 Most have been forced to come to treatment
 Some cognitive therapists try to guide clients to think about moral issues and the
needs of other people

26
Borderline Personality Disorder

Five or more of the following:

Frantic efforts to avoid abandonment
Unstable and intense relationships
Unstable self image
Impulsivity (self destructive)
Suicidal behavior
Affective instability
Chronic feelings of emptiness
Inappropriate, intense anger
 Borderline Personality Disorder

 Close to 75% of those diagnosed are women

 Highly comorbid
 The course of the disorder varies
 In the most common pattern, the instability and risk of suicide
reach a peak during young adulthood and then gradually
wane with advancing age
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 How Do Theorists Explain Borderline
Personality Disorder?

Because a fear of abandonment tortures so many people

with the disorder, psychodynamic theorists look to early
parental relationships to explain the disorder
Lack of early acceptance or abuse/neglect by parents
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 How Do Theorists Explain Borderline
Personality Disorder?
 Biological abnormalities: such as an overly reactive amygdala
and an underactive prefrontal cortex
 In addition, sufferers who are particularly impulsive
apparently have lower brain serotonin activity
 Close relatives of those with borderline personality disorder
are 5 times more likely than the general population to have
the disorder
30
 Treatments for
Borderline Personality Disorder
• It appears that psychotherapy can eventually lead to
some degree of improvement for people with this
disorder
• It is extraordinarily difficult, though, for a therapist to
strike a balance between empathizing with a patient’s
dependency and anger and challenging his or her way
of thinking 31
1. The initial assessment
• Evaluation of suicidal ideation and suicide attempts are common, safety
issues should be given priority, and a thorough safety evaluation and
consideration of other clinical factors should be done. It will determine the
necessary treatment setting (e.g., outpatient or inpatient).
• It is important at the outset of treatment to establish a clear and explicit
treatment framework which includes establishing agreement with the
patient about the treatment goals.
2. Psychiatric management
• The primary treatment for borderline personality disorder is psychotherapy,
complemented by symptom-targeted pharmacotherapy .
• In addition, psychiatric management consists of a broad array of ongoing activities and
interventions that should be instituted by the psychiatrist for all patients with borderline
personality disorder
• The components of psychiatric management for patients with border-line personality
disorder include
- Responding to crises
-Monitoring the patient’s safety,
-Establishing and maintaining a therapeutic framework and alliance, providing education
about borderline personality disorder and its treatment,
-Coordinating treatment provided by multiple clinicians,
-Monitoring the patient’s progress, and
- Reassessing the effectiveness of the treatment plan.
3. Principles of treatment selection
a) Type
• Certain types of psychotherapy (as well as other psychosocial modalities) and certain
psychotropic medications are effective in the treatment of borderline personality disorder .
• Although it has not been empirically established that one approach is more effective than
another
• Cclinical experience suggests that most patients with borderline personality disorder will
need extended psychotherapy to attain and maintain lasting improvement in their
personality, interpersonal problems, and overall functioning .
• Pharmacotherapy often has an important adjunctive role, especially for diminution of
symptoms such as affective instability, impulsivity, psychotic-like symptoms, and self-
destructive behavior .
• No studies have compared a combination of psychotherapy and pharmacotherapy to either
treatment alone, but clinical experience indicates that many patients will benefit most from
a combination of these treatments .
b) Focus Treatment planning should address borderline personality disorder as well as
comorbid axis I and axis II disorders, with priority established according to risk or
predominant symptoms .
c) Flexibility
• Because comorbid disorders are often present and each patient’s history is unique,
• The heterogeneous nature of borderline personality disorder, the treatment plan needs to
be flexible, adapted to the needs of the individual patient [I].
• Flexibility is also needed to respond to the changing characteristics of patients over time.
• d) Role of patient preference
• Treatment should be a collaborative process between patient and clinician, and patient
preference is an important factor to consider when developing an individual treatment
plan.
e) Multiple- versus single-clinician treatment
• Treatment by a single clinician and treatment by more than one clinician are both viable
approaches.
4. Specific treatment strategies
a) Psychotherapy
• Two psychotherapeutic approaches have been shown in randomized controlled trials to
have efficacy psychoanalytic/psychodynamic therapy and dialectical behavior therapy
b) Pharmacotherapy
(i) Treatment of affective dysregulation symptoms
• Patients with borderline personality disorder displaying this dimension exhibit mood
lability, rejection sensitivity, inappropriate intense anger, depressive “mood crashes,” or
outbursts of temper.
ii) Treatment of impulsive-behavioral dyscontrol symptoms
• Patients with borderline personality disorder displaying this dimension exhibit impulsive
aggression, self-mutilation, or self-damaging behavior (e.g., promiscuous sex, substance
abuse, reckless spending).
(iii) Treatment of cognitive-perceptual symptoms
• Patients with borderline personality disorder displaying this dimension exhibit
suspiciousness, referential thinking, paranoid ideation, illusions, derealization,
depersonalization, or hallucination- like symptoms.
(i) Treatment of affective dysregulation symptoms
• Patients with borderline personality disorder displaying this dimension
exhibit mood lability, rejection sensitivity, inappropriate intense anger,
depressive “mood crashes,” or outbursts of temper. These symptoms should
be treated initially with a selective serotonin reuptake inhibitor (SSRI) or
related antidepressant such as venlafaxine [I].
• Studies of tricyclic antidepressants have produced inconsistent results.
• When affective dysregulation appears as anxiety, treatment with an SSRI
may be insufficient, and addition of a benzodiazepine should be considered,
although research on these medications in patients with borderline
personality disorder is limited, and their use carries some potential risk [III].
• When affective dysregulation appears as disinhibited anger that coexists
with other affective symptoms, SSRIs are also the treatment of choice [II].
Clinical experience suggests that for patients with severe behavioral
dyscontrol, low-dose neuroleptics can be added to the regimen for rapid
response and improvement of affective symptoms [II].
• Although the efficacy of monoamine oxidase inhibitors (MAOIs) for
affective dysregulation in patients with borderline personality disorder has
strong empirical support, MAOIs are not a first-line treatment because of
the risk of serious side effects and the difficulties with adherence to required
dietary restrictions [I].
• Mood stabilizers (lithium, valproate, carbamazepine) are another second-
line (or adjunctive) treatment for affective dysregulation, although studies
of these approaches are limited [II].
• There is a paucity of data on the efficacy of electroconvulsive therapy (ECT)
for treatment of affective dysregulation symptoms in patients with border-
line personality disorder. Clinical experience suggests that while ECT may
sometimes be indicated for patients with comorbid severe axis I depression
that is resistant to pharmacotherapy, affective features of borderline
personality disorder are unlikely to respond to ECT [II].
• Twenty-seven trials were included in which first- and secondgeneration
antipsychotics, mood stabilisers, antidepressants and omega-3 fatty acids
were tested.
• Most beneficial effects were found for the mood stabilisers topiramate,
lamotrigine and valproate semisodium, and the second-generation
antipsychotics aripiprazole and olanzapine.
• However, the robustness of findings is low, since they are based mostly on
single, small studies.
• Selective serotonin reuptake inhibitors so far lack high-level evidence of
effectiveness.
 Treatments for
Borderline Personality Disorder

 “Dialectical behavior therapy”

Largely from the cognitive-behavioral treatment model
and borrows heavily from zen buddism.
DBT is often supplemented by the clients’
participation in social skill-building groups
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 Treatments for
Borderline Personality Disorder
Antidepressant, mood stabilizing, antianxiety, and
antipsychotic drugs have helped some individuals to
calm their emotional and aggressive storms
Given the numerous suicide attempts by these
patients, their use of drugs on an outpatient basis is
controversial
Most clients seem to benefit from a combination of drug
therapy and psychotherapy 46
Histrionic Personality Disorder
Five or more of the following:
 Uncomfortable if not the center of attention
 Inappropriately seductive or provocative
 Rapidly shifting and shallow emotions
 Use of appearance to draw attention
 Speech is impressionistic and lacking in detail
 Self-dramatization, theatricality
 Suggestibility
 Considers relationships more intimate than they
are
 How Do Theorists Explain
Histrionic Personality Disorder?
Most psychodynamic theorists believe that, as
children, people with this disorder experienced
unhealthy relationships in which cold parents left
them feeling unloved
To defend against deep-seated fears of loss, the
individuals learned to behave dramatically, inventing
crises that would require people to act protectively 48
 Treatments for
Histrionic Personality Disorder

• Unlike people with most other personality disorders,

more likely to seek treatment on their own
• Working with them can be difficult because of their
demands, tantrums, seductiveness, and attempts to
please the therapist
49
• Narcissistic Personality Disorder
• Five or more of the following:
• Grandiose sense of self-importance
• Preoccupied with fantasies of unlimited success,
power, brilliance, etc.
• Belief that he or she is “special”
• Requires excessive admiration
• Sense of entitlement
• Interpersonally exploitative
• Lacks empathy
• Often envious
• Arrogant or haughty
 How Do Theorists Explain
Narcissistic Personality Disorder?
 Psychodynamic theorists more than others have theorized about
this disorder, focusing on cold, rejecting parents
 Interpret this grandiose self-presentation as a way for people
with this disorder to convince themselves that they are self-
sufficient and without need of warm relationships
 Research has found increased risk for developing the disorder
among abused children and those who lost parents through
adoption, divorce, or death 51
 How Do Theorists Explain
Narcissistic Personality Disorder?

Cognitive-behavioral theorists propose that narcissistic

personality disorder may develop when people are
treated too positively rather than too negatively in early
life
Those with the disorder have been taught to
“overvalue their self-worth”
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 “Anxious” Personality Disorders
 People with these disorders typically display anxious and fearful
behavior
 Although many of the symptoms are similar to those of anxiety
and depressive disorders, researchers have found no direct links
between this cluster and those diagnoses
 As with most of the personality disorders, research is very limited
 But treatments for this cluster appear to be modestly to
moderately helpful, considerably better than for other
53
personality disorders
Avoidant Personality Disorder
Four or more of the following:
Avoids activities due to fear of criticism,
disapproval or rejection
Unwilling to get involved with people unless certain
of being liked
Restrained in relationships due to fear of being
shamed or ridiculed
Preoccupied with criticism or rejection in social
situations
Inhibited in new situations due to feelings of
inadequacy
Views self as inept, unappealing, inferior
Reluctant to take personal risks
 How Do Theorists Explain
Avoidant Personality Disorder?

 Theorists often assume that avoidant personality disorder has

the same causes as anxiety disorders, including:
 Early trauma
 Conditioned fears
 Upsetting beliefs
 Biochemical abnormalities
 Research has not directly tied the personality disorder to the
anxiety disorders 55
 How Do Theorists Explain
Avoidant Personality Disorder?

Cognitive theorists believe that harsh criticism and

rejection in early childhood may lead people to
assume that their environment will always judge
them negatively
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 Dependent Personality Disorder
People with dependent personality disorder have a
pervasive, excessive need to be taken care of
As a result, they are clinging and obedient, fearing
separation from their loved ones
They rely on others so much that they cannot make
the smallest decision for themselves
The central feature of the disorder is a difficulty with 57
separation
Dependent Personality Disorder
Five or more of the following:
Excessive need for advice and reassurance to make
decisions
Needs others to assume responsibility for most areas
of life
Difficulty expressing disagreement
Difficulty initiating or doing things on own
Goes to excessive lengths for nurturance or support
Feels helpless when alone, due to exaggerated fears
of being unable to care for self
Urgently seeks new relationship if close relationship
ends
Preoccupied with fears of being left to care for self
Obsessive-Compulsive Personality Disorder
Personality traits involving
preoccupation with
orderliness, perfectionism,
and control at the expense
of spontaneity, flexibility,
and enjoyment
Obsessive-Compulsive Personality Disorder
Four or more of the following:
Preoccupation with rules, lists, order, schedules, etc.
Perfectionism
Excessive devotion to work and productivity
Over-conscientious, scrupulous, inflexible about morality
Inability to discard worn-out or worthless objects
Reluctance to delegate tasks or work with
others unless they submit to exactly his or
her way of doing things
Miserly spending style
Rigidity and stubbornness
 Take home points:

• Personality disorders are common and more common in your

practice then the general population
• Identifying personality disordered patients informs how best to
approach them
• Don’t forget to screen for comorbid diagnoses
• Ask for help if you are feeling overwhelmed!