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Personality Disorder

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Essential feature is the presence of a " pervasive distrust and suspiciousness of others such that their motives are interpreted as malevolent."
Paranoid Personality Disorder
Symptoms are associated with significant impairment in work and personal relationships
Patients are hostile, stubborn, and defensive, and they avoid intimacy. They are rigid and uncompromising, interested primarily in immediate objects rather than human relationships, extremely sensitive to rank, and disinterested in the arts or esthetics.
Paranoid Personality Disorder
To diagnose Paranoid Personality Disorder
Symptoms begin in early adulthood and present in a variety of contexts, as indicated by four or more of the following:
1. Suspects without sufficient basis that others are exploiting, harming, or deceiving him or her.
2. Is preoccupied with unjustified doubts about the loyalty or trustworthiness of friends or associates.
3.Is reluctant to confide in others because of unwarranted fear that the information will be used maliciously against him or her.
4.Reads hidden demeaning or threatening meanings and into benign remarks or events.
5.Persistently bears grudges, is unforgiving of insults, injuries, or slights.
6.Perceives attacks on his or her character or reputation that are not apparent to others and is quick to react angrily or to counterattack.
7.Has recurrent suspicions, without justification, regarding fidelity of spouse or sexual partner.
key feature for adding paranoid personalitity disorder to your differential diagnosis
Does not occur during the course of schizophrenia, a mood disorder with psychotic features, or another psychotic disorder and is not due to the direct physiological effects of a general medical condition.
In paranoid schizophrenia and paranoid disorders, there are persistent psychotic symptoms, including hallucinations and delusions, that are not features of paranoid personality disorder
Individuals with paranoid personality disorder may develop paranoid psychoses, however, at which time an additional diagnosis is justified.
how to deal with your paranoid personality disorder
Low-key and friendly, but not overly intimate attitude on the part of the health care providers encourages a trusting relationship.
Inquire about the nature of previous relationships with health care providers to avoid pitfalls.
Acknowledge suspicions without defensiveness or judging patient's distorted view.
Characterized by a restrictive pattern of detachment from social relationships and a restricted range of expressions of emotions in personal settings.
Appear to derive little pleasure from intimacy and live mostly as isolated loners
Schizoid Personality Disorder
Patients with _______ personality disorder have difficulty expressing hostility.
schizoid
They appear to be excessively self-absorbed and detached, and engage in daydreaming.
Work performance may be better than their ability to participate in interpersonal relationships.
schizoid personality disorder patient
how does schizoid personality disorder differ from schizotypal personality disorder
Differs from Schizotypal Personality Disorder, in which there are eccentricities of communication and behavior
Patients with Schizotypal Personality Disorder also have a higher prevalence rate of schizophrenia in their families. There is little evidence to link Schizoid Personality Disorder with schizophrenia
how does schizoid personality disorder differ from avoidant personality disorder
Differs from Avoidant Personality, in which withdrawal is the result of an exquisite sensitivity to rejection
Avoidant Personality Disorder is characterized by social withdrawal, but this trait appears in concert with a desire for acceptance
factors to consider when treating your schizoid patients
Fragile emotional equilibrium
Difficulty accepting dependant involvement
Appearance of detachment
Often delays treatment until symptoms are severe
Tolerates technical aspects of treatment well
Characterized by 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
Suffers from anxiety, depression, and other dysphoric mood states.
Schizotypal Personality Disorder
Symptoms of Schizotypal Personality Disorder begin by early adulthood and present in a variety of contexts as indicated by five or more of the following:
1.Ideas of reference
2.Odd beliefs or magical thinking that influences behavior and is inconsistent with sub cultural norms
3.Unusual perceptual experiences, including bodily illusions
4.Off thinking and speech
5.Suspiciousness or paranoid ideation
6.Inappropriate or constricted affect
7.Behavior or appearance that is odd, eccentric, or peculiar
8.Lack of close friends and confidants other than first-degree relatives
9.Excessive social anxiety that does not diminish with familiarity and tends to be associated with paranoid fears rather than negative judgments about self.
factors to consider when treating your schizotypal patient
Requires help with reality testing and distinguishing fantasy from fact.
Consider use of antipsychotic medication if patient becomes frankly psychotic.
Psychiatric consultation must be considered if psychosis persists
Since schizophrenia is often a co-morbid disorder with this type of personality disorder________, psychiatric consultation is recommended if psychotic thought patterns persist or if the patient's thinking patterns interfere with recommended medical treatment requirements
schizotypal
Essential feature is pervasive and excessive emotionality and attention-seeking behavior.
Creative and imaginative
Experience dysphoria in the face of loss or rejection
Seek attention with dramatic, lively, and at times seductive social behavior
Histrionic Personality Disorder
These patients may have problems with linear, analytic thought. They are impressionable, suggestible, and intuitive. They often "play hunches" rather than thinking decisions through methodically. There is a tendency toward somatization, with dramatic and shifting presentations of physical symptoms
Histrionic Personality Disorder
Histrionic Patients show a 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
1. Is uncomfortable in situations in which he or she is not the center of attention
2. Interaction with others is often characterized by inappropriate sexually seductive or provocative behavior.
3. Displays rapidly shifting and shallow expression of emotions.
4. Consistently uses physical appearance to draw attention to self
5. Has a style of speech that is excessively impressionistic and lacking in detail
6. Shows self-dramatization, theatricality, and exaggerated expression of emotion
7. Is suggestible, easily influenced by others or circumstances
8. Considers relationships to be more intimate than they actually are.
Men with ______ Personality Disorder may, when physically ill, display hyper masculine ("macho") behavior to counteract their perceptions of themselves as weak. Such counter phobic behavior may worsen the course of the illness. Such men may act in an overtly seductive fashion toward female physicians and other members of the health care team
Histrionic
Women with ______Personality Disorder may attempt to reaffirm their sense of self-worth by exhibiting dependent and coquettish behavior in an attempt to evoke reassuring admiration from their male physicians. Patients of both sexes may attempt to draw their physician into a rescuing, admiring role in order to ward off anxiety associated with the threat to their self-esteem posed by the illness.
Histrionic
Histrionic Personality Disorder
Factors to Consider in Medical Practice
Self esteem is heavily centered in patient's perception of his or her body image.
Physical prowess and attractiveness are prized attributes.
Capacity for overly dramatic expression
May shift focus of somatic distress
Pervasive pattern of grandiosity, need for admiration, and lack of empathy
Exaggerated sense of self-importance
Belief that everyday responsibilities are for those who are beneath them
Crave excitement to ward off boredom and emptiness
Narcissistic Personality Disorder
Exaggerated sense of self importance may manifest in a pretentious, boastful overestimation of abilities and accomplishments, fantasies of beauty, brilliance or unlimited success
Narcissistic Personality Disorder
Brief reactive psychosis may occur under stress. Depression is common, as is chronic, intense envy
Narcissistic Personality Disorder
(Narcissistic) A pervasive pattern of grandiosity, need for admiration, and lack of empathy, beginning in early adulthood and present in a variety of contexts, as indicated by five or more of the following:
1.Has a grandiose sense of self-importance (exaggerates achievements and talents, expects to be recognized as superior without commensurate achievements)
2.Is preoccupied with fantasies of unlimited success, power, brilliance, beauty, or ideal love
3.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
4.Requires excessive admiration
5.Has a sense of entitlement, i.e.., unreasonable expectation of especially favorable treatment or automatic compliance with his or her expectations
6.Is interpersonally exploitative, i.e.., takes advantage of others to achieve his or her own ends
7.Lacks empathy, is unwilling to recognize or identify with the feelings of others
8.Is often envious of others or believes others are envious of him or her
9.Shows arrogant, haughty behaviors or attitudes
The grandiosity of the Narcissistic Personality Disorder is stable across time and not ____ driven, as seen in hypomanic behavior or stimulant abuse
mood
Narcissistic Personality Disorder
Differential Diagnosis
Lacks impulsivity, self-destructiveness, and instability of Borderline Personality Disorder
Less aggressive than those with Antisocial Personality Disorder
Greater contempt for sensitivities of others than Histrionic Personality Disorder
Characteristic disturbances in self-esteem
Alternating idealization and devaluation of others
Alternating grandiose and inferior images of self
Narcissistic Personality Disorder
Narcissistic Personality Disorder
Factors to Consider in Medical Care
Illness may shatter image of perfection and personal invincibility
May denigrate the health care provider to maintain a sense of superiority and mastery over illness.
Provider should convey a sense of respect, but avoid reinforcing grandiosity
________ patients try to sustain an image of perfection and personal invincibility for themselves and attempt to project that image to others as well. Illness may shatter this image and the patient may lose the feeling of safety inherent in a cohesive sense of self. This loss precipitates a panicky sense of insecurity, and the patient feels a sense of personal fragmentation
narcissitic
The narcissistic patient shares with the ____ personality a concern about loss of admiration and approval, but the narcissistic patient shows a more disturbed response to illness
historionic
The histrionic person's idealization of the health care provider stands in contrast to the narcissistic person's frequent contemptuous disregard for the provider.
Characterized by a pervasive pattern of disregard for and violation of the rights of others that begins in childhood or early adolescence and continues into adulthood
Antisocial Personality Disorder
May manifest in poor job performance, academic failure, participation in illegal activities, recklessness, and impulsive behavior
Antisocial Personality Disorder
Person with _____ personality disorder experiences a feeling of subjective dysphoria, characterized by tension, depression, inability to tolerate boredom, and a feeling of being victimized. There is also a diminished capacity for intimacy.
antisocial
Antisocial Personality Disorder
There is a pervasive pattern of disregard for and violation of the rights of others occurring since the age of 15 years as indicated by three or more of the following:
1.Failure to conform to social norms with respect to lawful behaviors as indicated by repeatedly performing acts that are grounds for arrest
2.Deceitfulness, as indicated by repeated lying, use of aliases, or conning others for personal profit or pleasure.
3.Impulsivity or failure to plan ahead.
4.Irritability and aggressiveness, as indicated by repeated physical fights or assaults.
5.Reckless disregard for safety of self or others
6.Consistent irresponsibility, as indicated by repeated failure to sustain consistent work behavior or honor financial obligations.
7.Lack of remorse, as indicated by being indifferent to or rationalizing having hurt, mistreated, or stolen from another.
This disorder is not diagnosed when symptoms occur during the course of schizophrenia or a manic episode.
The disorder tends to remit over time. As destructive behavior diminishes, patients tend to develop hypochondriacal or depressive disorders
Antisocial Personality Disorder
Antisocial Personality Disorder
Factors to Consider in Medical Practice
Mutual feelings of suspicion and occasionally hostility
May feign physical symptoms to obtain narcoleptic analgesics
At risk for illness associated with substance abuse and stress due to unstable interpersonal and occupational adjustments
Frantic efforts to avoid real or imagined abandonment
Pattern of unstable and intense relationships
Identity disturbance
Impulsivity in at least two self-damaging areas
Recurrent suicidal behavior, gestures, threats, or self-mutilating behavior
Affective instability
Intense episodic dysphoria, irritability, or anxiety
Intense, inappropriate anger
Transient stress-related paranoid ideation or dissociative symptoms
Borderline Personality Disorders
Persons with _______ Personality Disorder exhibit a pervasive pattern of instability in interpersonal relationships, self-image, and affect marked by impulsivity that begins by early adulthood and is present in a variety of contexts.
borderline
Patients are preoccupied with threats of real or imagined abandonment. Intimacy leads to fear of merger and subjugation of identify with another person. Patients alternate between wish for closeness and the need for distance. There are also sudden identity shifts with rapid change in values, goals, and career choices. Impulsivity is reflected in behaviors such as substance abuse, overeating, gambling addictions, unsafe sex, promiscuity, excessive spending, or reckless driving.
Borderline Personality Disorders
Chronically unstable
Little satisfaction from low-quality of life
Unlikely to marry
Higher functioning patients have a better prognosis
Borderline Personality Disorders
Others are perceived as caricatures that are either all good or all bad.
Tend to feel that he or she is either completely well or deathly ill.
Threat of physical illness is often exaggerated to terrifying proportions.
Disturbance occurs during rapprochement subphase of separation-individuation. When the child practices independent behavior and returns to the primary caretaker for approval, admiration, and emotional "refueling." The critical, rejecting or smothering parent interferes with optimal progression of attachment-separation sequences.
Borderline Personality Disorders
Borderline Personality Disorder
Factors to Consider in Medical Practice
Minor health problems may be perceived as life threatening.
Provide clear, non-technical answers to questions.
Avoid encouraging patient to idealize or denigrate any provider.
Schedule frequent, regular check-ups
Patients may have difficulty differentiating reality from fantasy, and may perceive minor problems as life-threatening events.
May delay in presenting for medical treatment due to their fears of the worst regarding the diagnosis. May mistrust health care providers
Borderline Personality Disorder
Social discomfort
Hypersensitivity to criticism and rejection
Timidity
Depression
Anxiety
Anger
Avoidant Personality Disorder
Persons with Avoidant Personality Disorder are diagnosed by having four or more of the following:
1.avoids occupational activities that involve significant interpersonal contact because of fears of criticism, disapproval, or rejection.
2.is unwilling to get involved with people unless certain of being liked
3.shows restraint within intimate relationships because of the fear of being shamed or ridiculed
4.is preoccupied with being criticized or rejected in social situations
5.is inhibited in new interpersonal situations because of feelings of inadequacy
6.views self as socially inept, personally unappealing, or inferior to others
7.is unusually reluctant to take personal risks or to engage in any new activities because they may prove embarrassing
Avoidant Personality Disorder
Factors to Consider in Medical Practice
Shyness and insecurity may intensify during illness
Feelings of being stigmatized
Embarrassment about being scrutinized during physical examination
Use, Tact and timing - particularly in history taking and physical examination - are important in establishing the gradual deepening of trust and rapport. This approach is needed to encourage the patient to give accurate information without undue embarrassment. An overly intrusive approach may threaten the patient's sense of privacy and modesty and possibly contribute to noncompliance with the ______ patient
avoidant personality patient
Pervasive need to be taken care of that leads to submissive and clinging behavior and fears of separation
Intense discomfort when alone for more than a short period of time
Preoccupation with possibility of abandonment
Dependent Personality Disorder
Dependent Personality Disorder
The disorder begins in early adulthood and present in a variety of contexts, as indicated by five or more of the following:
1.has difficulty making everyday decisions without an excessive amount of advice and reassurance from others
2.needs others to assume responsibility for most major areas of his or her life
3.has difficulty expressing disagreement with others because of fear of loss of support or approval
4.has difficulty initiating projects or doing things on his or her own because of lack of faith in own judgment or abilities rather than lack of motivation of energy
5.goes to excessive lengths to obtain nurturance and support from other to the point of volunteering to do things that are unpleasant
6.feels uncomfortable or helpless when alone because or exaggerated fears of being unable to care for himself or herself
7.urgently seeks another relationship as source of care and support when a close relationship ends
8.is unrealistically preoccupied with fears of being left to take care of himself or herself
Twin studies find that submissiveness and dominance are highly correlated in identical twins, indicating a genetic component.
A disturbance at the oral stage of development in the form of maternal deprivation is common in those who develop the disorder.
Dependent Personality Disorder
Etiology
Dependent Personality Disorder
Factors to Consider in Medical Practice
May make urgent and inappropriate demands for immediate attention
May make angry outbursts if not given an immediate response
Illness provides secondary gain
Tendency to abuse sedatives and analgesics
May seek unnecessary procedures
Dependent Personality Disorder
treating the patient
These patients may make dramatic and intense appeals for caretaking.
Demands may have an exaggerated quality.
Tend to be passive participants in the healing partnership rather than seeking active solutions.
May have food, drug, and alcohol problems due to oral characteristics of the dependent person.
Overly compliant in their acceptance of medical treatment.
the provider and the dependent personality patient
Provider should convey impression of availability but should be careful to explain clearly and firmly the realistic limits of such availability.
Providers must guard against burnout and the hostile rejection that may be aroused by these patients' strong needs for dependence.
Exaggerated compliance with treatment regimen may lead to overutilization of the medical care system.
Patient needs are best distributed throughout the health care team rather than being focused exclusively on one member.
A preoccupation with orderliness, perfectionism, and mental and interpersonal control at the expense of flexibility, openness, and efficiency.
Distress associated with indecisiveness and difficulty expressing tender feelings.
Depression and suppressed anger
Excessively conscientious, moralistic, scrupulous, and judgmental.
Work pursued to the exclusion of leisure
Miserly attitudes
Compulsive Personality Disorder
Compulsive Personality Disorder
The disorder begins in early adulthood, is present in a variety of contexts, and is indicated by four or more of the following:
1.is preoccupied with details, rules, lists, order, organization, or schedules to the extent that the major focus of the activity is lost.
2.shows perfectionism that interferes with task completion (is unable to complete a project because his or her own overly strict standards are not met).
3.is excessively devoted to work and productivity to the exclusion of leisure activities and friendships.
4.is over-conscientious, scrupulous, and inflexible in matters of morality, ethics, or values.
5.is unable to discard worn-out or worthless objects even when they have no sentimental value.
6.is reluctant to delegate tasks or to work with others unless they submit exactly to his or her way of doing things.
7.adopts a miserly spending style toward self and others; money is viewed as something to be hoarded for a future catastrophe.
8.shows rigidity and stubbornness.
Compulsive Personality Disorder
Factors to Consider in Medical Practice
Troubled by sense of loss of control over bodily functions
Anger about the disruption of routines
Fearful of relinquishing control to a health care team
May redouble efforts to at composure and emotionally detached manner to ward off anxieties
Healing process may be promoted by harnessing the innate thoroughness of the patient by encouraging self-monitoring activities such as measuring fluid intake and output and weight fluctuations and control of graduated exercise programs. Meticulous adherence to treatment protocols will restore morale as patients regain a sense of mastery and dignity in taking charge of their treatment.
Compulsive personality disorder patients