Personality

Reading= Andreason or Sadock &amp; Sadock, p239-260

=Goals=

8. Describe the consequences of personality disorders i doctr-patient relations and how these can be handled
DSM-IV: Trait: "enduring patterns of percieving, relatng to, and thinking about the environment and onesself that are exhibited in a wide range of personal and environmental situations

$Disorder: Only when personality traits are inflexible and maladaptive and cause signfiicant funcitonal impariment r subjectivbe distress do they constitute personality disorders

if not extreme, characteristics can be adaptive in some stuations


 * hypocrates**
 * Blood: emotional lability
 * Black bile: Depression
 * Yellow Bile: Anger
 * Phlegm - Slow, stolid, cold

comparison tophysical basis is not accurate, but lability, depression, anger are still aspects of personality disorders today.

Carl Jung: Introvert-Extrovert Thinking-Feeling Sensing-Intuiting Judging-Perceiving INTJ

MMTP Minnesota multiphasic personailty inventory Self-report inventories 500 %/F questions.... designed to be provocative 10 clincial scales...hypochondirasis, depression.... Three validity scales....faking good, faking bad four special scales: ego strength, anxiety empirically, come up with many dimensions; unwieldy

Meyers-Briggs--scores plotted along Jung's four dimensions

Assessment insturments...SID...screens for all disorders inclding personality disorders advantage...........score at end does lead to DSM diagnoses, not other 'dimensions'

Projective tests.... not diagnositc patterns of thought, dynamics, defeses, disorders of thought... Rorschach (Inkblot)

projective; not enough information to answer question, must fill in details

Thematic apperception test (TAT) tell stories about evocative pictures

Sentence completion test (SCT) I like.... Sometimes I wish...

Draw-A-Person (DAP)

rorshach used if suspect psychosis...nutt trying to hide.... very hard to psych out test.... Do you perceive motion? Big or small? In color?

Etiology... concordance rates for monozygotic twins are hgiher than for dizygotic tins, even if they are raised apart.

2 bodies of work&gt;:

Lary Siever Cognitive dsorganization...interpersonal detachment...cluster A

Impulsivity--Cluster B Decreaed 5-HT and 5-HIAA

Active instability....Cluster B hyperresponsivity of nadrenergic sytom

Anxiety/inhibition/cluster C high autonomic arousal from infnacy

3 qualities genetically driven Hihg Degree to shcihc indivdual is going out and looking for new stimuli Low High
 * Robert Cloninger**
 * Novelty Seeking
 * Harm Avoidance
 * Reward dependence

Medical school...day after day

Environmental factors.... parenting, family style, psychoscoail milieu

internal drives developmental stages

DSM-IV recognizes 10 personality types in 3 clusters Cluster A Personality Disorders
 * Odd or Eccentric

Need to be able to lok at case vignette and identify which one they fit into

CLuster A personality disorders

A pattern of distrust or suspiciousness such that others' motives are interpreted as malevolent ""The world i s a hostile place"" <> Prevalence: 2% of population Sex ratio: F:M 3:1 comorbidity: brief reactive psychosis, delusional disorder, anxiety, substance abuse, depression, chizophernia Family: Delusion disorder, schizophernia, Cluster A disorders
 * Paranoid Peronality Disorder:**

//story: long car ride, middle aged man, talking about himself starts off with diatribe about how tough he was toughest man around lives on isolated estate loaded with firearms and nobody messes with me anxious desperate laugh //

//story: man with shotgun... //

if meet criteria for one, may flow over into other disorders if meet criteria for one, probably meet criteria for more than one do best fit

Psychotherapy: treatment of choice, but patients have limited introspection
 * treatment
 * Medication: Anxiolytics, antipsychotics sometimes useful

don't pour on the empathy be yourself
 * Physician-patient interactioN:
 * a strightforward approach, without an expectation of personal warmth is most efective
 * Greater empathy may make patient //more// anxious


 * SCHIZOID PERSONALITY**

A pattern of detachment from social relationships and a restricted range of emotional expression interpersonal drives are just not there irrelevant whether people are around or not or whether keep in touch with family correlated with a restricted range of emotional expression don't do particularly well when forced into personal interactions hard to be with these folks--Don't feel qite 'real' don't see it, can't interpret it pretty bland in presentation <>

in a lot of ways...truly invisible in social settings fade into woodwork likely to be 1 or two people in every class.... it's fine unless forced to be in situations where have to be with other people dont schmooze well choose careers like lighthouse keeper write software security guards Sex ratio M>F Prevalence 3% Cluster A disorders
 * know** cormorbidity with psychotic disorders, family hx w/ psychotic disorder
 * 1) 1 prodrome of schizophrenia--overlap w/ negative symptoms

Schizooid personality disorder psychotherapy: treatment of choice: introspection is usually good MedicatioN: low doses of antispsychotics r eantidepressants are occasionaly helpful psychotherapy difficult, very boring I bought a clock and stuck it to my clipboard
 * treatment

How do they make it into the office? The exception, not the rule //'All my friends are pairing up'...'I've never had one, I'm curious why not.'//

//My one relationship of my life has broken up//

//My fiance broke up, I'm having trouble dealing with it. Grief session didn't go anywhere...Ask what happened Never had close friend or date moved into apt building young woman...very friendly...ran into each other at mail box. She said "Hello" Second time he had rehearsed his response..."Hello" adjusts his schedule so there at same time and after six months, she moved away. Focus of therapy changed...//

if get creeps...instincts not entirely unreasonable low dose antidepressants often helpful

Physician-patient interaction a strightforward approach not too much personal warmth

A pattern of acute discomfort in close relationships, cognitive or perceptal distoritons, and eccentricities of behavior not psychotic ...just weird 'Trekkies'
 * Schizotypal Personality Disorder**

//Socially having very hard time worked in medical records @ other hospital only male all single interests.... I know everything about trains Magazins, books on trains, conventions on trains in my spare time I go and wait by the railroad tracks... pinnacle experience: train had passed by...had to stop engineer invited him to come on board he was ecstatic looking at inside nothing worng with being interstedin trains He had no basis of making the judgement of how far he can go talking about trains...otherwise would have no way of knowing where that boundary was worked with him > 1 year seemed to be making headway terminated therapy working at hospital met him in the basement //

don't know where fits into larger interaction couldn't understand why everyone wasn't intersted in trains

Etiology High comorbidity with pschosis, delusion, schizophrenia

Treatment: psychotherapy Insight may be limited Medications: Antipsychotics may be useful

Phsyician-patient interaction ccare must be taken not to ridicule odd or over-valued ideas empathy may make more anxious avoid overt rejection: even a limited pesonal interaction may be very important for these folks

=Cluster B= 2 want to know antisocial, borderline consume a lot of our resources labile

A pattern fo disregard for, and violation of, the rights of tohers
Purge from your mind that 'antisocial' means desiring to avoid social behavior Antisocial means 'Career Criminal' 'a pattern of disregard for the rights and feelings of others' occuring since age 15... unusual in that this one has to start at early age tends to be a lifetime pattern its about breaking rules lie to you just for the hell of it

Commentator said...out of the many hours of interviews....there were two basic apttersnt alk, one thing never talked about 1) how tough they are to survive 2) whine about how tough prison is tended to blame victim
 * Never** talked about remorse

Prevalence: 3% of males, 1% of women SEx ratio M:F 3:1 Often ADD, depression, anxiety, substance abuse Somatization disorde,r substance abuse, other cluster B disorders

Clinical issues: violence > workplace, hospital, domestic ciminal behavior suicide rate 10%

Violence is age related....escalates in teens....gradual linear decline for the rest of life hits 50/50 mark in 40s once past violent stage...still dishonest, manipulative, irresponsible, but not violent

Treatment: Psychoterapy not generally useful. May alleviate depression and anxiety we have nothing to offer these people it's just not there may treat unconctrolled rage with antipscyotics or mood stabilizers best treatment is containment from a psyciatric perspective, they do better in prison less maladaptive, behavior improves, show more insight

Physician=patient interaction Firm limits are essential Substance abuse is a mjor problem 60% of those in jails have this disorder descriptions of behavior function well in a confined environment can they be rehabilitated? very little difference except decline in violence once remove constraints, they tend to regress if get a hint that they can manipulate the system, they will peripheral areas....can intervene rarely make it thorugh school not doing work, carrying weapons.... large percentage not gotten through school while in contained environment, can get through GED and associates' degree run through substance abuse treatment lots of debate about how helps when get out

firm limits are essential substance abuse is a major problem complicated by genuine distress and incessant manipulation can't trust anything they tell you complicated by genuine distress...when first get out of jail very little to offer

Borderline personality disorder
A pattern of instability in interpersonal relationships, self-image, and affects, and marked impulsivity often present with mood swings mood swings last hours

Stuff to watch for: Unstable affect? franti efforts to avoid real or imagined abandonment e.g. reschedule appointment where's your regular therapist when do they get back? alternating between extremes of idealization and devaluation the world is all thisw ay or all that way recklessness chronic suicidal behavior, threats, cutting needing to feel the pain suicide rate 10% chronic feelings of emptiness intense anger filled with rage
 * splitting**

other slide Prevalnce: 3% females, 1% men F:M 3:1 lots of depression, lots of substance abuse, eating disorders, brief reactive psychosis family: mood disorders, cluster B, substance abuse

Major clinical issues: Suicide, self-mutilation 5,10,15 suicide attempts lie about suicide attempts splitting--seing world as all good or all bad can't blow off or they will escalate rage psycosis report a lot of childhood trauma how much fictional versus historical dissociation: depersonalization, derealization, amnestic episode

Treatment: \Dialectical/ behavioral therapy works pretty doggone well indivdual, groupd, and CBT are difficult but may be useful focuses on etremes of mood, trying to help pt bring those together and on splitting...inability to hold 2 opposing ideas simultaneously

mediation: low-dose antipscychotics, mood stabilizers, and standard-dose antidepressants are mdoerately usefl. Anxiolytics are beneficial in a minority of pts won't make personality disorder go away, but may help with syptoms

Physician/patient interaction idealization, devaluation, and splitting are common firm limits and tolerance for regressive/childish behavior are essential Countertransference must be monitored carefully don't get excited they can't help it either terribly distressing to experience moods that way... every wave, current, breeze throws the boat feel bad, but drive crazy exaggerated 2 year olds

Histrionic personality disorder... pattern of excessive emotionality and attention seeking 1950s actress syndrome everything is melodramatic comes across as obsessive emotionality, seductive behavior 2-3% of population treatment: dynamictherapy is treatment of choice theese were the pts that frued created psychodynamics about anxiolytics may hel overly dependent or seductive behavior hard to tell difference between major, minor problems

Narcissistic personality disorder grandiosity, need for admiration, and lack of empathy other people need to meet your needs exploitive conceited, self-important Cluster B disorders not as prevalent as others psychotherapy is maddeeningly difficulty,, but does work. Interpersonal therapy may be most effective. Antidepressants or mood stabilizers for comorbid disorders Physician-patient interaciton...Idealization ives way rapidly to contemptuous devaluation entitlement and dcondescension are common be aware itis more often the physician than the patient who has these traits

why do people hate doctors? there are a number of reasons... time crunch one fo the big reasons...perceive this point out a couple of things.... we all decided that we were going to be in that 2% of the population that qualified on the exam we had the audacity to put our qualifications on peice of paper all have astonishing willingness assuming be taught enough to make life and death decisions with too little information, and living with it day to day

its a good thing some people who are willing to do that also selects for a lot of us who have a lot of confidence and the trainign experience,s including the lerkships and residency, is designed to enhance this subjetive to inhuman work hours, brutal critiques who desperate ly trying to critiues grossly unprepared to do master them what that's going to do to your mind intern...110 hours a week,

//on medicine rotation...30 hours into 36 hour shift family presenting chest pains w/ grandpa I've been here 30 hours nonstop These guys have no idea who they are dealing with I'm superman!//

That moment will come when that happens...remember this lecture I wawrned ou it as going to happen the reason we do it is that you've got to have a high level of confiedence in your ability ot do things fine line between that and narcissism trick is to be confident, but know limits patients who need our help as soon as loose sight of that, we are not serving**
 * only there for one reason: research grants, professorships, training, 1 reason:

keep that in mind, we can keep this in check. if we don't they're going to hate us for it, and they're going to be right.

Avoidant personality disorder "A pattern of social ihibition, feelings of inadequacy, and hypersensitivity to negative evaluation" painfully shy wanting social relationships being so anxious primary: intimacy not about being seen in large groups it's about in 1-on-1 relationships overlalp wth social

medicaiton: occaisionally antidepressants, anxiolytics

pt-physician interaction be aware nervous unconditional respect and concern avoid any implication of rejection even a limited personal interaction may be very important, and its loss very distressing

Dependent personality disorder excessive need to be taken care of typically see that. .25-27% of population F>M comorbidity: mood, aniety diorders, adjustment disorders family: cluster C who was it that made most of the decisions for the family who was it when yo had social interactions...whose friends were they? who made arrangements... Therapy: dynaic, behavior, group, familytherapies succesfful anxiolyticvs, antidepressants

Physicans should take an active role intreatment planning with clear explanations and recommendations Patients may need encouragement to make decisions about treatment plans family involvement is often helpful

"I suggest 'B'."

OCD
A pattern of preoccupation with orderlines, perfectioninsm, and controll adaptive in medicine, engineering, accounting love nlists what takes longer, writing the list, or formatting the lits differs from OCD...OCD is repetition, OCD PD is rigiditiy, 1% population 2:1 M:F obsesive-comulsive personality dsorder in family

Treatment: Psychoanalytic, behavioral, group therapies are often useful SSRI risk/benefit ratio