Personality Disorders - Psychiatry

Introduction

Personality trait
- enduring patterns of behavior exhibited in a wide range of personal contexts
Personality disorder
- pervasive, inflexible, extreme, maladaptive personality trait causing impaired functioning or subjective distress
- ego syntonic
  - patient has limited awareness of disorder
- must be developed by early adulthood
  - a personality disorder cannot begin later than as an early adult
- not usually diagnosed in children
- not caused by any other organic etiology or intoxication
Personality disorders are part of the Axis II of the DSM and can be broken down into three clusters, each with separate clinical conditions
- cluster A
  - schizoid
  - schizotypal
  - paranoid
- cluster B
  - histrionic
  - borderline
  - antisocial
  - narcisstic
- cluster C
  - obsessive compulsive
  - avoidant
  - dependent

Cluster A

Cluster commonalities
- "weird"
- odd or eccentric
- no meaningful social relationships
- no psychosis
- genetic association with schizophrenia
Schizoid
- snapshot
  - A 50-year-old male lives alone in a cabin on several acres of land. He rarely interacts with his family or community other than when he comes to town once a month to pick up supplies.
- characteristics
  - patients tend to have emotional aloofness, indifferent to praise or criticism, without bizarre or idiosyncratic thinking
  - exhibit voluntary social withdrawal
    - content with social isolation (vs avoidant)
  - limited emotional expression
  - no association with schizophrenia
- treatment
  - psychotherapy
    - cognitive, behavioral, psychoanalysis
  - pharmacologic
    - only if patient suffers from concomitant depression or transient psychosis
Schizotypal
- snapshot
  - A 45-year-old female has recently quit her job in order to start a small business. She claims that the spirits have told her to sell trinkets each of which has a unique power. She is known for dressing oddly and due to her strange behavior has trouble making friends.
- characteristics
  - patients tend to have eccentric appearance with odd beliefs or magical thinking
  - patients may develop schizophrenia
- treatment
  - psychotherapy
    - cognitive, behavioral, psychoanalysis
  - pharamcologic
    - short course of low-dose antipsychotics, if needed
Paranoid
- snapshot
  - A 35-year-old female says that her neighbors are planning to steal her things and often ridicule her when she is not there. She is attempting to pursue legal action to get her neighbors evicted for this behavior as she knows that they have an intention to harm her in some way.
- characteristics
  - excessive distrust and suspicion
  - higher incidence in families with schizophrenia
- treatment
  - psychotherapy
    - cognitive, behavioral, psychoanalysis
  - pharmacologic
    - anxiolytics

Cluster B

Cluster commonalities
- "wild"
- dramatic, emotional, or erratic
- genetic association with mood disorders and substance abuse
Histrionic
- snapshot
  - A 29-year-old females comes to your office in a very provocative dress. At the beginning of the interview she flirts with you and asks you if you like her dress. You overheard her yelling into her cell phone in the waiting room which later turned to tears. She describes her flu-symptoms as if she's "dying."
- characteristics
  - excessively emotional and attention seeking which commonly includes sexual provocativeness
  - large concern with appearance
  - think "telenovelas"
- treatment
  - psychotherapy
    - cognitive, behavioral, psychoanalysis
  - pharmacologic
    - symptomatic medical management only (i.e., anxiolytics, antidepressants)
Borderline
- snapshot
  - A 26-year-old Ph.D female student comes to your office for a check up. When you enter the room she is visibly upset and states that all of the nursing staff are incompetent and that you're the only doctor who has ever understood her despite only having one brief clinical encounter. When you tell her that you cannot prescribe her the sleep medications she requested, she states that you are incompetent and abruptly leaves the appointment.
- characteristics
  - unstable interpersonal relationships, with impulsive behavior and a sense of emptiness due to a fear of abandonment
  - females > males
  - splitting is a major defense mechanism
    - relationships are either all good ("my boyfriend is a perfect angel") or all bad ("my boyfriend is evil and I hate him")
  - self-mutilation
- treatment
  - psychotherapy
    - cognitive, behavioral, psychoanalysis
      - dialectical behavioral therapy
  - pharmacologic
    - symptomatic medical management only (i.e., anxiolytics, antidepressants)
Antisocial
- snapshot
  - A 23-year-old male with an extensive criminal record assaults an elderly woman to steal her purse. On interview, he is polite and has a normal affect and describes with excitement how he hit the old lady with a wooden mallet prior to robbing her.
- characteristics
  - disregard for and violation of rights of others with lack of remorse which commonly results in criminality
  - males > females
  - conduct disorder if < 18 years
    - rule out substance use, sexual abuse, and possible normal behavior
  - commonly known as "psychopathy"
  - classic triad
    - set fires, torture animals, bed wetting
- treatment
  - psychotherapy
    - cognitive, behavioral, psychoanalysis
  - pharmacologic
    - avoid medications with an abuse potential
Narcissistic
- snapshot
  - A 50-year-old male lawyer is being worked up for an abnormal PSA test. He demands that he sees the chief of urology and won't let any housestaff in the room. He says he knows "very important people" and that there will be "trouble" if he waits longer than 5 minutes in the waiting room.
- characteristics
  - grandiose with a need for admiration and sense of entitlement
  - lacks empathy
  - reacts to criticism with rage
- treatment
  - psychotherapy
    - cognitive, behavioral, psychoanalysis
  - pharmacologic
    - avoid medications with an abuse potential

Cluster C

Cluster commonalities
- "worried"
- anxious or fearful
- genetic association with anxiety disorders
Obsessive compulsive personality disorder
- snapshot
  - A 22-year-old female dental student is struggling with her studies because she must read every reading assignment at least 3 times, as well as taking meticulous notes which she color codes. She works poorly in groups because she cannot delegate tasks.
- characteristics
  - patents tend to be preoccupied with order, perfectionism, control
  - ego-syntonic
    - patient is not aware of their behavior causing issues
      - vs. OCD which is ego dystonic
- treatment
  - psychotherapy
    - cognitive, behavioral, psychoanalysis
  - pharmacologic
    - only for symptomatic treatment
Avoidant
- snapshot
  - A 36-year-old female administrative assistant does not socialize with coworkers or attend any social events because she is afraid they will not like her. She would like to meet people but feels to shy to initiate a conversation.
- characteristics
  - patents tend to be hypersensitive to rejection and socially inhibited resulting from feelings of inadequacy
  - desires relationships with others (vs. schizoid)
- treatment
  - psychotherapy
    - cognitive, behavioral, psychoanalysis
  - pharmacologic
    - β-blockers
    - SSRIs
Dependent
- snapshot
  - A 29-year-old female presents for therapy after a break-up with her boyfriend. She always did everything he wanted and cannot understand how he could not want to be with her. According to her the boyfriend said she was "too clingy" and asked him to make every decision for her.
- characteristics
  - submissive and clingy with an excessive need to be taken care of resulting from a low self-esteem
- treatment
  - psychotherapy
    - cognitive, behavioral, psychoanalysis
  - pharmacologic
    - only for symptomatic relief

Reference

Blood, Plasma, Serum	Reference Range
ALT	8-20 U/L
Amylase, serum	25-125 U/L
AST	8-20 U/L
Bilirubin, serum (adult) Total // Direct	0.1-1.0 mg/dL // 0.0-0.3 mg/dL
Calcium, serum (Ca²⁺)	8.4-10.2 mg/dL
Cholesterol, serum	Rec: < 200 mg/dL
Cortisol, serum	0800 h: 5-23 μg/dL //1600 h: 3-15 μg/dL 2000 h: ≤ 50% of 0800 h
Creatine kinase, serum	Male: 25-90 U/L Female: 10-70 U/L
Creatinine, serum	0.6-1.2 mg/dL
Electrolytes, serum
Sodium (Na⁺)	136-145 mEq/L
Chloride (Cl^-)	95-105 mEq/L
Potassium (K⁺)	3.5-5.0 mEq/L
Bicarbonate (HCO₃^-)	22-28 mEq/L
Magnesium (Mg²⁺)	1.5-2.0 mEq/L
Estriol, total, serum (in pregnancy)
24-28 wks // 32-36 wks	30-170 ng/mL // 60-280 ng/mL
28-32 wk // 36-40 wks	40-220 ng/mL // 80-350 ng/mL
Ferritin, serum	Male: 15-200 ng/mL Female: 12-150 ng/mL
Follicle-stimulating hormone, serum/plasma	Male: 4-25 mIU/mL Female: premenopause: 4-30 mIU/mL midcycle peak: 10-90 mIU/mL postmenopause: 40-250
pH	7.35-7.45
PCO₂	33-45 mmHg
PO₂	75-105 mmHg
Glucose, serum	Fasting: 70-110 mg/dL 2-h postprandial:<120 mg/dL
Growth hormone - arginine stimulation	Fasting: <5 ng/mL Provocative stimuli: > 7ng/mL
Immunoglobulins, serum
IgA	76-390 mg/dL
IgE	0-380 IU/mL
IgG	650-1500 mg/dL
IgM	40-345 mg/dL
Iron	50-170 μg/dL
Lactate dehydrogenase, serum	45-90 U/L
Luteinizing hormone, serum/plasma	Male: 6-23 mIU/mL Female: follicular phase: 5-30 mIU/mL midcycle: 75-150 mIU/mL postmenopause 30-200 mIU/mL
Osmolality, serum	275-295 mOsmol/kd H₂O
Parathyroid hormone, serume, N-terminal	230-630 pg/mL
Phosphatase (alkaline), serum (p-NPP at 30° C)	20-70 U/L
Phosphorus (inorganic), serum	3.0-4.5 mg/dL
Prolactin, serum (hPRL)	< 20 ng/mL
Proteins, serum

Hematologic	Reference Range
Bleeding time	2-7 minutes
Erythrocyte count	Male: 4.3-5.9 million/mm³ Female: 3.5-5.5 million mm³
Erythrocyte sedimentation rate (Westergren)	Male: 0-15 mm/h Female: 0-20 mm/h
Hematocrit	Male: 41%-53% Female: 36%-46%
Hemoglobin A1c	≤ 6 %
Hemoglobin, blood	Male: 13.5-17.5 g/dL Female: 12.0-16.0 g/dL
Hemoglobin, plasma	1-4 mg/dL
Leukocyte count and differential
Leukocyte count	4,500-11,000/mm³
Segmented neutrophils	54%-62%
Bands	3%-5%
Eosinophils	1%-3%
Basophils	0%-0.75%
Lymphocytes	25%-33%
Monocytes	3%-7%
Mean corpuscular hemoglobin	25.4-34.6 pg/cell
Mean corpuscular hemoglobin concentration	31%-36% Hb/cell
Mean corpuscular volume	80-100 μm³
Partial thromboplastin time (activated)	25-40 seconds
Platelet count	150,000-400,000/mm³
Prothrombin time	11-15 seconds
Reticulocyte count	0.5%-1.5% of red cells
Thrombin time	< 2 seconds deviation from control
Volume
Plasma	Male: 25-43 mL/kg Female: 28-45 mL/kg
Red cell	Male: 20-36 mL/kg Female: 19-31 mL/kg

Cerebrospinal Fluid	Reference Range
Cell count	0-5/mm³
Chloride	118-132 mEq/L
Gamma globulin	3%-12% total proteins
Glucose	40-70 mg/dL
Pressure	70-180 mm H₂O
Proteins, total	< 40 mg/dL

Sweat	Reference Range
Chloride	0-35 mmol/L
Urine
Calcium	100-300 mg/24 h
Chloride	Varies with intake
Creatinine clearance	Male: 97-137 mL/min Female: 88-128 mL/min
Estriol, total (in pregnancy)
30 wks	6-18 mg/24 h
35 wks	9-28 mg/24 h
40 wks	13-42 mg/24 h
17-Hydroxycorticosteroids	Male: 3.0-10.0 mg/24 h Female: 2.0-8.0 mg/24 h
17-Ketosteroids, total	Male: 8-20 mg/24 h Female: 6-15 mg/24 h
Osmolality	50-1400 mOsmol/kg H₂O
Oxalate	8-40 μg/mL
Potassium	Varies with diet
Proteins, total	< 150 mg/24 h
Sodium	Varies with diet
Uric acid	Varies with diet
Body Mass Index (BMI)	Adult: 19-25 kg/m²