Updated: 11/30/2019

Personality Disorders

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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

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(M2.PY.17.4867) A 15-year-old girl is brought into her pediatrician's office by her mother because the mother thinks her daughter has attention issues. The mother explains that her daughter started high school four months ago and had lackluster grades in a recent progress report despite having earned consistent top marks in middle school. The mother complains that her daughter never talks to her at home anymore. The patient yells at her mother in the exam room, and the mother is escorted out of the room. The patient scoffs that her mother is so overbeaing, ruining her good days with criticism. She begins to chew gum and states that she hates hanging out with the girls on the cheerleading squad. She denies experiencing physical abuse from anyone or having a sexual partner. She has seen kids smoke marijuana underneath the football field bleachers, but does not go near them and denies smoking cigarettes. She denies any intention to harm herself or others, thinks her grades went down because her teachers are not as good as her middle school teachers, and states she thinks she learns best by watching explanations through online videos. What is the most likely diagnosis?

QID: 109574
1

Oppositional defiant disorder

20%

(10/49)

2

Normal behavior

78%

(38/49)

3

Conduct disorder

2%

(1/49)

4

Attention deficit hyperactivity disorder

0%

(0/49)

5

Antisocial personality disorder

0%

(0/49)

M 6 D

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(M2.PY.17.4703) A 12-year-old boy is brought in by his parents as they are concerned about his behavior. He is constantly arguing with his parents and blatantly defying their every request. In school, he is known for being intentionally tardy and for defying his teachers. Upon further questioning of the patient you learn about some of his recent behaviors such as beginning smoking to bother his parents. You also notice that he is disrespectful towards you. You then learn that he has also gotten into weekly fights with his peers at school with no apparent cause. In addition, last week he was seen hitting one of the local neighborhood cats with a baseball bat trying to kill it. The patient lives at home with his two parents in a pre-World War II house that was recently renovated. Physical exam is unremarkable.

Laboratory values are as follows:

Na: 140 mmol/L
K: 4.5 mmol/L
Cl: 100 mmol/L
Glucose: 80 mg/dL
Ca: 10 mmol/L
Mg: 3 mEq/L
Cr: 0.8 mg/dL
BUN: 10 mg/dL
Serum lead: < .01 µg/dL
Hb: 15 g/dL
Hct: 45%
MCV: 95
Urine toxicology: negative

As the patient leaves the office you notice him stealing all of the candy from the office candy bowl. The patient seems unconcerned about his behavior overall. Which of the following statements is most likely to be true in this patient?

QID: 108413
1

This patient will likely function normally despite continuing to defy authority figures

10%

(2/21)

2

This patient is suffering from antisocial personality disorder and will likely be incarcerated in adulthood

5%

(1/21)

3

Environmental exposures are likely causing this patient's behavior

0%

(0/21)

4

The patient's symptoms could progress to antisocial personality disorder

86%

(18/21)

5

Strong D2 antagonists are first-line pharmacotherapy

0%

(0/21)

M 6 D

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(M3.PY.12.2) A 23-year-old woman is brought to the emergency room by her mother after she is found to have cut both of her wrists with razor blades. The patient admits to a history of self-mutilation and attributed this incident to a recent breakup with a man she had been seeing for the previous 2 weeks. On morning rounds, the patient reports that the nurses are incompetent but the doctors are some of the best in the world. The patient's vitals are stable and her wrist lacerations are very superficial requiring only simple dressings without sutures. The patient is discharged a few days later and she feels well. Which of the following is the most appropriate initial treatment for this patient?

QID: 103737
1

Amitriptyline

0%

(0/11)

2

Cognitive behavioral therapy

18%

(2/11)

3

Dialectical behavior therapy

64%

(7/11)

4

Fluoxetine

9%

(1/11)

5

Lithium

0%

(0/11)

M 11 E

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(M3.PY.12.1) A 23-year-old woman is brought to her primary care physician for being excessively sad and withdrawn lately. The patient states she was recently in a relationship for the past 5 months that just ended. She states she did everything right in the relationship including cooking, cleaning, organizing, and being there for him. The relationship ended 1 week ago and since then, the patient has not known what to do with herself. She says she counted on her partner to structure her day and give her things to do and simply can not manage without him. She has not been doing laundry, cooking, or bathing during this time. This has happened to her multiple times in the past. She has begun writing songs about her breakup to cope, but it is not working. Her temperature is 98.8°F (37.1°C), blood pressure is 120/80 mmHg, pulse is 82/min, respirations are 13/min, and oxygen saturation is 98% on room air. Physical exam is notable for a sad young woman and the finding in Figure A which is on her other arm as well. Which of the following is the most likely defense mechanism utilized in this patient's underlying diagnosis?

QID: 103736
FIGURES:
1

Displacement

40%

(4/10)

2

Identification

10%

(1/10)

3

Projection

10%

(1/10)

4

Splitting

30%

(3/10)

5

Sublimation

10%

(1/10)

M 6 E

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Evidence (11)
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EXPERT COMMENTS (15)
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