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 distinguish from pyromania (intrinsic motivation for fires) distinguish from intermittent explosive disorder more pervasive pattern of rule or law breaking, deception, disregard for the rights of others, and lack of remorse in antisocial personality disorder 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 psychodynamic psychotherapy focuses on unconscious motivators and past experiences 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