Adjustment, Personality Disorders

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Adjustment, Personality Disorders Chronic
Medical Conditions

• Jeff Baker, Ph.D.
• Chief Psychologist, Anesthesiology, Orthopaedics
  Rehabilitation, Surgery
• Professor, Division of Rehabilitation Sciences
• Director, Psychology Training Program

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Objectives

• Identify psychological influences of personality.
• Understand the influence of stress on
  personality.
• Types of Stressors that influence patients
  rehabilitation.
• Effective ways of managing patients with major
  psychosocial stressors

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Adjustment Disorders

• Development of emotional or behavioral symptoms
  in response to an identifiable stressor(s) within
  3 months of the onset of the stressor(s).
• Evidenced by either of the following

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Adjustment Disorders

• 1. Marked distress that is in excess of what
  would be expected.
• 2. Significant impairment in social or
  occupational functioning.

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Adjustment Disorders

• The stress-related disturbance does not meet the
  criteria for another AXIS I or AXIS 2 disorder.
• The symptoms do not represent bereavement.
• Once the stressor has terminated, the symptoms do
  not persist for more than an additional 6 months.

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Adjustment Disorders

• 309.0 Adj Disorder with Depressed Mood
• 309.24 Adj Disorder with Anxiety
• 309.28 with mixed anxiety and depression
• 309.3 with disturbance in conduct
• 309.4 with disturb of emotions and conduct
• 309.9 Adj Disorder unspecified

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Posttraumatic Stress Disorder

• The symptoms develop after a psychologically
  traumatizing event or events outside the range of
  normal human experience. May experience symptoms
  alone or in groups. The stressors contain a
  psychological component and frequently a
  concomitant physical component that may directly
  damage people's nervous systems. In adjustment
  disorder the precipitating stress event need not
  be severe or unusual.

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Personality Disorders Effect on the Individual
Depression Phobias Elevated family
violence Drug use Exacerbation of Existing
Issues Inhibit Healing Rehabilitation
Without Treatment
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Identifying Personality Disorders

• Maladaptive behaviors
• Pervasive
• Pattern
• Intensity

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Definition of Personality Disorder

• It is pervasive and inflexible.
• It has an onset in adolescence or early
  adulthood.
• It is stable over time.
• It leads to distrust or impairment.
• Is thought to be an enduring pattern of inner
  experience and behavior that deviates markedly
  from the expectations of the individuals
  culture.
• Coping or defense mechanisms, which are used to
  deal with high levels of stress that have been
  left untreated.
• Coping with pain, loss of identity, mobility, and
  independence all may have profound effects on
  personality.

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Mini Self-Test

• What are the characteristics of a person that
  would warrant a personality disorder diagnosis?
• How would that effect my ability to provide
  treatment/therapy for the patient?
• How is this going to effect the patients quality
  of life.
• Results of careless diagnosis. Video
• MC issues
• Debate. What are pros and cons of diagnosing
  with PD?

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What are Personality Disorders Like?

• Personality disorder symptoms stem from basic
  personality traits that developed over time. A
  person does not get a personality disorder.
• People with personality disorders typically have
  problems in many areas of their lives, including
  social skills, moods, and emotional states.
  People with these disorders have difficulty
  establishing normal, healthy relationships.
• In some disorders, some have no desire to have
  social relationships or they want relationships,
  but are scared to reach out to people.

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Personality Disorders Emotion

• Some disorders involve restricted affect
  (schizoid, schizotypal)
• Some disorders involve excess emotion
  (hystrionic)
• And some disorders involve problems with emotion
  modulation (borderline)

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Personality Disorders Treatment

• Because personality disorder traits are deeply
  ingrained in the personality, there is no quick
  treatment. Treatment is typically based on
  psychotherapy which evaluates faulty thinking
  patterns and teaches new thinking and behavior
  patterns.
• A problem in treating individuals with
  personality disorders is that many do not believe
  they have a problem.

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Diagnosis Criteria
1) There are 10 personality disorders listed in
the DSM-IV TR. 2) DSM-IV TR Diagnostic
and Statistical Manual of Mental
Disorders-Fourth Edition, TR APA 2003. 3) The
criteria for each Personality Disorder is listed
in the DSM-IV TR.
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Differentiation of Personality Disorder and
Disorder

• Personality Disorder tends to be EgoSyntonic
• Disorder tends to be EgoDystonic

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Types of Personality Disorders
Cluster A Odd or Eccentric 1. Paranoid
Personality Disorder 2. Schizoid Personality
Disorder 3. Schizotypal Personality Disorder
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Paranoid PD

• Pervasive distrust and suspiciousness of others
  and interpret their motives as malevolent.

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Schizoid PD

• Individuals with this disorder have a pervasive
  pattern of detachment from social relationships
  and a restricted range of expression of emotions
  in interpersonal settings.

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Schizotypal PD

• Pervasive pattern of deficits marked by
  discomfort with, and reduced capacity for, close
  relationships, as well as cognitive or perceptual
  distortions and eccentricities of behavior.

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Cluster B Dramatic, Emotional, or Erratic

• 4. Antisocial Personality Disorder
• 5. Borderline Personality Disorder
• 6. Histrionic Personality Disorder
• 7. Narcissistic Personality Disorder

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Antisocial PD

• At least 18 years of age, have evidence of
  Conduct Disorder occurring before age 15 years,
  and have a pervasive pattern of disregard for and
  violation of rights of others.

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Borderline PD

• A pervasive pattern of instability in
  interpersonal relationships, self-images,
  affects, and control over impulses.
• Suicidal threats/attempts
• Cutting behaviors

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Histrionic PD

• A pervasive pattern of excessive emotionality and
  attention seeking.
• Somatic complaints common
• May dress seductively or outrageously for
  attention.

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Narcissistic PD

• Pervasive pattern of grandiosity (in fantasy or
  behavior), need for admiration, and lack of
  empathy.
• Self-centered
• At the core are usually very insecure.

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Cluster C Anxious or Fearful

• 8. Avoidant Personality Disorder
• 9. Dependent Personality Disorder
• 10. Obsessive-Compulsive Personality Disorder
• Personality Disorder NOS

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Avoidant PD

• Pervasive pattern of social inhibition, feelings
  of inadequacy, and hypersensitivity to negative
  evaluation.

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Dependent PD

• Pervasive and excessive need to be taken care of,
  leading to submissive and clinging behavior and
  fears of separation.

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Obsessive-Compulsive PD

• Pervasive pattern of preoccupation with
  orderliness, perfectionism, and mental and
  interpersonal control, at the expense of
  flexibility, openness, and efficiency.
• Not like Axis I OCD because it does not include
  obsessions and compulsions.

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Diagnosis
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Case Examples

• Patient who is verbally abusive and aggressive to
  staff and family.
• Patient who is suspicious and questions your
  treatment methods.
• Patient who wants to go have a cup of coffee with
  you and be your friend.

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Case Examples

• Patient who is seductive and always seems dressed
  up and wearing lots of cologne when they come in
  for appointment.
• Patient who denies that their SCI will bring
  about any changes in their lifestyle.

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Psychological Factors Affecting Medical Condition

• A general medical condition
• Neurotransmitter Response to Stress
• Endocrine Response to Stress
• Immune Response to Stress
• Psychological factors adversely affecting the
  medical condition
• Disorder Psych symptoms Personality traits
  Maladaptive health behaviors Stress related
  physiological response Other (cultural
  religious)

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Major Medical Issues

• Gastrointestinal System
• Cardiovascular System
• Respiratory System
• Endocrine System
• Skin Disorders
• Musculoskeletal System
• Headaches
• Psycho-oncology

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Conclusions on PD

• Individuals Diagnosed with Personality Disorders
  vs Individuals with exacerbated Stressors
• Difficult to Treat, Difficult to Manage
• How Does it Affect Your Treatment of the Patient

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Disorders of Impulse