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Personality Disorders

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Personality Disorders W Klugh Kennedy, PharmD, BCPP, FASHP, FCCP Clinical Professor of Pharmacy Practice and Psychiatry Mercer University, Savannah Georgia – PowerPoint PPT presentation

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Title: Personality Disorders


1
Personality Disorders
  • W Klugh Kennedy, PharmD, BCPP, FASHP, FCCP
  • Clinical Professor of Pharmacy Practice and
    Psychiatry
  • Mercer University, Savannah Georgia
  • kennedy_wk_at_mercer.edu

2
Medications
  • No medications specifically approved by the Food
    and Drug Administration (FDA) to treat
    personality disorders.
  • Antidepressants. Antidepressants may be useful
    for have a depressed mood, anger, impulsivity,
    irritability or hopelessness, which may be
    associated with personality disorders.
  • Mood stabilizers. May help even out mood swings
    or reduce irritability, impulsivity and
    aggression.
  • Antipsychotic medications. may be helpful if
    symptoms include losing touch with reality
    (psychosis) or in some cases if you have anxiety
    or anger problems.
  • Anti-anxiety medications. These may help if you
    have anxiety, agitation or insomnia. But in some
    cases, they can increase impulsive behavior, so
    they're avoided in some personality disorders.

3
Personality Disorder
  • Enduring pattern of inner experience and behavior
    that deviates markedly from expectations of
    individual's culture. Pattern is manifested in
    two (or more) of the following areas
  • Cognition (i.e., ways of perceiving and
    interpreting self, others, and events)
  • Affectivity (i.e. range, intensity, lability, and
    appropriateness of emotional response)
  • Interpersonal functioning
  • Impulse control
  • Inflexible and pervasive across a broad range of
    personal and social situations
  • Clinically significant distress or impairment in
    one or more area of functioning
  • The pattern is stable and of long duration, and
    its onset can be traced back at least to
    adolescence or early adulthood
  • Not better accounted for as a manifestation or
    consequence of another mental disorder
  • Not due to the direct physiological effects of
    substance abuse or a general medical condition '
  • Other Criteria
  • If less than 18 years old, must have features for
    greater than or equal to one year
  • Ego-syntonic in nature (i.e, belief that there is
    dysfunction with the outside world, but not
    within one's self)

4
Personality Style
  • enduring pattern of inner experience and behavior
    that deviates markedly from the expectations of
    the culture of the individual who exhibits it
  • long-lasting rigid patterns of thought and
    behavior. inflexibility and pervasiveness of
    these patterns
  • They do not cause significant problems and
    impairment of functioning for the persons who are
    afflicted with these disorders

5
Clusters
  • Cluster A, B, C
  • Mad, Bad, Sad
  • Weird, Wild, Worried

6
Cluster A
  • Schizoid
  • Schizotypal
  • Paranoid

7
Paranoid Personality Disorder
  • Diagnosis 4 or more
  • Suspicion that others are deceiving him or her
  • Preoccupation with doubts of loyalty of
    acquaintances
  • Reluctance to confide in others
  • Interpretation of benign remarks as threatening
    or demeaning
  • Persistence of grudges
  • Perception of attacks on his/her character
  • Recurrence of suspicions regarding fidelity of
    spouse or lover

8
Paranoid Personality Disorder
  • Epidemiology
  • Prevalence 0.5-2.5
  • MengtWomen
  • Higher incidence in family members of
    schizophrenics
  • Course defined by personality DO
  • Treatment

9
Schizoid Personality Disorder
  • Diagnosis 4 or more
  • Neither enjoying nor desiring close relationships
  • Choosing solitary activities
  • Little interest in sexual activity
  • Taking pleasure in few activities
  • Few close friends
  • Indifference to praise or critism
  • Detached

10
Schizoid Personality Disorder
  • Epidemiology
  • Prevalence 7
  • MengtWomen
  • No increased incidence of schizoid personality in
    families with hx of schizophrenia
  • Course defined by personality DO
  • Treatment

11
Schizotypal Personality Disorder
  • Diagnosis 5 or more
  • Ideas of reference
  • Magical thinking
  • Unusual perceptual experiences
  • Suspiciousness
  • Inappropriate or restricted affect
  • Odd or eccentric appearance or behavior
  • Few close friends
  • Odd thinking or speech
  • Excessive social anxiety

12
Schizotypal Personality Disorder
  • Epidemiology
  • Prevalence 3
  • Course defined by personality DO
  • Treatment

13
Cluster B
  • Antisocial
  • Borderline
  • Histrionic
  • Narcissistic

14
Antisocial Personality Disorder
  • Diagnosis 3 or more
  • Failure to conform to social norms
  • Deceitful/manipulative
  • Impulsive
  • Irritable/aggressive
  • Recklessness and disregard for safety of self or
    others
  • Lack of remorse for actions
  • Irresponsibility/failure to sustain work or honor
    financial obligations

15
Antisocial Personality Disorder
  • Epidemiology
  • Prevalence 3 in men and 1 in women
  • Higher incidence in poor urban areas
  • Genetic component Five times increased risk
    among first-degree relatives
  • Course defined by personality DO
  • Treatment

16
Borderline Personality Disorder
  • Diagnosis 5 or more
  • Desperate efforts to avoid real or imagined
    abandonment
  • Unstable, intense interpersonal relationships
  • Unstable self image
  • Impulsive in at least 2 potentially harmful ways
    (spending, sexual activity, CD, etc.)
  • Recurrent suicidal threats/attempts or self
    mutilation
  • Unstable mood/affect
  • General feeling of emptiness
  • Difficulty controlling anger
  • Transient, stress related paranoid ideation or
    dissociative sx

17
Borderline Personality Disorder
  • Epidemiology
  • Course defined by personality DO
  • Treatment

18
Histrionic Personality Disorder
  • Diagnosis 5 or more
  • Uncomfortable when not the center of attention
  • Inappropriately seductive
  • Uses physical appearance to draw attn to self
  • Uspech is impressionistic and lacking in detail
  • Dramatic
  • Easily influenced by others
  • Perceives relationships as more intimate than
    they are

19
Histrionic Personality Disorder
  • Epidemiology
  • Prevalence 2-3
  • WomengtMen
  • Course defined by personality DO
  • Treatment

20
Narcissistic Personality Disorder
  • Diagnosis 5 or more
  • Exaggerated sense of self-importance
  • Preoccupied with fantasies of unlimed money,
    success, brillance
  • Believes that he/she/ is special and can only
    associate with other high status people
  • Needs excessive admiration
  • Sense of entitlement
  • Takes advantage of others for self-gain
  • Lacks empathy
  • Envious of others or believes others are envious
    of him/her
  • Arrogant or haughty

21
Narcissistic Personality Disorder
  • Epidemiology
  • Prevalence lt1
  • Course defined by personality DO
  • Treatment

22
Cluster C
  • Avoidant
  • Dependent
  • Obsessive-compulsive

23
Avoidant Personality Disorder
  • Diagnosis At least 4 of the following
  • Avoids occupation that involves interpersonal
    contact due to fear of criticism
  • Unwilling to interact unless certain of being
    liked
  • Cautious of intrapersonal relationships
  • Preoccupied with being criticized or rejected in
    social situations
  • Inhibited in new social situations b/c he/she
    feels inadequate
  • Believes he/she is socially inept
  • Reluctant to engage in new activities for fear of
    embarrassment

24
Avoidant Personality Disorder
  • Epidemiology
  • Prevalence 1-10
  • Sex ratio unknown
  • Course defined by personality DO
  • Treatment

25
Dependent Personality Disorder
  • Diagnosis At least 5 of the following
  • Difficulty making everyday decisions without
    reassurance from others
  • Needs others to assume responsibilities for most
    areas of life
  • Cannot express disagreement because of fear of
    loss of approval
  • Difficulty initiating projects b/c of lack of
    self-confidence
  • Goes to excessive lengths to obtain support from
    others
  • Feels helpless when alone
  • Urgently seeks another relationship when one ends
  • Preoccupied with fears of being left to take care
    of self

26
Dependent Personality Disorder
  • Epidemiology
  • Prevalence Approx. 1
  • WomengtMen
  • Course defined by personality DO
  • Treatment

27
Obsessive Compulsive Personality Disorder
  • Diagnosis At least four of the following
  • Preoccupation with details
  • Perfectionism that is detrimental to completion
    of task
  • Excessive devotion to work
  • Excessive conscientiousness about morals
  • Will not delegate tasks
  • Unable to discard worthless objects
  • Miserly
  • Rigid and stubborn

28
Obsessive Compulsive Personality Disorder
  • Epidemiology
  • Prevalence unknown
  • MengtWomen
  • Most often in eldest child
  • Increased incidence in first degree relatives
  • Course defined by personality DO
  • Treatment

29
Personality Disorder Gender Incidence (ratio) Prevalence Rates Prevalence Rates Prevalence Rates Prevalence Rates
Personality Disorder Gender Incidence (ratio) General Population Inpatient Psychiatric Setting Outpatient Psychiatric Setting Outpatient Psychiatric Setting
Paranoid Males gt females 0.5-2.5 10-30 2-10 2-10
Schizoid Males gt females Uncommon and undocumented Uncommon and undocumented Uncommon and undocumented     own
Schizotypal Males gt females 3 Unknown Unkn     own
Antisocial Males gt females 3 (males) 1 (females) 10-30 3 -30 3 -30
Narcissistic Malesgt females (21) lt1 Unknown 2-16 2-16
Histrionic Femalesgt males 2-3 10-15 10-15 10-15
Borderline Femalesgt males (31) 2 20 10 10
Avoidant Males females 0.5-1.0 Unknown 10 10
Dependent Femalesgt males Undocumented most frequently reported personality disorder in mental health clinics Undocumented most frequently reported personality disorder in mental health clinics Undocumented most frequently reported personality disorder in mental health clinics Undocumented most frequently reported personality disorder in mental health clinics
Obsessive- compulsive Malesgt females (21) 1 Unknown 3-10 3-10
Higher prevalence in substance abuse treatment
settings and prison/forensic settings (50-
60 prevalence rate in correctional settings)
30
Pharmacologic Treatment (Evidence Based) No
medications are FDA-approved for the treatment of
personality disorders Medications may be
useful for the treatment of target symptoms
(i.e., depressed mood, impulsivity, and anxiety)
as an adjunct to psychotherapy Clusters A and
C no established pharmacological treatments
31
c.
32
  • Cluster B Evidence-based Pharmacotherapy
  • Antisocial Personality Disorder
  • Anticonvulsant/mood stabilizers and target
    dosages used to treat symptoms of impulsivity
    and violent behavior (Refer to the Bipolar and
    the Neurology chapters for a more detailed
    description on the pharmacology of mood
    stabilizers and anticonvulsants.)
  • a. Lithium carbonate 1200 mg/day (0.6 -1.5
    mEq/L)
  • Phenytoin 300 mg/day
  • Divalproex 750 mg/day
  • Carbamazepine 450 mg/day
  • Stimulants target symptoms of inattention,
    irritability, and impulsivity. Rarely used
    because of abuse potential. Methylphenidate
    dosages mimic those used for treatment of
    attention deficit hyperactivity disorder (ADHD)
  • Selective Serotonin Reuptake Inhibitors (SSRis)
    target symptoms of hostility, impulsivity, and
    violent behavior
  • Sertraline 150-200 mg/day b. Fluoxetine 60 - 80
    mg/day

33
Borderline Personality Disorder Symptom clusters
responsive to medications Affective
dysregulation (e.g., mood lability, anger,
depressed mood, temper outbursts) Impulsive-behav
ioral dyscontrol (e.g., impulsive aggression,
self-damaging behavior) Cognitive-perceptual
symptoms (e.g., suspiciousness, referential
thinking, paranoid ideation)
34
Evidence Based Treatment precautions Cluster
B Polypharmacy should be minimized Benzodiazep
ines are considered high risk treatments because
of suicidality, emotional dyscontrol, and abuse
potential Bupropion should not be used in a
patient with a co-occurring eating disorder,
because of increased seizure risk Tricyclic
antidepressants (TCAs) should be avoided in
patients with suicidality because of the risk of
lethality in overdose Antidepressants TCAs and
monoamine oxidase inhibitors (MAOis) have
inconsistent results and may cause a paradoxical
reaction in patients with BPD. Therefor SSRIs
if an antidepressant appears to be indicated
35
Treatment Summary RCT evidence supports the use
of Interpersonal Therapy plus fluoxetine for the
treatment of depression and impulsive aggression
associated with borderline personality disorder.
Mixed results for TCAs and MAOs for the
treatment of depressive symptoms Antipsychotics
and mood stabilizers may be consider if SSRI is
ineffective Reserved for patients who display
temper outbursts, irritability, anger, or poor
impulse control Antipsychotic Pharmacologic
Treatment Summary Moderate evidence supports the
use of olanzapine or aripiprazole for the
treatment of depression, anger, and anxiety. Case
reports and open studies exist for the use of
clozapine and quetiapine in the treatment of BPD.
Ziprasidone has one failed study. RCT of
conventional antipsychotics have demonstrated
mixed results in the treatment of anger,
depression, and suicidality, with haloperidol
being studied the most. Mood Stabilizer
Pharmacologic Treatment Summary Mixed results
suggest not using lithium or carbamazepine for
target symptoms of BPD. Divalproex should be
considered for patients with co-occurring bipolar
disorder. Positive studies with topiramate and
lamotrigine indicate that they are effective for
specific BPD target symptoms of anger, anxiety,
aggression, and impulsivity.
36
Less well studied Pharmacotherapy of Personality
Disorders Naltrexone 50-200 mg/day Case
reports and open trials suggest it may be helpful
for self-injurious behavior, flashbacks
associated with trauma, and dissociative
symptoms Clonidine 0.15 mg every morning 0.3 mg
at bedtime. A study in 2009 indicates that
clonidine may be advantageous for symptoms of
hyperarousal, subjective sleep latency, and
anxiety however a diagnosis of PTSD is likely
necessary. It is unlikely to be efficacious for
primary BPD symptoms, such as affective
dysregulation, impulsive-behavioral dyscontrol,
and cognitive-perceptual symptoms. Methylphenidat
e?
37
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