Back to Basics April 2011 Presenter: Dr. Lyndal Petit, MD,
FRCPC
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Describe the core feature presented in PD: An enduring pattern
of behavior and inner experience Pattern goes against sociocultural
norms and affects multiple areas of ones life including (2 of):
Cognition Impulse control, Interpersonal functioning Affect
Inflexible; Pervasive; Across a broad range of personal and social
situations Pattern is stable and lg duration. Traced back to teens
or early adulthood Causes distress or impairment in soc-occ func
Not better accounted for by another mental illness. Not subs
induced or GMC
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What are the 4 temperaments with cloninger? Most affected by
biology Novelty seeking DA Harm avoidance (shy...) 5HT Reward
dependence (warm, affectionate if low you are cluster A and cold
and detached) NE and 5HT Persistance Hippocampus involved
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Personality charactersitics that remain constant throughout
life: (OCEAN) Openness Conscientiousness Extraversion Agreeableness
Neuroticism
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What tools can you use for PD? MMPI (Minnesota Multiphasic
Personality Inventory) SCID II (Structured Clinical Interview for
DSM) PDQ (Personality Disorder Questionnaire)
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Biological Etiology: All PDs have a genetic risk 40-60%
heritability
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Psychosocial etiology: Single parent Parental death Parenting
style: Avoidant/Absent/Aversive PD: Abuse Low SES/Welfare Social
Isolation
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All are about 1-2% 9% of population have a PD Gender is really
equal in both (controversial)
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Cluster A Projection Fantasy Denial Cluster B Splitting
Dissociation Denial Projective identification Acting out Cluster C
Isolation of affect Passive aggression Undoing Hypochondriasis
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Cant only be in the course of SCZ Mood with psychotic features
PDD GMC/Subs
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Cluster A and the familial link to scz: Schizotypal >
Paranoid > Schizoid
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Genetics Possible family link to scz Introversion = heritable
Psychosocial Neglectful family, cold Learned: relationship not
worth pursing.
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Core: Detached Social Relationships Restriction in emotional
expression 4/7 SIRSAFE Solitary lifestyle Indifferent to
praise/criticism Reln not interesting Sex not interesting
Activities solitary Few friends Emotionally cold and detached
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Other cluster A Avoidant PD Scz Delusion Disorder MDD with
psychotic features Aspergers/PDD OCPD
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Very Brief Psychotic Episodes Schizotypal, Paranoid, Avoidant
Personality Disorders
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Onset early in childhood DSM improvement with time However, may
also just be stable. Not known how many eventually develop
scz.
Rarely seek tx Low insight Low motivation Questionable degree
of suffering Psychotherapy Focus: Supportive therapy Skills
training Encourage activity Advice Often devoted to coming but
distant Initial distance needed for trust Fear dependence
Medications Low dose antipsychotics, antidep, psychostimulants 5HT
agents help for less sensitivity to rejection
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1-2% M>F (but supposed to be =) High rates of family
scz
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Genetics Inc family of scz Have some similar scz findings:
Enlarged ventricles Saccadic gaze High HVA in CSF reduced temp lobe
size; impaired exec fnc But: preserved frontal lobe vol (unlike
schizophrenia). Not related to psychotic affective d/o Mzg>Dzg
Psychosocial Low SES Critical over involved family Neglect;
Physical abuse Psychotic regression in face of stress
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Core: Eccentric Behavior Cog/Perceptual Distortions Discomfort
in and reduced capacity for relationship Dx 5/9 Peculiar and
eccentric Illusions and perceptual abn Ideas of reference
Suspiciousness/paranoid Odd beliefs - Claire Voyant; superstition
Speech/thoughts vague/circumferential Affect
inappropriate/constricted Social reluctant in social settings Few
friends
Psychodynamic = contraindicated Supportive = best Skills
training Give advice Encourage activity CBT Meds Comorbidities Olz
and Risp: mild to mod improve in +ve and ve psychotic sx
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Biological Genetics Increase first degree relatives
DD>Scz>General pop Temperment Non-adaptive, intense rxn, neg
mood, hyperactivity Psychosocial Aversive and critical parenting
Excessive parental rage and humiliation inadequacy and
vulnerability projection of hostility/rage onto others
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Other risk factors: Immigrants Hearing impaired Minority
groups
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10-30% of inpatients 2-10% outpts
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Core: Malevolent; Suspicious; Distrust; 4/7 SUSPECT Spousal
infidelity Unforgiving Suspicious friends/associates are
disloyal/untrustworthy Perceives attacks on character/reputation
quick to counterattack Expect exploitation/harm/deceit Confiding is
hard Threats or demeaning intentions seen in benign statements
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Not well studied Life long Occupation/Marital problems common
Sensitive to criticism Anger and hostile Externalize blame for
difficulties Litiginous
DDX Delusional D/O Scz Spectrum MDD with psychotic features
Chronic - Substances Other axis 2: Schizoid; Schzotypal; BPD;
Narcisstic; ASPD; Avoidant
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MDD Agoraphobia OCD Substance abuse/Dependence Other cluster A,
Narcissistic PD, Avoidant PD and BPD
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CBT Respect, Tact, Patience are key Increased sense of
competence Address core belief re others Psychodynamic rarely
indicated AP may reduce paranoia
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How common is BPD? 1-2% of population 2F:1M 10% inpts; 20%
outpts
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Biological 5X risk in 1 st deg Dec 5HIAA Psychosocial Insecure
attachment abandonment fear Move from anx/amb to disorg/disoriented
Unable establish concept of self, and to depict feelings/thoughts
in self and others Childhood trauma Hx of abuse (65% of severe BPD)
But: neither necessary nor sufficient Childhood sexual abuse most
accurate predictor of poor outcome Family Env High conflict and
unpredictability Temperment Vulnerable temperament in invalidating
env.
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Describe criteria: Core: Instability in self-image,
relationship, affect and impulsivity 5 of: I DESPAIRR Identity
confusion Derailed affect Empty Suicidal beh Paranoid ideation
Abandonment Impulsive Relationship instability Rage
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List defences Projection Identification Acting out Splitting
Projection Denial Distortion
List common co-morbidities with BPD Mood disorder Substance
abuse/Dep Anxiety Disorder PTSD ADHD Eating disorder Other PD
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How is MDD different in BPD More Atypical presentation
Emptiness is common Chronic dysphoria Poor response to antidep
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Main therapies available for BPD Dilectical Behavioral Therapy
Psychodynamic Therapy
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What does DBT result in? Less suicide attempts, self-harm, ER
visits and hospital days
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General Goals of DBT Enhance coping skills and adaptive
behavior Modify environment Improve motivation for change Therapist
support Includes Individual therapy Group 24 hr telephone
availability Therapist supervision
Slide 54
What medications would you be Rx: Target sx: Affect Lability;
Impulsivity; Paranoia. Affect Lability First Line: SSRI or related
AD Second Line: Small lose dose AP (anger) or clonazepam (anx)
Third: CBZ, Epival or Li add if partial effect, switch if none.
Impulsivity: First Line: SSRI Second Line: Low dose neuroleptic
(add or switch) Third: Li or MAOI Fourth : CBZ or Epival Cog
Perceptual Sx First Line: Low dose typical, risperidone or
olanzapine Second Line: increase dose Third Line: If affective sx
SSRI; If not atypical/clozapine
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How long is a treatment trial? 6 months
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3 ways to approach using meds in Borderline PD Limited supplies
(ie weekly supply) Safe in OD meds Dosettes Educate pt re limits of
med effectiveness Set target symptoms [ex SSRI to decrease
impulsivity] Avoid polypharmacy Avoid medications with a high
potential for abuse
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BPD prognosis Affect regulation improves the least Impulsivity
improves the most 25% still meet criteria after 15 years.
Maturation Social learning Avoidance of conflictual relationships
Prob with interpersonal fnc may persist....
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How common is ASPD 3% Male 1% Female
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Describe the biological etiology of ASPD: Biological Genetics:
5x risk if 1 st degree relative Adoption: If only gene no risk If
only disturbed family and no gene no risk If both high risk!!!
Chemical differences: 5HT: 5HIAA is decreased in CSF Low cortisol
arousal Less adrenergic activity (Less reactive ANS) Temperment
differences High novelty seeking; Low reward dep; Low harm
avoidance
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Describe the psychosocial etiology Psychosocial factors: Low
SES Poverty Losses Family break-ups Large families Frequent Moves
Parental deprivation or deviance Harsh or inconsistent parenting
Role modeling Substances Childhood: Fire setting, enuresis, cruelty
to animals.
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Provide dx criteria for ASPD Core: disrespect for and violation
of the rights and safety of others since 15. Callous man Must have
evidence of CD sx before age of 15 3/7 of Arrests due to ASPD beh
Lies Lacunae superego Obligations avoided Unstable (no plan ahead)
Safety of others disregarded Money not supporting others $ *** not
a criteria per se Aggressive Not SCZ: Occurs not exclusively during
the course of SCZ or Manic Episode They are at least 18
What are the co-morbidities with ASPD? Substances Somatization
Anxiety D/O Pathological Gambling ADHD Depression Though some think
this is not possible bcs of lack of empathy.
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List common defences in ASPD Acting Out Projection Controlling
Dissociation
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List 7 contraindications to psychotherapy Threatening to
therapist Intense counter transference by clinician Obvious 2 nd
gain High or low IQ Hx of sadistic violence causing injury No
remorse Hx inability to develop attachments
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What type of therapy is contraindicated: Psychoanalysis!!!
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What are some psychotherapy approaches CBT (K&S) Therapy
techniques: Minimize secondary gain. Confront denial and
minimization. Focus feelings that are not productive (dont focus on
empathy initially). Focus on possible ASPD behavior outcomes Find
healthier ways to act out. Homogenous groups
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What meds would you consider? Target comorbidity, impulsivity
and aggression SSRI, Li Anger outbursts: mood stabilizers Be
realistic in expected gains...
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Prognosis: Subs abuse = most accurate predictor of poor
outcome!!!! 1/3 grow out of dx decreased impulsivity and
criminality. continue to be difficult. 5% complete suicide
Increased risk of violent death No form of tx reduces
psychopathology.
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What are good prognostic factors? No substances Presence of MDD
or anxiety Ability to form therapeutic alliance Any superego
(including socially desirable need to rationalize) Positive work
and relationship Married Older (over 40 at f-u) Under 1 yr
incarceration
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How common is NPD? Under 1% Abt 10% of clinical population M
> F but some say M=F
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Etiology Biological Increased in offspring Psychosocial
Cultural winning forgives evtg Self-verification has inflated s-e;
looks to confirm it. Kohut self-object needs not met; use others as
self-objects
Slide 76
Two types of narcissistic personality disorder patients
Oblivious subtype Hostile and arrogance Self-centeredness and
self-absorption Little appreciation of the impact of behavior on
others. Hypervigilant subtype Greater psychological vulnerability
Disavows the desire to be the center of attention Constantly scans
the world for slights and criticisms.
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Core: AGE: Admiration; Grandiose; Lack Empathy A FAME GAME 5/9
Arrogant Fantacies of unlimited success Admiration required
Manipulative Envious Grandiose Associated with special people Me
entitled Empathy lacking
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Other PD Other Cluster B OCPD Adjustment d/o Manic/Hypomanic
Substance amph/cocaine Delusional D/O
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Mood disorder Substances Eating d/o Other Cluster B
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Depression from disappointment Difficulties with aging Often
get axis I
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Defences Used Idealization/Devaluation Identification
Projection
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Psychodynamic CBT
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Psychodynamic Tx of choice Kohut *Type 2 for hypervigilant type
Issue = dev arrest bcs of non-validation from self-obj. Never able
to dev sense of self and remains dep on others for it. Person is
thin skinned, easily hurt, self-effacing and sensitive Gentle,
empathy, take responsibility if pt hurt, stress +ve. Focus on
transference needs: Idealization Im good my therapist is good
Mirroring Im good my therapist likes me Twinship Im good Im like my
therapist Kernberg *Type 1 for oblivious type Issue = Rage bcs of
indifferent parents. Rage is covered up bcs of a gift. Become
exploitive in relationships. Person is oblivious, thick skinned,
craves attention and disregards others Greed and devaluation of
others needs tactful confrontation and intepretation
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2-3% 10-15% of practice F > M in clinical pop
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Biological Genetics increased risk Possibly linked to subs,
somatization, ASPD Psychosocial Sig separation before age 4 Lack of
meaningful reln Males preferred. Attention via appearance
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Core: Excessive emotionality; Attention sought I CRAVE SIN 4/8
Inappropriately seductive/provocative Center of attention
Relationships closer than are Appearance to draw attention
Vulnerable to suggestion Emotional exaggerated Shifting shallow
emotions Impressionistic speech (Novelty seeking)
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Other Cluster B Dependent PD Bipolar Substances
Somatization
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Sexualization Denial Dissociation Repression
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MDD Substances Somatization Disorder Conversion Disorder
Cluster B Dependent PD
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Tend to mature with age Least destructive of all cluster B
Substances can give them legal prob.
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Psychodynamic is the best CBT Meds for axis I only.
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They all seem to be w/in 1-3% Clinical pop ~ 10% M=F
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Biological Shared genetics with social phobia Env determines
one vs the other Increased cortisol Psychosocial Temperament: Inc
arousal and avoidant beh seen early. Learned behavior Psychodynamic
avoidance = defence against shame Parents: unavailable insecure
avoidant attachment; Abusive parents (avoid getting hurt).
Slide 98
List core features and Dx criteria CORE: Hypersensitivity to
neg evaluation; Inadequacy; Social inhibition 4/7 Behavioural
Avoids occupational activities (need sig interpersonal contact -
fear disapproval/criticism) Avoids any new activities (reluctant to
take personal risks) Relationship Restrained in intimate
relationships Inhibited in new interpersonal relationships
Unwilling to get involved unless certain to be liked Cognition
Feels inept + inferior Preoccupied with being criticized or
rejected
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Differential MDD Anxiety disorder esp social phobia gen.;
Agoraphobia Cluster A Dependent PD
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MDD Dysthymia Social phobia Anxiety D/O Dependent PD Cluster
A
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Defences Inhibition Displacement Isolation of affect
Projection
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Course Shyness normal decreases with age. It increases in
avoidant PD bcs of inc IP reln. Elderly bcm less shy. Do ok if not
exposed to new people.
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Treatment CBT > Psychodynamic Psychotherapy Assertiveness
and social skills Distress tolerance Mindfullness Exposure and
rational responding
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SSRI for anx/rejection Wellbutrin for novelty seeking
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M > F 10% of clinical practice ~1% of population
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Biological Increased in 1 st degree relatives No apparent
genetic link to OCD Psychosocial Factors First born Harsh
discipline Praise for actions vs who they were Anal stage problem
Punitive superego
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Core Feature: Preoccupation with perfection, orderliness,
control at expense of flexibility, openess and efficiency. 4/8 of
PERFECTION: Preoccupied with rules/details/planning/organizing
Emotionally constricted *** not included Reluctant to delegate
Frugal Excessively dedicated to work Controlling*** not included
Task completion impeded from perfectionism Inflexible Over
conscientious Never throws things out; Hoards Italicized not
included in dx
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OCD (30% of OCPD have OCD) Anxiety d/o Mood d/o very common!!!
Somatoform d/o Eating Disorders Hypochondriasis
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Anxiety d/o OCD OCD more clear obs + comp; egodystonic; more
insight; behaviors are not realistically connected or excessive to
rules or obs they are addressing; GAD Worry is excessive and
egodystonic. Narcissism May seem controlling but OCPD not
self-inflated. OCPD dont feel they deserve leisure Schizoid May
withdraw to maintain control; Able to have relationships ASPD
Schzoid PD
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Teens can grow out of OCPD traits!!!
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Rationalization; Intellectualization; Undoing; Isolation of
affect
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Psychodynamic = best evidence CBT Group Sometimes
SSRI/benzo
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~1% F>M
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Biological Submissiveness is a bio component Psychosocial
Insecure attachment from deprivation Overcontrolling parents Sick
child who had evtg done for them Got scolded for autonomy vs
shame
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Core: Need to be take care of; Clingy; Submissive; Fear
Separation 5/9 NEED PUSH: Need other to take responsibility
Excessive need for nurturance/support Disagreement limited
Expressed Decision making hard Preoccupied with fears of being left
alone Urgent find new reln when one ends Self-motivation is lacking
Self confidence lacking Helpless if alone
Dont meet criteria for a specific PD ie Dont meet full criteria
for any one PD but together cause distress or impairment.
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General Therapy Recommendations: Supportive Schizotypal;
Schzoid Psychodynamic No : Cluster A - Schizotypal, Schizoid,
Paranoid (rarely indicated), ASPD. CBT For All but Schizoid! CBT
BUT: BPD is DBT ASPD None of the above. K+S does say CBT
though.
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Which d/o are Most, Intermediate and Low and Untx amenable to
tx: Most: Cluster C Intermediate: Most of Cluster B Low: Cluster A
Severe BPD Some ASPD Not treatable: Most ASPD Malignant narcisism
Psychopathy Sadism
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Cluster A Stable Cluster B Unstable; Some remission with age
Cluster C - Modifiable
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Which have the least impairment: OCPD HPD best outcome of them
all. NPD Most have DSM improvement with time. May not correlate
with GAF
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Which have the most impairment? BPD Avoidant Schizotypal Most
live alone (Except OCPD)
