personality disorders: current concepts and controversies

Personality Disorders: Current Concepts Personality Disorders: Current Concepts and Controversiesand Controversies

2006 Wolfe-Adler Lecture2006 Wolfe-Adler LectureSheppard Pratt Health SystemSheppard Pratt Health SystemSeptember 27, 2006September 27, 2006

John M. Oldham, M.D.John M. Oldham, M.D.Professor and ChairmanProfessor and ChairmanDepartment of Psychiatry and Behavioral SciencesDepartment of Psychiatry and Behavioral SciencesMedical University of South CarolinaMedical University of South [email protected]@musc.edu

mailto:[email protected]

Personality =Personality =Temperament + CharacterTemperament + Character

Hippocrates ClassificationHippocrates Classification

ElementElement HumorHumor TypeType StyleStyle

AirAir BloodBlood SanguineSanguineHopefulHopeful

EnthusiasticEnthusiasticOptimisticOptimistic

EarthEarth Black BileBlack Bile MelancholicMelancholic SadSad

FireFire Yellow BileYellow Bile CholericCholericIrascibleIrascibleIrritableIrritable

WaterWater PhlegmPhlegm PhlegmaticPhlegmaticApatheticApathetic

SlowSlow

DIMENSIONAL

CATEGORICAL

Examples of Dimensional SystemsExamples of Dimensional Systems

Interpersonal Circumplex - Leary, Wiggins, KieslerInterpersonal Circumplex - Leary, Wiggins, Kiesler Three factors - Eysenck & EysenckThree factors - Eysenck & Eysenck Four factors - Livesley et al., Clark et al.Four factors - Livesley et al., Clark et al. Five factors - Costa & McCraeFive factors - Costa & McCrae Seven factors - Cloninger et al.Seven factors - Cloninger et al.

The Five-Factor Model of PersonalityThe Five-Factor Model of PersonalityNeuroticismNeuroticism Calm – WorryingCalm – Worrying Even-tempered – TemperamentalEven-tempered – Temperamental Self-satisfied – Self-pityingSelf-satisfied – Self-pitying Comfortable – Self-consciousComfortable – Self-conscious Unemotional – EmotionalUnemotional – Emotional Hardy – VulnerableHardy – Vulnerable

ExtroversionExtroversion Reserved – AffectionateReserved – Affectionate Loner – JoinerLoner – Joiner Quiet – TalkativeQuiet – Talkative Passive – ActivePassive – Active Sober – Fun-lovingSober – Fun-loving Unfeeling – PassionateUnfeeling – Passionate

Openness to ExperienceOpenness to Experience Down-to-earth – ImaginativeDown-to-earth – Imaginative Uncreative – CreativeUncreative – Creative Conventional – OriginalConventional – Original Prefer routine – Prefer varietyPrefer routine – Prefer variety Uncurious – CuriousUncurious – Curious Conservative – LiberalConservative – Liberal

AgreeablenessAgreeableness Ruthless – Soft-heartedRuthless – Soft-hearted Suspicious – TrustingSuspicious – Trusting Stingy – GenerousStingy – Generous Antagonistic – AcquiescentAntagonistic – Acquiescent Critical – LenientCritical – Lenient Irritable – Good-naturedIrritable – Good-natured

ConscientiousnessConscientiousness Negligent – ConscientiousNegligent – Conscientious Lazy – HardworkingLazy – Hardworking Disorganized – Well-organizedDisorganized – Well-organized Late – PunctualLate – Punctual Aimless – AmbitiousAimless – Ambitious Quitting – PerseveringQuitting – Persevering

Adapted from Costa & McCrae 1986

Three Major Brain Systems Influencing Stimulus – Three Major Brain Systems Influencing Stimulus – Response CharacteristicsResponse Characteristics

Brain System Brain System (Related Personality (Related Personality Dimension)Dimension)

Principal Principal Monoamine Monoamine NeuromodulatorNeuromodulator

Relevant StimuliRelevant Stimuli Behavioral Behavioral ResponseResponse

Behavioral activationBehavioral activation(novelty seeking)(novelty seeking)

DopamineDopamine NoveltyNovelty Exploratory pursuitExploratory pursuit

Potential rewardPotential reward Appetitive approachAppetitive approach

Potential relief of Potential relief of monotony or monotony or punishmentpunishment

Active avoidance, Active avoidance, escapeescape

Behavioral inhibition Behavioral inhibition (harm avoidance)(harm avoidance)

SerotoninSerotonin Conditioned signals Conditioned signals for punishment, for punishment, novelty, or frustrative novelty, or frustrative nonrewardnonreward

Passive avoidance, Passive avoidance, extinctionextinction

Behavioral Behavioral maintenancemaintenance(reward dependence)(reward dependence)

NorepinephrineNorepinephrine Conditioned signals Conditioned signals for reward or relief of for reward or relief of punishmentpunishment

Resistance to Resistance to extinctionextinction

Cloninger’s Seven-Factor ModelCloninger’s Seven-Factor Model

1.1. Temperament DomainsTemperament Domains (Moderately heritable, not greatly (Moderately heritable, not greatly influenced by family environment)influenced by family environment)

a.a. Novelty SeekingNovelty Seekingb.b. Harm AvoidanceHarm Avoidancec.c. Reward DependenceReward Dependenced.d. PersistencePersistence

2.2. Character DomainsCharacter Domains (Moderately influenced by family (Moderately influenced by family environment, only weakly heritable)environment, only weakly heritable)

a.a. Self-transcendenceSelf-transcendenceb.b. CooperativenessCooperativenessc.c. Self-directednessSelf-directedness

The DSM The DSM Categorical SystemCategorical System

DSM-IV Personality DisordersDSM-IV Personality Disorders

A. Cluster A (odd/eccentric)A. Cluster A (odd/eccentric)1.1. ParanoidParanoid2.2. SchizoidSchizoid3.3. SchizotypalSchizotypal

B. Cluster B (dramatic/emotional/impulsive)B. Cluster B (dramatic/emotional/impulsive)1.1. AntisocialAntisocial2.2. BorderlineBorderline3.3. HistrionicHistrionic4.4. NarcissisticNarcissistic

C. Cluster C (anxious/fearful)C. Cluster C (anxious/fearful)1.1. AvoidantAvoidant2.2. DependentDependent3.3. Obsessive-CompulsiveObsessive-Compulsive

D. Personality Disorder Not Otherwise SpecifiedD. Personality Disorder Not Otherwise Specified

Connecting Order with DisorderConnecting Order with Disorder- A Quantitative, Continuum Model- A Quantitative, Continuum Model

The Personality Style-Personality The Personality Style-Personality Disorder ContinuumDisorder Continuum

DSM-IV Definition of Personality DisorderDSM-IV Definition of Personality Disorder

A.A. An enduring pattern of inner experience and An enduring pattern of inner experience and behavior that deviates markedly from the behavior that deviates markedly from the expectations of the individual’s culture. This pattern expectations of the individual’s culture. This pattern is manifested in two (or more) of the following areas:is manifested in two (or more) of the following areas:

1.1. Cognition (i.e., ways of perceiving and Cognition (i.e., ways of perceiving and interpreting self, other people, and events)interpreting self, other people, and events)

2.2. Affectivity (i.e., the range, intensity, ability, Affectivity (i.e., the range, intensity, ability, appropriateness of emotional response)appropriateness of emotional response)

3.3. Interpersonal functioningInterpersonal functioning

4.4. Impulse controlImpulse control


B.B. The enduring pattern is inflexible and pervasive The enduring pattern is inflexible and pervasive across a broad range of personal and social across a broad range of personal and social situations.situations.


C.C. The enduring pattern leads to clinically significant The enduring pattern leads to clinically significant distress or impairment in social, occupational, or distress or impairment in social, occupational, or other important areas of functioning.other important areas of functioning.


D.D. The pattern is stable and of long duration and its The pattern is stable and of long duration and its onset can be traced back at least to adolescence onset can be traced back at least to adolescence or early adulthood.or early adulthood.


E.E. The enduring pattern is not better accounted for as The enduring pattern is not better accounted for as a manifestation or consequence of another mental a manifestation or consequence of another mental disorder.disorder.


F.F. The enduring pattern is not due to the direct The enduring pattern is not due to the direct physiological effects of a substance (e.g., a drug of physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical abuse, a medication) or a general medical condition (e.g., head trauma).condition (e.g., head trauma).

Prevalence of PDs in a Community SamplePrevalence of PDs in a Community Sample(N=2053)(N=2053)

Overall – 13.4%Overall – 13.4%

Torgersen, Kringlen, Cramer, 2001Torgersen, Kringlen, Cramer, 2001

Prevalence of PDs in a Community SamplePrevalence of PDs in a Community Sample(N=2053)(N=2053)

Personality DisorderPersonality Disorder Present PrevalencePresent PrevalenceParanoidParanoid 2.42.4SchizoidSchizoid 1.71.7SchizotypalSchizotypal 0.60.6AntisocialAntisocial 0.70.7BorderlineBorderline 0.70.7HistrionicHistrionic 2.02.0NarcissisticNarcissistic 0.80.8AvoidantAvoidant 5.05.0DependentDependent 1.51.5Obsessive-CompulsiveObsessive-Compulsive 2.02.0Passive-AggressivePassive-Aggressive 1.71.7Self-DefeatingSelf-Defeating 0.80.8

Torgersen, Kringlen, Cramer; 2001 Torgersen, Kringlen, Cramer; 2001

AuthorsAuthors LocationLocation NN

Zimmerman & Coryell, 1989Zimmerman & Coryell, 1989 IowaIowa 797797

Black et al., 1992Black et al., 1992 IowaIowa 247247

Maier et al., 1992Maier et al., 1992 MainzMainz 452452

Moldin et al., 1994Moldin et al., 1994 New YorkNew York 303303

Klein et al., 1995Klein et al., 1995 New York StateNew York State 229229

Lenzenweger et al., 1997Lenzenweger et al., 1997 New York StateNew York State 258258

Torgersen et al., 2001Torgersen et al., 2001 OsloOslo 20532053

Samuels et al., 2002Samuels et al., 2002 BaltimoreBaltimore 742742

PD Prevalence StudiesPD Prevalence Studies

Torgersen, 2005

PD Prevalence Studies (n=5081)PD Prevalence Studies (n=5081)

Torgersen, 2005

PD Range Median MeanParanoid 0.0-2.2 1.25 1.48

Schizoid 0.0-1.6 0.65 0.96

Schizotypal 0.0-3.2 0.70 1.20

Antisocial 0.2-4.5 1.70 1.77

Borderline 0.0-3.2 1.45 1.16

Histrionic 0.4-3.2 1.85 1.77

Narcissistic 0.0-4.4 0.05 0.61

Avoidant 0.4-5.0 1.35 2.91

Dependent 0.4-1.8 1.30 1.24

Obsessive-Compulsive 0.0-9.3 1.95 2.09

Passive-Aggressive 0.0-10.5 1.80 1.99

Self-Defeating 0.0-0.83 0.40 0.74

Sadistic 0.0-0.19 0.10 0.17

Any PD 3.9-22.7 11.55 12.26

AXIS I / AXIS II

Phenomenologically Corresponding Axis I & Axis II Disorders, Potential Phenomenologically Corresponding Axis I & Axis II Disorders, Potential Biological Indexes, and Characteristic Traits (Core Vulnerabilities), Biological Indexes, and Characteristic Traits (Core Vulnerabilities),

Defenses and Coping Strategies of Dimensions of Personality DisordersDefenses and Coping Strategies of Dimensions of Personality Disorders

DimensionDimension Axis I DisorderAxis I Disorder Axis II DisorderAxis II Disorder Biological IndexesBiological Indexes Characteristic TraitsCharacteristic Traits Defenses and Defenses and Coping StrategiesCoping Strategies

Cognitive/ Cognitive/ Perceptual Perceptual OrganizationOrganization

SchizophreniaSchizophrenia Odd clusterOdd cluster(schizotypal PD)(schizotypal PD)

Eye movement Eye movement dysfunction*, continuous dysfunction*, continuous performance task, performance task, backward masking test*, backward masking test*, plasma HVA*, CSF plasma HVA*, CSF HVA*, evoked potential HVA*, evoked potential response, VBRresponse, VBR

Disorganization, Disorganization, psychotic-like psychotic-like symptomssymptoms

Social isolation, Social isolation, detachment, detachment, guardednessguardedness

Impulsivity/Impulsivity/AggressionAggression

Impulse Impulse disordersdisorders

Dramatic clusterDramatic cluster(borderline & (borderline & antisocial PDs)antisocial PDs)

CSF 5-HIAA*, responses CSF 5-HIAA*, responses to serotonergic to serotonergic challenge, galvanic skin challenge, galvanic skin response*, continuous response*, continuous performance taskperformance task

Readiness to action, Readiness to action, irritability/irritability/aggressionaggression

Externalization, Externalization, dissociation, dissociation, enactment, enactment, repressionrepression

AffectiveAffectiveInstabilityInstability

Major affective Major affective disordersdisorders

Dramatic clusterDramatic cluster(borderline & (borderline & possibly possibly histrionic PDs)histrionic PDs)

REM latency, responses REM latency, responses to cholinergic to cholinergic challenges*, responses challenges*, responses to catecholamingeric to catecholamingeric challenges*challenges*

Environmentally Environmentally responsive, transient responsive, transient affective shiftsaffective shifts

Exaggerated Exaggerated affectivity, affectivity, “manipulativeness”, “manipulativeness”, “splitting”“splitting”

Anxiety/ Anxiety/ InhibitionInhibition

Anxiety Anxiety disordersdisorders

Anxious clusterAnxious cluster(avoidant PD)(avoidant PD)

Heart rate variability*, Heart rate variability*, orienting responses, orienting responses, responses to lactate and responses to lactate and yohimbineyohimbine

Autonomic arousal, Autonomic arousal, fearfulness, inhibitionfearfulness, inhibition

Avoidant, Avoidant, compulsive, and compulsive, and dependent dependent behaviorsbehaviors

* Preliminary data are available in patients with personality disorder (PD)

Schizotypal

Schizotypal PDSchizotypal PD

Dopamine [+ sx] (Coccaro & Siever, 2005)Dopamine [+ sx] (Coccaro & Siever, 2005) Dopamine [Dopamine [-- sx] (Siever & Davis, 2004) sx] (Siever & Davis, 2004) Ventricles (Siever, 1991)Ventricles (Siever, 1991) Cognitive functioning (Gold & Harvey, 1993)Cognitive functioning (Gold & Harvey, 1993) Working memory (Lees-Roitman et al., 1996)Working memory (Lees-Roitman et al., 1996) Verbal memory (Saykin et al., 1991)Verbal memory (Saykin et al., 1991) Sustained attention (Harvey et al., 1996)Sustained attention (Harvey et al., 1996) Arousal to stimuli (Siever, 1985)Arousal to stimuli (Siever, 1985)

Spectrum Model

Impulsive/Compulsive Spectrum of ControlImpulsive/Compulsive Spectrum of Control

Compulsive Impulsive

Control Control Inhibition Disinhibition

Impulsive DisordersImpulsive Disorders

Axis IIAxis II Borderline Personality DisorderBorderline Personality Disorder Antisocial Personality DisorderAntisocial Personality Disorder

Axis IAxis I Psychoactive Substance Use DisorderPsychoactive Substance Use Disorder BulimiaBulimia ParaphiliasParaphilias Impulsive Control Disorder NECImpulsive Control Disorder NEC

ANTISOCIALANTISOCIAL

Antisocial Personality Disorder (ASPD)Antisocial Personality Disorder (ASPD) Prefrontal gray matter volumePrefrontal gray matter volume Autonomic activity in ASPDAutonomic activity in ASPD May underlie low arousal, poor fear conditioning, lack May underlie low arousal, poor fear conditioning, lack of conscience, and decision-making deficits in ASPDof conscience, and decision-making deficits in ASPD

Raine et al., 2000

Psychopathic Antisocial PD (P-ASPD)Psychopathic Antisocial PD (P-ASPD) Corpus Callosum in P-ASPD vs Controls:Corpus Callosum in P-ASPD vs Controls:

white matter volumewhite matter volume lengthlength thicknessthickness functional interhemispheric connectivityfunctional interhemispheric connectivity

May reflect atypical neurodevelopment, e.g., May reflect atypical neurodevelopment, e.g., arrested early axonal pruning or ↑ white matter arrested early axonal pruning or ↑ white matter myelinationmyelination

May help explain affective deficitsMay help explain affective deficits

Raine et al., 2003

Malnutrition and Externalizing BehaviorMalnutrition and Externalizing Behavior

Malnutrition predisposes to neurocognitive Malnutrition predisposes to neurocognitive deficits, which predispose to persistent deficits, which predispose to persistent externalizing (antisocial and aggressive) externalizing (antisocial and aggressive) behavior throughout childhood and adolescence.behavior throughout childhood and adolescence.

Liu et al., 2004

The Gradations of AntisocialityThe Gradations of Antisociality

Some antisocial personality traits insufficient to meet DSM criteria; some antisocial traits Some antisocial personality traits insufficient to meet DSM criteria; some antisocial traits occurring in another personality disorderoccurring in another personality disorder

Explosive/Irritable Personality Disorder with some antisocial traitsExplosive/Irritable Personality Disorder with some antisocial traits Malignant NarcissismMalignant Narcissism Antisocial Personality Disorder, with property crimes onlyAntisocial Personality Disorder, with property crimes only Sexual Offenses without violence (viz., voyeurism, exhibitionism, frotteurism)Sexual Offenses without violence (viz., voyeurism, exhibitionism, frotteurism) Antisocial Personality Disorder, with violent felonies. (There may be some psychopathic Antisocial Personality Disorder, with violent felonies. (There may be some psychopathic

traits, but insufficient to meet Hare’s PCL-R criteria: score >29)traits, but insufficient to meet Hare’s PCL-R criteria: score >29) Psychopathy without violence (viz., con-artists, financial scams)Psychopathy without violence (viz., con-artists, financial scams) Psychopathy with violent crimesPsychopathy with violent crimes Psychopathy with sadistic control (viz., unlawful imprisonment of a kidnap victim while Psychopathy with sadistic control (viz., unlawful imprisonment of a kidnap victim while

awaiting ransom)awaiting ransom) Psychopathy with violent sadism and murder, but no prolonged torturePsychopathy with violent sadism and murder, but no prolonged torture Psychopathy with prolonged torture followed by murderPsychopathy with prolonged torture followed by murder

Stone, 2000

TreatabilityTreatability

Presence ofPresence of– Adequate motivationAdequate motivation– Ability to take seriously the nature of one’s antisocial Ability to take seriously the nature of one’s antisocial

attitudes and behaviorsattitudes and behaviors Absence ofAbsence of

– Pathological lying/deceitfulnessPathological lying/deceitfulness– Conning/manipulativenessConning/manipulativeness– Lack of remorse or guiltLack of remorse or guilt– Callousness/lack of compassionCallousness/lack of compassion

Stone, 2002

PsychopathyPsychopathy

Kraeplin (1915) – Psychopathic personalitiesKraeplin (1915) – Psychopathic personalities Cleckley (1940) – PsychopathCleckley (1940) – Psychopath Hare PCL-RHare PCL-R

PCL-R Factor-I ItemsPCL-R Factor-I Items

Glibness, superficial charmGlibness, superficial charm Grandiose sense of self worthGrandiose sense of self worth Pathological lyingPathological lying Conning/manipulativeConning/manipulative Lack of remorse or guiltLack of remorse or guilt Shallow affectShallow affect Callous/lack of empathyCallous/lack of empathy Failure to accept responsibility for one’s actionsFailure to accept responsibility for one’s actions

Black, 1999

Example of Offender RecidivismExample of Offender Recidivism

3 Year Reconviction3 Year Reconviction

PCL-R PCL-R > 30> 30 75%75%PCL-R PCL-R 20-2920-29 50%50%PCL-R PCL-R 0-190-19 25%25%

Hemphill et al., 1998

Predictors of ASPDPredictors of ASPD

Preschool child’s inability to inhibit socially inappropriate Preschool child’s inability to inhibit socially inappropriate behavior predicts later asocial behavior, and behavior predicts later asocial behavior, and undercontrolled behavior in school-age children is the undercontrolled behavior in school-age children is the best predictor of adult antisocial behavior. This best predictor of adult antisocial behavior. This association may be the most reliable relation between association may be the most reliable relation between characteristics in young children and later characteristics in young children and later psychopathology.psychopathology.

From Kagan J, Zentner M, Early childhood predictors of adult psychopathology. Harvard Review of Psychiatry, 1996.

Is ASPD Genetic?Is ASPD Genetic?

Genetic factors do play a significant role in Genetic factors do play a significant role in antisocial behaviorantisocial behavior

Twin studies show genetic factors to be particularly Twin studies show genetic factors to be particularly important in AS behavior with early-onset important in AS behavior with early-onset hyperactivityhyperactivity

Genetic factors least influential in adolescent onset Genetic factors least influential in adolescent onset delinquencydelinquency

JIMMY, SIXTH-GENERATION PAIN IN THE ASS

BORDERLINE

Borderline Personality Disorder (DSM-IV)Borderline Personality Disorder (DSM-IV)

1.1. Frantic efforts to avoid real or imagined abandonment. Note: do Frantic efforts to avoid real or imagined abandonment. Note: do not include suicidal or self-mutilating behavior covered in Criterion not include suicidal or self-mutilating behavior covered in Criterion 5.5.

2.2. A pattern of unstable and intense interpersonal relationships A pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and characterized by alternating between extremes of idealization and devaluation.devaluation.

3.3. Identity disturbance: markedly and persistently unstable self-image Identity disturbance: markedly and persistently unstable self-image or sense of self.or sense of self.

4.4. Impulsivity in at least two areas that are potentially self-damaging Impulsivity in at least two areas that are potentially self-damaging (e.g., spending, sex, substance abuse, reckless driving, binge (e.g., spending, sex, substance abuse, reckless driving, binge eating). Note: do not include suicidal or self-mutilating behavior eating). Note: do not include suicidal or self-mutilating behavior covered in Criterion 5.covered in Criterion 5.

A pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity beginning by early adulthood and present in a variety of contexts as indicated by five (or more) of the following:

Borderline Personality Disorder (DSM-IV)Borderline Personality Disorder (DSM-IV)

5.5. Recurrent suicidal behavior, gestures, or threats, or self-mutilating Recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior.behavior.

6.6. Affective instability due to a marked reactivity of mood (e.g., intense Affective instability due to a marked reactivity of mood (e.g., intense episodic dysphoria, irritability, or anxiety usually lasting a few hours episodic dysphoria, irritability, or anxiety usually lasting a few hours and only rarely more than a few days).and only rarely more than a few days).

7.7. Chronic feelings of emptiness.Chronic feelings of emptiness.

8.8. Inappropriate, intense anger or difficulty controlling anger (e.g., Inappropriate, intense anger or difficulty controlling anger (e.g., frequent displays of temper, constant anger, recurrent physical frequent displays of temper, constant anger, recurrent physical fights).fights).

9.9. Transient, stress-related paranoid ideation or severe dissociative Transient, stress-related paranoid ideation or severe dissociative symptoms.symptoms.

A pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity beginning by early adulthood and present in a variety of contexts as indicated by five (or more) of the following:

Heterogeneity of BPDHeterogeneity of BPD

DSM-IV - defined BPD is an extremely DSM-IV - defined BPD is an extremely heterogeneous construct (Est. 256 varieties)heterogeneous construct (Est. 256 varieties)

Mix of unstable, stress-induced symptoms Mix of unstable, stress-induced symptoms and stable personality characteristics and stable personality characteristics

(i.e., dimensional traits)(i.e., dimensional traits)

BPD as a Personality Disorder Emerging From the BPD as a Personality Disorder Emerging From the Interaction of Underlying Genetically-Based TraitsInteraction of Underlying Genetically-Based Traits

Impulsive aggression and affective instability = heritable Impulsive aggression and affective instability = heritable endophenotypes that would contribute significantly to endophenotypes that would contribute significantly to development of BPDdevelopment of BPD

Siever et al., 2002Siever et al., 2002

Heritability of BPDHeritability of BPD

Twin study (Torgersen et al. 2000)Twin study (Torgersen et al. 2000) Novelty seeking (Cloninger, 2005)Novelty seeking (Cloninger, 2005) Impulsivity (New and Siever, 2002)Impulsivity (New and Siever, 2002)

Childhood Abuse and BPDChildhood Abuse and BPD Severe childhood trauma Severe childhood trauma persistent serotonergic disturbancepersistent serotonergic disturbance Dose/response correlation (age of onset, frequency, seriousness)Dose/response correlation (age of onset, frequency, seriousness) Only males show Only males show serotonin and serotonin and aggression or aggression or impulsivity impulsivity Sustained childhood abuse Sustained childhood abuse

– Hyporesponsiveness of 5-HT systemHyporesponsiveness of 5-HT system

– Hyper-responsiveness of HPA systemHyper-responsiveness of HPA system

(correlated with sustained abuse, (correlated with sustained abuse, notnot BPD pathology) BPD pathology) To know what characterizes BPD, must correct for chronic To know what characterizes BPD, must correct for chronic

childhood traumachildhood trauma Possibly faulty attachment in genetically vulnerable children Possibly faulty attachment in genetically vulnerable children

selected by abusers selected by abusers sustained abuse sustained abuse HPA disturbances HPA disturbances susceptibility to stress and stress-related disorders (e.g. BPD, susceptibility to stress and stress-related disorders (e.g. BPD, MDD)MDD)

Rinne, T, ISSPD, Florence, 2003Rinne, T, ISSPD, Florence, 2003

MRI in Patients with BPDMRI in Patients with BPD 16% reduction in volume of hippocampus16% reduction in volume of hippocampus8% reduction in volume of amygdala in BPD patients vs. healthy 8% reduction in volume of amygdala in BPD patients vs. healthy

controlscontrols Not clearly related to traumaNot clearly related to trauma(results only significant for total BPD group [with and without hx of (results only significant for total BPD group [with and without hx of

trauma])trauma])

Driessen et al., 2000Driessen et al., 2000

MRI in Patients with BPDMRI in Patients with BPD

↓ ↓ Volume hippocampus and amygdala Volume hippocampus and amygdala (Schmahl et al, 2003; Rusch et al., (Schmahl et al, 2003; Rusch et al., 2003)2003)

PET and BPDPET and BPD

BPD patients vs ControlsBPD patients vs Controls • • frontal and prefrontal hypermetabolismfrontal and prefrontal hypermetabolism • • hippocampus and cuneus hypometabolismhippocampus and cuneus hypometabolism

= limbic and prefrontal dysfunction, implicated in = limbic and prefrontal dysfunction, implicated in regulation of emotionregulation of emotion

Juengling et al., 2003

Implications of Imaging Studies in BPDImplications of Imaging Studies in BPD

Abnormalities in prefrontal, Abnormalities in prefrontal, corticostriatal, and limbic networkscorticostriatal, and limbic networks

Perhaps related to lowered serotonin Perhaps related to lowered serotonin neurotransmission and behavioral neurotransmission and behavioral disinhibition.disinhibition.

Johnson et al., 2003Johnson et al., 2003

Neurocognitive Deficits in BPDNeurocognitive Deficits in BPD

BPD patients vs ControlsBPD patients vs Controls delayed, maladaptive choicesdelayed, maladaptive choices impulsive, disinhibited responsesimpulsive, disinhibited responses impairment in planningimpairment in planning

suggest complex impairments in cognitive suggest complex impairments in cognitive processes involving frontal lobesprocesses involving frontal lobes

Bazanis et al., 2002

Continuity of Treatment for Patients with Continuity of Treatment for Patients with Personality DisordersPersonality Disorders

Collaborative Longitudinal Personality Collaborative Longitudinal Personality Disorders StudyDisorders Study

Donna S. Bender, Ph.D.Donna S. Bender, Ph.D.Andrew E. Skodol, M.D.Andrew E. Skodol, M.D.John M. Oldham, M.D.John M. Oldham, M.D.Ingrid R. Dyck, M.P.H.Ingrid R. Dyck, M.P.H.Regina T. Dolan, Ph.D.Regina T. Dolan, Ph.D.M. Tracie Shea, Ph.D.M. Tracie Shea, Ph.D.

John G. Gunderson, M.D.John G. Gunderson, M.D.Charles Sanislow, Ph.D.Charles Sanislow, Ph.D.

Collaborative Longitudinal Personality Collaborative Longitudinal Personality Disorders Study (CLPS)Disorders Study (CLPS)

• 5 Collaborative Sites5 Collaborative SitesBrown (Shea), Columbia (Skodol), Harvard Brown (Shea), Columbia (Skodol), Harvard (Gunderson),Yale (McGlashan), Texas A&M (Morey)(Gunderson),Yale (McGlashan), Texas A&M (Morey)

• 668 Patients Recruited Originally (+65)668 Patients Recruited Originally (+65)STPD (N= 86), BPD (N=175), AVPD (N= 158),STPD (N= 86), BPD (N=175), AVPD (N= 158),OCPD (N= 154), MDD and no PD (N= 95)OCPD (N= 154), MDD and no PD (N= 95)

• Followed Longitudinally for >8 YearsFollowed Longitudinally for >8 Years

To determine the stability of symptoms, diagnoses, To determine the stability of symptoms, diagnoses, dimensions, and functioning and to determine the dimensions, and functioning and to determine the predictors of clinical coursepredictors of clinical course

Utilization of Psychosocial TreatmentsUtilization of Psychosocial Treatments

Mean Lifetime Months of Outpatient Mean Lifetime Months of Outpatient Treatment ReceivedTreatment Received

0

10

20

30

40

50

60

70

80

STPD BPD AVPD OCPD MDD

Self-HelpFamilyGroupIndividual

Mean Lifetime Weeks of Residential Mean Lifetime Weeks of Residential Treatment ReceivedTreatment Received

05

10152025303540


Halfway Hse.Psych. Hosp.Day Tmt.

Utilization of Psychopharmocologic Utilization of Psychopharmocologic TreatmentsTreatments

Utilization of Psychiatric Medications: Utilization of Psychiatric Medications: Lifetime Lifetime

0

10

20

30

40

50

60

70

80

Percent of Group


Antianxiety

Mood Stabilizer

Antipsychotic

Antidepressant

APA Practice Guidelines Work Group on APA Practice Guidelines Work Group on Borderline Personality DisordersBorderline Personality Disorders

John Oldham, M.D. (Chair)John Oldham, M.D. (Chair)Glen Gabbard, M.D.Glen Gabbard, M.D.Marcia Goin, M.D., Ph.D.Marcia Goin, M.D., Ph.D.John Gunderson, M.D.John Gunderson, M.D.Paul Soloff, M.D.Paul Soloff, M.D.David Spiegel, M.D.David Spiegel, M.D.Michael Stone, M.D.Michael Stone, M.D.Katherine Phillips, M.D.Katherine Phillips, M.D.

Part A: Treatment Recommendations Part A: Treatment Recommendations for Patients with Borderline Personality Disorder for Patients with Borderline Personality Disorder

II.II. Formulation and Implementation of a Treatment PlanFormulation and Implementation of a Treatment PlanE.E. Specific Treatment Strategies for the Clinical Features of Specific Treatment Strategies for the Clinical Features of

Borderline Personality DisorderBorderline Personality Disorder1.1. PsychotherapyPsychotherapy2.2. Pharmacotherapy and other somatic treatmentsPharmacotherapy and other somatic treatments

Partial Hospital Psychoanalytic Partial Hospital Psychoanalytic PsychotherapyPsychotherapy

BPD patients (n = 38)BPD patients (n = 38) Randomized controlled design:Randomized controlled design:

– Partial hospital vs. Standard treatmentPartial hospital vs. Standard treatment 18 months, psychoanalytic individual & group therapy18 months, psychoanalytic individual & group therapy

suicidal actssuicidal acts self-mutilatory actsself-mutilatory acts depressive symptomsdepressive symptoms hospital patient dayshospital patient days social and interpersonal functioningsocial and interpersonal functioning

36 month, maintained gains36 month, maintained gains

Bateman & Fonagy, AJP, 1999Bateman & Fonagy, AJP, 1999Bateman & Fonagy, AJP, 2001Bateman & Fonagy, AJP, 2001

Dialectical Behavior TherapyDialectical Behavior Therapy

Frequency and severity of parasuicidal episodesFrequency and severity of parasuicidal episodes Therapy attritionTherapy attrition Number of psychiatric inpatient daysNumber of psychiatric inpatient days

Improved scores on measures of anger, interviewer-Improved scores on measures of anger, interviewer-related global social adjustment, and Global related global social adjustment, and Global Assessment ScaleAssessment Scale

Improved self-rating on overall social adjustmentImproved self-rating on overall social adjustment One-year maintenance of treatment gainsOne-year maintenance of treatment gains

-Linehan et al, Arch Gen Psychiatry 1991-Linehan et al, Arch Gen Psychiatry 1991-Linehan et al, Arch Gen Psychiatry 1993 -Linehan et al, Arch Gen Psychiatry 1993 -Linehan et al, Am J Psychiatry 1994-Linehan et al, Am J Psychiatry 1994

Symptom-Oriented Symptom-Oriented Psychopharmacology for BPDPsychopharmacology for BPD

1.1. Cognitive/Perceptual SymptomsCognitive/Perceptual Symptoms2.2. Affective Dysregulation: MoodAffective Dysregulation: Mood3.3. Affective Dysregulation: AnxietyAffective Dysregulation: Anxiety4.4. Impulsive Behavioral DyscontrolImpulsive Behavioral Dyscontrol

From Paul Soloff

Algorithm for the Treatment ofAlgorithm for the Treatment of Cognitive-Perceptual Symptoms in BPD Cognitive-Perceptual Symptoms in BPD

Algorithm for the Treatment of Impulsive-Algorithm for the Treatment of Impulsive-Behavioral Symptoms in BPDBehavioral Symptoms in BPD

Algorithm for the Treatment of Affective Algorithm for the Treatment of Affective Dysregulation in BPDDysregulation in BPD

New DirectionsNew Directions

The Effectiveness of Psychodynamic Therapy and The Effectiveness of Psychodynamic Therapy and Cognitive Behavior Therapy in the Treatment of Cognitive Behavior Therapy in the Treatment of

Personality Disorders: A Meta-AnalysisPersonality Disorders: A Meta-Analysis

Both psychodynamic therapy and cognitive behavior Both psychodynamic therapy and cognitive behavior therapy are effective treatments of personality disorderstherapy are effective treatments of personality disorders

For psychodynamic therapy, the effect sizes indicate For psychodynamic therapy, the effect sizes indicate long-term rather than short-term change in personality long-term rather than short-term change in personality disorders (mean follow-up period = 1.5 years [78 weeks] disorders (mean follow-up period = 1.5 years [78 weeks] vs CBT mean follow-up = 13 weeks)vs CBT mean follow-up = 13 weeks)

Leichsenring F, Leibing E, Am J Psychiatry 2003; 160:1223-1232

Biology in the Service of PsychotherapyBiology in the Service of Psychotherapy

Psychotherapy can induce robust changes in Psychotherapy can induce robust changes in brain function that are detectable with brain function that are detectable with neuroimagingneuroimaging..

Etkin et al., 2005


From Furmark et al., 2002.

amygdala

cognitive-behavioral therapy citalopram

Areas decreased after vs. before treatment


Identification of brain regions associated with Identification of brain regions associated with deficits of impulse control in patients with BPD deficits of impulse control in patients with BPD may be useful to predict a patient’s ability to may be useful to predict a patient’s ability to respond to psychotherapy and recover.respond to psychotherapy and recover.

Etkin et al., 2005

Toward a New Model of PDs for DSM-V

Categorical vs. Dimensional Models: Categorical vs. Dimensional Models: Advantages and DisadvantagesAdvantages and Disadvantages

Limitations of categorical model• Excessive diagnostic co-occurrence, i.e., most patients meet criteria Excessive diagnostic co-occurrence, i.e., most patients meet criteria

for more than one PD.for more than one PD.• Heterogeneity among persons with the same diagnosis, e.g., there are Heterogeneity among persons with the same diagnosis, e.g., there are

256 ways to meet criteria for BPD.256 ways to meet criteria for BPD.• Arbitrary diagnostic thresholds, i.e., no empirical rationale for boundary Arbitrary diagnostic thresholds, i.e., no empirical rationale for boundary

with “normal” personality functioning.with “normal” personality functioning.• Inadequate coverage, e.g., PDNOS is the most frequently used Inadequate coverage, e.g., PDNOS is the most frequently used

diagnosis.diagnosis.

Limitations of dimensional models• Unfamiliar to those trained in medical model, i.e., communication of Unfamiliar to those trained in medical model, i.e., communication of

much information via single diagnostic concept.much information via single diagnostic concept.• More complex and difficult to use, e.g., up to 30 dimensions to More complex and difficult to use, e.g., up to 30 dimensions to

describe personality.describe personality.• Little empirical information on treatment or other clinical implications of Little empirical information on treatment or other clinical implications of

scale elevations or on cut-points for clinical decision-making.scale elevations or on cut-points for clinical decision-making.

Personality Disorders and the Personality Disorders and the Research Agenda for DSM-VResearch Agenda for DSM-V

• ““There is a clear need for dimensional models to be There is a clear need for dimensional models to be developed and their utility compared with that of existing developed and their utility compared with that of existing typologies in one or more limited fields, such as typologies in one or more limited fields, such as personality. If a dimensional system performs well and personality. If a dimensional system performs well and is acceptable to clinicians, it might be appropriate to is acceptable to clinicians, it might be appropriate to explore dimensional approaches in other domains (e.g., explore dimensional approaches in other domains (e.g., psychotic or mood disorders)” (Rounsaville et al., 2002).psychotic or mood disorders)” (Rounsaville et al., 2002).

• Thus, personality disorders are “test case” for return to a Thus, personality disorders are “test case” for return to a dimensional approach to the diagnosis of mental dimensional approach to the diagnosis of mental disorders in DSM-V.disorders in DSM-V.

18 Alternative Proposals for a 18 Alternative Proposals for a Dimensional Model of Personality DisordersDimensional Model of Personality Disorders

• Proposals to provide dimensional representation of Proposals to provide dimensional representation of existing constructs.existing constructs.

• Proposals to provide dimensional reorganization of Proposals to provide dimensional reorganization of diagnostic criteria.diagnostic criteria.

• Proposals to integrate Axes II and I with respect to Proposals to integrate Axes II and I with respect to common spectra.common spectra.

• Proposals to integrate Axis II with dimensional models of Proposals to integrate Axis II with dimensional models of general personality structure.general personality structure.

18 Alternative Proposals for a 18 Alternative Proposals for a Dimensional Model of Personality DisordersDimensional Model of Personality Disorders

• Proposals to provide dimensional Proposals to provide dimensional representation of existing constructs:representation of existing constructs:Oldham & Skodol (2000)Oldham & Skodol (2000) Any instrumentAny instrumentTyrer & Johnson (1996)Tyrer & Johnson (1996) Personality Personality Assessment Assessment Schedule (PAS)Schedule (PAS)Westen & Schedler (2000)Westen & Schedler (2000) S&W Assessment S&W Assessment

Procedure (SWAP-200)Procedure (SWAP-200)

(Widiger & Simonsen: (Widiger & Simonsen: JPDJPD, 2005), 2005)

Dimensional Representation of Dimensional Representation of DSM-IV PD CategoriesDSM-IV PD Categories

Summary TermSummary Term Number of Criteria MetNumber of Criteria Met• Absent (1)Absent (1) 00• Traits (2)Traits (2) 1, 2, or 3 1, 2, or 3• Subthreshold (3)Subthreshold (3) 3 or 4 3 or 4• Threshold (4)Threshold (4) 4 or 5 4 or 5• Pervasive (5)Pervasive (5) 5, 6, 7, or 8 5, 6, 7, or 8• Prototypic (6)Prototypic (6) 7, 8, or 9 7, 8, or 9

Oldham & Skodol: Oldham & Skodol: JPDJPD, 2000, 2000

PROPOSALPROPOSALAxis II: Personality Disorder Traits Axis II: Personality Disorder Traits

and Personality Disordersand Personality Disorders

Instructions:Instructions: Personality disorder traits or personality Personality disorder traits or personality disorders are identified according to the number of criteria disorders are identified according to the number of criteria met, as specified in each personality diagnosis, utilizing met, as specified in each personality diagnosis, utilizing the following categories:the following categories:

- - AbsentAbsent- Traits- Traits- Subthreshold features- Subthreshold features- Threshold- Threshold- Moderate- Moderate- Prototype- Prototype

PROPOSAL (continued)PROPOSAL (continued)

Instructions (continued):Instructions (continued): If a patient is at or above If a patient is at or above threshold for up to two PDs, the diagnosis or diagnoses threshold for up to two PDs, the diagnosis or diagnoses should be made. If a patient is at or above threshold for should be made. If a patient is at or above threshold for three or more PDs, the patient’s diagnosis should be:three or more PDs, the patient’s diagnosis should be:

Extensive Personality Disorder, characterized by:Extensive Personality Disorder, characterized by:

(A, B, C) components,(A, B, C) components,

subcategorized as traits, subthreshold, threshold, subcategorized as traits, subthreshold, threshold, moderate, or prototypemoderate, or prototype

EXAMPLE #1EXAMPLE #1

DiagnosisDiagnosis CategoriesCategories Number of Number of CriteriaCriteria

Paranoid PDParanoid PD AbsentAbsentTraitsTraitsSubthresholdSubthresholdThresholdThresholdModerateModeratePrototypePrototype

001-21-233445-65-677

EXAMPLE #2EXAMPLE #2

DiagnosisDiagnosis ComponentsComponents Categories of Categories of CriteriaCriteria

NumberNumber

Extensive PDExtensive PD BorderlineBorderlineParanoidParanoidNarcissisticNarcissistic

PrototypePrototypeModerateModerateThresholdThreshold

995555

Histrionic featuresHistrionic featuresSchizotypalSchizotypal

SubthresholdSubthresholdTraitsTraits

3333

Personality Disorders Over TimePersonality Disorders Over Time

““Remission” Rates of PDs Over 2 Years by Remission” Rates of PDs Over 2 Years by Different Definitions of RemissionDifferent Definitions of Remission

(Grilo et al: (Grilo et al: JCCPJCCP, 2004), 2004)

Personality Personality DisorderDisorder

2 months 2 months <<2 criteria2 criteria

12 months 12 months < < 2 criteria2 criteria

Below Below threshold on threshold on blind re-testblind re-test

STPDSTPD 33%33% 23%23% 61%61%

BPDBPD 42%42% 28%28% 56%56%

AVPDAVPD 47%47% 31%31% 50%50%

OCPDOCPD 55%55% 38%38% 60%60%

Mean Proportion of Criteria Met for PD Mean Proportion of Criteria Met for PD Groups Over Two YearsGroups Over Two Years

(Grilo et al: (Grilo et al: JCCPJCCP, 2004), 2004)

0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0.8

Baseline 6 months 1 year 2 years

STPDBPDAVPDOCPD

Probability of Remission of PDs Over 6 Years by Probability of Remission of PDs Over 6 Years by Different Definitions of RemissionDifferent Definitions of Remission

Personality Personality DisorderDisorder

2 months 2 months <<2 criteria2 criteria

12 months 12 months < < 2 2 criteriacriteria

STPDSTPD .74.74 .67.67

BPDBPD .77.77 .66.66

AVPDAVPD .79.79 .68.68

OCPDOCPD .89.89 .82.82

Skodol, AE (Unpublished)

Probability of PD Relapse After 6 YearsProbability of PD Relapse After 6 Years

STPDSTPD BPDBPD AVPDAVPD OCPDOCPD

2+ month 2+ month remissionremission

.02.02 .16.16 .29.29 .27.27

12+ month 12+ month remissionremission

.00.00 .07.07 .17.17 .17.17

Skodol, AE (Unpublished)

Persistence of Functional Impairment in Persistence of Functional Impairment in Personality DisordersPersonality Disorders

Axis V (GAFS) Ratings Over 2 Years

50

60

70

Baseline 1 year 2 yearTime of Assessment

STPDBPDAVPDOCPDMDD

Skodol et al: Psychol Med, 2005

Toward a New Model of PDsToward a New Model of PDs

• Personality disorders show consistency as syndromes Personality disorders show consistency as syndromes over time, but rates of improvement that are inconsistent over time, but rates of improvement that are inconsistent with DSM-IV definitionswith DSM-IV definitions

• Functional impairment in PDs is more stable than Functional impairment in PDs is more stable than psychopathologypsychopathology

• Some PD criteria are more stable than othersSome PD criteria are more stable than others• Personality traits are more stable than personality Personality traits are more stable than personality

disorders, predict stability and change, and are disorders, predict stability and change, and are associated with outcome over timeassociated with outcome over time

• PDs may be “hybrids” of more stable PDs may be “hybrids” of more stable personalitypersonality traitstraits and less stable and less stable symptomatic behaviorssymptomatic behaviors

Toward a New Model of PDs: Toward a New Model of PDs: Diagnostic and Treatment ImplicationsDiagnostic and Treatment Implications

• Redefine personality disorders in terms of trait and Redefine personality disorders in terms of trait and symptom componentssymptom components

• Reconceptualize course of personality disorders as Reconceptualize course of personality disorders as waxing and waning, depending on circumstanceswaxing and waning, depending on circumstances

• Delay definitive PD diagnosis until late 20s?Delay definitive PD diagnosis until late 20s?• Convey more optimistic prognosis to younger patients Convey more optimistic prognosis to younger patients

and their familiesand their families• Focus treatment more on attaining adequate Focus treatment more on attaining adequate

psychosocial functioningpsychosocial functioning

Psychopathology Over Time: Hypothetical Psychopathology Over Time: Hypothetical Data for One SubjectData for One Subject

from Pfohl B, 1999from Pfohl B, 1999

DIMENSIONAL

CATEGORICAL

personality disorders: current concepts and controversies

Health & Medicine