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1 PERSONALITY PERSONALITY DISORDERS DISORDERS Dept.of Dept.of Psychiatry Psychiatry and and Psychotherapy Psychotherapy, P , Pécs cs http://psychiatry.pote.hu http://psychiatry.pote.hu PERSONALITY DISORDERS: PERSONALITY DISORDERS: Encompass Encompass impairments impairments in in personality personality ( i.e.character i.e.character traits traits) ) that that are are maladaptive maladaptive, , pervasive pervasive, , inflexible inflexible and and enduring enduring These These impairments impairments start start in in early early child child- hood hood or or adolescence adolescence and and not not are are caused caused by by other other psychiatric psychiatric or or medical medical disorder disorder The enduring pattern leads to clinically significant distress or impairment in social, occu- pational, or other important areas of functioning. A behaviour or traits that are stable and of long duration, its onset can be traced back at least to adolescence or early adulthood The enduring pattern is not due to the direct physiological effects of a substance ( a drug of abuse) another psychiatric disorder, or a general medical condition (e.g.head trauma) As clinical diagnoses, they are coded in DSM system on axis II - to separate them from major mental disorders which are coded on axis I Groups Groups - by by the the similarity similarity ( clusters clusters) ) of of symptoms symptoms Cluster Cluster A - paranoid paranoid, , schizoid schizoid, , schizotypal schizotypal are are characterized characterized as as odd odd and and excentric excentricgroup group Cluster Cluster B - narcissistic narcissistic, , borderline borderline, , hystrio hystrio- nic nic and and antisocial antisocial are are characterized characterized as as dramatic dramatic, , emotional emotional , , erratic erraticgroup group Cluster Cluster C - obsessive obsessive- compulsive compulsive, , avoidant avoidant , , dependent dependent PD PD- s s are are characterized characterized as as anxious anxious and and fearful fearfulgroup group DSM-IV-TR Personality Disorders Cluster A personality disorders: Paranoid personality disorder Schizoid personality disorder Schizotypal personality disorder Cluster B personality disorders: Antisocial personality disorder Borderline personality disorder Histrionic personality disorder Narcissistic personality disorder Cluster C personality disorders: Avoidant personality disorder Dependent personality disorder Obsessive-compulsive personality disorder Personality disorder not otherwise specified Personality change due to a general medical condition Some Some epidemiological epidemiological data data PD PD’s lifetime lifetime prevalence prevalence is is about about 10 10– 15 % 15 % ( Andreasen Andreasen) Borderline Borderline PD is PD is found found in in approx approx. 2.5% . 2.5% of of gen.population gen.population in in 10% 10% of of psych psych outpatients outpatients in in 15 15- 20% 20% of of psych psych inpatients inpatients Borderlines Borderlines account account for for about about 50% 50% of of all all persons persons with with PDs PDs Tipically Tipically starts starts in in adolescence adolescence

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    PERSONALITY PERSONALITY DISORDERSDISORDERS

    Dept.ofDept.of PsychiatryPsychiatry andandPsychotherapyPsychotherapy, P, Péécscs

    http://psychiatry.pote.huhttp://psychiatry.pote.hu

    PERSONALITY DISORDERS:PERSONALITY DISORDERS:

    EncompassEncompass impairmentsimpairments inin personalitypersonality((i.e.characteri.e.character traitstraits) ) thatthat areare maladaptivemaladaptive, , pervasivepervasive, , inflexibleinflexible andand enduringenduring

    TheseThese impairmentsimpairments start start inin earlyearly childchild--hoodhood oror adolescenceadolescence andand notnot areare causedcausedbyby otherother psychiatricpsychiatric oror medicalmedical disorderdisorder

    The enduring pattern leads to clinically significant distress or impairment in social, occu-pational, or other important areas of functioning.

    A behaviour or traits that are stable and of long duration, its onset can be traced back at least to adolescence or early adulthood

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

    As clinical diagnoses, they are coded in DSM system on axis II - to separate them from major mental disorders which are coded on axis I

    GroupsGroups -- byby thethe similaritysimilarity ((clustersclusters) ) ofofsymptomssymptoms

    ClusterCluster AA -- paranoidparanoid, , schizoidschizoid, , schizotypalschizotypalareare characterizedcharacterized asas „„ oddodd andandexcentricexcentric ”” groupgroup

    ClusterCluster BB -- narcissisticnarcissistic, , borderlineborderline, , hystriohystrio--nicnic andand antisocialantisocial areare characterizedcharacterized asas„„dramaticdramatic , , emotionalemotional , , erraticerratic ”” groupgroup

    ClusterCluster CC -- obsessiveobsessive--compulsivecompulsive, , avoidantavoidant, , dependentdependent PDPD--s s areare characterizedcharacterized asas„„anxiousanxious andand fearfulfearful ”” groupgroup

    DSM-IV-TR Personality Disorders

    Cluster A personality disorders:

    Paranoid personality disorder

    Schizoid personality disorder

    Schizotypal personality disorder

    Cluster B personality disorders:

    Antisocial personality disorder

    Borderline personality disorder

    Histrionic personality disorder

    Narcissistic personality disorder

    Cluster C personality disorders:

    Avoidant personality disorder

    Dependent personality disorder

    Obsessive-compulsive personality disorder

    Personality disorder not otherwise specified

    Personality change due to a general medical condition

    SomeSome epidemiologicalepidemiological datadata

    PDPD’’ss lifetimelifetime prevalenceprevalence is is aboutabout 1010–– 15 % 15 % ((AndreasenAndreasen))

    BorderlineBorderline PD is PD is foundfoundinin approxapprox. 2.5% . 2.5% ofof gen.populationgen.populationinin 10% 10% ofof psychpsych outpatientsoutpatientsinin 1515--20% 20% ofof psychpsych inpatientsinpatients

    BorderlinesBorderlines accountaccount forfor aboutabout 50% 50% ofof allall personspersonswithwith PDsPDs

    TipicallyTipically startsstarts inin adolescenceadolescence

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    DSM IV DSM IV diagnosticdiagnostic criteriacriteria

    AnAn enduringenduring patternpattern ofof innerinner experienceexperienceandand behaviorbehavior thatthat deviatesdeviates markedlymarkedly fromfromthethe expectationsexpectations ofof thethe individualindividual’’ss cultureculture

    ThisThis patternpattern is is manifestedmanifested inin::

    cognitioncognition ((waysways ofof perceivingperceiving andandinterpretinginterpreting selfself, , otherother peoplepeople andand eventsevents

    affectivityaffectivity ((rangerange, , intensityintensity, , labilitylability ofofemottionalemottional responerespone

    impulseimpulse controlcontrol

    interpersonalinterpersonal functioningfunctioning

    EtiologicalEtiological FormulationsFormulationsHistoricalHistorical considerationsconsiderations ::

    The The termterm borderlineborderline reflectsreflects anan earlyearly categorizationcategorization ofofpatientspatients whowho werewere felt felt toto be be onon thethe borderborder betweenbetweenneurosisneurosis andand psychosispsychosis ((possiblypossibly schizophreniaschizophrenia).).

    BiologicalBiological considerationsconsiderations ::

    MoodMood disordersdisorders maymay playplay anan etiologicaletiological rolerole, , asasevidencedevidenced byby a a highhigh comorbiditycomorbidity withwith depressiondepression, , increasedincreased prevalenceprevalence ofof major (major (butbut notnot bipolarbipolar) ) depressiondepression inin relativesrelatives, EEG, EEG ((electroencephalographicelectroencephalographic) ) patternspatterns similarsimilar toto thosethose foundfound inin depresseddepressed individualsindividuals, , andand similarsimilar responseresponse patternspatterns toto somesome ((butbut notnot allall) ) antidepressantsantidepressants..

    ::

    ETIOLOGICAL FORMULATIONS IIETIOLOGICAL FORMULATIONS II

    Genetic formulations:Genetic formulations:A genetic predisposition has been implicated. A genetic predisposition has been implicated. Some Some PDsPDs are more prevalent are more prevalent

    in monozygotic twins than in in monozygotic twins than in dizygoticdizygotic twinstwins..The The Cluster A grouping of Cluster A grouping of PDsPDs (paranoid, schizoid, (paranoid, schizoid, schizotypalschizotypal) may) may hhaveave aa

    genetic link to schizophreniagenetic link to schizophrenia. Present as the . Present as the prodromalprodromal phase for phase for schizophrenia.schizophrenia.

    Family members of schizophrenicFamily members of schizophrenic patients are more likely to present with patients are more likely to present with paranoid and paranoid and schizoid schizoid PDsPDs..

    Childhood factors:Childhood factors:An increased prevalence of An increased prevalence of childhood CNS dysfunctionchildhood CNS dysfunction (e.g., head injury) is (e.g., head injury) is

    found in persons with antisocial and borderline found in persons with antisocial and borderline PDsPDs..Children with Children with attentionattention--deflcitdeflcit/hyperactivity/hyperactivity disorder are at greater risk of disorder are at greater risk of

    developing antisocial PD.developing antisocial PD.Females with a Females with a history of sex abuse are at greater risk of developing history of sex abuse are at greater risk of developing

    borderline PDborderline PD

    EndocrinologicalEndocrinological formulations:formulations:Impulsive traitsImpulsive traits in persons with antisocial PD linked to higher levels of in persons with antisocial PD linked to higher levels of

    testosterone. Thyroidtestosterone. Thyroid dysfunction is more common in individualsdysfunction is more common in individuals

    OtherOther biologicalbiological andand psychosocialpsychosocialformulationsformulations ((especiallyespecially BPD)BPD)

    Neurotransmitter formulations:Neurotransmitter formulations:ChangingChanging levelslevels ofof serotoninserotonin maymay influenceinfluence personalitypersonalitytraitstraits, , depressiondepression, , impulsivityimpulsivity, , aggressionaggressionLowLow levellevel ofof serotoninserotonin maymay predisposepredispose toto borderlineborderline PDPD

    Trauma Trauma hypothesishypothesis ::ThereThere areare pathologicalpathological similaritiessimilarities inin earlyearly childhoodchildhoodtraumastraumas thatthat lead lead toto thethe developmentdevelopment ofof borderlineborderline PD PD andand PTSDPTSD (e.g., (e.g., childhoodchildhood physicalphysical andand sexualsexual abuseabuseissuesissues ))

    PatientsPatients withwith PDsPDs cancan be be characterizedcharacterized byby theirtheirmost most dominantdominant defensedefense mechanismsmechanisms((maturemature oror archaicarchaic ))

    SplittingSplitting::PeoplePeople areare seenseen asas eithereither allall goodgood oror allall badbad, , withwith frequentfrequentshiftsshifts betweenbetween thesethese twotwo idealizationsidealizations. . ThereThere is a is a diminisheddiminishedabilityability toto viewview peoplepeople inin shadesshades ofof graygray (i.e., a (i.e., a mixturemixture ofof goodgoodandand badbad qualitiesqualities). ). OftenOften, , thethe patientpatient withwith borderlineborderline PD PD likeslikesoror dislikesdislikes anan individualindividual basedbased onon thethe patient'spatient's assessmentassessment ofofhishis oror herher lastlast encounterencounter withwith thethe personperson..

    ProjectiveProjective identificationidentification::IntolerableIntolerable aspectsaspects oror feelingsfeelings ofof selfself areare projected projected ontoontoothersothers, , andand thethe otherother personperson is is inducedinduced toto fulfillfulfill thatthat rolerole. . IfIfsuchsuch projection is projection is successfulsuccessful, , thethe patientpatient andand thethe otherother personperson""feelfeel asas oneone."."

    DeniaDeniall——denial of the existence of painful thoughts.denial of the existence of painful thoughts.MagicalMagical thinkingthinking::

    The The beliefbelief thatthat thoughtsthoughts cancan causecause eventsevents toto occuroccur..

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    DSMDSM--IV criteria for schizoid personality IV criteria for schizoid personality disordedisorder r „„AA”” clustercluster

    A. A. A pervasive A pervasive pattern of detachment from social relationshipspattern of detachment from social relationships and a and a restricted range ofrestricted range of expression of emotions in interpersonal settingsexpression of emotions in interpersonal settings, , beginning by early adulthood andbeginning by early adulthood and present in a variety of contexts, present in a variety of contexts, as indicated by four (or more) of the following:as indicated by four (or more) of the following:Neither desires Neither desires nor enjoys close relationshipsnor enjoys close relationships, including being part , including being part of a familyof a familyAlmost always chooses Almost always chooses solitary activitiessolitary activitiesHas Has little, if any, interest in having sexuallittle, if any, interest in having sexual experiences with another experiences with another personpersonTakes Takes pleasure in few, if any, activitiespleasure in few, if any, activitiesLacks close friends or confidants other than firstLacks close friends or confidants other than first--degree relativesdegree relativesAppears indifferent to the praise or criticism of othersAppears indifferent to the praise or criticism of othersShows Shows emotional coldness, detachmentemotional coldness, detachment , or flattened affectivity, or flattened affectivity

    B.B. Does Does not occur exclusively during the course of schizophrenianot occur exclusively during the course of schizophrenia, a mood , a mood disorder withdisorder with psychotic features, psychotic features, another psychoticanother psychotic disorder, or a disorder, or a pervasive developmental disorder,pervasive developmental disorder, and is not due to the direct and is not due to the direct physiological effects of a physiological effects of a general medicalgeneral medical condition.condition.

    DSMDSM--IV criteria for paranoid personality disorderIV criteria for paranoid personality disorder„„AA”” clustercluster

    A.A. A A pervasive distrust and suspiciousness of otherspervasive distrust and suspiciousness of others such that their motives are such that their motives are interpreted as malevolent, beginning by early adulthood are presinterpreted as malevolent, beginning by early adulthood are present in a variety of ent in a variety of contexts, as indicated by four (or more) of the following:contexts, as indicated by four (or more) of the following:

    1.Suspects, without sufficient basis, that 1.Suspects, without sufficient basis, that others are exploitingothers are exploiting or deceiving him or heror deceiving him or her2.Is preoccupied with unjustified 2.Is preoccupied with unjustified doubts about the loyalty or trustworthinessdoubts about the loyalty or trustworthiness of friendsof friendsor associatesor associates3.Is reluctant to confide in others because of 3.Is reluctant to confide in others because of unwarranted fearunwarranted fear that the information that the information willwill be used maliciously against him or herbe used maliciously against him or her4.Reads hidden demeaning or threatening meanings into benign rem4.Reads hidden demeaning or threatening meanings into benign remarks or eventsarks or events5.Persistently bears grudges, i.e., is unforgiving of insults, i5.Persistently bears grudges, i.e., is unforgiving of insults, injuries, or slightsnjuries, or slights6.Perceives attacks on his or her character6.Perceives attacks on his or her character or reputation that are not apparent to or reputation that are not apparent to othersothers and is quick to react angrily or to counterattackand is quick to react angrily or to counterattack7.Has recurrent 7.Has recurrent suspicions, without justification, regarding fidelity of spouse suspicions, without justification, regarding fidelity of spouse or sexualor sexualpartnerpartner

    B.B. Does Does not occur exclusively during the course of schizophrenia, a moodnot occur exclusively during the course of schizophrenia, a mood disorder withdisorder withpsychotic features, or psychotic features, or another psychoticanother psychotic disorder, and is not due to the directdisorder, and is not due to the directphysiological effects of a physiological effects of a general medicalgeneral medical condition.condition.

    DSMDSM--IV criteria for IV criteria for schizotypalschizotypal personality disorderpersonality disorder„„AA”” clustercluster

    A.A. A pervasive pattern of social and interpersonal deficits marked A pervasive pattern of social and interpersonal deficits marked by acute discomfort by acute discomfort with,and with,and reduced capacity for close relationships as well as by cognitivreduced capacity for close relationships as well as by cognitive ore orperceptualperceptual distortions and eccentricities of behaviordistortions and eccentricities of behavior , beginning by early adult , beginning by early adult hood and present in a variety of contexts, as indicated by five hood and present in a variety of contexts, as indicated by five (or more) of the (or more) of the following:following:

    Ideas of referenceIdeas of reference (excluding delusions of reference)(excluding delusions of reference)Odd beliefs or magical thinkingOdd beliefs or magical thinking that influences behavior and is inconsistent withthat influences behavior and is inconsistent withsubculturalsubcultural norms (e.g., norms (e.g., superstitiousnesssuperstitiousness, belief in clairvoyance, telepathy, or , belief in clairvoyance, telepathy, or "sixth"sixth sense"; in children and adolescents, bizarre fantasies or preoccsense"; in children and adolescents, bizarre fantasies or preoccupations)upations)Unusual perceptual experiencesUnusual perceptual experiences , including bodily illusions, including bodily illusionsOdd thinking and speechOdd thinking and speech (e.g., vague, circumstantial, metaphorical, (e.g., vague, circumstantial, metaphorical, overelaborateoverelaborate,,or stereotyped)or stereotyped)Suspiciousness Suspiciousness or paranoid ideationor paranoid ideationInappropriate or constructed affectInappropriate or constructed affectBehavior or appearance that Behavior or appearance that is odd, eccentric, or peculiaris odd, eccentric, or peculiarLack of close friends or confidants other than firstLack of close friends or confidants other than first--degree relativesdegree relativesExcessive Excessive social anxiety thatsocial anxiety that does not diminish with familiarity and tends to bedoes not diminish with familiarity and tends to beassociated with paranoid fears rather than negative judgments abassociated with paranoid fears rather than negative judgments about selfout self

    B.B. Does Does not occur exclusively during the course of schizophrenia, a moodnot occur exclusively during the course of schizophrenia, a mood disorderdisorderwith psychotic features, with psychotic features, another psychoticanother psychotic disorder,pervasive development.disorder,pervasive development. DisordDisord..

    DSMDSM--IV criteria for histrionic personality disorder IV criteria for histrionic personality disorder ““BB”” clustercluster

    A pervasive pattern of A pervasive pattern of excessive emotionality and attention excessive emotionality and attention seekingseeking , beginning by early adulthood and present in a variety , beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following:of contexts, as indicated by five (or more) of the following:

    1.1. Is uncomfortable in situations in which he or she is not the Is uncomfortable in situations in which he or she is not the center center of attentionof attention

    2.2. Interaction with others is often characterized Interaction with others is often characterized by inappropriate by inappropriate sexually seductive orsexually seductive or provocative behaviorprovocative behavior

    3.3. Displays Displays rapidly shifting and shallow expression of emotionsrapidly shifting and shallow expression of emotions4.4. Consistently Consistently uses physical appearance to draw attention to selfuses physical appearance to draw attention to self5.5. Has a style of speech that is excessively impressionistic and Has a style of speech that is excessively impressionistic and

    lacking in detaillacking in detail6.6. Shows Shows selfself --dramatization, theatricalitydramatization, theatricality , and exaggerated , and exaggerated

    expression of emotionexpression of emotion7.7. Is Is suggestible, i.esuggestible, i.e ., easily influenced by others or circumstances., easily influenced by others or circumstances8.8. Considers relationships to be more intimate than they actually aConsiders relationships to be more intimate than they actually arere

    DSMDSM--IV criteria for narcissistic personality disorderIV criteria for narcissistic personality disorder„„BB”” clustercluster

    A pervasive A pervasive pattern of grandiosity (in fantasy or behavior), need for admirapattern of grandiosity (in fantasy or behavior), need for admirationtion, , and and lack of empathylack of empathy, beginning by early adulthood and present in a variety , beginning by early adulthood and present in a variety of contexts, as indicated by the following:of contexts, as indicated by the following:

    1.1. Has a grandiose Has a grandiose sense of selfsense of self--importanceimportance (e.g., exaggerates achievements (e.g., exaggerates achievements and talents,and talents, expects to be recognized as superior without achievements)expects to be recognized as superior without achievements)

    2.2. IIs preoccupied with s preoccupied with fantasies of unlimited success, powerfantasies of unlimited success, power, brilliance, beauty, , brilliance, beauty, or ideal loveor ideal love

    3.3. Believes that he or she Believes that he or she is "special" and unique andis "special" and unique and can only be understood can only be understood by, or should associate with, other special or highby, or should associate with, other special or high--status people (or status people (or institutions)institutions)

    4.4. Requires excessive admirationRequires excessive admiration5.5. Has a sense of entitlement, i.e., Has a sense of entitlement, i.e., unreasonable expectationsunreasonable expectations of especially of especially

    favorable treatment or automatic compliance with his or her expefavorable treatment or automatic compliance with his or her expectationsctations6.6. Is Is interpersonally exploitativeinterpersonally exploitative, i.e., takes advantage of others to achieve his , i.e., takes advantage of others to achieve his

    or her ownor her own endsends7.7. Lack of empathy:Lack of empathy: unwilling to recognize or identify with the feelings and unwilling to recognize or identify with the feelings and

    needs of othersneeds of others8.8. Is often Is often envious of othersenvious of others or believes that others are envious of him or heror believes that others are envious of him or her9.9. Shows arrogantShows arrogant, haughty behaviors or attitudes, haughty behaviors or attitudes

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    DSMDSM--IV criteria for borderline IV criteria for borderline personality disorder personality disorder ““BB”” clustercluster

    A pervasive pattern of A pervasive pattern of instability of interpersonalinstability of interpersonalrelationships, selfrelationships, self--image, and affectsimage, and affects, and marked , and marked impulsivityimpulsivity beginning by early adulthood and present beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) in a variety of contexts, as indicated by five (or more) of the following:of the following:-- Efforts to avoid real or imagined Efforts to avoid real or imagined abandonment.abandonment.-- A pattern of A pattern of unstable and intense interpersonalunstable and intense interpersonalrelationships characterized byrelationships characterized by alternating between alternating between extremes of idealization and devaluationextremes of idealization and devaluation-- Identity disturbanceIdentity disturbance: persistent and markedly : persistent and markedly disturdistur--bed, distorted, or unstablebed, distorted, or unstable selfself--image or sense of selfimage or sense of self-- ImpulsivityImpulsivity in at least two areas that are potentially in at least two areas that are potentially selfself--damagingdamaging (e.g.sex,(e.g.sex, substance abuse, reckless substance abuse, reckless driving, binge eating).driving, binge eating).

    -- Recurrent suicidalRecurrent suicidal behavior, gestures, or threats, behavior, gestures, or threats, or selfor self--mutilating behaviormutilating behavior-- Affective instabilityAffective instability due to a marked reactivity of due to a marked reactivity of mood (e.g., intense episodic mood (e.g., intense episodic dysphoriadysphoria,, irritability, or irritability, or anxiety usually lasting a few hours and only rarely anxiety usually lasting a few hours and only rarely more than a few days)more than a few days)-- Chronic feelings of Chronic feelings of emptinessemptiness-- Inappropriate, Inappropriate, intense anger or lack of controlintense anger or lack of control of of anger (e.g., frequent displays ofanger (e.g., frequent displays of temper, constant temper, constant anger, recurrent physical fights)anger, recurrent physical fights)-- Transient, Transient, stressstress--related paranoidrelated paranoid ideation or ideation or severe severe dissociativedissociative symptomssymptoms

    DSMDSM--IV criteria for obsessiveIV criteria for obsessive--compulsive compulsive personality disorderpersonality disorder

    A pervasive pattern of A pervasive pattern of preoccupation with orderliness, preoccupation with orderliness, perfectionism, and mental and interpersonal controlperfectionism, and mental and interpersonal control , at , at the expense of flexibility, openness, and efficiency, beginning the expense of flexibility, openness, and efficiency, beginning by early adulthood and present in a variety of contexts, as by early adulthood and present in a variety of contexts, as indicated by four (or more) of the following:indicated by four (or more) of the following:

    --Is Is preoccupied with details, rules, lists, orderpreoccupied with details, rules, lists, order , , organization, or schedules to the extentorganization, or schedules to the extent that the major point that the major point of the activity is lostof the activity is lost

    --Shows Shows perfectionism that interferes with task perfectionism that interferes with task completioncompletion (e.g., is unable to complete a(e.g., is unable to complete a project because his project because his or her own overly strict standards are not met)or her own overly strict standards are not met)

    --Is Is excessively devoted to workexcessively devoted to work and productivity to the and productivity to the exclusion of leisure activities andexclusion of leisure activities and friendshipsfriendships

    -- Is Is overconscientiousoverconscientious, , scrupulous, and inflexiblescrupulous, and inflexibleabout matters of morality, ethics, orabout matters of morality, ethics, or values (not values (not accounted for by cultural or religious identification)accounted for by cultural or religious identification)

    -- Is unable to discard wornIs unable to discard worn--out or worthless objects out or worthless objects even when they have no sentimentaleven when they have no sentimental valuevalue

    -- Is Is reluctant to delegate tasksreluctant to delegate tasks or to work with others or to work with others unless they submit to exactly his orunless they submit to exactly his or her way of doing her way of doing thingsthings-- Shows Shows rigidity and stubbornnessrigidity and stubbornness

    DSMDSM--IV criteria for avoidant personality IV criteria for avoidant personality disorderdisorder

    A pervasive pattern of A pervasive pattern of social inhibition, feelings of inadequacysocial inhibition, feelings of inadequacy , and, andhypersensitivity to negative evaluation, beginning by early adulhypersensitivity to negative evaluation, beginning by early adulthood thood andand present in a variety of contexts, as indicated by four (or more)present in a variety of contexts, as indicated by four (or more) of of thethe following:following:

    1.1. Avoids occupational activities that involve significant interperAvoids occupational activities that involve significant interpersonalsonalcontact because ofcontact because of fears of criticism, disapproval, or rejectionfears of criticism, disapproval, or rejection

    2.2. Is unwilling to get involved with people unless certain of beingIs unwilling to get involved with people unless certain of being likedliked3.3. Shows Shows restraint within intimate relationshipsrestraint within intimate relationships because of the fear because of the fear

    ofof being shamed orbeing shamed or ridiculedridiculed4.4. Is Is preoccupied withpreoccupied with being criticized or rejectedbeing criticized or rejected in social situationsin social situations5.5. Is inhibited in new interpersonal situations because of feelingsIs inhibited in new interpersonal situations because of feelings of of

    inadequacyinadequacy6.6. Views self as socially inept, personally unappealing, or inferioViews self as socially inept, personally unappealing, or inferior to r to

    othersothers7.7. Is unusually Is unusually reluctant to take personal risksreluctant to take personal risks or to engage in any new or to engage in any new

    activities becauseactivities because they may prove embarrassingthey may prove embarrassing

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    DSMDSM--IV criteria for dependent personality IV criteria for dependent personality

    disorderdisorderA pervasive and A pervasive and excessive need to be taken care ofexcessive need to be taken care of , leading to submissive , leading to submissive

    and clinging behavior and and clinging behavior and fears of separationfears of separation , beginning by early , beginning by early adulthood and present in a variety of contexts, as indicated by adulthood and present in a variety of contexts, as indicated by the following:the following:

    1.1. Is Is unable to make everyday decisionsunable to make everyday decisions without an excessive amount of without an excessive amount of advice and reassurance from othersadvice and reassurance from others

    2.2. Needs others to assume responsibilityNeeds others to assume responsibility for most major areas of his or her lifefor most major areas of his or her life3.3. Has Has difficulty expressing disagreementdifficulty expressing disagreement with others because of fear of loss of with others because of fear of loss of

    support ofsupport of approval. approval. 4.4. Has difficulty initiating projects or doing things on his or herHas difficulty initiating projects or doing things on his or her own (because of own (because of

    a lack of selfa lack of self--confidence in judgment or abilities rather than a lack of confidence in judgment or abilities rather than a lack of motivation or energy)motivation or energy)

    5.5. Goes to excessive lengths to obtain nurturance and support from Goes to excessive lengths to obtain nurturance and support from others, to others, to the point ofthe point of volunteering to do things that are unpleasantvolunteering to do things that are unpleasant

    6.6. Feels uncomfortable or Feels uncomfortable or helpless when alonehelpless when alone because of exaggerated fears because of exaggerated fears of being unable to care for himself or herselfof being unable to care for himself or herself

    7.7. Urgently seeks another relationship as a source of care and suppUrgently seeks another relationship as a source of care and support when a ort when a close relationship endsclose relationship ends

    8.8. Is Is unrealistically preoccupied with fears of being left to take carunrealistically preoccupied with fears of being left to take care of himselfe of himselfor herselfor herself

    GeneralGeneral principlesprinciples ofof therapytherapy

    GenerallyGenerally outpatientoutpatient therapytherapy

    PsychiatricPsychiatric hospitalisationhospitalisation neededneeded::–– SeriousSerious functionalfunctional damagedamage ((comorbiditycomorbidity!)!)–– BehaviouralBehavioural disturbancedisturbance–– TransientTransient psychoticpsychotic statestate–– SeriousSerious suicidesuicide ideationideation

    combinationcombination ofof pharmacopharmaco-- andandpsychotherapypsychotherapy

    FollowFollow upup -- carecare

    GeneralGeneral recommendationsrecommendations

    SomeSome patientspatients withwith PDsPDs cancan be be difficultdifficultandand manipulativemanipulative

    a a longlong termterm therapytherapy

    maintainmaintain professionalprofessional distancedistance ((avoidavoidoverinvolvementoverinvolvement) ) -- countertransferencecountertransference!!

    EstablishEstablish groundground rulesrules, , setset limitslimits

    AvoidAvoid phantasiesphantasies ofof becomingbecoming a a „„saviorsavior”” ofofthethe patientpatient

    SeekSeek supportsupport forfor yourselfyourself fromfrom peerspeers ororsupervisorssupervisors

    POSSIBILITIES OF THE GENERAL DRUG POSSIBILITIES OF THE GENERAL DRUG THERAPYTHERAPY

    BENZODIAZEPINESBENZODIAZEPINES

    SEROTONERGIC (5SEROTONERGIC (5--HTHT1A1A) RECEPTOR ) RECEPTOR PARTIAL AGONISTSPARTIAL AGONISTS

    ANTIDEPRESSANTSANTIDEPRESSANTS

    MOOD STABILIZERSMOOD STABILIZERS

    ANTIPSYCOTICSANTIPSYCOTICS

    ANTIDEPRESSIVE , ANTIPSYCHOTIC DRUGS, ANTIDEPRESSIVE , ANTIPSYCHOTIC DRUGS, MOOD STABILIZERSMOOD STABILIZERS

    SSRI SSRI -- citalopramcitalopram, , paroxetinparoxetin, , fluoxetinfluoxetin, , sertalinsertalin, , fluvoxaminfluvoxamin,,

    SNRI SNRI -- venlafaxinvenlafaxinNaSSaNaSSa –– mirtazapinmirtazapin

    AtypicalAtypical APsAPs –– risperidonrisperidon, , olanzapinolanzapin, , ziprasidonziprasidon

    MoodMood stabstab..-- carbamazepincarbamazepin, , valproicvalproic acidacid, , lithiumlithium, , lamotriginlamotrigin

    PSYCHOTERAPEUTIC THERAPIESPSYCHOTERAPEUTIC THERAPIES

    SupportiveSupportive ((problemproblem solvingsolving psychotherapypsychotherapy))

    cognitivecognitive andand behaviouralbehavioural therapiestherapies ((correctingcorrecting

    falsefalse schemasschemas andand cognitivecognitive distortionsdistortions, ,

    dysfunctionaldysfunctional attitudesattitudes))

    psychodynamicpsychodynamic psychoterapiespsychoterapies workingworking throughthrough

    unconsciousunconscious conflictsconflicts ((interpretativeinterpretative, , confrontativeconfrontative))

    GroupGroup terapiesterapies, , familyfamily therapiestherapies ((maymay helphelp toto

    dilutedilute transferencetransference))

  • 6

    TreatmentTreatment -- BLsBLs

    PsychotherapyPsychotherapy((thethe cornerstonecornerstone ofof treatmenttreatment forfor borderlineborderline PD): PD): PatientsPatients withwith borderlineborderline PD PD areare a a challengechallenge toto treattreat. . PatientsPatients areare veryvery willingwilling toto be be treatedtreated andand readilyreadilyattachattach toto thethe therapist.Thereforetherapist.Therefore highhigh percentagepercentage ofofpatientspatients withwith borderlineborderline PD PD areare seenseen inin bothbothoutpatientoutpatient andand inpatientinpatient psychiatricpsychiatric settingssettings..

    MaintainMaintain honestyhonesty, , reliabilityreliability, , andand a a professionalprofessionaldemeanordemeanor andand insistinsist onon limit limit settingsetting. . MaintainMaintainobjectivityobjectivity toto protectprotect againstagainst developingdeveloping a a personalpersonaloror overlyoverly attachedattached relationshiprelationship withwith thethe patientpatient..

    IndividualIndividual ((usuallyusually supportivesupportive, , ororpsychodynamicpsychodynamic) ) -- interpretativeinterpretative, , confrontationalconfrontational) ) therapytherapy

    groupgroup andand, , ifif appropriateappropriate, , familyfamily therapytherapy cancan be be helpfulhelpful::

    CognitiveCognitive --behavioralbehavioral therapytherapy ..DialecticalDialectical behaviorbehavior therapytherapy (DBT)(DBT)——a a psychosocialpsychosocialtreatmenttreatment forfor borderlineborderline PD PD thatthat is is becomingbecoming ananacceptedaccepted ((ifif notnot expectedexpected) ) treatmenttreatment inin conjunctionconjunctionwithwith otherother typestypes ofof psychotherapypsychotherapy. . DBT DBT involvesinvolvesfundamentalfundamental skillsskills trainingtraining, , teachesteaches patientspatients totoimproveimprove copingcoping skillsskills, , andand helpshelps patientspatients learnlearn totoappropriatelyappropriately managemanage angeranger andand toto toleratetolerate stressstress

    HospitalizationHospitalization::

    ConsiderConsider shortshort --termterm hospitalizationhospitalization forfor a a lifelife --threateningthreatening crisiscrisis , a , a transienttransient psychoticpsychotic episodeepisode , a , a relapserelapse intointo drugdrug abuseabuse , , persistentpersistent depressivedepressivesymptomssymptoms , , oror a a severesevere transferencetransference reactionreaction duringduringoutpatientoutpatient treatmenttreatment ..

    TryTry toto avoidavoid hospitalizationhospitalization whenwhen itit representsrepresents a a repeatrepeatofof a a treatmenttreatment thatthat has has repeatedlyrepeatedly failedfailed oror whenwhen thethepatientpatient is is malingeringmalingering (e.g., (e.g., toto avoidavoid legallegalconsequencesconsequences , , toto stop a stop a loverlover fromfrom leavingleaving ). ). HoweverHowever , , suicidalsuicidal threatsthreats must be must be takentaken seriouslyseriously ..

    WardWard managementmanagement ::MaintainMaintain closeclose communicationcommunication betweenbetween staffstaff toto avoidavoid

    splittingsplitting ((propensitypropensity ofof patientspatients withwith borderlineborderline PD PD totodividedivide staffstaff intointo thosethose whowho stronglystrongly defensedefense ..