PERSONALITY DISORDERS

ESSENTIALS OF DIAGNOSIS

• Long history dating back to childhood.
• Recurrent maladaptive behavior.
• Low self-esteem.
• Minimal introspective ability with a tendency to blame others for all problems.
• Major difficulties with interpersonal relationships or society.
• Depression with anxiety when maladaptive behavior fails.

General Considerations

1. An individual’s personality structure, or character, is an integral part of self-image.
2. It reflects genetics, interpersonal influences, and recurring patterns of behavior adopted to cope with the environment.
3. The classification of subtypes of personality disorders depends on the predominant symptoms and their severity.
4. The most severe disorders that bring the patient into the greatest conflict with society tend to be classified as antisocial psychopathic)or borderline.
5. Personality disorders can be considered a matrix for some of the more severe psychiatric problems (eg,schizo-typal, relating to schizophrenia, and avoidance types, relating to some anxiety disorders).

Classification&Clinical FindingsSee Table (IMAGE) Next page

Differential Diagnosis

1. Patients with personality disorders tend to show anxiety and depression when pathologic coping mechanisms fail, and their symptoms can be similar to those disorders.
2. Occasionally, the more severe cases may decompensate into psychosis under stress and mimic other psychotic disorders.

Treatment

• Social and therapeutic environments such as day hospitals, halfway houses, and self-help communities utilize peer pressures to modify self-destructive behavior.
• The patient with a personality disorder often has failed to profit from experience, and difficulties with authority impair the learning experience.
• The use of peer relationships and the repetition possible in a structured setting of a helpful community enhance the behavioral treatment opportunities and increase learning.
• When problems are detected early, both the school and the home can serve as foci of intensified social pressure to change the behavior, particularly with the use of behavioral techniques.

B.Behavioral

• The behavioral techniques used are principally operant conditioning and aversive conditioning.
• The former simply emphasizes the recognition of acceptable behavior and its reinforcement with praise or other tangible rewards.
• Assertive responses usually mean punishment, although this can range from a mild rebuke to some specific punitive responses such as deprivation of privileges.
• Extinction plays a role in that an attempt is made not to respond to inappropriate behavior, and the lack of response eventually causes the person to abandon that type of behavior.
• Pouting and tantrums, for example, diminish quickly when such behavior elicits no reaction.
• Dialectical behavioral therapy is a program of individual and group therapy specifically designed for patients with chronic suicidality and borderline personality disorder.
• It blends mindfulness and a cognitive-behavioral model to address self-awareness, interpersonal functioning, affective lability, and reactions to stress.

C.Psychological

• Psychological intervention is best conducted in group settings. Group therapy is helpful when specific interpersonal behavior needs to be improved.
• This mode of treatment also has a place with so-called “acting-out” patients, ie, those who frequently act impulsively and inappropriately.
• The peer pressure in the group tends to impose restraints on rash behavior.
• The group also quickly identifies the patient’s types of behavior and helps improve the validity of the patient’s self-assessment.
• so that the antecedents of the unacceptable behavior can be effectively handled, thus decreasing its frequency
• Individual therapy should initially be supportive, ie, helping the patient to restabilize and mobilize coping mechanisms.
• If the individual can observe his or her behavior, a longer-term and more introspective therapy may be warranted.
• The therapist must be able to handle countertransference feelings(which are frequently negative), maintain appropriate boundaries in the relationship（no physical contacts, however well-meaning), and refrain from premature confrontations and interpretations

D.Medical

1. Hospitalization is indicated in the case of serious suicidal or homicidal danger.
2. In most cases, treatment can be accomplished in the day treatment center or self-help community.
3. Antidepressants have improved anxiety, depression, and sensitivity to rejection in some patients with a borderline personality disorder.
4. SSRIs also have a role in reducing aggressive behavior in impulsive aggressive patients(eg, fluoxetine 20-60 mg orally daily or sertraline 50-200 mg orally daily)
5. Antipsychotics may be helpful in targeting hostility,agitation,and as adjuncts to antidepressant therapy(eg,olanzapine [2.5-10 mg/d orally,risperidone [0.5-2 mg/d orally,or haloperidol [0.5-2 mg/orally,split into two doses])
6. In some cases, these medications are required only for several days and can be discontinued after the patient has regained a previously established
7. level of adjustment they can also provide ongoing support.
8. In other patients, carbamazepine,400-800 mg orally daily in divided doses, decrease the severity of behavioraldyscontrol

Prognosis

Antisocial and borderline categories generally have a guarded prognosis. Those patients with a history of parental abuse and a family history of mood disorder tend to have the most challenging treatments.

Reference

• Ingenhoven T et al.Effectiveness of pharmacotherapy for severe personality disorders: meta-analyses of randomized controlled trials.J Clin Psychiatry.2010 Jan;71(1):14-25.[PMID:19778496]
• Stoffers JM et al.Psychological therapies for people with a borderline personality disorder.Cochrane Database Syst Rev.2012 Aug 15;8:CD005652.[PMID:22895952]