Personality DisordersPersonality Disorders

Heidi Combs, MDHeidi Combs, MD

Objectives:Objectives:

• Describe why it is important to Describe why it is important to identify personality disorders identify personality disorders

• Understand the etiology of Understand the etiology of personality disorderspersonality disorders

• Identify screening questions for Identify screening questions for personality disorderspersonality disorders

• List the key features of each List the key features of each personality disorderpersonality disorder

Personality DisordersPersonality Disorders

• An enduring pattern of inner An enduring pattern of inner experience and behavior that experience and behavior that manifests in two or more of the manifests in two or more of the following: following: • cognition (i.e., ways of perceiving and cognition (i.e., ways of perceiving and

interpreting self and others); interpreting self and others); Affectivity (i.e., range, intensity, Affectivity (i.e., range, intensity, lability) ;Interpersonal functioning; lability) ;Interpersonal functioning; Impulse controlImpulse control

• The enduring pattern is inflexibleThe enduring pattern is inflexible• It leads to significant distress or It leads to significant distress or

impairment in functioning impairment in functioning • The pattern is stable and can be The pattern is stable and can be

traced back to adolescence or traced back to adolescence or early adulthoodearly adulthood

Why should you look for Why should you look for personality disorders?personality disorders?• They are common! Prevalence They are common! Prevalence

estimated between 6-13% of the adult estimated between 6-13% of the adult population in the United States has a population in the United States has a personality disorder!!personality disorder!!

• Recognizing personality disorders can Recognizing personality disorders can guide your approach to them guide your approach to them

• Identifying a personality disorder allows Identifying a personality disorder allows you to assess for comorbities including you to assess for comorbities including Axis I disorders and suicide riskAxis I disorders and suicide risk

Paris. J. 2010 Estimating the prevalence of personality disorders in Paris. J. 2010 Estimating the prevalence of personality disorders in the community. J personal dis, 24(4):405-411the community. J personal dis, 24(4):405-411

PrevalencePrevalence

• OCPD 2% OCPD 2% • Paranoid 2%Paranoid 2%• Antisocial 1-4%Antisocial 1-4%• Schizoid 1%?Schizoid 1%?• Schizotypical 1%Schizotypical 1%

• AvoidantAvoidant 1- 1-2%2%

• Histrionic 2%Histrionic 2%• Borderline 2-3%Borderline 2-3%• Dependent 0.5%Dependent 0.5%• Narcissistic .5-1%Narcissistic .5-1%

Torgerson, S.2009 The nature and nurture of personality disorders. Scan Torgerson, S.2009 The nature and nurture of personality disorders. Scan J psychol 50:624-632J psychol 50:624-632

Knowing how to approach Knowing how to approach these patients helps with:these patients helps with:

• understanding confusion about why understanding confusion about why patients do not act as you expect patients do not act as you expect them tothem to

• the emotional distress they can illicitthe emotional distress they can illicit• protecting you from inappropriate protecting you from inappropriate

relationships and engaging in relationships and engaging in medical practice outside your medical practice outside your standard of carestandard of care

EtiologyEtiology

• Likely multi-factorial like almost all Likely multi-factorial like almost all other psychiatric diagnoses. other psychiatric diagnoses.

• Genetic and environmental factors Genetic and environmental factors such as chaotic home environment such as chaotic home environment and abuse have been implicated in and abuse have been implicated in development of maladaptive development of maladaptive behavioral patterns. behavioral patterns.

Heritability of personality Heritability of personality disordersdisorders

Personality disorder Mean

Paranoid 0.34

Schizoid 0.43

Schizotypal 0.54

Antisocial 0.41

Borderline 0.61

Histrionic 0.59

Narcissistic 0.56

Avoidant 0.42

Dependent 0.56

Obsessive-compulsive 0.60

Torgerson, S, et al 2000 A twin study of personality disorders. Comp psych 41:416-425Torgerson, S, et al 2000 A twin study of personality disorders. Comp psych 41:416-425Coolidge F et al. 2001 Heritability of personality disorders in childhood: A preliminary investigation. J person dis 15:33-40Coolidge F et al. 2001 Heritability of personality disorders in childhood: A preliminary investigation. J person dis 15:33-40

Genetics of PD cont.Genetics of PD cont.

• For comparison heritability of For comparison heritability of normal personality traits is normal personality traits is approximately 0.5approximately 0.5

• Molecular genetics studies of PDs Molecular genetics studies of PDs indicate that genes linked to indicate that genes linked to neurotransmitter pathways, neurotransmitter pathways, particularly the serotonergic and particularly the serotonergic and dopaminergic systems are involved.dopaminergic systems are involved.

Reichborn-Kjennerud T. 2010 Dialogues Clin Neurosci 12(1):103-114Reichborn-Kjennerud T. 2010 Dialogues Clin Neurosci 12(1):103-114

? Cultural influences ?? Cultural influences ?

• Studies have found that in Norway compared Studies have found that in Norway compared to US, Germany and UK avoidant personality 3-to US, Germany and UK avoidant personality 3-4X more prevalent, dependent personality 2-4X more prevalent, dependent personality 2-3X more prevalent and schizoid is 2X more 3X more prevalent and schizoid is 2X more prevalent. Borderline is prevalent. Borderline is <<½ as frequent and ½ as frequent and antisocial is ½ has prevalent. antisocial is ½ has prevalent.

• Pattern exhibits increased internalization Pattern exhibits increased internalization personality disorders are prevalent and personality disorders are prevalent and externalization disorders are rarer.externalization disorders are rarer.

Torgerson, S.2009 The nature and nurture of personality disorders. Scan J psychol 50:624-Torgerson, S.2009 The nature and nurture of personality disorders. Scan J psychol 50:624-632632

Personality Disorder Personality Disorder ClustersClusters

• Cluster A: suspicious, oddCluster A: suspicious, odd• Paranoid, Schizoid, SchizotypalParanoid, Schizoid, Schizotypal

• Cluster B: dramaticCluster B: dramatic• Antisocial, borderline, histrionic, Antisocial, borderline, histrionic,

narcissisticnarcissistic

• Cluster C:anxiousCluster C:anxious• Avoidant, dependent, obsessive-Avoidant, dependent, obsessive-

compulsivecompulsive

Paranoid Personality Paranoid Personality disorderdisorder• A pervasive distrust and suspiciousness of A pervasive distrust and suspiciousness of

others such that their motives are interpreted others such that their motives are interpreted as malevolent.as malevolent.• Suspects others are exploiting or deceiving Suspects others are exploiting or deceiving

himhim• Preoccupied with unjustified doubts of Preoccupied with unjustified doubts of

loyaltyloyalty• Is reluctant to confide in others because he Is reluctant to confide in others because he

believes they will use the information believes they will use the information against himagainst him

Paranoid Personality Paranoid Personality Disorder cont.Disorder cont.

• Reads hidden demeaning meanings Reads hidden demeaning meanings into benign remarksinto benign remarks

• Persistently bears a grudge Persistently bears a grudge • Perceives attacks on his characterPerceives attacks on his character• Recurrent suspicions regarding Recurrent suspicions regarding

fidelity of spouse or sexual partner fidelity of spouse or sexual partner

Schizoid Personality Schizoid Personality DisorderDisorder• Pervasive pattern of detachment from social Pervasive pattern of detachment from social

relationships and restricted expression of relationships and restricted expression of emotion with 4 or more the following:emotion with 4 or more the following:• Neither desires nor enjoys close Neither desires nor enjoys close

relationshipsrelationships• Almost always chooses solitary activitiesAlmost always chooses solitary activities• Little if any interest in sexual experiences Little if any interest in sexual experiences

with another personwith another person• Takes pleasure in few in any activitiesTakes pleasure in few in any activities

• Lacks close friends other than first-Lacks close friends other than first-degree relativesdegree relatives

• Appears indifferent to the praise or Appears indifferent to the praise or criticism of otherscriticism of others

• Shows emotional coldness or Shows emotional coldness or flattened affectflattened affect

Schizotypal Personality Schizotypal Personality DisorderDisorder• A pervasive pattern of social and interpersonal A pervasive pattern of social and interpersonal

deficits with reduced capacity for close deficits with reduced capacity for close relationships as well as cognitive or perceptual relationships as well as cognitive or perceptual distortions and eccentricities of behavior with distortions and eccentricities of behavior with 5 or more of the following:5 or more of the following:• Ideas of referenceIdeas of reference• Odd beliefs or magical thinking Odd beliefs or magical thinking • Unusual perceptual experiences including Unusual perceptual experiences including

bodily illusionsbodily illusions

• Odd thinking and speechOdd thinking and speech• Suspiciousness or paranoid ideationSuspiciousness or paranoid ideation• Inappropriate or constricted affectInappropriate or constricted affect• Behavior or appearance that is odd or Behavior or appearance that is odd or

eccentriceccentric• Lack of close friends other than first-Lack of close friends other than first-

degree relativesdegree relatives• Excessive social anxiety that does not Excessive social anxiety that does not

diminish with familiaritydiminish with familiarity

Antisocial Personality Antisocial Personality DisorderDisorder• A pervasive pattern of disregard for A pervasive pattern of disregard for

and violation of the rights of others and violation of the rights of others occurring since the age of 15 years occurring since the age of 15 years as indicated by 3 or more of the as indicated by 3 or more of the following:following:• Failure to conform to social norms with Failure to conform to social norms with

respect to lawful behaviorsrespect to lawful behaviors• Deceitfulness and conning others for Deceitfulness and conning others for

personal profit or pleasurepersonal profit or pleasure

• Impulsivity or failure to plan aheadImpulsivity or failure to plan ahead• Irritability or aggressiveness as Irritability or aggressiveness as

indicated by repeated fights or assaultsindicated by repeated fights or assaults• Reckless disregard for safety of self or Reckless disregard for safety of self or

othersothers• Consistent irresponsibilityConsistent irresponsibility• Lack of remorse Lack of remorse • There is evidence of Conduct Disorder There is evidence of Conduct Disorder

with onset before age 15with onset before age 15

Neuroimaging and Neuroimaging and psychopathypsychopathy• Study by Blair found person with Study by Blair found person with

psychopathic tendencies showed psychopathic tendencies showed decreased amygdala and orbitofrontal decreased amygdala and orbitofrontal cortex responses to emotionally cortex responses to emotionally provocative stimuli which the author felt provocative stimuli which the author felt was suggestive of difficulties with basic was suggestive of difficulties with basic forms of emotional learning and forms of emotional learning and decision making.decision making.

Blair R. 2010 Neuroimaging of psychopathy and antisocial behavior: a Blair R. 2010 Neuroimaging of psychopathy and antisocial behavior: a targeted review. Curr Pysch Res Feb;12(1):76-82targeted review. Curr Pysch Res Feb;12(1):76-82

Borderline Personality Borderline Personality DisorderDisorder• Pervasive pattern on instability of Pervasive pattern on instability of

interpersonal relationships, self image and interpersonal relationships, self image and affects and marked impulsivity as indicated by affects and marked impulsivity as indicated by 5 or more of the following:5 or more of the following:• Frantic efforts to avoid abandonmentFrantic efforts to avoid abandonment• Unstable and intense interpersonal Unstable and intense interpersonal

relationships characterized by alternating relationships characterized by alternating between extremes of idealization and between extremes of idealization and devaluationdevaluation

• Identity disturbanceIdentity disturbance• Impulsivity in at least two areas that are Impulsivity in at least two areas that are

potentially self-damagingpotentially self-damaging• Recurrent suicidal behaviors, gestures or Recurrent suicidal behaviors, gestures or

threats or self-mutilating behaviorsthreats or self-mutilating behaviors• Affective instability due to a marked Affective instability due to a marked

reactivity of moodreactivity of mood• Chronic feelings of emptinessChronic feelings of emptiness• Inappropriate angerInappropriate anger• Transient, stress-related paranoiaTransient, stress-related paranoia

Histrionic Personality Histrionic Personality DisorderDisorder• Pervasive pattern of excessive Pervasive pattern of excessive

emotionality and attention seeking emotionality and attention seeking indicated by indicated by >>5 of the following:5 of the following:• Uncomfortable in situations in which he is Uncomfortable in situations in which he is

not the center of attentionnot the center of attention• Interaction with others often characterized Interaction with others often characterized

by inappropriate sexually seductive by inappropriate sexually seductive behaviorbehavior

• Displays rapidly shifting and shallow Displays rapidly shifting and shallow expression of emotionexpression of emotion

• Consistently uses physical appearance to Consistently uses physical appearance to draw attention to selfdraw attention to self

• Has a style of speech that is excessively Has a style of speech that is excessively impressionistic and lacking in detailimpressionistic and lacking in detail

• Shows self-dramatization and exaggerated Shows self-dramatization and exaggerated emotionemotion

• Is suggestibleIs suggestible• Considers relationships to be more intimate Considers relationships to be more intimate

than they arethan they are

Narcissistic Personality Narcissistic Personality DisorderDisorder• A pervasive pattern of grandiosity (in A pervasive pattern of grandiosity (in

fantasy or behavior), need for fantasy or behavior), need for admiration, lack of empathy as admiration, lack of empathy as indicated by indicated by >>5 of the following:5 of the following:• Grandiose sense of self-importanceGrandiose sense of self-importance• preoccupied with fantasies of unlimited preoccupied with fantasies of unlimited

success, power, brilliance or beautysuccess, power, brilliance or beauty• Believes he is special and can only be Believes he is special and can only be

understood or should associate with other understood or should associate with other special or high status peoplespecial or high status people

• Requires excessive admirationRequires excessive admiration• Has a sense of entitlementHas a sense of entitlement• Is interpersonally exploitiveIs interpersonally exploitive• Lacks empathyLacks empathy• Is often envious of others and Is often envious of others and

believes others are envious of himbelieves others are envious of him• Shows arrogant, haughty behaviors or Shows arrogant, haughty behaviors or

attitudesattitudes

Avoidant Personality Avoidant Personality DisorderDisorder• A pervasive pattern of social inhibition, A pervasive pattern of social inhibition,

feelings of inadequacy and feelings of inadequacy and hypersensitivity to negative evaluation hypersensitivity to negative evaluation as indicated byas indicated by > >4 of the following:4 of the following:• Avoids social occupations that involve Avoids social occupations that involve

significant interpersonal contactsignificant interpersonal contact• Is unwilling to get involved with people Is unwilling to get involved with people

unless certain of being likedunless certain of being liked• Is preoccupied with being criticized in social Is preoccupied with being criticized in social

situationssituations

• Shows restraint in intimate relationships Shows restraint in intimate relationships because of fear of being shamed or because of fear of being shamed or ridiculedridiculed

• Inhibited in new interpersonal situations Inhibited in new interpersonal situations because of feeling inadequatebecause of feeling inadequate

• Views self as socially inept and unappealingViews self as socially inept and unappealing• Is unusually reluctant to take personal risks Is unusually reluctant to take personal risks

or engage in any new activities because or engage in any new activities because they may prove embarrassingthey may prove embarrassing

Dependent Personality Dependent Personality DisorderDisorder• A pervasive and excessive need to be taken A pervasive and excessive need to be taken

care of that leads to submissive and clinging care of that leads to submissive and clinging behaviors and fears of separation as indicated behaviors and fears of separation as indicated by by >>5 of the following:5 of the following:• Has difficulty making everyday decisions Has difficulty making everyday decisions

without an excessive amount of without an excessive amount of reassurancereassurance

• Needs others to assume responsibility for Needs others to assume responsibility for most major areas of his lifemost major areas of his life

• Has difficulty expressing disagreement with others Has difficulty expressing disagreement with others because of fear of loss of approvalbecause of fear of loss of approval

• Difficulty initiating projects on his own because of Difficulty initiating projects on his own because of lack of self confidencelack of self confidence

• Goes to excessive lengths to obtain nurturance and Goes to excessive lengths to obtain nurturance and support from otherssupport from others

• Feels uncomfortable or helpless when alone Feels uncomfortable or helpless when alone • Urgently seeks another relationship as a source of Urgently seeks another relationship as a source of

care and support when a relationship endscare and support when a relationship ends• Is unrealistically preoccupied with fears of being left Is unrealistically preoccupied with fears of being left

to take care of himselfto take care of himself

Obsessive-Compulsive Obsessive-Compulsive Personality DisorderPersonality Disorder• A pervasive pattern of preoccupation A pervasive pattern of preoccupation

with orderliness, perfectionism and with orderliness, perfectionism and mental and interpersonal control at the mental and interpersonal control at the expense of flexibility, openness as expense of flexibility, openness as indicated by indicated by >>4 of the following:4 of the following:• Preoccupied with details, rules, lists, order Preoccupied with details, rules, lists, order

or schedules to the extent that the major or schedules to the extent that the major point of the activity is lostpoint of the activity is lost

• Shows rigidity and stubbornnessShows rigidity and stubbornness

• Perfectionism that interferes with task completionPerfectionism that interferes with task completion• Excessively devoted to work and productivity to the Excessively devoted to work and productivity to the

exclusion of leisure activity and friendsexclusion of leisure activity and friends• Over conscientious and inflexible about matters of Over conscientious and inflexible about matters of

morals or ethicsmorals or ethics• Is unable to discard worn or worthless objects even Is unable to discard worn or worthless objects even

those without sentimental valuethose without sentimental value• Reluctant to delegate tasksReluctant to delegate tasks• Adopts miserly spending style toward self and othersAdopts miserly spending style toward self and others

TreatmentTreatment

• Can reduce symptomatology, improve social Can reduce symptomatology, improve social and interpersonal functioning, reduce and interpersonal functioning, reduce frequency of maladaptive behaviors and frequency of maladaptive behaviors and decrease hospitalizations.decrease hospitalizations.

• Always screen for comorbid psych dxAlways screen for comorbid psych dx• If the personality disorder is ego-syntonic (eg. If the personality disorder is ego-syntonic (eg.

Antisocial and Narcissistic) it will be hard to Antisocial and Narcissistic) it will be hard to engage the patient in treatmentengage the patient in treatment

Medication TreatmentMedication Treatment

• Increasing serotonin levels may Increasing serotonin levels may reduce depression, impulsiveness, reduce depression, impulsiveness, rumination and may enhance a rumination and may enhance a sense of well beingsense of well being

• Low dose neuroleptics and mood Low dose neuroleptics and mood stabilizers can may be effective in stabilizers can may be effective in modulating affective stabilitymodulating affective stability

TherapyTherapy

• For BPD DBT, Schema-focused therapy, For BPD DBT, Schema-focused therapy, transference-focused therapy and transference-focused therapy and Mentalization-based treatment have all Mentalization-based treatment have all been found to be effective.been found to be effective.

• Therapy for other disorders limited to a Therapy for other disorders limited to a small number of open labeled trials and small number of open labeled trials and case studies. These findings have been case studies. These findings have been positive.positive.

Hadjipavlou G. Et al 2010 Promising psychotherapies for personality Hadjipavlou G. Et al 2010 Promising psychotherapies for personality disorders. La Revue Can De Psychiatric 55(4):202-209disorders. La Revue Can De Psychiatric 55(4):202-209

Screening for comorbid Screening for comorbid disordersdisorders• Antisocial PD: Alcohol dependence and Antisocial PD: Alcohol dependence and

depressive disordersdepressive disorders• BPD: alcohol and drug dependence, mood BPD: alcohol and drug dependence, mood

disorders, anxiety disorders inc PTSDdisorders, anxiety disorders inc PTSD• Histrionic PD: alcohol dependence, Histrionic PD: alcohol dependence,

somatization disordersomatization disorder• Avoidant PD: social phobiaAvoidant PD: social phobia• Any PD puts pt at higher risk than the gen Any PD puts pt at higher risk than the gen

population for Etoh and drug dep.population for Etoh and drug dep.

Trull T et al. 2010 Revised NESARC personality disorder diagnosis: gender, prevalence, and Trull T et al. 2010 Revised NESARC personality disorder diagnosis: gender, prevalence, and comorbidity with substance dependence disorders. J personal Dis 24(4):412-426comorbidity with substance dependence disorders. J personal Dis 24(4):412-426

The other side of the coinThe other side of the coin

• Personality disorders have a Personality disorders have a negative prognostic significance negative prognostic significance for Axis I disorders such as anxiety for Axis I disorders such as anxiety and mood disorders.and mood disorders.

Ansell E et al. 2010 The association of personality disorders with the prospective 7- year Ansell E et al. 2010 The association of personality disorders with the prospective 7- year course of anxiety disorders. Psychol Med Aug 10th in presscourse of anxiety disorders. Psychol Med Aug 10th in press

Case 1Case 1

• Ms Ellie is referred to you by her primary Ms Ellie is referred to you by her primary care MD because she is concerned she care MD because she is concerned she has an anxiety disorder. When the pt has an anxiety disorder. When the pt comes into your office she is looking comes into your office she is looking down and when she shakes your hand it down and when she shakes your hand it is very sweaty. When asked about how is very sweaty. When asked about how her relationships were in junior high she her relationships were in junior high she stated “terrible. I never fit in and didn’t stated “terrible. I never fit in and didn’t do much with other kids because I was do much with other kids because I was afraid they would judge me”. afraid they would judge me”.

With this information what With this information what Dx are you thinking about?Dx are you thinking about?

• Social phobia?Social phobia?• Avoidant Avoidant

personality personality disorder?disorder?

• Generalized Generalized anxiety disorder?anxiety disorder?

• Schizoid Schizoid personality personality disorder?disorder?

• What do you need What do you need to know to figure to know to figure out which one if out which one if any it is? Is this any it is? Is this circumscribed or circumscribed or more global, does more global, does this person have this person have relationships with relationships with others?others?

You illicit the following You illicit the following informationinformation• She has never had an intimate relationship She has never had an intimate relationship

although she would like to have one and has although she would like to have one and has one friend that she has known since childhood. one friend that she has known since childhood. She is intensely afraid of of being ridiculed so She is intensely afraid of of being ridiculed so works as a transcriptionist from her home and works as a transcriptionist from her home and sits in the back row when she goes to church. sits in the back row when she goes to church. She describes herself as “not as good as other She describes herself as “not as good as other people” and doesn’t like to do new things”. people” and doesn’t like to do new things”. She avoids new relationships unless she “is She avoids new relationships unless she “is sure they are going to like me”.sure they are going to like me”.

Her diagnosisHer diagnosis

• Given the long standing pervasive Given the long standing pervasive nature of her symptoms her nature of her symptoms her diagnosis is most consistent with diagnosis is most consistent with Avoidant Personality Disorder. Avoidant Personality Disorder. Social phobia tends to be very Social phobia tends to be very situational and GAD is less situational and GAD is less pervasive. pervasive.

Case 2Case 2

• Jason is a 45 year old male who comes Jason is a 45 year old male who comes to see you to establish primary care to see you to establish primary care clinic. In the ROS he notes he has to be clinic. In the ROS he notes he has to be very careful about what he eats very careful about what he eats because “certain foods I can feel work because “certain foods I can feel work against my system. I feel them as they against my system. I feel them as they are integrated into my body”. He also are integrated into my body”. He also notes he tries to be careful about what notes he tries to be careful about what he says “because words have power…he says “because words have power…they can change the way of things”. they can change the way of things”.

With this information what is With this information what is your differential diagnosis?your differential diagnosis?

• Schizophrenia?Schizophrenia?• Delusional Delusional

disorder?disorder?• Mood disorder Mood disorder

with psychotic with psychotic features?features?

• Schizotypal Schizotypal personality personality disorder?disorder?

• What do you need What do you need to know to to know to determine which determine which it is?it is?

You illicit the following:You illicit the following:

• He is fairly close to his family but doesn’t really He is fairly close to his family but doesn’t really have any other people in his life. He denied have any other people in his life. He denied auditory, visual or tactile hallucinations, has no auditory, visual or tactile hallucinations, has no thought broadcasting or thought insertion and is thought broadcasting or thought insertion and is able to provide organized answers although you able to provide organized answers although you notice he speaks in a vague way and his affect is notice he speaks in a vague way and his affect is constricted. His appearance is striking because constricted. His appearance is striking because he is wearing all yellow including his shoes, belt, he is wearing all yellow including his shoes, belt, hat and earring which he states “is because hat and earring which he states “is because yellow is the color that recharges me”. yellow is the color that recharges me”.

• His diagnosis is most consistent with a His diagnosis is most consistent with a Schizotypal personality disorder. He does Schizotypal personality disorder. He does not have schizophrenia because of lack of not have schizophrenia because of lack of disorganization and lack of true psychotic disorganization and lack of true psychotic Sx. He does have magical thinking but it Sx. He does have magical thinking but it is not crossing into psychosis. Other is not crossing into psychosis. Other history to obtain would be whether he history to obtain would be whether he has a declining course over time which has a declining course over time which you often see with schizophrenia. you often see with schizophrenia.

Case 3Case 3

• You are picking up your daughter from You are picking up your daughter from daycare and one of the other parents engages daycare and one of the other parents engages you in conversation. He states “I see you got you in conversation. He states “I see you got here 5 minutes after the cut off time to…are here 5 minutes after the cut off time to…are they going to charge you extra too? You know they going to charge you extra too? You know I think this daycare is always trying to stick it I think this daycare is always trying to stick it to us. I get this same thing at work. I think to us. I get this same thing at work. I think they purposely make the clock in times and they purposely make the clock in times and pick up times inconvenient so they can dock pick up times inconvenient so they can dock you here and there. Its like a conspiracy I you here and there. Its like a conspiracy I swear!”swear!”

With this information what is With this information what is your differential diagnosis?your differential diagnosis?

• Irritated but Irritated but normal parent?normal parent?

• Persecutory Persecutory delusional delusional disorder?disorder?

• Schizophrenia?Schizophrenia?• Paranoid Paranoid

personality personality disorder?disorder?

• What would you What would you need to find out need to find out to determine to determine which dx is which dx is correct? Screen correct? Screen for psychotic sx, for psychotic sx, delusions.delusions.

You illicit the following:You illicit the following:

• He goes on to tell you that its been the He goes on to tell you that its been the same story his whole life. He has been same story his whole life. He has been passed over for promotions at work, he passed over for promotions at work, he can’t trust his friends any further than can’t trust his friends any further than he can throw them and he thinks his he can throw them and he thinks his wife is cheating on him too. With your wife is cheating on him too. With your excellent clinical skills you also find out excellent clinical skills you also find out he doesn’t actually believe there is a he doesn’t actually believe there is a plot and doesn’t have any psychotic sx.plot and doesn’t have any psychotic sx.

• His diagnosis is most consistent His diagnosis is most consistent with a Paranoid personality with a Paranoid personality disorder. He has a pervasive disorder. He has a pervasive distrust and suspiciousness of distrust and suspiciousness of others but it is not to the point of a others but it is not to the point of a delusion and he is not psychotic.delusion and he is not psychotic.

Take home points:Take home points:

• Personality disorders are common and Personality disorders are common and more common in your practice then the more common in your practice then the general populationgeneral population

• Identifying personality disordered patients Identifying personality disordered patients informs how best to approach them informs how best to approach them

• Don’t forget to screen for comorbid Don’t forget to screen for comorbid diagnoses diagnoses

• Ask for help if you are feeling Ask for help if you are feeling overwhelmed!overwhelmed!