Personality Disorders (PD's) (Last Updated - 5/27/2003)
-personality patterns which are pervasive, inflexible, maladaptive & produce functional impairment
-usually wait until early adulthood / late adolescence to make diagnosis (esp. antisocial PD -> requires >18 y.o.) exception is conduct disorder -> requires <18 y.o.
-are ego-syntonic (acceptable to the ego) -> patients do not feel they are doing anything wrong -> usually resist suggestions for treatment
-product of the interaction b/w patients born temperament & developmental environment
-PD's more common in males:
   1) Antisocial PD
   2) Narcissistic PD
-PD's more common in females:
   1) Borderline PD
   2) Histrionic PD
-Risk Factors:
   -innate (born w/) temperamental difficulties (Ex.) irritability)
   -child neglect
   -child abuse
   -PD's in parents -> genetic & environmental linkage
-Symptoms:
   -long patterns of difficult interpersonal relationships
   -difficulty adapting to stress
   -failure to achieve goals
   -chronic unhappiness
   -low self-esteem
-Differential Diagnosis:
   1) Mood disorders (Ex.) Major Depressive or Bipolar Disorders)
   2) Personality changes due to medical condition
   3) Adjustment Disorder
-Treatments:
   1) Psychotherapy: long-term psychodynamic and cognitive therapy (TOC's)
   2) Pharmacotherapy: Mood stabilizers & Antidepressants for Cluster B PD's
-3 clusters:
   1) Cluster A disorders:
      -odd, eccentric or weird group of personality disorders
      -unable to develop social relationships
      -more common among relatives w/ schizophrenia (esp. schizotypal PD)
      -3 subtypes:
      A) Paranoid Personality Disorder:
         -assoc. w/ distrust and suspiciousness leading to patients being secretive & socially isolated
         -emotionally cold and odd
         -can see brief episodes of psychosis w/ persecutory delusions
         -may see pre-existing sensory impairments (Ex.) Deaf patients believe you are talking about them b/c they cannot hear you
         -common defense mechanism -> projection (attributing your thoughts to others)
         -symptoms tend to worsen w/ age
         -must differentiate from schizophrenia:
            1) Duration of symptoms: Schizophrenia (more recently) vs. Paranoid PD (always)
            2) Level of Functioning: Schizophrenia (non-functional) vs. Paranoid PD (relatively functional)
            3) Psychotic symptoms: Schizophrenia (yes) vs. Paranoid PD (no not usually)
      B) Schizoid Personality Disorder:
         -char. by detachment & restricted emotionality
         -patients are emotionally distant -> fear intimacy
         -disinterested in others -> enjoy being alone (not afraid to be) -> work @ night
         -voluntary social w/drawal
         -indifferent to praise or criticism
         -symptoms tend to worsen w/ age
         -no psychosis
      C) Schizotypal Personality Disorder:
         -char. by discomfort w/ social relationships (interpersonal awkwardness), thought discomfort & illusions
         -odd preoccupations, speech & affect
         -peculiar patterns of thnking (ideas of reference, persecutory illusions & magical thinking (lucky shoes or rituals)) -> differentiates
            schizotypal PD and schizoid PD
         -more common among relatives w/ schizophrenia
         -PD most resembling schizophrenia -> differentiate by the duration of symptoms:
            -Schizotypal (always) vs. Schizophrenia (more recently)
         -decreased platelet monoamine oxidase (MAO) levels -> less social (platelet MAO levels correlate w/ social functioning)
         -odd, eccentric or weird
         -unable to develop social relationships
         -more common among relatives w/ schizophrenia (esp. schizotypal PD)
   2) Cluster B disorders:
      -dramatic, emotional or wild
      A) Antisocial Personality Disorder:
         -disregard for other's rights
         -affex males > females
      B) Borderline Personality Disorder:
         -unstable mood
         -impulsiveness
         -affex females > males
      C) Histrionic Personality Disorder:
         -excessive emotions
         -attention-seeking
         -sexually provocative
      D) Narcissistic Personality Disorder:
         -grandiosity
         -sense of entitlement
   3) Cluster C disorders:
      -anxious / fearful or worried
      A) Avoidant Personality Disorder:
         -sensitive to rejection
         -socially inhibited
         -feelings of inadequacy
      B) Obsessive-Compulsive Personality Disorder (OCPD):
         -extreme concern for order, perfection and control
         -do not confuse w/ OCD (anxiety disorder)
      C) Dependent Personality Disorder:
         -submissive
         -low self-confidence
         -have a need to be taken care of or controlled

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References:

1) First Aid for the USMLE Step 1. Bhushan et al. 2002. pg. 135 - 136.
2) Kaplan USMLE Step 2 Lecture Notes: Psychiatry and Epidemiology & Ethics. Gonzalez-Mayo A. and Shaner, R. 2002. pg. 73-76.
3) Kaplan & Sadock's Synopsis of Psychiatry. 8th Edition. Kaplan, H. and Sadock, B. 1998. pg. 775-784.