questions 21

Personality Disorders

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Topic updated on 11/12/17 5:58pm

Introduction
  • Personality trait
    • enduring patterns of behavior exhibited in a wide range of personal contexts
  • Personality disorder
    • pervasive, inflexible, extreme, maladaptive personality trait causing impaired functioning or subjective distress
    • ego syntonic
      • patient has limited awareness of disorder
    • must be developed by early adulthood
      • a personality disorder cannot begin later than as an early adult
    • not usually diagnosed in children
    • not caused by any other organic etiology or intoxication
  • Personality disorders are part of the Axis II of the DSM and can be broken down into three clusters, each with separate clinical conditions
    • cluster A
      • schizoid  
      • schizotypal
      • paranoid 
    • cluster B
      • histrionic
      • borderline 
      • antisocial 
      • narcisstic
    • cluster C
      • obsessive compulsive
      • avoidant 
      • dependent 
Cluster A
  • Cluster commonalities
    • "weird"
    • odd or eccentric
    • no meaningful social relationships
    • no psychosis
    • genetic association with schizophrenia
  • Schizoid
    • snapshot 
      • A 50-year-old male lives alone in a cabin on several acres of land. He rarely interacts with his family or community other than when he comes to town once a month to pick up supplies.
    • characteristics  
      • patients tend to have emotional aloofness, indifferent to praise or criticism, without bizarre or idiosyncratic thinking
      • exhibit voluntary social withdrawal 
        • content with social isolation (vs avoidant)
      • limited emotional expression
      • no association with schizophrenia
    • treatment
      • psychotherapy
        • cognitive, behavioral, psychoanalysis
      • pharmacologic
        •  only if patient suffers from concomitant depression or transient psychosis 
  • Schizotypal 
    • snapshot 
      • A 45-year-old female has recently quit her job in order to start a small business.  She claims that the spirits have told her to sell trinkets each of which has a unique power.  She is known for dressing oddly and due to her strange behavior has trouble making friends.
    • characteristics 
      • patients tend to have eccentric appearance with odd beliefs or magical thinking 
      • patients may develop schizophrenia
    • treatment
      • psychotherapy
        • cognitive, behavioral, psychoanalysis
      • pharamcologic
        • short course of low-dose antipsychotics, if needed
  • Paranoid
    • snapshot
      • A 35-year-old female says that her neighbors are planning to steal her things and often ridicule her when she is not there.  She is attempting to pursue legal action to get her neighbors evicted for this behavior as she knows that they have an intention to harm her in some way.
    • characteristics 
      • excessive distrust and suspicion
      • higher incidence in families with schizophrenia
    • treatment
      • psychotherapy
        • cognitive, behavioral, psychoanalysis
      • pharmacologic
        • anxiolytics
Cluster B
  • Cluster commonalities
    • "wild"
    • dramatic, emotional, or erratic
    • genetic association with mood disorders and substance abuse
  • Histrionic
    • snapshot  
      • A 29-year-old females comes to your office in a very provocative dress. At the beginning of the interview she flirts with you and asks you if you like her dress.  You overheard her yelling into her cell phone in the waiting room which later turned to tears. She describes her flu-symptoms as if she's "dying." 
    • characteristics 
      • excessively emotional and attention seeking which commonly includes sexual provocativeness
      • large concern with appearance
      • think "telenovelas"
    • treatment
      • psychotherapy
        • cognitive, behavioral, psychoanalysis
      • pharmacologic
        • symptomatic medical management only (i.e., anxiolytics, antidepressants)
  • Borderline  
    • snapshot 
      • A 26-year-old Ph.D female student comes to your office for a check up. When you enter the room she is visibly upset and states that all of the nursing staff are incompetent and that you're the only doctor who has ever understood her despite only having one brief clinical encounter.  When you tell her that you cannot prescribe her the sleep medications she requested, she states that you are incompetent and abruptly leaves the appointment.
    • characteristics 
      • unstable interpersonal relationships, with impulsive behavior and a sense of emptiness due to a fear of abandonment
      • females > males
      • splitting is a major defense mechanism  
        • relationships are either all good ("my boyfriend is a perfect angel") or all bad ("my boyfriend is evil and I hate him")
      • self-mutilation
    • treatment
      • psychotherapy
        • cognitive, behavioral, psychoanalysis
      • pharmacologic
        • symptomatic medical management only (i.e., anxiolytics, antidepressants)
  • Antisocial
    • snapshot 
      • A 23-year-old male with an extensive criminal record assaults an elderly woman to steal her purse. On interview, he is polite and has a normal affect and describes with excitement how he hit the old lady with a wooden mallet prior to robbing her.
    • characteristics 
      • disregard for and violation of rights of others with lack of remorse which commonly results in criminality
      • males > females
      • conduct disorder if < 18 years  
        • rule out substance use, sexual abuse, and possible normal behavior
      • commonly known as "psychopathy"
      • classic triad
        • set fires, torture animals, bed wetting
    • treatment
      • psychotherapy
        • cognitive, behavioral, psychoanalysis
      • pharmacologic
        • avoid medications with an abuse potential
  • Narcissistic
    • snapshot 
      • A 50-year-old male lawyer is being worked up for an abnormal PSA test. He demands that he sees the chief of urology and won't let any housestaff in the room. He says he knows "very important people" and that there will be "trouble" if he waits longer than 5 minutes in the waiting room.
    • characteristics 
      • grandiose with a need for admiration and sense of entitlement 
      • lacks empathy
      • reacts to criticism with rage
    • treatment
      • psychotherapy
        • cognitive, behavioral, psychoanalysis
      • pharmacologic
        • avoid medications with an abuse potential
Cluster C
  • Cluster commonalities
    • "worried"
    • anxious or fearful
    • genetic association with anxiety disorders
  • Obsessive compulsive personality disorder
    • snapshot 
      • A 22-year-old female dental student is struggling with her studies because she must read every reading assignment at least 3 times, as well as taking meticulous notes which she color codes. She works poorly in groups because she cannot delegate tasks.
    • characteristics 
      • patents tend to be preoccupied with order, perfectionism, control 
      • ego-syntonic
        • patient is not aware of their behavior causing issues
          • vs. OCD which is ego dystonic
    • treatment
      • psychotherapy
        • cognitive, behavioral, psychoanalysis
      • pharmacologic
        • only for symptomatic treatment
  • Avoidant 
    • snapshot 
      • A 36-year-old female administrative assistant does not socialize with coworkers or attend any social events because she is afraid they will not like her. She would like to meet people but feels to shy to initiate a conversation.
    • characteristics 
      • patents tend to be hypersensitive to rejection and socially inhibited resulting from feelings of inadequacy 
      • desires relationships with others (vs. schizoid)
    • treatment
      • psychotherapy
        • cognitive, behavioral, psychoanalysis
      • pharmacologic 
        • β-blockers
        • SSRIs
  • Dependent
    • snapshot 
      • A 29-year-old female presents for therapy after a break-up with her boyfriend.  She always did everything he wanted and cannot understand how he could not want to be with her.  According to her the boyfriend said she was "too clingy" and asked him to make every decision for her.
    • characteristics 
      • submissive and clingy with an excessive need to be taken care of resulting from a low self-esteem 
    • treatment
      • psychotherapy
        • cognitive, behavioral, psychoanalysis
      • pharmacologic
        • only for symptomatic relief

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(M3.PY.1) A 23 year-old woman is brought to the emergency room by her mother after cutting both of her wrists with razor blades. The daughter admits that she has been admitted to the hospital numerous times for self-mutilation and that this time it was because the man she was seeing for the past two weeks ended their relationship. As an intern is closing her wound with stitches, she remarks on how skillful, attractive, and intelligent he is and how "[he is] probably the best doctor in the world." Which of the following defense mechanisms is she likely using? Topic Review Topic

1. Identification
2. Denial
3. Displacement
4. Splitting
5. Projection

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(M3.PY.2) A 23 year-old woman is brought to the emergency room by her mother after she is found to have cut both of her wrists with razor blades. The patient admits a history of self-mutilation and attributed this incident to a recent breakup with a man she had been seeing for the previous two weeks. On morning rounds the patient reports to the team that "the nurses here are the worst I've ever seen, but all the doctors are absolute geniuses." After her immediate injuries are addressed, which of the following should be used as a first-line therapy for the patient's psychiatric condition? Topic Review Topic

1. Alprazolam
2. Amitryptiline
3. Dialectical behavior therapy
4. Fluvoxamine
5. Classical conditioning

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(M2.PY.1) The guidance counselor at your town's high school calls to ask your advice about a particular student. The counselor is currently meeting with all juniors to discuss plans after graduation. She tells you one of the students she spoke with today exhibited some concerning behaviors and wonders if she should suggest that the parents bring her to a psychiatrist. Reportedly, the student is very much a "loner" and seems to express no emotion. He states that he has no friends and doesn't wish to have any. He prefers spending time at home. He denied any depressive symptoms and his thinking seemed logical, though strange. Which of the following best fits this student? Topic Review Topic

1. Acute psychosis
2. Schizoid personality disorder
3. Schizotypal personality disorder
4. Schizoaffective disorder
5. Paranoid personality disorder

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(M2.PY.10) A prison guard working at a state penitentiary has a new 24-year-old male inmate come to the cell block that he patrols. This new inmate has a psychiatric diagnosis of antisocial personality disorder. What types of behavior (past or present) can the prison guard expect from this inmate? Topic Review Topic

1. Pattern of unstable relationships, poorly formed identity, impulsive, reckless, self-mutilating, and feelings of emptiness
2. Sense of superiority, need for admiration, and lack of empathy
3. Attention-seeking, excessive emotions, dramatic, flamboyant, sexually inappropriate, and provocative
4. Social withdrawal, reclusive, no desire for close relationships, and prefers to be alone.
5. Direct violation of the rights of others, aggressive, impulsive, and superficial charm that allows for manipulation of others

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(M2.PY.33) The husband of a 27-year-old female meets with a social worker to discuss his wife's behavior. He reports that her mood has been unstable and that they have been having problems with their marriage. She acts impulsive at times but also becomes easily bored. She often complains to him that she feels empty. Lately, he has been especially concerned because she has started cutting herself. The wife of this gentlemen probably has: Topic Review Topic

1. A psychiatric disorder where projection is the major defense mechanism
2. A psychiatric disorder which rarely coexists with mood disorders or substance abuse
3. A psychiatric disorder that has a genetic association with schizophrenia
4. A psychiatric disorder associated with the belief that people are either all good or all bad at different times
5. A psychiatric disorder associated with anxiety disorders

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(M2.PY.37) A 22-year-old male is brought to a psychiatrist by his mother, who claims that he has refused to bathe for two weeks and has not shaven for several months. The patient states that he refrains from grooming because he is sure such practices will help him win the lottery. This behavior is most typical of which of the following personality disorders? Topic Review Topic

1. Obsessive-compulsive
2. Schizoid
3. Avoidant
4. Dependent
5. Schizotypal

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(M2.PY.38) A 45-year-old male agrees to take part in a psychiatric research study of financial executives. The patient is the head of commodities trading at an international investment firm. The aim of the study is to track the incidence of narcissistic personality disorder among participants. Which of the following is characteristic of narcissistic personality disorder? Topic Review Topic

1. Preoccupation with order
2. Voluntary social withdrawal
3. Hypersensitivity to rejection
4. Lack of empathy and sense of entitlement
5. Excessive emotionality and excitability

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(M2.PY.39) A 20-year-old male college student volunteers to be interviewed by a psychiatrist for a university research project. Following an extensive history, the psychiatrist writes in a note that the patient suffers from dependent personality disorder. Which of the following is characteristic of dependent personality disorder? Topic Review Topic

1. Preoccupation with order
2. Voluntary social withdrawal
3. Hypersensitivity to rejection
4. Submissive and clinging behavior
5. Excessive emotionality and excitability

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(M2.PY.40) An 18-year-old female is brought to a psychiatrist by her parents, who complain that the she has not left the house except for school in several weeks. The psychiatrist writes in a note that the patient has schizoid personality disorder. Which of the following is characteristic of schizoid personality disorder? Topic Review Topic

1. Pervasive suspiciousness
2. Voluntary social withdrawal
3. Hypersensitivity to rejection
4. Submissive and clinging behavior
5. Odd beliefs and magical thinking

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(M2.PY.41) A 40-year-old man presents for psychological evaluation prior to beginning work at a government facility that handles encrypted data. Following an extensive history, the psychiatrist writes in a note that the man likely suffers from avoidant personality disorder. Which of the following is characteristic of avoidant personality disorder? Topic Review Topic

1. Pervasive distrust of others
2. Voluntary social withdrawal
3. Hypersensitivity to rejection
4. Submissive and clinging behavior
5. Excessive emotionality and excitability

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(M2.PY.81) A 46 year-old-man presents to a primary care physician with a chronic cough. He reports that he has not seen a physician in 25 years, but he has not been sick during this time. He lives in a cabin in the woods, and although he does not have any friends, he reports that he does not feel lonely. He is well-groomed, dressed normally, and does not have any bizarre beliefs. He describes his mood as "fine", and his speech is fluid, albeit limited in amount. His thought process is linear, and his thought content is appropriate. He denies any visual or auditory hallucinations. Which of the following is true about this patient's psychiatric condition? Topic Review Topic

1. It has a high correlation with schizophrenia
2. The patient should be treated with an antidepressant
3. No specific treatment is needed at this time
4. The patient is likely very responsive to criticism and praise
5. The patient likely suffers from a co-morbid substance use disorder

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(M2.PY.126) A 24-year-old female is referred to a psychiatrist by her employer, who notes that she has had trouble finishing projects in a timely manner. After a lengthy interview, the psychiatrist writes that he believes the patient has obsessive-compulsive personality disorder. Which of the following is characteristic of obsessive-compulsive personality disorder? Topic Review Topic

1. Preoccupation with order and control
2. Recurring thoughts partly relieved by repetitive actions
3. Hypersensitivity to rejection
4. Submissive and clinging behavior
5. Excessive emotionality and excitability

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