A Brief Overview of Material Presented as Part of the Lecture

on Personality Disorders for Medical Students

Marc A. Schuckit, M.D.

November, 2000

I. Introduction

A. I ask the audience to begin by thinking about a friend or relative they know well.

B. I then ask them to think about rating this person on a scale of 1 (low) to 10 on levels of energy, cheerfulness, curiosity, outgoing nature, independence, flexibility, etc.

C. Each student should consider how long this relative or friend has had these characteristics.

D. They should estimate how much these characteristics are likely to change in the future.

E. I remind them, therefore, that there are numerous personality characteristics that combine to describe an individual's personality. The goal of this lecture is to discuss some of these characteristics, and distinguish between these enduring aspects of a person's personality and personality disorders.

F. I remind the students that it is important to consider personality characteristics in dealing with any patient (or anyone in their lives). At the same time, there are personality disorders that must be considered. However, the usefulness of some of the personality disorder labels varies dramatically.

II. Some history and definitions.

A. Slide 1 - Reviews the long history of temperaments, concepts that date back to the Greeks.

B. Slide 2 - Discusses how some temperaments/long-term characteristics of individuals have formed the basis of a variety of psychological theories. The example used in the slide is Freud, but other concepts are relevant.

C. Slide 3 - Reminds the audience of the definitions of differences between personality, personality traits, temperament, and character.

D. Slide 4 - Summarizes the DSM-III-R and DSM-IV definition of personality disorders. It is important to emphasize that these are enduring, inflexible, consistent, and maladaptive. It is important to recognize that these generally have an onset early in life and remain fairly fixed. The DSM criteria also demand evidence of significant impairment and/or significant distress.

III. An overview of the DSM-IV approach to personality disorders.

A. Slide 5 - Gives an overview of:

1. The history of Axis II.

2. The fact that there are ten established diagnoses, diagnosis of "not otherwise specified," and a diagnosis "passive-aggressive" that is raised in the Appendix.

3. The diagnoses are polythetic in structure.

4. They are divided into clusters as will be described later.

B. Slide 6 - Presents the personality disorder diagnoses from DSM-IV. The audience is told that each of these will be reviewed in more detail.

C. Slide 7 - Presents the clusters. The students are reminded that these are not necessarily linked together within clusters, and that the clusters are not scientifically based. Rather, they are a mnemonic tool.

D. Slide 8 - Gives the opportunity for the presenter to discuss a variety of related topics regarding personality disorders in DSM-IV overall.

1. How it is important to distinguish between some of the diagnoses (e.g., obsessive-compulsive personality) and some of the Axis I disorders (e.g., obsessive-compulsive disorder). Similar discussions are worthwhile regarding the difference between paranoid personality disorder and schizophrenia, or between avoidant personality disorder and the anxiety disorders.

2. If all the personality disorders are added up, they probably apply to 10% to 20% of the general population.

3. There are important gender differences for some of the personality disorders.

4. There are a variety of etiological theories about the basis of the personality disorders. The presenter could choose to emphasize more about the dynamic history; or could choose to discuss a bit about neurochemistry as it relates to personality disorders. However, more details about specific neurochemistry are probably best presented with each of the personality disorders.

 

IV. A brief review of the personality disorders themselves.

A. Slide 9 - Reminds the audience that the discussion of personality disorders must incorporate the DSM-IV overall characteristics. This is a repeat of an earlier slide, but it is important to emphasize that somebody is not called a paranoid personality because they are feeling paranoid one week, and someone else is not called a dependent personality just because they find themselves in a situation (perhaps with an overbearing spouse) where their general characteristics change temporarily within that situation.

B. Slide 10 - Presents the criteria for paranoid personality disorder.

1. It is worthwhile to discuss the potential relationship to schizophrenia.

2. The key to the diagnosis is suspiciousness, but not psychosis nor unlawful behavior.

3. It is estimated that the rate of this disorder is 0.5% to 2.5% in the general population.

4. Before moving on to the next personality disorder it is worthwhile to show how paranoid personality differs from schizophrenia (i.e., the former has no delusions or hallucinations and does not occur without insight), and how it differs from borderline personality (i.e., there is not evidence of chaotic relationships). This pattern of briefly describing the definition, talking about key elements, dealing with epidemiology, and then reminding the student how a particular definition is likely to differ in key ways from other disorders, sets the basis for the discussion of all the remaining material.

C. Slide 11 - Presents the schizoid personality disorder.

1. The definition is reviewed.

2. The history whereby schizoid used to be part of a broad category of intimacy problems, but in 1980 was moved to its own label in distinction from schizotypal is discussed.

3. It is estimated to be between 5% and 7% of the general population with a two to one male to female ratio.

4. It is differentiated from schizophrenia because the individual is not psychotic; from schizotypal because the individual is not odd; and it is different from avoidant personality because the schizoid person does not feel as strongly inadequate, does not fear separation as much, and is not as sensitive to criticism.

D. Slide 12 - Describes the schizotypal personality disorder.

1. The definition is presented.

2. The relationship to a schizophrenia spectrum is discussed.

3. It is emphasized that these people are odd but not paranoid nor psychotic. To arrive at a diagnosis it is important to remember that the beliefs must not be culturally syntonic. It is also important to emphasize that the affect is inappropriate or constricted.

4. The rate of schizotypal personality disorder in the general population is estimated to be 3% or so.

5. A discussion of how this disorder differs from schizophrenia (no hallucinations or delusions), avoidant personality (higher levels of odd behavior and schizotypal), and paranoid personality (lacking the same level of paranoid thoughts) is worthwhile.

6. This is an excellent opportunity to now begin to discuss some of the biological data regarding backward masking, P300 wave amplitude decrements, and to highlight some of Kristin Cadenhead's work.

E. Slide 13 - Presents an overview of the antisocial personality disorder. It is worthwhile to spend extended period of time with this label that has one of the highest levels of reliability and prognostic validity of any of the personality disorders.

1. The definition is presented. An emphasis is placed on the need for conduct disorder to be recognized.

2. A bit of the history is discussed including Pinel's Moral Insanity, Cleckley's Concept of Psychopathy; and Hare's 1990 Concept of Sociopathy---an approach that is useful but not very reliable.

3. The rate of ASPD in the general population is approximately 3% in men and 1% in women as a life time risk. For violent felons, the rate might be as high as 75%.

4. A fair amount is known about the clinical course of this disorder (in distinction from most other personality disorders). It is useful to describe the potential relationship to somatization disorder in women. Other important data relate to a life-long risk for substance use disorders of at least 75%; a high rate of suicide attempts with an estimated 5% rate of death by suicide; a high rate of accidents; and the possibility of a "burn out" with improvement of levels of functioning somewhere in the 40's.

5. This is a useful opportunity to discuss etiology and biology. Important topics include the data that support the importance of genetic influences in ASPD; findings regarding a decrease in prefrontal gray matter in individuals with ASPD (see Raine, Archives of General Psychiatry, February, 2000); evidence of decreased CSF 5HIAA and possible differences regarding serotonin 1 and B receptors (Lappalainen, Archives of General Psychiatry, Nov., 1998); evidence of decreased autonomic nervous system responsiveness (Brennan, American Journal of Psychiatry, June, 1997); increases in slow waves on EEGs (Raine, 2000); higher levels of prolactin responses to fenfluoramine (Manuck, Neurophysiology, 1998), etc.

6. It is also useful to describe treatments with the importance of behavioral and cognitive approaches, along with the lack of data regarding the helpfulness of antipsychotic medication. The possibility (requiring a great deal more research) that anticonvulsants or beta blockers might be useful is also worthwhile.

7. This section should be ended by describing the differences between ASPD and borderline personality disorder, as well as the need to not diagnose ASPD when the antisocial behaviors are only being observed in the context of an Axis I disorder (such as schizophrenia or substance use disorders).

8. The historical relationship to schizophrenia is worth describing.

F. Slide 14 - Describes the borderline personality disorder.

1. The criteria are presented, but the students are reminded that these are vague and crossover greatly with other diagnoses. The key to the diagnosis is a chaotic lifestyle, frequent crises, anger, suicidal thoughts, and the possible presence of temporary psychotic behaviors.

2. It is estimated that 2% or so of the general population has borderline personality disorder, with a higher rate in women than men.

3. There are important data regarding the clinical course. These include information that once the diagnosis is carefully established, people are likely to continue to have relatively unstable lifestyles.

4. It is important to recognize the crossover with additional psychiatric disorders. For example, 50% or more of people with borderline also meet criteria for a mood disorder, anxiety disorder, PTSD, eating disorders, and substance use disorders. Overall, about 85% of people with borderline meet criteria for at least one other psychiatric disorder. (Useful references are Hudziak, American Journal of Psychiatry, Dec., 1996; Zanarini, American Journal of Psychiatry, Dec., 1998; Antikainen, ACTA Psychiatrica, 1995).

5. A brief discussion of potential treatments should be given. This is a complex literature and I would have planned to re-review that before giving the lecture.

6. This section ends with a brief review of how borderline personality disorders could be distinguished from the antisocial personality disorder (the latter are more unlawful and violent); from narcissistic personality disorder (who tend to be more grandiose and self-important); the Axis I diagnosis of somatization disorder (where the major emphasis of symptoms is on medical problems); and from histrionic personality disorder (which tends to be associated with less chaos in lifestyle.

G. Slide 15 - Describes histrionic personality disorder.

1. The criteria are briefly reviewed. The key to the diagnosis is gregariousness, superficiality, charming, and manipulative, but not unlawful or chaotic.

2. The history as it relates to the DSM-II diagnosis of hysterical personality is described. The students should be reminded that the term "hysterical or histrionic" is used in many different ways.

3. In light of the amount of time available for these lectures, from this point on things are reviewed fairly quickly. The students are reminded how histrionic personality disorder differs from borderline (with the latter more likely to show suicide attempts and temporary psychosis), somatization disorder (with the lack of conversion symptoms in histrionic personality), etc.

H. Slide 16 - Describes the narcissistic personality disorder.

1. A definition is presented, with an emphasis on selfish, ultra self-centered behavior in an individual who is hypersensitize to criticism and must always feel important.

2. It is estimated to be seen in about 1% of the general population, but would be elevated (2% to 16%) in patients in practice.

3. There are mixed data regarding the natural history, with a demonstration that this diagnosis might not be very stable (Ronningstrom, American Journal of Psychiatry, February, 1995).

4. This diagnosis is differentiated from borderline because narcissistic patients are not overly anxious, nor suicidal, nor chaotic; is different than ASPD because the narcissistic patients are not aggressive or unlawful; and different from histrionic in that narcissistic individuals are usually not overly emotional.

I. Slide 17 - Presents the avoidant personality disorder.

1. The key to the diagnosis here is that an individual wants to companionship but feels inadequate to make them.

2. The criteria are discussed. The history of the beginning of this label in DSM-III as a variant of schizoid and inadequate personality disorder is presented.

3. The life time risk in the general population is 1% to 10%.

4. The avoidant personality disorder is differentiated from schizoid (the avoidant wants relationships); from borderline (because the latter are more irritable, unpredictable, and chaotic); from dependent (because the latter are more fearful of being abandoned), and is distinguished from the Axis 1 diagnosis of social phobia (because avoidant has general feelings of inadequacy as opposed to a specific social phobic situation).

J. Slide 18 - Describes the dependent personality disorder.

1. The diagnostic criteria are discussed, with the emphasis on neediness and clinging behavior in an individual who subordinates his or her own needs to others. It is important to avoid making this diagnosis solely in the context of a chronic medical or psychiatric illness.

2. The history of an appearance of a diagnosis of passive-aggressive personality in DSM-I, which was dropped in DSM-II, and then back in DSM-III---leading to the Dependent Personality should be discussed.

3. The rate in the general population isn't known, but might be estimated to be fairly low (perhaps 1% or 2%).

4. The dependent personality is to be distinguished from avoidant because the latter avoids social situations and avoids relationships and intimacy; from borderline (because the latter is more chaotic); and from schizoid (because the latter usually does not want closeness while the dependent person does).

K. Slide 19 - Presents the obsessive-compulsive personality.

1. The criteria can be presented with an emphasis on the person being rigid, perfectionistic, and inefficient. It is important to remember that the diagnosis here (as with any personality disorder) can only be made if there is evidence of significant distress or impairment in functioning.

2. The history of this concept as it relates to a variety of other conditions including Axis I disorders should be discussed. It might be worthwhile to briefly talk about its relationship to anal fixation in Freudian theories.

3. The epidemiology is unknown, but it is estimated that it is more likely to be seen in males than females.

4. The differentiation between this disorder and obsessive compulsive disorder should be discussed.

L. Slide 20 - Describes the diagnosis from the Appendix of passive aggressive personality disorder.

1. The criteria should be discussed with an emphasis on how an individual is stubborn, procrastinates, is inefficient, and has a generally negative attitude.

2. The history of this disorder should be discussed, along with the manner in which it has gone in and out of the diagnostic framework. The reasons why it is in the Appendix should be presented.

3. It is hard to gather data on the prevalence of this disorder.

4. Distinctions between passive aggressive and histrionic or borderline should be presented.

V. Summary and conclusions.

A. Slide 21 - Remind the student once again about what a personality disorder should be.

B. Slide 22 - Briefly describes the essential elements of the various personality disorders.

C. Slide 23 - Continues this brief overview. It should be noted that in giving the lecture these slides are usually flashed on the screen, and the students are reminded that they have slide copy and might choose to use these slides as a study guide. However, there would be too much redundancy if these were discussed in detail.

D. Slide 24 - Talks about the usual treatment approaches that are appropriate for personality disorders.

 

BIBLIOGRAPHY:

PERSONALITY AND SUBSTANCE USE DISORDERS

Marc A. Schuckit, M.D.

October, 2000

1. Caspi A, Moffitt TE, Newman DL, Silva PA: Behavioral observations at age 3 predict adult psychiatric disorders: longitudinal evidence from a birth cohort. Arch Gen Psychiatry 1996; 53:1033-1039.

2. Driessen M, Veltrup C, Wetterling T, John U, Dilling H: Axis I and Axis II comorbidity in alcohol dependence and the two types of alcoholism. Alcohol Clin Exp Res 1998; 22:77-86.

3. Ebstein RP, Novick O, Umansky R, Priel B, Osher Y, Blaine D, et al: Dopamine D4 receptor (D4DR) exon III polymorphism associated with the human personality trait of novelty seeking. Nat Genet 1996; 12:78-80.

4. Gelernter J, Kranzler H, Coccaro EF, Siever LJ, New AS: Serotonin transporter protein gene polymorphism and personality measures in African American and European American subjects. Am J Psychiatry 1998; 155:1332-1338.

5. Gershenfeld HK, Paul SM: Towards a genetics of anxious temperament: from mice to men. Acta Psychiatr Scand 1998; 98:56-65.

6. Grilo CM, Becker DF, Fehon DC, Edell WS, McGlashan TH: Conduct disorder, substance use disorders, and coexisting conduct and substance use disorders in adolescent inpatients. Am J Psychiatry 1996; 153:914-920.

7. Grilo CM, Martino S, Walker ML, Becker DF, Edell WS, McGlashan TH: Controller study of psychiatric comorbidity in psychiatrically hospitalized young adults with substance use disorders. Am J Psychiatry 1997; 154:1305-1307.

8. Hill SY, Shen S, Locke J, Steinhauer SR, Konicky C, Lowers L, Connolly J: Developmental delay in P300 production in children at high risk for developing alcohol-related disorders. Biol Psychiatry 1999; 46:970-981.

9. Hill SY, Zezza N, Wipprecht G, Locke J, Neiswanger K: Personality traits and dopamine receptors (D2 and D4): linkage studies in families of alcoholics. Am J Med Genet 1999; 88:634-641.

10. McGue M, Slutske W, Taylor J, Iacono WG: Personality and substance use disorders: I. Effects of gender and alcoholism subtype. Alcohol Clin Exp Res 1997; 21:513-520.

 11. Raine A, Reynolds C, Venables PH, Mednick SA, Farrington DP: Fearlessness, stimulation-seeking, and large body size at age 3 years as early predispositions to childhood aggression at age 11 years. Arch Gen Psychiatry 1998; 55:745-751.

12. Thomas VH, Melchert TP, Banken JA: Substance dependence and personality disorders: comorbidity and treatment outcome in an inpatient treatment population. J Stud Alcohol 1999; 60:271-277.

13. Verheul R, Kranzler HR, Poling J, Tennen H, Ball S, Rounsaville BJ: Axis I and Axis II disorders in alcoholics and drug addicts: fact or artifact? J Stud Alcohol 2000; 61:101-110.

14. Verheul R, van den Brink W, Hartgers C: Prevalence of personality disorders among alcoholics and drug addicts: an overview. Eur Addict Res 1995; 1:166-177.

15. Verheul R, van den Brink V, Hartgers C: Personality disorders predict relapse in alcoholic patients. Addict Behav 1998; 23:869-882.

16. Verheul R, van den Brink W, Koeter MWJ, Hartgers C: Antisocial alcoholic patients show as much improvement at 14-month follow-up as non-antisocial alcoholic patients. Am J Addict 1999; 8:24-33.

17. Zanarini MC, Frankenburg FR, Dubo E, Sickel A, Trikha A, Levin A, Reynolds V: Axis I comorbidity of borderline personality disorder. Am J Psychiatry 1998; 155:1733-1739.

18. Zaninelli RM, Porjesz B, Begleiter H: The tridimensional personality questionnaire in males at high and low risk for alcoholism. Alcohol Clin Exp Res 1992; 16:68-70.