One topic I would like to talk about is personality disorders and traits. Prior to learning about these in PA school, I did not realize that there were even categories for these types of patients. I will forewarn you, as like myself and my classmates, you may read these and think "thats me!" or "I know someone just like that!" While that may be true, it is likely that these people you are thinking of just display some traits of these disorders. In order for it to truly be a "disorder" patients will struggle in society, have significant distress or impairment in their everyday functioning. One of the PGY4 residents taught us that typically, patients will personality disorders will cause you some frustration or exhaustion after interviewing them. Why? Well, these patients have rigid views and beliefs that make it difficult to have discussions with them, especially about their mental health. Many of these types of personality disordered patients do not believe they have a problem.
They are broken down into clusters, here is how I was taught to remember them
Cluster A: Mad Cluster B: Bad Cluster C: Sad
Pts are odd, eccentric, or withdrawn. The dx's are very similar to psychotic disorders
Paranoid: Patients are suspicious of others, preoccupied with trust and loyalty, interpret harmless remarks as threatening or demeaning, hold grudges, quick to counterattack if they perceive an attack. Treat best with psychotherapy. May also use anti-psychotics if transient psychosis exists.
Schizotypal: Magical thinking. Patients have peculiar thought patterns and odd beliefs that are inconsistent with cultural thinking. This may inccude belief in clairvoyance or telepathy, fantasies, or superstitions. They may be involved in cults or strange religious practices. They often have ideas of reference, few close friends, excessive social anxiety. Best treated with psychotherapy or low dose anti-psychotics for a short time.
Schizoid: Withdrawn. These patients have very few friends if any, and do not want any (even family). They are content by themselves and prefer activities by themselves. Little, if any, sexual activities with another person. Emotionally cold, detached and withdrawn. Flat affect. Best treated with psychotherapy or low dose anti-psychotics.
Pts are emotional, dramatic, or inconsistent. The dx's are similar to mood disorders
Antisocial: Rule-Breakers. Patients must be 18+ years (if under 18 then its dx'd as Conduct Disorder). Failure to follow social norms/rules. Deceitful, manipulating, lying, impulsive. May have a history of incarceration. Irritable/angry and reckless. Expresses NO REMORSE for actions. Best treated with exercises about social norms (Dialectical behavior therapy, DBT) and behavior therapy. Patients do not benefit from psychotherapy.
Borderline: Intense personal relationships (love or hate). Impulsive, moody, unstable self-image, paranoid under stress, emptiness, vulnerable to abandonment, and suicidal/self-mutilation. Best treatment is psychotherapy or social skills training. Medications can be used as needed to control symptoms.
Histrionic: Seductive. Attention seeking. They often revert to child-like behaviors, need to be center of attention, and lack details in speech. They have inappropriately provocative and seductive behaviors. Best treatment is psychotherapy.
Narcissistic: Extremely grandiose. Believes that they are special or unique. They lack empathy, have a sense of entitlement and take advantage of others for self gain. They are often envious of others or believe that others envy them. Do not realize that they have a problem (more-so than the other disorders). Psychotherapy is treatment of choice but the patients may also benefit from group therapy as well.
Pts are anxious and fearful. The dx's are similar to anxiety disorders
Avoidant: Desperately wants to be accepted by others but is socially withdrawn out of fear of rejection. Typically partake in activities or jobs that require little human interaction out of fear of embarrassment or being disliked. Believes that they are inferior in comparison to others. Very few interpersonal relationships out of fear of rejection. Best treatment is psychotherapy and assertiveness training.
Dependent: Reliant on others for happiness. Poor self confidence and self esteem. They are obsessive about approval, bound by others decisions, feel that their feelings are invalid when they are alone, and need to be in a relationship at all times. They have difficulties initiating projects because of lack of self confidence. Best therapy is psychotherapy, group therapy and social skills training.
Obsessive Compulsive: Detail oriented, to the point that is detrimental to completion of activities or projects. Perfectionists. Excessive conscientiousness and scrupulousness about morals and ethics. Will not delegate tasks, is very rigid and stubborn. Unable to throw away "worthless" objects. Treatment is psychotherapy, group therapy and behavior therapy. Unlike OCD, OCPD patients do not think they have a problem, OCD patients are troubled by their rituals and habits which causes them great anxiety.