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Personality Disorders

Personality disorders manifest in the ways that people think, behave, have feelings, or  have emotions. And that these personality disorders, by definition, are somewhat stereotyped and maladaptive. So that we are looking at extremes rather than something in the middle part of the personality disorder.

Each of us inherits a set of genes. And we inherit them for our brain as well as for other parts of our body. Now, with each of the neurotransmitters there is a particular type of temperament that goes with this particular neurotransmitter. Iím saying neurotransmitter in a general sense, because we are also talking about receptors and variability and sensitivity to receptors and so forth, of that type. Now if we have these inheritable temperaments, and there are several temperaments that we can inherit - and Iíll go through some of these in a moment - they also have somewhat of a normal distribution, each one of these. Most people are going to fall in the middle and some people are going to fall at one end, with a deficiency, and the other at the other end with somewhat of an excess.

If you take each one of these temperaments, then each one of them might be a characteristic that a person would have. Let me use a general term that everyone understands. Introversion versus extroversion. Some people are a little bit introverted, others a little extroverted, some of you a whole lot extroverted, and some people are a whole bunch introverted. Youíve got this kind of thing.

Schizotypal personality disorder. These are people who are weird. They look a little different. They are the ones that dress funny. You know, with the beanies with propellers or whatever it may be. They talk funny. They often have peculiar mannerisms, peculiar ways of thought, they maybe get lost in fantasies. They donít relate well to other people. They kind of stick out as sore thumbs and at times are humiliated because of this awkwardness and these peculiarities. They have poor relationships with other people because itís hard to get along with someone like that. Now our current thinking about schizotypal personality.

Schizoid Personality Disorder. We need to keep these two separate despite their similarities of how they found. Schizoid people are not particularly peculiar. They just prefer to be by themselves. They prefer to be alone. Characteristically schizoids have relatively low sexual drives so they are not into the dating game and so forth as vigorously as others. They often prefer the company of animals to people.

Paranoid personality disorder includes people who are characteristically angry, they are suspicious, often litigious, secretive, they are unpleasant people.

Antisocial personality. This has also been called dry rot of the superego, or cancer of the conscience or various terms like that. These are people we basically donít like because they donít follow the rules of society. They lie, they cheat, they steal, they are irresponsible. They are the people who often end up in prison.

Borderline personality. Now the borderline can be in either men or women, more likely to be women. What characterizes these people is the intense emotionality. They tend to often have emotional storms. Rage reactions, often chronic anger. Their interpersonal relationships are often characterized by idealization.

Narcissistic personality disorder is a relatively new problem. It has become very popular in psychiatry over the past 20 -30 years. What characterizes the narcissist is a grandiosity, often in behavior or in fantasy. These people have a pumped-up opinion about themselves. A need to be admired, feelings of special-ness.

Obsessive-compulsive personality disorder and keep in mind that this is the most common personality disorder and trait in physicians. It has a certain degree of survivability for us. The obsessive tends to be very rigid, controlled, constricted, preoccupied with regulation, orderliness, perfection, things of that type.

Avoidant personality is a relatively new diagnosis that has been described over the last few years. These people are characteristically shy, timid, fearful of social situations, very fearful of humiliation.

Dependent personality. People who are dependent, and interestingly there does seem to be more women who fit into this category and youngest children. If you were the baby of the family, that also makes you at a bit.

"We donít treat personality disorders per se." What we do, in terms of looking at what these people present to us, and their characteristics.

Let me start off then and go through them in the same order that we did before and talk about the schizotypal, the weird ones. Now these people have, as we have talked about, some perceptual problems and some cognitive difficulties. And they are at risk for developing schizophrenia.

Social skills training is very useful too. This sometimes can be provided in day-hospital types of settings.

Now, schizoids, moving along to the next disorder, these people often donít come in because they are not really unhappy with being alone so that they donít make many demands upon us. There is no specific pharmacologic therapy. If they do come in, which is usually for some co-morbid problem such as depression.

Paranoid patients are a major problem for all of us. They are a major problem in primary care. So let me talk a little bit about these people. To begin with, they are very suspicious, they are angry. They often are complaining about something or the past physician that treated them. Thereís always the hint right around the

The antisocials. One of the great problems that occur with judges - because these people are always in trouble with the law - is that the judge will mandate individual psychotherapy.

Pharmacologically, of course, we will treat any type of co-morbid problem. The low dosage SSRIís may possibly reduce impulsivity. But we are talking generally about low dose, perhaps half as much as we ordinarily use to treat patients with depression. We want to avoid habituating medications for two reasons. One reason is: these patients are at high risk for addiction, the other reason is that they come in, work you for the medication, and then they go out and sell it. Not that they need it for themselves, but itís worth something on the street. So they will try often to work you for just as much opiate, Lortabs, Ritalin, Dexedrine.

Let me talk a little bit about psychotherapy. These are patients who get referred to psychotherapists very frequently. And psychotherapy - canít tell you how many times I have seen - has been counterproductive. What happens is that an inexperienced psychotherapist will get in with these patients.