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New Treatments for Personality Disorders

Letís see how much we can get through the personality somatoform and dissociative disorders. Personality disorders. These are the people who come into your practice and you see their name in the book and you are like, "Oh, no." Or maybe the day before, "I dread that person coming in."

Cluster A: paranoid personality disorders. It is pervasive paranoid feelings, but not of a delusional intensity. It can be adaptive in certain situations, e.g. combat, anger, jealousy, love, weíve all experienced paranoia. When does it become pathology? It becomes pathology when you are inflexible and maladaptive in your environment. And remember, that is very environment specific. Letís say you are a combat soldier and they send you over to Kosovo, or you were down in Nicaragua or El Salvador a few years back. Is it helpful to have paranoid personality disorder? Yes it is. Because you are not trusting anybody, you are suspicious of everybody and that can be adaptive.

How about this versus delusional disorder, which weíll talk about a little later? Personality disorders are not psychotic. Psychotic people are delusional or they are hearing voices, or they are acting or speaking in a bizarre or inappropriate way. What does this mean for our purposes, now? Okay, when you cross over the line from paranoid personality disorder to delusional disorder, paranoid type, itís when you become psychotic.

Schizoid personality disorder: unfortunately, psychiatrists chose to give five different syndromes the first name of "schiz". Schizoid personality disorder, how do you remember it? You remember by the schizoid rhymes with avoid. Schizoid people like to avoid other people and thatís why itís very similar to avoidance personality disorder. These people classically like to be alone.

Schizotypal personality disorder. The way to remember this is that schizotypal ends in L and I think of it as "schizophrenia-like". Itís like having schizophrenia without the psychosis. Another way to remember it, how I tell the residents to remember it, is schizotypal ends in pal. These people are pals with schizophrenics. Their first cousins are schizophrenics. Itís like schizophrenia in that they are odd, bizarre, eccentric.

Cluster B: these are the people everybody has real problems with because they are very self-focused and very entitled. Antisocial personality disorder. Some, like me, just see this as a fancy term for criminal. But the sociopath is often classically thought of as a charming, articulate person with no loyalty or conscience. Like a deceptively charming serial killer.

This is cluster B. Nobody else matters, itís all about me. The person with antisocial personality disorder is, "Hey, you know what? I needed a car." You say to the person, "How come you are in jail?" "Well, I needed a car so I stole one. I took one. The keys were in it." "Yeah, but it wasnít your car." "Look, doc. I just told you, I needed a car. I didnít have a car, I had to get to work, I had to get my check. I needed the car." There is just this incredible entitlement and lack of understanding for other peopleís needs. For example, a real sociopathic guy a colleague was treating, slept with every woman in the world. Eventually got HIV and gave it to his poor girlfriend.

Borderline personality disorder. These people give physicians a lot of problems. Unstable, frantic, fears of abandonment, problems with identity, impulse problems, suicidal gestures. On the Board, that is probably pathognomonic for a borderline personality disorder. Mood swings. Difficult on paper to distinguish between bipolar disorder, but most of the time, if you are a psychiatrist, it is obvious. Not all the time, but Iíd say most of the time.

Just a quick review: remember, oppositional defiance disorder, thatís the kid who talks back and the kid who doesnít mind and the kid who is really annoying and argumentative. Conduct disorder is much more serious. Itís a kid who is violating the rights of other people. Heís stealing, heís torturing animals. Itís a much more vicious and pathological, pernicious condition. And it often develops into antisocial personality disorder.

Histrionic personality disorder: question 35. You have a woman who comes in. She is provocatively attired dance student. These people they just kind of flitter around. Classically, I can remember this one patient. Cadillac Michigan, Northern Michigan. Itís like May and itís cold up there still about 50 degrees. And this woman is walking around - I got consulted - sheís got like a halter top and shorts. Just totally inappropriate for the weather.

Narcissistic personality disorder: self-centered to an unreasonable extent, easily wounded. They think they are entitled and special. This is the graduate student. Heís got this poor girlfriend - maybe with dependent personality - heís a graduate student, he thinks heís brilliant. He canít understand why everyone doesnít love him. His supervisor, he thinks "The guy is always coming down on me. He doesnít see my brilliance. He doesnít see how special I am."

I do a lot of court work, and one time I was sitting there waiting for the hearing to come up and they had all the prisoners to be arraigned from the jail, and they were all these kind of bad-ass looking guys. Just exactly what you would expect. At the front of the line was this little blonde, all-American cheerleader kind of person.

Cluster C: this is kind of a mixed bag. Avoidant personality disorder. Wants friends but is terrified of rejection. They tend to have very bad feelings of themselves. They are unlike the schizoid personality who doesnít want friends, and this is a classic Board exam question. Youíve got somebody with no friends. Either of three things are going on.

Next, dependent personality disorder. Hates to be alone, tries to be taken care of. I once had a patient telling me about her sister. Her sister clearly had some traits, I donít know if she had the disorder, but her sister was married to this guy Ö or, her sister-in-law, the girl who was married to her brother.

Obsessive-compulsive personality disorder: this is important. Whatís the difference between OCD, obsessive-compulsive disorder, and OCPD, obsessive-compulsive personality disorder? OCD is the checking, the counting, the little ritualized behaviors. OCPD, the personality disorder, itís a way of life. Itís perfectionism. Itís not little circumscribed rituals, itís the way they live their life. They are rigid, they are inflexible, they are preoccupied with order and rules.

Whatís coming up. Let me just give you the preview. All the schizís. Thereís two personality disorders. Schizoid; those people avoid others. The schizotypal, those people are "pals" with schizophrenics. Then thereís three psychotic disorders, schizophreniform, the short-acting form of schizophrenia, schizoaffective, those are schizophrenics with affective problems, and then schizophrenia, which is schizophrenia.