Personality Disorders

What are some examples of personality traits?

- Friendly
- Outgoing
- Shy
- Reserved
- Anxious
- Impulsive
- Rude
- Arrogant
- Self centered
- Malicious
What is a personality disorder?

Personality disorders are considered to be exaggerations of normal

personality traits.

Personality Trait/Style VS Personality Disorder:

Histrionic Personality Trait/Style
Enjoys compliments and praise
Attentive to appearance and grooming, enjoys
clothes, style, and fashion
Enjoy being the center of attention
Histrionic Personality Disorder
Constantly seeks or demands reassurance, approval,
or praise
Overly concerned with physical attractiveness
Uncomfortable in situations where they cannot be
the center of attention
Personality disorders are conditions in which an individual differs
significantly from an average person, in terms of how they think,
perceive, feel or relate to others.

For someone to be diagnosed with a personality disorder, their

behavioral pattern must cause significant distress or impairment in
personal, social and/or occupational situations.
There are 10 personality disorders that can be grouped into 3
groups/clusters based on descriptive similarities:

1. Cluster A: Odd

2. Cluster B: Dramatic

3. Cluster C: Anxious
For each personality disorder, there is a patient “self-statement”, which
is a hypothetical description that a patient with the given disorder
would make about himself.

The statements are simplistic and stereotypic and are ONLY MEANT TO
BE USED AS MEMORY AIDS.
Cluster A: Odd
Which personality disorder does this patient have?

Others are untrustworthy, and they

try to take advantage of me
Paranoid personality disorder:

- Patients with this disorder are suspicious of everybody around them

- They think everyone is plotting against them and everybody is

believed to have an agenda

- This is different from paranoid schizophrenia

- Here the patient has no hallucinations and their beliefs are well within
the realm of possible reality
What are some good “probing” questions to ask a patient with
suspected paranoid personality disorder?

- Have you often found that people in your life have not been
trustworthy?

- Have people turned against you for no good reason?

If you obtain positive responses to your probing questions, follow up with more
questions related to specific diagnostic criteria.
Diagnostic criteria for paranoid personality disorder:
Mnemonic SUSPECT

Spousal infidelity
Have you ever thought that your partner might be cheating on you?

Unforgiving (bears grudges)

Do you find it hard to forgive people? Do you often hold grudges against
people?

Suspicious of others
Are you plagued by suspicions that other people, including loved ones, may be
doing things behind your back that will end up hurting you?
Perceives attacks

Views everyone as either an Enemy or a friend

Do you classify people as either good or bad?

Confiding in others is feared

Do you find it hard to confide in others?

Threats perceived in benign events

Which personality disorder does this patient have?

I prefer to be alone; my world is

completely empty
Schizoid personality disorder:

- The patient is shy and aloof

- He seems to be preoccupied, in his own world

- He has “split off” from society

- He is a loner who prefers to be alone

- He doesn’t have close relationships with people and he is quite

content with situation
What are some good “probing” questions to ask a patient with
suspected schizoid personality disorder?

- Are you a people person or are you someone who prefers to be

alone?
Prefers to be alone

- Can you name some things that you really enjoy doing?
Takes pleasure in few, if any, activities

If you obtain positive responses to your probing questions, follow up with more questions related to
specific diagnostic criteria.
Diagnostic criteria for schizoid personality disorder:
Mnemonic DISTANT

Detached (or flattened) affect

Indifferent to criticism or praise

How do you feel/react when others criticize you? How do you feel/react when others pay
you a compliment?

Sexual experiences of little interest

Are you currently sexual active? Have you noticed a change in your sex drive?

Tasks (activities) performed solitarily

Do you enjoy the company of others or do you prefer to do things by yourself?
Absence of close friends
Do you have any close friends?

Neither desires nor enjoys close relations

Do you have close relationships with people? Do you have the desire to
have close relationships with people?

Takes pleasure in few activities

What do you do for fun?
Which personality disorder does this patient have?

I’d like to have friends but it’s hard,

because people find me pretty strange
Schizotypal personality disorder:

- Patients are distant and introverted

- Similar to patients with schizoid personality disorder BUT

- In this case, the patient has “magical thinking”

- They describe strange ideas that border on psychotic

What are some good “probing” questions to ask a patient with
suspected schizotypal personality disorder?

- Do you tend to feel pretty uncomfortable around other people?

- Do you sometimes have ideas that other people don’t really

understand or find unusual?

If you obtain positive responses to your probing questions, follow up

with more questions related to specific diagnostic criteria.
Diagnostic criteria for schizotypal personality disorder:
Mnemonic ME PECULIAR

Magical thinking or odd beliefs

Experiences unusual perceptions

Paranoid ideation

Eccentric behaviour or appearance

Constricted (or inappropriate) affect

Unusual (odd) thinking and speech

Lacks close friends

Ideas of reference

Anxiety in social situations

Rule out psychotic disorder and pervasive developmental disorder

Cluster B: Dramatic
Which personality disorder does this patient have?

I need people desperately, and when people

reject me I fall apart completely. I hate them,
and I get suicidal.
What are some good “probing” questions to ask a patient with
suspected borderline personality disorder?

- Have people often disappointed you in your life?

- When something has gone really wrong in your life, such as losing a
job or getting rejected, have you often done something to hurt
yourself, such as cutting yourself or overdosing?

If you obtain positive responses to your probing questions, follow up

with more questions related to specific diagnostic criteria.
Diagnostic criteria borderline personality disorder:
Mnemonic I DESPAIRR

Identity disturbance
- Have you generally been pretty clear about what your goals are in life and what sort of
person you are, or do you have trouble knowing who (say patient’s name) is?
- Are you able to see goals through?
- How do you feel about yourself?

Disordered, unstable affect owing to a marked reactivity of mood

- Are you a moody person?
- Does your mood tend to fluctuate a lot?

Chronic feeling of Emptiness

- Do you often feel empty inside?
Recurrent Suicidal behaviour, gestures, or threats, or self-mutilating
behaviour
- Looking back, when something has gone really wrong in your life, like losing a job or
getting rejected, have you often done something to hurt yourself, such as cutting
yourself?

Transient, stress-related Paranoid ideation or severe dissociative

symptoms
- When you’re under stress, do you feel you lose touch with you environment or
yourself?
- During those times, do you feel as if people are ganging up against you?

Frantic efforts to avoid real or imagined Abandonment

- When someone abandons or rejects you, how do you react?
Impulsivity in at least two areas that is potentially self-damaging
- Do you see yourself as an overly impulsive person?
- Have you ever done things that can get you into trouble, such as spending all your
money, driving like a maniac using a lot of drugs, having a lot of sex, and so forth?

Inappropriate, intense Rage or difficulty controlling anger

- What do you do when you get angry?
- Do you hold it inside or let loose with it so that everybody knows how you’re
feeling?

A pattern of unstable and intense Relationships characterized by alternating

extremes of idealization and devaluation
- Do your relationships tend to be calm and stable or stormy and unstable, with lots
of ups and downs?
I DESPAIRR

I Identity disturbance (“Who am I?”)

D Disordered/unstable mood (Mood swings)

E Emptiness

S Suicidal

P Paranoid (“Everybody is ganging up on me!”)

A Abandonment

I Impulsivity

R Rage

R Relationships (stormy and unstable)

Which personality disorder does this patient have?

I love to take advantage of other people,

and I never feel bad about it
Antisocial personality disorder:

- People with this disorder disregard and violate the rights of other people

- They lack empathy and tend to be callous and cynical of the feelings, rights and
sufferings of others

- They are excessively opinionated, self assured and cocky

- They are deceitful and con others for personal profit or pleasure

- They experience no remorse

- That is, they are indifferent to having hurt, mistreated or stolen from another
What are some good “probing” questions to ask a patient with
suspected antisocial personality disorder?

Have you ever done anything that could have gotten you in trouble with
the law?
Diagnostic criteria for antisocial personality disorder:
Mnemonic CORRUPT

Conformity to law lacking

Have you ever been arrested before ? Or performed certain actions constituting grounds for
arrest?

Obligations ignored

Reckless disregard for safety of self or others

- Do you take actions without thinking about the consequences?
- Do you (or would you) like to drive and / or behave in reckless ways ? Play dangerous pranks on
people?

Remorse lacking
How do you feel when you find out one of your actions has indirectly hurt other people?
Underhanded (deceitful, lies, cons others)
- Do you sometimes profit at the expense of others, without being bothered by the
pain or damage you may cause them?
- Do you see people who get taken advantage of as being weak and deserving of
being used?
- Do you consider your needs to be more important to you than the needs of others?

Planning insufficient (impulsive)

- Do you normally plan things or do you do them impulsively?
- Do you take actions without thinking about the consequences?

Temper
Do you have a bad temper? How do you express your anger?
Which personality disorder dos this patient have?

I’m quite an emotional and sexually charming

person, and I need to be the center of
attention!
Histrionic personality disorder:

- People with this disorder want to be the center of attention at all

times and feel uncomfortable if they are not

- Interaction with other people are characterized by inappropriate

sexually seductive or provocative behaviour
What are some good “probing” questions to ask a patient with
suspected histrionic personality disorder?

- Do you like to be the center of attention?

- When you feel an emotion, do you keep it inside or do you express it?

If you obtain positive responses to your probing questions, follow up

with more questions related to specific diagnostic criteria.
Diagnostic criteria for histrionic personality disorder:
Mnemonic PRAISE ME

Provocative (or sexually seductive) behaviour

Do you often ty and draw attention to yourself? Do you often flirt with the opposite sex/same sex?

Relationships (considered more intimate than they are)

They may consider relationships to be more intimate than they actually are, describing almost every acquaintance as "my dear," or "my
dear friend."

Attention (uncomfortable when not the center of attention)

- Do you like to be the center of attention? How do you feel when you’re not the center of attention?
- Do consider yourself having a strong love for approval and praise?
Anytime the patient perceives that they are not commanding the attention they seek, they may do something dramatic, create a scene, or tell an
exaggerated story to draw the focus of attention to themselves.

Influenced easily
Are you easily influenced by other people?
Style of speech (impressionistic, lacks detail)
Do you go into details when describing something?
They express strong opinions with a dramatic flair, but when asked to explain themselves, their underlying reasons are vague and
without supporting facts and details. When describing another person, for example, they may say, "He's incredible," "He's huge,"
or "I hate her." They are strong on impressions but weak on details.

Emotions (rapidly shifting and shallow)

Do your emotions swiftly change from negative to positive and vice versa?

Made up (physical appearance used to draw attention to self)

How much do you tend to your physical appearance?

Emotions exaggerated (Theatrical)

How do you express your emotions? If something enjoys or disappoints you, do you vigorously
express your emotions?
Which personality disorder does this patient have?

I’m an extremely talented and special person,

better than most people, and yet I get angry
and depressed people don’t recognize how
great I am!
Narcissistic personality disorder:

- Patients with this disorder have an overwhelming need for admiration

- They have an inflated sense of self-importance

What are some good “probing” questions to ask a patient with
suspected narcissistic personality disorder?

- Do you often find yourself getting frustrated because other people

don’t meet your standards?

- What are some ambitions for yourself?

Will be unrealistically high

If you obtain positive responses to your probing questions, follow up with more
questions related to specific diagnostic criteria.
Diagnostic criteria for narcissistic personality disorder:
Mnemonic SPEECIAL

Special (believes he is special and unique)

- Do you frequently reassure yourself that you are deserving of praise?
- How special are you?

Preoccupied with fantasies (e.g., of unlimited success and power)

Do you have any ambitions for yourself? What are they?

Envious
- Do you ever feel threatened by other people’s success?
- How envious are you of those better off than you ? (Physically, financially etc..)?

Entitlement
Excessive admiration required
How do you feel about flattery, and being spoken grandiosely of or admired?

Conceited
How do you think of yourself? Do you feel a sense of superiority?

Interpersonal exploitation

Arrogant

Lacks empathy
Cluster C: Anxious
Which personality disorder does this patient have?

I’m really afraid of what people will think of me, so I

avoid making new friends to prevent rejection
Avoidant personality disorder:

- Patients with this disorder experience a long standing feeling of

inadequacy

- They are extremely sensitive to what people think about them

- They have very low self esteem

- They are loners (like people with schizoid personality disorder) BUT

- In this case, the want to have close relationships with people but are too
afraid of rejection to try
What are some good “probing” questions to ask a patient with
suspected avoidant personality disorder?

- Do you tend to avoid meeting people or getting close to people?

- Is that because you prefer to be alone or because you’ve been

rejected before and don’t want it to happen again?
Diagnostic criteria for avoidant personality disorder:
Mnemonic CRINGES

Certainty of being liked required before willing to risk involvement

Rejection possibility preoccupies his thoughts

Do you yearn for intimate relationships yet feel that you are too socially inept to obtain them?

Intimate relationships avoided

- Do you have any close friends? Is there any reason in particular why you don’t have a lot of close friends?
- Are you currently in a romantic relationship? Is there any reason in particular why you are currently single?

New relationships avoided

- Do you like meeting new people? Why not?
- Do you like making new friends? Why not?
Gets around occupational activities that involve interpersonal contact

Embarrassment potential prevents new activities

- Are you quiet in social situations, often out of fear of saying something stupid?
- Do you like to attend crowded events such as parties and concerts? Why not?

Self viewed as unappealing and inferior

How do you feel about yourself? Do you suffer from low confidence?
Which personality disorder does this patient have?

I’m pretty passive and pretty dependent on

other for direction, and I go far out of my
way not to displease people who are
important to me.
Dependent personality disorder:

- Patients with this disorder have an excessive need to be taken care of

- They have an excessive fear of being abandoned by the people that

are important in their lives

- They fear that they can’t live their lives without the help of others

- They are seen as being very “clingy”

What are some good “probing” questions to ask a patient with
suspected dependent personality disorder?

- Do you consider yourself a completely independent person?

- Have you tended to lean on others in your life for emotional support
and guidance?

- Who has made most major decisions in your life, you or your
spouse/parent/other?
Diagnostic criteria for dependent personality disorder:
Mnemonic RELIANCE

Reassurance required for decisions

- Are you able to make important life decisions on your own or do you often seek approval
from your loved ones?
- How indecisive are you on a daily basis?

Expressing disagreements difficult (because of fear of loss of support or approval)

Life responsibilities assumed by other

- How do you feel about responsibility?
- Do you often let others make important decisions for you?

Initiating projects difficult

Alone (feels hopeless and a sense of discomfort when alone)
Are you very afraid of being alone?

Nurturance (goes to excessive lengths to obtain nurturance and support)

Companionship (sought urgently when close relationship ends)

Assuming you just broke up with a loved one, how fast are you to look for another
relationship?

Exaggerated fears of being left to care for self

- Do you have an intense fear of separation from those you love?
- If you were completely alone, do you think you could take care of yourself?
Which personality disorder does this patient have?

I’m a perfectionist. I keep lists, I drive myself

hard, and I’m very serious about life.
Obsessive-compulsive personality disorder:

- Patients with this disorder are perfectionists

- They are preoccupied with details, lists, rules, order, schedules etc.

- They become quite upset when control is lost or when something is

out of order

- NOT the same as obsessive compulsive disorder

What are some good “probing” questions to ask a patient with
suspected obsessive compulsive personality disorder?

Do you consider yourself a perfectionist?

Do you drive yourself so hard with your work that you find you have no
time for leisure activities?
Diagnostic criteria for obsessive-compulsive personality disorder:
Mnemonic LAW FIRMS

Loses point of activity

- Are you so focused on order and perfection that you forget about the task at hand?
- Do you often get stuck on the details while missing the larger picture?

Ability to complete tasks compromised by perfectionism

Does your concern for doing everything "right" interfere with your productivity?

Worthless objects (unable to discard)

Do you have a hard time throwing things away, even if they are old and worn out?

Friendships (and leisure activities) excluded (owing to preoccupation with work)

What do you do for fun? Do you have any hobbies? Do you have time for hobbies?
Inflexible, scrupulous, over conscientious

Reluctant to delegate
- Do you have trouble delegating?
- Do you avoid working in teams because you are convinced that others are too careless and will
not work to your standards?

Miserly
Have you ever been accused of being stingy?

Stubborn
- Do others accuse you of being rigid or stubborn?
- Picking a place to eat, a place to travel, or at a clothing store, how open to suggestions are you
from others ?
42 year old Mike comes to your GP clinic to discuss with you certain
issues that he is having. His employer has asked him to come and meet
you as he thinks his performance is going down at work and he’s not
completing any projects within the required time frame. Tasks:

- History
- Diagnosis
- Management
History
Presenting illness and history of presenting illness:

- Can you tell me why you’ve come in to see me today?

- Why do you think your boss has asked you to come and see me?

- Do you think his concerns are valid?

- How do you feel about coming in to see me today?

Duration of symptoms:

- When did you first start having problems at work?

- When did your boss first raise concerns about your performance at work?

- When did your boss first suggest that you come and see me?

- How long have you had your current job?

- How many jobs have you had before this?

- Did you have similar problems with your previous jobs?

Diagnostic questions:

- Tailor your questions to the presenting complaint

- You now need to focus your questions on the areas relevant to the
patient’s problem

- Start with the probing questions and then launch into the diagnostic
questions
What are some good “probing” questions to ask a patient with
suspected obsessive compulsive personality disorder?

Do you consider yourself a perfectionist?

Do you drive yourself so hard with your work that you find you have no
time for leisure activities?

If you obtain positive responses to your probing questions, follow up

with more questions related to specific diagnostic criteria.
Diagnostic criteria for obsessive-compulsive personality disorder:
Mnemonic LAW FIRMS

Loses point of activity

- Are you so focused on order and perfection that you forget about the task at hand?
- Do you often get stuck on the details while missing the larger picture?

Ability to complete tasks compromised by perfectionism

Does your concern for doing everything "right" interfere with your productivity?

Worthless objects (unable to discard)

Do you have a hard time throwing things away, even if they are old and worn out?

Friendships (and leisure activities) excluded (owing to preoccupation with work)

What do you do for fun? Do you have any hobbies? Do you have time for hobbies?
Inflexible, scrupulous, over conscientious

Reluctant to delegate
- Do you have trouble delegating?
- Do you avoid working in teams because you are convinced that others are too careless and will
not work to your standards?

Miserly
Have you ever been accused of being stingy?

Stubborn
- Do others accuse you of being rigid or stubborn?
- Picking a place to eat, a place to travel, or at a clothing store, how open to suggestions are you
from others ?
- What do you think the issue is?

- Have you been completing the projects on time? If not, why not?
OCPD can be associated with anxiety and depression so ask a few
screening questions:

- I understand that you’ve been having problems at work. Has this

brought you down? Have you been feeling low?

- I understand that you’ve been having problems at work. Has this

made you feel more tense than usual? Do you feel anxious at all?
Precipitants:

Not very relevant this case

Risk assessment:

Not very relevant to this case

Social history:

Remember love, work and fun…

Ask the questions that weren’t covered in the presenting illness and history of
presenting illness section
Work is already covered!

- Do you have a partner?

- Are you close to your family?

- Do you have any close friends?

- Do you get along well with people?

- Do people ever comment that you are stubborn or rigid?

- Do people find it hard to follow your rigid routines?

- Do you get annoyed at people if they don’t follow a certain routine?

- What do you do for fun?

- Do you have any hobbies?

- Do you have time for hobbies?

Alcohol and drug use

Past psychiatric and treatment history

Past medical and treatment history

Family history
Diagnosis
- Mike, you mentioned that you are a perfectionist OR

- Mike, based on what you’ve told me, it sounds like you are a perfectionist.

- Perfectionism is a personality trait that a lot of people have.

- Many of us will exhibit perfectionist traits and the need for things to be clean and orderly, but for some
people this perfectionism becomes a preoccupation.

- Some people can become extremely preoccupied with rules, orderliness and self-control.

- This may interfere with the person’s ability to complete tasks because their standards are so high and so
rigid.

- We call this condition obsessive compulsive personality disorder.

- Based on what you’ve told me about your work situation, I think that’s what has been going on with you.
- People with obsessive compulsive personality disorder tend to be
occupationally high achievers with an excessive devotion to work, like
you.

- However, perfectionism and preoccupation with details interfere with

their ability to complete tasks.

- Being so overly focused on orderliness and rigidly adhering to certain

rules can also affect other aspects of your life.

- People with OCPD strongly believe that their way of thinking and
doing things is the right way, and that everyone else is wrong and as a
result their relationships with other people can suffer.
Management
Living in such a controlled and inflexible way can cause significant distress BUT there is help
available!

You will be cared for by a multidisciplinary team which will consist of me (your GP), a
psychologist and we can involve a psychiatrist if necessary.

Cognitive Behavioral Therapy (CBT)

- This can help improve your insight into OCPD
- It can also give you tools to put less emphasis on work and more emphasis on recreation,
family, and other relationships.

Antidepressant medication known as SSRIs are also an option.

I will give you some reading material on this condition.

Do you have any questions or concerns?

You’re an HMO in the ED of a rural hospital when a 22 year old Jane is
brought to you after slashing her thigh with a laser blade. She also
appears a bit drunk. There are no 24 hour psychiatric services available
at this hospital and she is insisting that she just wants to go home.
Tasks:

- History
- Diagnosis
- Management
History
Presenting illness and history of presenting illness:

- Jane, I understand that you want to go home but can we please have
a quick chat?

- How is the cut on your thigh?

- How did your hurt your thigh?

- Can you tell me what happened?

Precipitants:
- Was there a particular incident that drove you to hurt yourself? What was it?

Risk assessment:

Suicide risk assessment:

- Why did your cut your thigh?

- Was it as an attempt to end your life?

- Have you ever thought about ending your life?

- Have you thought how you might do this?

- Have you made any plans for doing this?

- Have you ever attempted it in the past?

Homicide risk assessment:

- Have you ever had thoughts about hurting someone else?

- Have you ever attempted it in the past?

Diagnostic questions:

- Tailor your questions to the presenting complaint

- You now need to focus your questions on the areas relevant to the
patient’s problem

- Start with the probing questions and then launch into the diagnostic
questions
What are some good “probing” questions to ask a patient with
suspected borderline personality disorder?

- Have people often disappointed you in your life?

- When something has gone really wrong in your life, such as losing a
job or getting rejected, have you often done something to hurt
yourself, such as cutting yourself or overdosing?

If you obtain positive responses to your probing questions, follow up

with more questions related to specific diagnostic criteria.
Diagnostic criteria borderline personality disorder:
Mnemonic I DESPAIRR

Identity disturbance
- Have you generally been pretty clear about what your goals are in life and what sort of
person you are, or do you have trouble knowing who (say patient’s name) is?
- Are you able to see goals through?
- How do you feel about yourself?

Disordered, unstable affect owing to a marked reactivity of mood

- Are you a moody person?
- Does your mood tend to fluctuate a lot?

Chronic feeling of Emptiness

- Do you often feel empty inside?
Recurrent Suicidal behaviour, gestures, or threats, or self-mutilating
behaviour
- Looking back, when something has gone really wrong in your life, like losing a job or
getting rejected, have you often done something to hurt yourself, such as cutting
yourself?

Transient, stress-related Paranoid ideation or severe dissociative

symptoms
- When you’re under stress, do you feel you lose touch with you environment or
yourself?
- During those times, do you feel as if people are ganging up against you?

Frantic efforts to avoid real or imagined Abandonment

- When someone abandons or rejects you, how do you react?
Impulsivity in at least two areas that is potentially self-damaging
- Do you see yourself as an overly impulsive person?
- Have you ever done things that can get you into trouble, such as spending all your
money, driving recklessly, using a lot of drugs, having a lot of unprotected sex, and so
forth?

Inappropriate, intense Rage or difficulty controlling anger

- What do you do when you get angry?
- Do you hold it inside or let loose with it so that everybody knows how you’re feeling?

A pattern of unstable and intense Relationships characterized by alternating

extremes of idealization and devaluation
- Do your relationships tend to be calm and stable or stormy and unstable, with lots of
ups and downs?
I DESPAIRR

I Identity disturbance (“Who am I?”)

D Disordered/unstable mood (Mood swings)

E Emptiness

S Suicidal

P Paranoid (“Everybody is ganging up on me!”)

A Abandonment

I Impulsivity

R Rage

R Relationships (stormy and unstable)

Transient psychotic symptoms, including brief delusions and
hallucinations, may also be present.

- Do you ever hear things that other people don't hear or see things
that other people don't see?

- Do you have any thoughts or beliefs that others might find unusual or
strange?

- Do you ever feel as if someone is spying on you or plotting to hurt

you?
Social history:
Remember love, work and fun…
Ask the questions that weren’t covered in the presenting illness and
history of presenting illness section
Love is already covered!

- Do you have a partner?

- Are you close to your family?

- Do you have any close friends?

- How would you describe your relationships with people?

- What was your relationship with your ex-boyfriend like?

- Have you ever had a falling with a friend or family member?

- Do you work or study? How are things at work/school?

- Do you have any hobbies? What do you do for fun?

Some risk factors/causes for BPD include:

- Traumatic experiences in childhood (neglect)

- Physical or sexual abuse

- Early loss of parents.

- Can you tell me a little bit about your childhood and how you grew up?

- How many siblings do you have?

- How did you get along with your siblings?

- What did your parents do for a living?

- How did you get along with your parents?

This will give you an idea of the general flavor of he home. Was it a peaceful, loving environment, or
was it angry and chaotic?

- What did they do when you disobeyed?

This question can gently introduce the topic of physical or sexual abuse. Depending on the answer, you
can follow up with a more explicit question such as…

- Were you abused physically or sexually as you grew up?

Alcohol and drug use

Past psychiatric and treatment history

Past medical and treatment history

Family history
Diagnosis
- Jane, you’ve mentioned that your mood tends to fluctuate a lot and
that you can be quite impulsive at times.

- You also mentioned that your relationships with other people are quite
unstable.

- These are all common occurrences.

- BUT in some people, such behaviour can interfere with daily

functioning, affect their relationships with other people and cause
significant emotional distress.

- We call this condition borderline personality disorder.

- Borderline personality disorder is a mental disorder that is marked by
a pattern of emotional instability, impulsive behaviour, distorted self-
image, and unstable relationships.

- This disorder makes it difficult for the individual to cope in all areas of
life.

- People with BPD may appear to lead chaotic lives, act impulsively or
intentionally harm themselves as a method of coping.
Management
Fortunately there is treatment available to help and this can allow you to lead a
happier and more fulfilling life.

You will be taken care of by a multidisciplinary team which will consist of me

(your GP), a psychologist and we can involve a psychiatrist if necessary.

Treatment mainly revolves around talk therapy which includes:

- Cognitive behavioral therapy

Helps people with BPD identify and change core beliefs and/or behaviors that
underlie

- Schema focused therapy

This focuses on reframing the way people view themselves
Medications are not used for the treatment of BPD unless there are co-
morbid conditions.
- Jane, I can see that you are in a lot of distress and I understand that
you want to go home.

- BUT given your recent history of self harm, we need to keep you here
overnight and have someone from the psychiatry team assess you in
the morning.

- Is there anything I can do to make your stay here more comfortable?

- Is there anything that I can get you?

- Do you want me to call someone?

If the patient refuses to stay in hospital voluntarily…

- Involuntary hospitalization under the Mental Health Act may be

necessary.

No patient with suicidal ideation/self-harm risk should be discharged

from the ED prior to discussion with an experienced mental health
clinician:
- Since the patient is insistent on being discharged, I will speak to the
psychiatrist on call over the phone to discuss the need the involuntary
hospitalization.
26 year old John has been brought to the ED where you are the HMO
by police from a local pub where he had a fight with one of his flat
mates while having a drink with him. He has dislocated his right little
finger in the fight and the police wants him to be medically examined
before charging him with assault. Tasks:

- History

- Diagnosis

- Management
History
Presenting illness and history of presenting illness:

- I understand that you’ve hurt your finger. I will have a look at it in a minute.

- But first would you mind if we had a quick chat?

- Can you tell me what happened? How did you hurt your finger?

- Who was involved in the fight?

- How did it start?

- Did anyone else get injured?

- Who called the police?

- Were you under the influence of any alcohol or drugs at the time of the fight?

- How do you feel about the incident?

- Do you regret the incident?

- Have you gotten into similar fights in the past?

- What happened then?

Diagnostic questions:

Keep the diagnostic criteria in mind and launch into the diagnostic questions.
Diagnostic criteria for antisocial personality disorder:
Mnemonic CORRUPT

Conformity to law lacking

Have you ever been arrested before ? Or performed certain actions constituting grounds for
arrest?

Obligations ignored

Reckless disregard for safety of self or others

- Do you take actions without thinking about the consequences?
- Do you (or would you) like to drive and / or behave in reckless ways ? Play dangerous pranks on
people?

Remorse lacking
How do you feel when you find out one of your actions has indirectly hurt other people?
Underhanded (deceitful, lies, cons others)
- Do you sometimes profit at the expense of others, without being bothered by the
pain or damage you may cause them?
- Do you see people who get taken advantage of as being weak and deserving of
being used?
- Do you consider your needs to be more important to you than the needs of others?

Planning insufficient (impulsive)

- Do you normally plan things or do you do them impulsively?
- Do you take actions without thinking about the consequences?

Temper
Do you have a bad temper? How do you express your anger?
Risk assessment:

Suicide risk assessment:

- Have you ever thought about ending your life?

- Have you thought how you might do this?

- Have you made any plans for doing this?

- Have you ever attempted it in the past?

Homicide risk assessment:

- Have you ever had thoughts about hurting someone else?

- Have you ever attempted it in the past?

Social history:

Remember love, work and fun…

Ask the questions that weren’t covered in the presenting illness and
history of presenting illness section

- Do you get along with people?

- Are you in touch with your family and friends?

- Are you currently in a romantic relationship?

- Are you currently working or studying?

- How is your performance at school/ work?

- How long have you had your current job?

- Have you had many other jobs in the past?

- Do you have any hobbies?

- What do you do for fun?

Conduct disorder often develops into adult antisocial personality disorder…

Features of conduct disorder include:

- Cruelty to animals and people

- Destructiveness to property

- Fire setting

- Stealing

- Truancy

- Lying

- Bullying

- Severe disobedience

- Temper tantrums
Duration of symptoms:
- Can you tell me a little bit about your childhood and how you grew
up?

- What was school like?

- Did you enjoy going to school? Did you ever skip school?

- When you were younger, did you ever hurt animals?

- Did you ever set fire to a property or try to damage it in any other
way?
People with antisocial personality disorder have often grown up with parental
conflict and harsh inconsistent parenting.

- What did your parents do for a living?

- How did you get along with your parents?

This will give you an idea of the general flavor of he home. Was it a peaceful,
loving environment, or was it angry and chaotic?

- What did they do when you disobeyed?

This question can gently introduce the topic of physical or sexual abuse. Depending
on the answer, you can follow up with a more explicit question such as…

- Were you abused physically or sexually as you grew up?

Screen for any psychotic symptoms or mood disorders:

- Do you ever hear things that other people don't hear or see things that other people don't see?

- Do you have any thoughts or beliefs that others might find unusual or strange?

- Do you ever feel as if someone is spying on you or plotting to hurt you?

- What has your mood been like?

- Have you been feeling sad, blue, down or depressed?

- Have you felt especially good about yourself?

- Have you been needing less sleep than usual?

- Do you feel that you are special or that you have special powers?

- Have you been spending more than usual?

Alcohol and drug use (IMPORTANT)

Past psychiatric and treatment history

Past medical and treatment history

Family history
Diagnosis
- Everybody has a temper and everybody acts recklessly from time to time.

- And it is a fairly common occurrence for people to sometimes mistreat others.

- But this behaviour becomes a problem when it creates trouble at work, in your
personal relationships and in social situations.

- We call this condition antisocial personality disorder.

- You mentioned that ______________.

- Based on what you’ve told me so far, I think that’s what has been going on with
you.
- Antisocial personality disorder is a type of mental condition in which a
person's ways of thinking, perceiving situations and relating to others
are dysfunctional — and destructive.

- As a result, people with antisocial personality disorder typically have

no regard for right and wrong and often disregard the rights, wishes
and feelings of others.

- They are quite impulsive and act recklessly.

- It usually begins in childhood or as a teen and continues into their

adult lives.
Management
- You will be cared for by a multidisciplinary team which will consist of your GP, a
psychologist and we can involve a psychiatrist if necessary.

- Psychotherapy is at the core of care.

- Cognitive Behavioral Therapy (CBT) is the most widely used form of psychotherapy
used to treat this condition.

- No drug has been specifically for the treatment of antisocial personality disorder.
However, medications such as antidepressants and antipsychotics are often used
to treat some of the associated problems and symptoms.

- I will give you some reading material on this condition.

- Do you have any questions or concerns?

30 year old Mike comes to your GP clinic saying that his life is falling
apart as his girlfriend has left him. He can’t sleep and he keep thinking
about her all the time and really misses her. In the middle of the
consultation he starts crying and you observe that the patient is
wearing a bright orange shirt. Tasks:

- History

- Perform a MSE and present your findings to the examiner

- Diagnosis to the patient

History
Presenting illness and history of presenting illness:

- Can you tell me why you’ve come in to see me today?

- When did your girlfriend leave you?

- How long were you in a relationship with her?

- What happened? Was there a specific reason why the relationship

ended?

- Tell me more about how you have been feeling.

Could the patient be depressed?

- What has your mood been like?

- Have you been feeling sad, blue, down or depressed?

- Have you lost interest in things you usually enjoy?

- How have you been sleeping?

- What is your appetite like?

Risk assessment:
Suicide risk assessment:

- I understand that you have been feeling down but have you ever
thought about ending your life?

- Have you thought how you might do this?

- Have you made any plans for doing this?

- Have you ever attempted it in the past?

- Have you been in other relationships in the past?

- Have you always have a hard time getting over break ups?

Diagnostic questions:

Start with the probing questions and then launch into the diagnostic
questions
What are some good “probing” questions to ask a patient with
suspected histrionic personality disorder?

- Do you like to be the center of attention?

- When you feel an emotion, do you keep it inside or do you express it?

If you obtain positive responses to your probing questions, follow up

with more questions related to specific diagnostic criteria.
Diagnostic criteria for histrionic personality disorder:
Mnemonic PRAISE ME

Provocative (or sexually seductive) behaviour

Do you often ty and draw attention to yourself? Do you often flirt with the opposite sex/same sex?

Relationships (considered more intimate than they are)

They may consider relationships to be more intimate than they actually are, describing almost every acquaintance as "my dear," or "my
dear friend."

Attention (uncomfortable when not the center of attention)

- Do you like to be the center of attention? How do you feel when you’re not the center of attention?
- Do consider yourself having a strong love for approval and praise?
Anytime the patient perceives that they are not commanding the attention they seek, they may do something dramatic, create a scene, or tell an
exaggerated story to draw the focus of attention to themselves.

Influenced easily
Are you easily influenced by other people?
Style of speech (impressionistic, lacks detail)
- Do you go into details when describing something?
- What was special about your ex-girlfriend? Why were you in love with her?
They express strong opinions with a dramatic flair, but when asked to explain themselves, their underlying reasons are vague and without
supporting facts and details. When describing another person, for example, they may say, "He's incredible," "He's huge," or "I hate her."
They are strong on impressions but weak on details.

Emotions (rapidly shifting and shallow)

Do your emotions swiftly change from negative to positive and vice versa?

Made up (physical appearance used to draw attention to self)

How much do you tend to your physical appearance?

Emotions exaggerated (Theatrical)

How do you express your emotions? If something enjoys or disappoints you, do you vigorously express your
emotions?
Social history

Alcohol and drug use

Past psychiatric and treatment history

Past medical and treatment history

Family history
Mental State Examination
MSE:

History
This will cover appearance, behavior, mood/affect, speech, thought content and thought
process.

Perception
Hallucinations

Check cognition
Orientation, memory and concentration

Insight and judgment

If not covered in the history.
Do you think your emotions are justified?
Appearance:
- Mike is a 30 year old man of average height and weight.
- At the time of examination, he was well groomed and well dressed.
He was wearing a brightly colored shirt.
- There were no distinctive features on examination.

Behavior:
- During the interview, Mike was cooperative.
- He was overly friendly and flirtatious.

Mood and Affect:

- He described his mood as being low and this was congruent with his
restricted/blunted affect.
Speech:
- His speech was of normal rate, tone and volume.
- There was no pressured speech.

Thought content:
- Although he was feeling down, Mike denied suicidal ideation.
- There was no evidence of any delusions.

Thought process:
- There was no evidence of flight of ideas, loosening of associations or
neologism.
- His speech was coherent and goal directed.
Perception:
Mike denied any auditory or visual hallucinations.

Cognition:
- He was oriented to person, place and time.
- His memory, attention and concentration was good.

Insight and Judgment:

- He has poor insight but exhibited good judgment.
Diagnosis
- Everybody enjoys compliments and praises and it is normal for a
person to sometimes enjoy being the center of attention.

- But some people constantly seek approval or praise and they become
uncomfortable in situations where they cannot be the center of
attention.

- We call this condition histrionic personality disorder.

- Based on what you’ve told me so far, I think that’s what has been
going on with you.
- Histrionic personality disorder is a condition in which people have
intense, unstable emotions and distorted self-images.

- For people with histrionic personality disorder, their self-esteem

depends on the approval of others.

- They have an overwhelming desire to be noticed, and often behave

dramatically or inappropriately to get attention.
Management
- You will be cared for by a multidisciplinary team which will consist of your GP, a
psychologist and we can involve a psychiatrist if necessary.

- Psychotherapy is at the core of care.

- Cognitive Behavioral Therapy (CBT) is the most widely used form of

psychotherapy used to treat this condition.

- No drug has been specifically for the treatment of histrionic personality

disorder.

- I will give you some reading material on this condition.

- Do you have any questions or concerns?

References:

The Psychiatric Interview

A Practical Guide
Third Edition
Daniel J. Carlat, M.D

http://
www.health.vic.gov.au/mentalhealth/suicide/suicidal-person-book2010
.pdf

http://
www.simplypsychiatry.co.uk/sitebuildercontent/sitebuilderfiles/person
alitydisordersAsBpd.pdf