WELCOME TO ALL

PROFFESSIONALS
OF
ALI REHABILITAION
CENTER ISLAMABAD
ARCI
 PERSONALITY
DISORDERS

BY
MUHAMMAD USMAN
CLINICAL PSYCHOLOGIST
(GOLD MEDALIST)
ALI REHAB GHOURI GARDEN IBD
 Two General Approaches
Two general strategies are useful
for assessing PDs in the interview.
They are not mutually exclusive,
and clinicians commonly use both
over the course of the evaluation.
 The Ground-Up Technique
• In the ground-up technique, you gradually fashion a
picture of your patient’s personality by working from
the ground up—that is, by learning about his/her life
history chronologically in the context of the social
and family history. As outlined in Chapter 18, the
formal social history often begins with a general
question about family life. Tell me a bit about what
growing up was like for you
 CLINICAL VIGNETTE
The interviewer is asking a patient about his work history:
• Interviewer: What sorts of jobs have you had?
• Patient: I’ve had a whole bunch of different jobs. I don’t stick with any one job for very long.
• Interviewer: What usually happens with these jobs?
• Patient: I usually quit, because the people I work with end up backstabbing me.
• At this point, the interviewer suspects paranoid PD and asks the probing questions.
• Interviewer: Have you found in your life that people have turned against you for no good
reason?
• Patient: Yeah, beginning with my parents.
• Interviewer: Do you tend to think of people in general as being disloyal or dishonest?
• Patient: Well, I’ve found that you just can’t trust anyone, because they’ll always try to do you
in if you let down your guard.
• The interviewer, having established two of the four criteria required to make the diagnosis of
paranoid PD, will then go on to ask questions regarding other criteria.
 The Symptom-Window Technique

• The symptom-window technique entails beginning with your

patient’s major symptoms and using them as “windows” for
exploring possible roots in PDs. This is generally done toward the
end of the past psychiatric history (PPH), by which time you will
have identified the major symptoms and delineated the syndromal
and treatment history. The next step is to ask questions about events
that may have occurred each time the symptoms arose. Were these
interpersonal events? Were they related to life transitions? In your
judgment, do the symptoms seem to be reasonable responses to the
events, or do they seem exaggerated?
 The Symptom-Window Technique
The nature of the symptoms per se does little to point to a specific PD, but using the
symptoms as windows to the personality is often productive.
• For example, a major depression can be a product of virtually any of the PDs, but
each patient will arrive at the depression by a different route. Here are some typical
examples:
• Narcissistic PD: The patient finds that nobody meets his high standards, thereby
alienating friends and family, leading to a social isolation that can cause depression.
• Avoidant PD: The patient avoids friendships for fear of rejection, leading to
loneliness and depression.
• Dependent PD: Patient develops a sense of worthlessness and demoralization
because of an inability to make life decisions without relying on someone else.
• Borderline PD: A chronic sense of inner emptiness may lead to depression,
suicidality, and other problems, such as substance abuse, bulimia, and impulse
control disorder.
 Important note
A PD refers to a persisting pattern of dysfunctional relating
styles over many years, at least since adolescence or young
adulthood. Thus, when you ask about criteria for a PD, make
clear to your patient that you’re interested in the long-term
view. Beginners often forget this and may end up falsely
diagnosing a PD.
For example, depressed patients commonly appear irritable,
needy, and suicidal, features that could easily lead to the
diagnosis of borderline PD.
 Cluster A (“Odd”) Paranoid

Self-statement:
• “Others are untrustworthy, and they try to take advantage of me.”
Probing questions:
• Have you often found that people in your life have not been trustworthy?
Have people turned against you for no good reason?
Behavioral clues:
• Patient appears guarded and suspicious; patient answers questions
reluctantly and with an air of suspicion.
Mnemonic: SUSPECT (four of these seven)
 Mnemonic: SUSPECT
• Spousal infidelity suspected
• Unforgiving (bears grudges)
• Suspicious of others
• Perceives attacks
• Views everyone as either an Enemy or a friend
• Confiding in others feared
• Threats perceived in benign events
 Schizoid
Self-statement:
• “I prefer to be alone; my world is completely empty.”
Probing questions:
• 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.)
Behavioral clues:
• Patient appears shy and aloof. Patient seems to be preoccupied, in her own world.
Mnemonic: DISTANT (four of these seven)
 Mnemonic: DISTANT
• Detached (or flattened) affect
• Indifferent to criticism or praise
• Sexual experiences of little interest
• Tasks (activities) performed solitarily
• Absence of close friends
• Neither desires nor enjoys close relations
• Takes pleasure in few activities
 Schizotypal
Self-statement:
• “I’d like to have friends but it’s hard, because people find me pretty
strange.”
Probing questions:
• 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?
Behavioral clues:
• Patient appears odd in any number of ways—for example, she may be
disheveled, wearing strange clothes, or have odd mannerisms. Patient
describes strange ideas that border on psychotic.
Mnemonic: ME PECULIAR (five of first nine plus “rule out” specifier)
 Mnemonic: ME PECULIAR
• Magical thinking or odd beliefs
• Experiences unusual perceptions
• Paranoid ideation
• Eccentric behavior 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 autistic disorder
 Cluster B (“Dramatic”)Borderline

Self-statement:
• “I need people desperately, and when people reject meI fall apart completely. I
hate them, and I get suicidal.”
Probing questions:
• 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?
Behavioral clues:
• May alternatively idealize and devalue you over the course of the interview; may
be unusually emotionally labile.
Mnemonic: I DESPAIRR
 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_____is? (Say patient’s name.)
Disordered, unstable affect owing to a marked reactivity of mood
• Are you a moody person?
Chronic feelings of Emptiness
• Do you often feel empty inside?
Recurrent Suicidal behavior, gestures, or threats, or self-mutilating behavior
• 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 or
overdosing?
 Mnemonic: I DESPAIRR
Transient, stress-related Paranoid ideation or severe
dissociative symptoms
• When you’re under stress, do you feel you lose touch with
your environment or with yourself? During those times,
do you feel as if people are ganging up on you?
Frantic efforts to avoid real or imagined Abandonment
• When someone abandons or rejects you, how do you
react?
 Mnemonic: I DESPAIRR
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?
 Mnemonic: I DESPAIRR
A pattern of unstable and intense interpersonal
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?
 Antisocial
Self-statement:
• “I love to take advantage of other people, and I never feel bad about it.”
Probing questions:
• Do you admire a good scam when you see it? Have you ever done
anything that could have gotten you in trouble with the law?
Behavioral clues:
The patient is excessively cocky and arrogant. The patient always portrays
self as innocent and a victim in violent or criminal circumstances.
• Mnemonic: CORRUPT (three of these seven)
 Mnemonic: CORRUPT
• Conformity to law lacking
• Obligations ignored
• Reckless disregard for safety of self or others
• Remorse lacking
• Underhanded (deceitful, lies, cons others)
• Planning insufficient (impulsive)
• Temper
 Histrionic
Self-statement:
• “I’m quite an emotional and sexually charming person, and I need to be the center
of attention!”
Probing questions:
• Do you like to be the center of attention? (Yes.) When you feel an emotion, do you
keep it inside or do you express it? (Express it.)
Behavioral clues:
• The patient is flamboyantly and seductively groomed or dressed. The patient is
rapidly and dramatically self revealing to the point of inappropriateness, even in
the context of a psychiatric evaluation.
• Mnemonic: PRAISE ME (five of these eight)
 Mnemonic: PRAISE ME
• Provocative (or sexually seductive) behavior
• Relationships (considered more intimate than they are)
• Attention (uncomfortable when not the center of attention)
• Influenced easily
• Style of speech (impressionistic, lacks detail)
• Emotions (rapidly shifting and shallow)
• Made up (physical appearance used to draw attention to self)
• Emotions exaggerated (theatrical
 Narcissistic
Self-statement:
• “I’m an extremely talented and special person, better than most people, and yet I get
angry and depressed because people don’t recognize how great I am!”
Probing questions:
• Do you often find yourself getting frustrated because other people don’t meet your
standards? (Yes.) What are your ambitions for yourself? (Will be unrealistically high.)
Behavioral clues:
• The patient may appear arrogant and excessively critical of your credentials or
experience. She may begin the interview with a responses of angry complaints about
how unfairly others have treated her.
• Mnemonic: SPEEECIAL (five of these nine)
 Mnemonic: SPEEECIAL
• Special (believes he is special and unique)
• Preoccupied with fantasies (e.g., of unlimited success, power)
• Envious
• Entitlement
• Excessive admiration required
• Conceited
• Interpersonal exploitation
• Arrogant
• Lacks empathy
 Cluster C (“Anxious”)Avoidant
Self-statement:
• “I’m really afraid of what people will think of me, so I avoid making new friends to
prevent rejection.”
Probing questions:
• Do you tend to avoid meeting people or getting close to people? (Yes.) Is that because
you prefer to be alone or because you’ve been rejected before and you don’t want it to
happen again? (The latter.)
Behavioral clues:
• The patient may appear shy and nervous but with a affecting eagerness to make contact.
He may begin the interview reluctant to open up and will typically become quite self-
revealing once rapport has been established.
Mnemonic: CRINGES (four of these seven)
 Mnemonic: CRINGES
• Certainty of being liked required before willing to risk involvement
• Rejection possibility preoccupies his thoughts
• Intimate relationships avoided
• New relationships avoided
• Gets around occupational activities that involve interpersonal
contact
• Embarrassment potential prevents new activities
• Self viewed as unappealing, inept, inferior
 Dependent
Self-statement:
• “I’m pretty passive and dependent on others for direction, and I go far out of my
way not to displease people who are important to me.”
Probing questions:
• Do you consider yourself a completely independent person, or have you tended to
lean on others in your life for emotional support and guidance? (Lean on someone
else.) Who has made most major decisions in your life, you or your_____ (spouse,
parents, or other, depending on situation)? (Someone other than the patient.)
Behavioral clues:
• The patient will seem to make extraordinary attempts to immediately gain your
affection.
Mnemonic: RELIANCE (five of these eight)
 Mnemonic: RELIANCE
• Reassurance required for decisions
• Expressing disagreement difficult (because of fear of loss of support or
• approval)
• Life responsibilities assumed by others
• Initiating projects difficult
• Alone (feels helpless and a sense of discomfort when alone)
• Nurturance (goes to excessive lengths to obtain nurturance and support)
• Companionship sought urgently when close relationship ends
• Exaggerated fears of being left to care for self
 Obsessive-Compulsive
Self-statement:
• “I’m a perfectionist. I keep lists, I drive myself hard, and I’m very serious
about life.”
Probing questions:
• 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?
Behavioral clues:
The patient is meticulously groomed and dressed. He will tend to give an
excessively detailed and accurate account of his symptoms.
Mnemonic: LAW FIRMS (four of these eight)
 Mnemonic: LAW FIRMS
• Loses point of activity
• Ability to complete tasks compromised by perfectionism
• Worthless objects (unable to discard)
• Friendships (and leisure activities) excluded (owing to preoccupation with
• work)
• Inflexible, scrupulous, over conscientious
• Reluctant to delegate
• Miserly
• Stubborn