Personality Disorders in Primary Care: Pearls and Pitfalls

Robert Albanese, MD Shakaib Rehman, MD Dennis Cope, MD

Plato versus Aristotle: Rationalism versus Empiricism

Painting: La Scuola di Atene, by Rafaele Lo Santi

Empiricist or Rationalist?

Albert Einstein: Theory of Relativity

Enrico Fermi: Father of Fission

The Brain: Rational Hemisphere, Empirical Hemisphere

What was Freuds most important discovery?

The discovery of the UNCONSCIOUS Not the Subconscious. Subconscious is not a psychiatric term. It is a lay corruption of the term Unconscious.

Freud and Charcot 1885

Charcot treats a patient with Hysteria

UCS UCS UCS UCS UCS CS

UCS UCS UCS UCS

UCS

Characteristics of the Unconscious: Primary Process

Illogical Dedicated to Wish Fulfillment and Drive Satisfaction Has no Ethical System (other than the Pleasure Principle) Parameters such as Time have no Meaning Every Persons UCS is Basically the Same

The Structural Model

SUPEREGO

EGO
ID
WORLD

The Three Harsh Taskmasters

The World: A Dangerous Place

and often the source of conflict

ID: The Monster of Rage, Lust, Hunger

SuperEgo: The Demanding Quest For Perfection

Principles of Personality Theory:

Fixation Regression Repetition/Compulsion That Earlier Lesions tend to be more Devastating than Later Ones Ego Defense Mechanisms That in Some Patients, Nurture is More Important than Nature

DSM-IV-TR
is an empirical document that strives to be neutral with respect to theories of etiology.

DSM-IV Classification of Personality Disorders

Cluster A weird Schizotypal Schizoid Paranoid Cluster B wild Antisocial Borderline Narcissistic Histrionic Cluster C worried Avoidant Dependent ObsessiveCompulsive

Left Shift

Left Shift Also.

Cluster A weird Schizotypal Schizoid Paranoid Cluster B wild Antisocial Borderline Narcissistic Histrionic Cluster C worried Avoidant Dependent ObsessiveCompulsive

Primary Process

Developmental Psychology

Freuds Stages of Psychosexual Development

Designation
Oral Stage Anal Stage Phallic Stage Latency Stage Genital Stage

Chronological Setting
1st Year of Life 2nd Year of Life Ages 3-6, Oedipal Conflicts Age 7 to Puberty Begins with Onset of Puberty

Erik Eriksson: Stages (Age) I. Ages 0-1: infant II. Ages 2-3: toddler III. Ages 3-6: preschooler IV. Ages 7-12: school age child V. Ages 12-18: adolescence VI. The 20s: young adult VII. Late 20s-50s: middle adult VIII. 50s and beyond: old adult

Psychosocial crisis Trust vs. mistrust Autonomy vs. shame and doubt Initiative vs. guilt Industry vs. inferiority Ego identity vs. role confusion Intimacy vs. isolation Generativity vs. selfabsorption Integrity vs. despair

Significant relations Mother

Psychosocial modalities To get, to give in return To hold on, to let go To go after, to play To complete, to make things together To be oneself, to share oneself To lose and find oneself in another To make be, to take care of To be, through having been, to face not being

Psychosocial virtues Hope, faith

Maladaptions and malignancies Sensory distortion, withdrawal Impulsivity compulsion Ruthlessness, ambition Narrow virtuosity, inertia Fanaticism-repudiations Promiscuity exclusivity Overextension rejectivity Presumption-despair

Parents

Will, determination Purpose, courage Competence

Family Neighborhood and school Peer groups, role models Partners, friends Household, workmates Mankind or my kind

Fidelity, loyalty

Love

Care

Wisdom

Margaret Mahlers Stages of Development

NORMAL AUTISTIC PHASE NORMAL SYMBIOTIC PHASE BIRTH TO 4 WEEKS 4 WEEKS TO 5 MONTHS

SEPARATION INDIVIDUATION PROPER

FIRST SUBPHASE SECOND SUBPHASE THIRD SUBPHASE FOURTH SUBPHASE DIFFERENTIATION PRACTICING RAPPROCHEMENT OBJECT CONSTANCY 5 TO 10 MONTHS 10 TO 16 MONTHS 16 TO 24 MONTHS 24 TO 36 MONTHS

The Narcissistic Defense Mechanisms

Denial Distortion Primitive Idealization Projection Projective Identification Splitting

The Immature Defense Mechanisms

Acting out Blocking Hypochondriasis Identification Introjection Passive-Aggression Projection Regression Schizoid fantasy Somatization

The Neurotic Defense Mechanisms

Controlling Displacement Dissociation Externalization Inhibition Intellectualization Isolation Rationalization Reaction formation Repression Sexualization

The Mature Defense Mechanisms

Sublimation Anticipation Altruism Suppression Asceticism Humor

Margaret Mahlers Stages of Development--Schizotypal

NORMAL AUTISTIC PHASE BIRTH TO 4 WEEKS

NORMAL SYMBIOTIC PHASE

4 WEEKS TO 5 MONTHS

SEPARATION INDIVIDUATION PROPER

FIRST SUBPHASE SECOND SUBPHASE THIRD SUBPHASE FOURTH SUBPHASE DIFFERENTIATION PRACTICING RAPPROCHEMENT OBJECT CONSTANCY 5 TO 10 MONTHS 10 TO 16 MONTHS 16 TO 24 MONTHS 24 TO 36 MONTHS

Margaret Mahlers Stages of Development--Schizotypal

NORMAL AUTISTIC PHASE BIRTH TO 4 WEEKS NORMAL SYMBIOTIC PHASE 4 WEEKS TO 5 MONTHS

SEPARATION INDIVIDUATION PROPER

FIRST SUBPHASE SECOND SUBPHASE THIRD SUBPHASE FOURTH SUBPHASE DIFFERENTIATION PRACTICING RAPPROCHEMENT OBJECT CONSTANCY 5 TO 10 MONTHS 10 TO 16 MONTHS 16 TO 24 MONTHS 24 TO 36 MONTHS

Erik Eriksson: Stages (Age) I. Ages 0-1: infant II. Ages 2-3: toddler III. Ages 3-6: preschooler IV. Ages 7-12: school age child V. Ages 12-18: adolescence VI. The 20s: young adult VII. Late 20s-50s: middle adult VIII. 50s and beyond: old adult

Psychosocial crisis Trust vs. mistrust Autonomy vs. shame and doubt Initiative vs. guilt Industry vs. inferiority Ego identity vs. role confusion Intimacy vs. isolation Generativity vs. selfabsorption Integrity vs. despair

Significant relations Mother

Psychosocial modalities To get, to give in return To hold on, to let go To go after, to play To complete, to make things together To be oneself, to share oneself To lose and find oneself in another To make be, to take care of To be, through having been, to face not being

Psychosocial virtues Hope, faith

Maladaptions and malignancies Sensory distortion, withdrawal Impulsivity compulsion Ruthlessness, ambition Narrow virtuosity, inertia Fanaticism-repudiations Promiscuity exclusivity Overextension rejectivity Presumption-despair

Parents

Will, determination Purpose, courage Competence

Family Neighborhood and school Peer groups, role models Partners, friends Household, workmates Mankind or my kind

Fidelity, loyalty

Love

Care

Wisdom

Freuds Stages of Psychosexual Development

Designation
Oral Stage Anal Stage Phallic Stage Latency Stage Genital Stage

Chronological Setting
1st Year of Life 2nd Year of Life Ages 3-6, Oedipal Conflicts Age 7 to Puberty Begins with Onset of Puberty
Hervey Cleckley MD, MCG

Jonathan Shay: Achilles in Vietnam

In this book, Shay proposes that trauma can have the effect of breaking down established defenses that are more mature, replacing them with less adaptive, more primitive ego defense mechanisms.

Margaret Mahlers Stages of Development

NORMAL AUTISTIC PHASE NORMAL SYMBIOTIC PHASE BIRTH TO 4 WEEKS 4 WEEKS TO 5 MONTHS

SEPARATION INDIVIDUATION PROPER

FIRST SUBPHASE SECOND SUBPHASE THIRD SUBPHASE FOURTH SUBPHASE DIFFERENTIATION PRACTICING RAPPROCHEMENT OBJECT CONSTANCY 5 TO 10 MONTHS 10 TO 16 MONTHS 16 TO 24 MONTHS 24 TO 36 MONTHS

1995 Drowning Deaths

1995 Drowning Statistics in the US (per 100,000 children)
ages Total #s Total % Male total Male % Female T Female %

0-4 yrs 5-9 yrs 10-14 yrs 15-19 yrs

596 222 242 442

3.04% 1.16% 1.28% 2.54%

371
(~2:1 M:F)

3.7% 1.7% 1.8% 4.3%

225 54 66 43

2.34% .58% .72% .49%

168 176 399

Source: Centers for Disease Control

Sexual Trauma and Borderline PDO

Freuds Stages of Psychosexual Development

Designation
Oral Stage Anal Stage Pre-oedipal Stage Phallic Stage Latency Stage Genital Stage

Chronological Setting
1st Year of Life 2nd Year of Life
Ages 2-3, Empathic Parenting Ages 3-6, Oedipal Conflicts

Age 7 to Puberty Begins with Onset of Puberty

Freuds Stages of Psychosexual Development

Designation
Oral Stage Anal Stage

Chronological Setting
1st Year of Life 2nd Year of Life Ages 3-6, Oedipal Conflicts Age 7 to Puberty Begins with Onset of Puberty

Phallic Stage
Latency Stage Genital Stage

The womb is an animal that longs to generate children. If it remains barren too long after puberty, it strays about in the body, choking off the passages of the respiration, provoking the sufferer to the extremest of anguish, and causing all manner of other symptoms besides. --Plato, The Timaeus

Somatization:
In SOMATIZATION, the patient generates somatic symptoms in order to get dependency needs met in the setting of the clinic. The trick is to identify the somatizer and titrate minimum contact to minimum symptoms.

Freuds Stages of Psychosexual Development

Designation
Oral Stage Anal Stage Phallic Stage Latency Stage Genital Stage

Chronological Setting
1st Year of Life 2nd Year of Life Ages 3-6, Oedipal Conflicts Age 7 to Puberty Begins with Onset of Puberty

Erik Eriksson: Stages (Age) I. Ages 0-1: infant II. Ages 2-3: toddler III. Ages 3-6: preschooler IV. Ages 7-12: school age child V. Ages 12-18: adolescence VI. The 20s: young adult VII. Late 20s-50s: middle adult VIII. 50s and beyond: old adult

Psychosocial crisis Trust vs. mistrust Autonomy vs. shame and doubt Initiative vs. guilt Industry vs. inferiority Ego identity vs. role confusion Intimacy vs. isolation Generativity vs. selfabsorption Integrity vs. despair

Significant relations Mother

Psychosocial modalities To get, to give in return To hold on, to let go To go after, to play To complete, to make things together To be oneself, to share oneself To lose and find oneself in another To make be, to take care of To be, through having been, to face not being

Psychosocial virtues Hope, faith

Maladaptions and malignancies Sensory distortion, withdrawal Impulsivity compulsion Ruthlessness, ambition Narrow virtuosity, inertia Fanaticism-repudiations Promiscuity exclusivity Overextension rejectivity Presumption-despair

Parents

Will, determination Purpose, courage Competence

Family Neighborhood and school Peer groups, role models Partners, friends Household, workmates Mankind or my kind

Fidelity, loyalty

Love

Care

Wisdom

Freuds Stages of Psychosexual Development

Designation
Oral Stage Anal Stage Phallic Stage Latency Stage Genital Stage

Chronological Setting
1st Year of Life 2nd Year of Life Ages 3-6, Oedipal Conflicts Age 7 to Puberty Begins with Onset of Puberty

DSM-IV Classification of Personality Disorders

Cluster A weird Schizotypal Schizoid Paranoid Cluster B wild Antisocial Borderline Narcissistic Histrionic Cluster C worried Avoidant Dependent ObsessiveCompulsive

DSM-IV Classification of Personality Disorders

Cluster A Cluster B weird wild Pervasive Adult ADD Developmental Disorders Bipolar Paranoid Personality Disorder Narcissistic Histrionic Cluster C worried Social Anxiety Disorder Dependent
ObsessiveCompulsive Personality Disorder ObsessiveCompulsive Disorder

Personality Theory (Systematics)

In personality development, nurture is at least as important as nature. Personality disorders are best understood by a theoretical, rationalistic framework. Personality disorders can be characterized by a particular ego defense mechanism or a library of ego defense mechanisms; characterization of those defense mechanisms facilitates accurate diagnosis.