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WORLD LEADERS AND
PERSONALITY DISORDERS
Dr. B. Al-Saigh
PERSONALITY DISORDERS
Psychiatry Rounds
August ‘06
RESOURCES :

Assessment and Management of Personality Disorders
Randy Ward, M.D., Medical College of Wisconsin, Milwaukee,
Wisconsin
American Family Physician, October 2004

Practice Guideline for the Treatment of Patients With
Borderline Personality Disorder
American Psychiatric Association

Fasten Your Seat Belts
ELIAS A. ZERHOUNI, Mayo Clinic Proceedings Commencement
Address, May 2005
DR. B. Al-Saigh
Regina General Hospital
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RESOURCES :

Association for Academic Psychiatry
Video Series
http://www.hsc.wvu.edu/aap/

From American Psychiatric Association. Personality disorders. In:
Diagnostic and statistical manual of mental disorders, 4th.
ed., text revision. Washington, D.C.: American Psychiatric
Association, 2000:685-729
DR. B. Al-Saigh
Regina General Hospital
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ELIAS ZERHOUNI, MD, DIRECTOR, NIH :

“We need to understand more about human
behavior. What is it about humans that they do
things they know they shouldn’t do? What makes
it possible for us to smoke, eat a poor diet, and not
exercise, knowing full well that all this is harmful?
Research on human behavior will need to be done
during the next 10 to 15 years.”
Commencement Address
Mayo Clinic School of Medicine
May 2005
DR. B. Al-Saigh
Regina General Hospital
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DEFENITION OF PERSONALITY DISORDER (PD) :
Chronic pattern of inner experience and behavior that is inflexible
and presents across a broad range of situations
DR. B. Al-Saigh
Regina General Hospital
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INTRODUCTION TO THE PERSONALITY DISORDERS
- FROM Association for Academic Psychiatry
Video Series
http://www.hsc.wvu.edu/aap/
DR. B. Al-Saigh
Regina General Hospital
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VIDEO CLIP OF 10 PERSONALITY DISORDERS
DR. B. Al-Saigh
Regina General Hospital
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KEY PRINCIPLES :

PD are not diseases

PD are dynamic systems

Personality exists as a continuum

Personality pathogenesis is not linear

PD can be assessed but not definitively diagnosed

Require strategically planned and combined modes of tactical
intervention
DR. B. Al-Saigh
Regina General Hospital
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OVERVIEW :

Coded on DSM-IV axis II –
 Personality disorders
 Personality traits
 Mental retardation

Separate axis exists to ensure that appropriate attention is paid to
these clinically significant disorders when a comprehensive
psychiatric assessment is performed
DR. B. Al-Saigh
Regina General Hospital
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OVERVIEW :

Lifetime P in general population : 10 to 13 %.

P in primary care outpatient settings : 20 to 30 %

Poorer treatment outcomes and health status / higher rates of
health care use and costs in patients with co morbid personality
disorders

Many patients with whom physicians experience problematic
relationships, and who have been referred to in the literature as
patients who are "difficult" have personality disorders
DR. B. Al-Saigh
Regina General Hospital
10
OVERVIEW :

Style of engagement may be inappropriate to the situation





Distant
Hostile
Overly intimate
Seductive
Anxious
DR. B. Al-Saigh
Regina General Hospital
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OVERVIEW :

Interpersonal behavior of patient may elicit strong emotional
reactions in physician

Unrealistic expectations for the physician's:



Availability
Time
Ability to help the patient
DR. B. Al-Saigh
Regina General Hospital
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OVERVIEW :

Medical and psychiatric illnesses may present in an atypical
fashion, and may not respond as expected to treatment

Reactions to illness may exacerbate and intensify the patient's
personality characteristics, further hampering his or her ability to
obtain proper care

The patient's insight into the presence of these disorders is
usually limited or absent
DR. B. Al-Saigh
Regina General Hospital
13
OVERVIEW :

Axis I psychiatric disorders can present with patterns of
symptoms similar to those of a personality disorder

These symptoms usually have an identifiable onset, and remit
or improve with appropriate treatment

Most efforts focus on maintaining and supporting the physicianpatient relationship and establishing a working alliance

Goal is to ensure that the patient is able to receive appropriate
medical care despite the difficulty he or she may have in
interacting with the physician and the health care system
DR. B. Al-Saigh
Regina General Hospital
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DDX OF PD SYMPTOMS OR CHANGE IN
PERSONALITY :

Adjustment reaction

Axis I psychiatric disorder

Central nervous system disorder

Medical disorder

Medication use

Substance abuse or dependence
DR. B. Al-Saigh
Regina General Hospital
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PD CLUSTERS :
A – “WEIRD”
B – “WILD”
C – “WORRIED”
DR. B. Al-Saigh
Regina General Hospital
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CONTENT :

PART I






Cluster A PD (Paranoid, Schizoid, Schizotypal)
Cluster C PD (Avoidant, OC, Dependant)
Narcissistic DP
Histrionic
Antisocial PD
PART II
 Borderline PD
DR. B. Al-Saigh
Regina General Hospital
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PART I :

Cluster A PD (Paranoid, Schizoid, Schizotypal)

Cluster C PD (Avoidant, OC, Dependant)

Narcissistic DP

Histrionic

Antisocial PD
DR. B. Al-Saigh
Regina General Hospital
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CLUSTER A : OVERVIEW

Paranoid – Schizoid - Schizotypal

Often referred to as the "schizophrenic spectrum cluster"

Do not respond appropriately to affective cues from the physician

Are unable to form connections on a basic emotional level
DR. B. Al-Saigh
Regina General Hospital
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PARANOID PD :
Verbs used to describe …

Distrust

Suspicion

Heightened sense of fear / vulnerability

Fear physician may harm / arguments / conflict
DR. B. Al-Saigh
Regina General Hospital
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PARANOID PD :
Physician should …

Adopt a professional stance

Provide clear explanations

Be empathetic to fears

Avoid direct challenge to paranoid ideation
DR. B. Al-Saigh
Regina General Hospital
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PARANOID PD :


Mistrust of Friends
 Doubts the loyalty or trustworthiness of
friends or associates

Bearing Grudges
 Bears grudges; seldom forgives others’
mistakes

Feeling Victimized
 Feels exploited or victimized; seldom
expresses gratitude
Healthy people trust their friends, are forgiving,
and freely express praise and gratitude.
DR. B. Al-Saigh
Regina General Hospital
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PARANOID PD :

Historically, all of the world’s most
murderous leaders exhibited
Paranoid Personality Disorder

Mistrust of Friends


Bearing Grudges


They promoted a culture of fear in
which no one was trusted
They promoted hatred of a
common “enemy” to gain political
power
Feeling Victimized

They convinced their followers that
they were the “victims” of a global
conspiracy of evil
DR. B. Al-Saigh
Regina General Hospital
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PARANOID PD :

Paranoia Cycles Out Of Control
Feeling victimized by an imaginary “villain”
leads to …
Wanting revenge against the imaginary
“villain” which leads to …
A preemptive attack against the imaginary
“villain” which leads to …
A defensive counter-attack from the injured
party which leads to …
Feeling more victimized
DR. B. Al-Saigh
Regina General Hospital
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PARANOID PD :

Paranoia Has Killed Millions

Leaders with Paranoid
Personality Disorder eventually
destroy millions of innocent
civilians:

Mao Tse-Tung brought about the
death of more than 70 million
people – during peacetime

Hitler brought about the Holocaust
which killed 6 million Jews and
millions of other innocent minorities

Stalin brought about the death of
20-60 million people as a direct
result of his tyrannical rule
DR. B. Al-Saigh
Regina General Hospital
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SCHIZOID PD :
Verbs used to describe …

Emotional restriction

Social detachment

Anxiety because of forced contact with others

Delay seeking care

Appear unappreciative
DR. B. Al-Saigh
Regina General Hospital
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SCHIZOID PD :
Physician should …

Adopt a professional stance

Provide clear explanations

Avoid over involvement in personal
and social issues
DR. B. Al-Saigh
Regina General Hospital
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SCHIZOTYPAL PD :
Verbs used to describe …

Odd beliefs and behavior

Socially isolative

Odd interpretations of illness

Anxiety because of forced contact with others

Delay seeking care
DR. B. Al-Saigh
Regina General Hospital
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SCHIZOTYPAL PD :
Physician should …

Adopt a professional stance

Provide clear explanations

Tolerate odd beliefs and behaviors

Avoid over-involvement in personal and social issues
DR. B. Al-Saigh
Regina General Hospital
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CLUSTER A TARGET S/S :

Cognitive distortions

Perceptual distortions

Thought disorder

Interpersonal mistrust and distance
DR. B. Al-Saigh
Regina General Hospital
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CLUSTER A TARGET S/S TX :

ATYPICAL ANTIPSYCHOTIC

+/- SSRI
DR. B. Al-Saigh
Regina General Hospital
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CLUSTER C : OVERVIEW

Avoidant – OC - Dependant

All patients exhibit anxiety in some form

Caused by fears of evaluation by others, abandonment, or loss of
order

Uncomfortable ideas/sensations cause distress & interfere with
functioning within the physician-patient relationship

Physician must use appropriate strategies to help allay this
anxiety and establish an effective working relationship with these
patients
DR. B. Al-Saigh
Regina General Hospital
32
AVOIDANT PD :
Verbs used to describe …

Social inhibition due to fears of rejection or
humiliation

Heightened sense of inadequacy

Low self-esteem

Withholds information

Avoids questioning or disagreeing with physician
DR. B. Al-Saigh
Regina General Hospital
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AVOIDANT PD :
Physician should …

Provide reassurance

Validate concerns

Encourage reporting of symptoms and concerns
DR. B. Al-Saigh
Regina General Hospital
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OBSESSIVE-COMPULSIVE :
Verbs used to describe …

Preoccupation with orderliness, perfection,
control

Fear of losing control of bodily functions
and emotions

Fear of relinquishing control

Excessive questioning and attention to details

Anger about disruption of routines
DR. B. Al-Saigh
Regina General Hospital
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OBSESSIVE-COMPULSIVE :
Physician should …

Complete thorough history and
examinations

Provide thorough explanations

Do not overemphasize uncertainty

Encourage patient participation in treatment
DR. B. Al-Saigh
Regina General Hospital
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DEPENDANT :
Verbs used to describe …

Excessive need to be taken care of

Submissive/clinging behavior/fear of abandonment

Helplessness

Urgent demands for attention

Prolongation of illness behavior to obtain attention and care
DR. B. Al-Saigh
Regina General Hospital
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DEPENDANT :
Physician should …

Provide reassurance

Schedule regular check-ups

Set realistic limits on availability

Enlist others to support patient

Avoid rejection of patient
DR. B. Al-Saigh
Regina General Hospital
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CLUSTER C TARGET S/S :

Anxiety

Behavioral Inhibition

Obsessional Thinking
DR. B. Al-Saigh
Regina General Hospital
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CLUSTER C TARGET S/S TX :

ANTI-DEPRESSANTS

BZ FOR CONTROL OF SHORT-TERM S/S
DR. B. Al-Saigh
Regina General Hospital
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CLUSTER B : OVERVIEW

Narcissistic – Histrionic – Antisocial - Borderline

Can be among the most challenging patients encountered in
clinical settings

Can be excessively demanding, manipulative, emotionally
unstable, and interpersonally inappropriate

May attempt to create relationships that cross professional
boundaries

Can place physicians in difficult or compromising positions
DR. B. Al-Saigh
Regina General Hospital
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CLUSTER B : OVERVIEW

Physicians often experience strong emotional reactions to these
patients

Physicians must be keenly aware of the issues of manipulative
behavior, professional boundaries, limit setting, and monitoring
their own emotional state
DR. B. Al-Saigh
Regina General Hospital
42
NARCISSISTIC :
Verbs used to describe …

Grandiosity, Need for Admiration, Attitude
of entitlement

Lack of empathy

Anxiety caused by doubts of personal adequacy

Demanding / Denial of illness

Alternating praise and devaluation of physician
DR. B. Al-Saigh
Regina General Hospital
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NARCISSISTIC :
Physicians should …

Validate concerns

Give attentive and factual responses to
questions

Channel patient's skills into dealing with illness
DR. B. Al-Saigh
Regina General Hospital
44
NARCISSISTIC :

Healthy people are humble,
democratic, and unselfish.
Three behaviors form core of NPD:

Arrogance
 Is arrogant or proud; feels
superior to others

Domineering Behavior
 Is domineering or dictatorial;
has a bossy way of ordering
others around

Greed
 Is selfishly greedy; wants to
possess much more than what
he/she needs or deserves
DR. B. Al-Saigh
Regina General Hospital
45
NARCISSISTIC LEADERS :

Historically, many tyrants
exhibited Narcissistic
Personality Disorder:

Arrogance


Domineering Behavior


They were dictatorial and
autocratic
Greed


They were very arrogant and
proud
They monopolized their nation’s
power and wealth
Usually exhibit both Paranoid
and Narcissistic PD.
DR. B. Al-Saigh
Regina General Hospital
46
HISTRIONIC :
Verbs used to describe …

Excessive attention-seeking behavior

Emotionality Threatened sense of
attractiveness and self-esteem

Overly dramatic / Somatization

Attention-seeking behavior

Inability to focus on facts and details
DR. B. Al-Saigh
Regina General Hospital
47
HISTRIONIC :
Physician should …

Avoid excessive familiarity

Show professional concern for feelings

Emphasize objective issues
DR. B. Al-Saigh
Regina General Hospital
48
ANTISOCIAL :
Verbs used to describe …

Disregards rights of others

Anger

Entitlement masking fear

Impulsive behavior

Deceit, manipulative
DR. B. Al-Saigh
Regina General Hospital
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ANTISOCIAL :
Physicians should …

Carefully investigate concerns and motives

Communicate in a clear and
non-punitive manner

Set clear limits
DR. B. Al-Saigh
Regina General Hospital
50
ANTISOCIAL :

Healthy people are tolerant,
responsible, honest, and don’t
unethically exploit others
Three behaviors form the core of
APD:

Intolerance
 Is judgmental or prejudiced;
doesn’t respect the beliefs
and practices of others

Irresponsibility or Dishonesty
 Doesn’t take responsibility for
own actions; is dishonest; lies,
cheats, or steals

Manipulativeness
 Selfishly or unethically
manipulates others for his/her
own advantage
DR. B. Al-Saigh
Regina General Hospital
51
ANTISOCIAL LEADERS :

Historically, the most ruthless world
leaders had Antisocial Personality
Disorder:

Intolerance
 Persecuted their minorities
and permitted genocides

Irresponsibility or Dishonesty
 They habitually lied to their
citizens as their friends
looted their nation’s wealth

Manipulativeness
 They constantly manipulated
others for their own unethical
advantage
DR. B. Al-Saigh
Regina General Hospital
52
CLUSTER B1 TARGET S/S :

Depression

Interpersonal Sensitivity

Impulsivity

Aggression
DR. B. Al-Saigh
Regina General Hospital
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CLUSTER B1 TARGET S/S TX :

ANTI-DEPRESSANTS

+/- MOOD STABILIZER

+/- ATYPICAL ANTIPSYCHOTIC
DR. B. Al-Saigh
Regina General Hospital
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CLUSTER B2 TARGET S/S :

Mood lability

Impulsivity

Aggression

FHx Bipolar Spectrum D/O
DR. B. Al-Saigh
Regina General Hospital
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CLUSTER B2 TARGET S/S TX :

MOOD STABILIZER

+/- ANTI-DEPRESSANT

+/- ATYPICAL ANTIPSYCHOTIC
DR. B. Al-Saigh
Regina General Hospital
56
CLUSTER B3 TARGET S/S :

Paranoia

Psychosis

Hostility

Overwhelming Anxiety
DR. B. Al-Saigh
Regina General Hospital
57
CLUSTER B3 TARGET S/S TX :

ATYPICAL ANTI-PSYCHOTIC

+/- ANTI-DEPRESSANT

+/- MOOD STABILIZER
DR. B. Al-Saigh
Regina General Hospital
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PART II :

Borderline PD
DR. B. Al-Saigh
Regina General Hospital
59
CORE CLINICAL FEATURES :

Pervasive pattern of :



Instability of interpersonal relationships
Instability of affect
Instability of self-image

Marked impulsivity beginning in early
childhood

Severe and persistent enough to result in clinically significant
impairment in social, occupational, or other important areas of
functioning

Severely impaired capacity for attachment

Predictably maladaptive behavior in response to separation
DR. B. Al-Saigh
Regina General Hospital
60
CORE CLINICAL FEAURES :

Very sensitive to abandonment

Inappropriate rage

Unfair accusations
DR. B. Al-Saigh
Regina General Hospital
61
CORE CLINICAL FEAURES :

Self-mutilation or suicidal
behaviors

Relationships are unstable,
intense, and stormy

Views of others may suddenly and dramatically shift

Alternating between extremes of idealization and
devaluation, or seeing others as beneficent and nurturing
and then as cruel, punitive, and rejecting
DR. B. Al-Saigh
Regina General Hospital
62
CORE CLINICAL FEATURES :

Impulsive in :






Spending money irresponsibly
Gambling
Engaging in unsafe sexual behavior
Abusing drugs or alcohol
Driving recklessly
Binge eating

Self-mutilation (e.g., cutting or burning)

Unstable self-image

Chronic feelings of emptiness
DR. B. Al-Saigh
Regina General Hospital
63
CORE CLINICAL FEATURES :

Inappropriate, intense anger

Difficulty controlling anger during periods
of extreme stress (e.g., perceived or actual abandonment)

May experience transient paranoid ideation
or severe dissociative symptoms
(e.g., depersonalization)

Recurrent suicidal behaviors, gestures, or threats

Affective instability

Marked mood reactivity (e.g., intense episodic dysphoria, irritability,
or anxiety
DR. B. Al-Saigh
Regina General Hospital
64
ASSOCIATED FEATURES :


Transient psychotic-like symptoms @
times of stress

Usually last for minutes or hours

Generally of insufficient duration or
severity to warrant an additional
diagnosis
Tendency to undermine themselves when a goal is about to be
reached (e.g., severely regressing after a discussion of how well
therapy is going).
DR. B. Al-Saigh
Regina General Hospital
65
ASSOCIATED FEATURES :

Individuals with this disorder may feel
more secure with transitional objects
(e.g., a pet or inanimate object) rather than
with interpersonal relationships

Physical and sexual abuse, neglect,
hostile conflict, and early parental loss or separation are more
common in the childhood histories of those with borderline
personality disorder than in those without the disorder
DR. B. Al-Saigh
Regina General Hospital
66
COMORBID CONDITIONS :

Commonly co-occurring Axis I disorders :
 Mood disorders
 Substance-related disorders
 Eating disorders (notably bulimia)
 PTSD
 Panic disorder
 ADHD

Commonly co-occurring axis II disorders :
 Antisocial
 Avoidant
 Histrionic
 Narcissistic
 Schizotypal
DR. B. Al-Saigh
Regina General Hospital
67
COMORBID CONDITIONS :

BPD vs Bipolar D/O :


In BPD, the mood swings are often
triggered by interpersonal stressors
(e.g., rejection), and a particular mood
is usually less sustained than in
bipolar disorder
BPD vs MDD :

Depressive features that appear particularly characteristic of
borderline personality disorder are emptiness, self-condemnation,
abandonment fears, self-destructiveness, and hopelessness
DR. B. Al-Saigh
Regina General Hospital
68
COMORBID CONDITIONS :
BPD vs Dysthymic Disorder :

Chronic dysphoria is very
common in individuals
with borderline personality disorder

Presence of the aforementioned
affective features (e.g., mood
swings triggered by interpersonal
stressors) should prompt consideration of the diagnosis of
BPD

Other features of BPD (e.g., identity disturbance, chronic selfdestructive behaviors, frantic efforts to avoid abandonment)
are generally not characteristic of axis I mood disorders
DR. B. Al-Saigh
Regina General Hospital
69
COMORBID CONDITIONS :

BPD vs PTSD :

Hx of trauma often characteristic of
patients with BPD and does not
necessarily warrant an additional
diagnosis of PTSD

PTSD should be diagnosed only when
full criteria for the disorder are met

PTSD is characterized by rapid-onset
symptoms that occur, usually in adulthood,
in reaction to exposure to a recognizable and extreme
stressor; in contrast, borderline personality disorder consists
of the early-onset, enduring personality traits described earlier
DR. B. Al-Saigh
Regina General Hospital
70
COMORBID CONDITIONS :

BPD vs DID :

DID is characterized by the
presence of two or more distinct
identities or personality states that
alternate, manifesting different
patterns of behavior
DR. B. Al-Saigh
Regina General Hospital
71
EPIDEMIOLOGY :

Most common personality disorder in clinical
settings

Present in :

10% of individuals seen in outpatient MHC

15%–20% of psychiatric inpatients

30%–60% of clinical populations with a
personality disorder

2% of the general population
DR. B. Al-Saigh
Regina General Hospital
72
EPIDEMIOLOGY :

Present in cultures around the world

Approximately five times more
common among first-degree
biological relatives of
those with the disorder than in the
general population

Greater familial risk for substance-related disorders, antisocial
personality disorder, and mood disorders

Diagnosed predominantly in women (gender ratio 3:1)
DR. B. Al-Saigh
Regina General Hospital
73
COMPLICATIONS :

Notable distress / Functional impairment

Majority attempt suicide


Completed suicide occurs in 10% of pts

50 times higher than in the general population.

Risk highest when pts. are 20s as well
as in presence of co-occurring MD/Substance-Related
Disorders
Difficulty with occupational, academic, or role functioning

Recurrent job loss and interrupted education are common
DR. B. Al-Saigh
Regina General Hospital
74
COMPLICATIONS :

Difficulties in relationships, as well
as divorce

Social cost for patients with BPD and their
families is substantial

•

May gradually attain functional roles
10–15 years after admission to
psychiatric facilities
Still only about one-half will have stable,
full-time employment or stable marriages
Greater lifetime utilization of most major categories of medication
and of most types of psychotherapy than do patients with
Schizotypal, Avoidant, OC PD or patients with MDD
DR. B. Al-Saigh
Regina General Hospital
75
BORDERLINE PD :
Physician should …

Avoid excessive familiarity

Schedule regular visits

Provide clear, nontechnical explanations

Tolerate angry outbursts, but set limits

Maintain awareness of personal feelings
DR. B. Al-Saigh
Regina General Hospital
76
BAD WORLD LEADERS :

Historically, the worst world
leaders had a combination of
APD + NPD + PPD

Their behavior exhibited:
 Pathological mistrust
 Lack of forgiveness
 Feeling constantly the
“victim”
 Arrogance / Greed
 Dictatorial behavior
 Intolerance / Dishonesty
 Manipulativeness
DR. B. Al-Saigh
Regina General Hospital
77
PERSONALITY DISORDERS
GEORGE W. BUSH :
DR. B. Al-Saigh
Regina General Hospital
78